I read with interest "The Fifteen-minute consultation on the infant
with a large head" published recently by Arnab Seal.
Clinicians should also be aware of 'Benign Enlargement of Subarachnoid
Space (BESS)'. It is described under various names in literature including
benign extra-axial collections of infancy, external hydrocephalus,
subdural effusions, etc (1).
It presents in infancy with rapid enlarged of head circumferen...
I read with interest "The Fifteen-minute consultation on the infant
with a large head" published recently by Arnab Seal.
Clinicians should also be aware of 'Benign Enlargement of Subarachnoid
Space (BESS)'. It is described under various names in literature including
benign extra-axial collections of infancy, external hydrocephalus,
subdural effusions, etc (1).
It presents in infancy with rapid enlarged of head circumference on the
background of normal development.
It should be differentiated from isolated or familial macrocephaly as the
head circumference is normal at birth followed by rapid growth in infancy
crossing more than 2 centiles. Hence although it would fall in category E
(figure 2) neuroimaging (Computed tomography (CT)/Magnetic resonance
imaging (MRI) head) would be required to rule out any intracranial
pathology and establish the diagnosis. In the majority of cases there is a
positive family history of macrocephaly, thus can be misdiagnosed as
familial macrocephaly if neuroimaging is not undertaken.
The anterior fontanelle is enlarged along with enlargement of fronto-
parietal subarachnoid space. There is no associated brain atrophy or signs
of raised intracranial pressure.
As the name indicates it is completely benign condition and no surgical
intervention is required. This condition is self-limiting with spontaneous
resolution usually by 2 years of age. Although the macrocephaly may
persist it plateaus by 2 years of age and associated with resolution of
subarachnoid space as the child grow older (1).
It is important to monitor the head growth and developmental progress. If
there is any deviation from normal in neuro-development or there is
persistence of rapid head growth beyond 2 years of age further evaluation
is required to exclude other intracranial pathologies (2).
In summary, clinicians should consider BESS in any infant presenting with
rapid head growth and normal development. This is a benign self-limiting
condition and no surgical intervention is required.
The Fifteen-minute consultation on the infant with a large head just
published on line (1) has one major weakness: no mention of which chart
the child's head is compared to. Comparison with representative Belgian,
Norwegian (2) and British data (3) has shown that European infants' heads
appear large compared to the WHO standards. We have undertaken further
analyses of the data from the Southampton Women's Survey used fo...
The Fifteen-minute consultation on the infant with a large head just
published on line (1) has one major weakness: no mention of which chart
the child's head is compared to. Comparison with representative Belgian,
Norwegian (2) and British data (3) has shown that European infants' heads
appear large compared to the WHO standards. We have undertaken further
analyses of the data from the Southampton Women's Survey used for our
previous paper (3) and these suggest that, out of 1731 healthy infants
aged 6 months, 3.3% have a head circumference (HC) above the WHO 99.6th
centile and half of these (1.8% of all infants) will also have crossed 2
or more centile spaces upwards since birth. Reassuringly, between 6 and 12
months there was much less centile crossing and only 5 infants (0.3% of
all infants) move further upwards by more than the equivalent of one
centile space (0.67SD). It is probably these latter children who should
be investigated further.
If compared to the previous UK 1990 growth chart only around 0.5% of
children will have a head circumference above the 99.6th, but it should be
born in mind that compared to the UK 1990 UK more infants' heads appear
small. After the age of 6 months between 5-8% of children have heads
below the UK1990 2nd centile (3) and our further analyses of the latter
data3 suggest that by 6 months of age 17% of healthy infants will have
crossed 2 or more centile spaces downwards compared to the UK 1990
reference.
So the growth chart you choose makes a huge difference: make sure you
know which one is being referred to!
Reference List
(1) Seal A. Fifteen-minute consultation on the infant with a large
head. Arch Dis Child Educ Pract Ed 2013.
(2) Juliusson PB, Roelants M, Hoppenbrouwers K, Hauspie R, Bjerknes R.
Growth of Belgian and Norwegian children compared to the WHO growth
standards: prevalence below -2 and above +2 SD and the effect of
breastfeeding. Arch Dis Child 2011; 96(10):916-921.
(3) Wright CM, Inskip HM, Godfrey K, Williams AF, Ong KK. Monitoring head
size and growth using the new UK-WHO growth standard. Arch Dis Child 2011;
96(4):386-388.
Conflict of Interest:
I am academic lead for the RCPCH growth chart group that published the new UK-wHO growth charts
The reservations exepressed about the interpretation of interferon
gamma release assays(IGRAs)(1)are underpinned by the following
observations:-
IGRAs do not reliably identify subjects with active tuberculosis(even in
the context of culture positive disease)(2), as shown by a study where 45
subjects received a diagnosis of active tuberculosis characterised, in 37
of those subjects, by positive cultures for mycobacterium...
The reservations exepressed about the interpretation of interferon
gamma release assays(IGRAs)(1)are underpinned by the following
observations:-
IGRAs do not reliably identify subjects with active tuberculosis(even in
the context of culture positive disease)(2), as shown by a study where 45
subjects received a diagnosis of active tuberculosis characterised, in 37
of those subjects, by positive cultures for mycobacterium
tuberculosis(MTB). Nevertheless, in 17 of the 45 patients with a final
diagnosis of active tuberculosis the IGRA test was negative(2). This means
that, in that study,the spectrum of 17 negative IGRA tests included, at a
bare minimum, at least eight patients with culture positive tuberculosis.
The suboptimal sensitivity of IGRAs is compounded by apparently
spontaneous reversion from positive to negative test status(3)(4), and
also by apparently spontaneous by conversion from negative to positive
test status(3)(4). This state of affairs has implications for recognition
and management of latent tuberculosis, not only in the context of low
disease prevalence(3), but also in the context of high disease
prevalence(4). In the former context, an American study utilised IGRAs to
screen 3,234 individuals considered to be at low risk of mycobacterium
tuberculosis infection, including low risk of infection in the remote
past. Of these, 2,819 tested unequivocally negative, 218 tested
unequivocally positive, and 177 yielded indeterminate tests per
manufaturer's criteria. On retesting 13(9%) of initially negative tests
converted to positive, and 15(7%) of initially positive tests reverted to
negative test status using the manufacturer's cut-off value(3). In the
context of high disease prevalence a review was published which included
evaluation of in-subject variability of IGRAs in India and in South
Africa. In the Indian context, over a 2 weeks period, 2 of 14 health care
workers experienced reversion from positive to negative test status. In
the South African study, over a 3 week period, 7 of 26 helth care workers
experienced either a conversion or a reversion. In both the Indian and the
South African studies subjects who experienced either reversion or
conversion had initial values close to the cut-off point(4).
These observations(2)(3)(4) should serve as fundamental caveats to the use
of IGRAs in clinical practice.
References
(1) Pollock L., Roy RB., Kampmann B
How to use: interferon gamma release assays for tuberculosis
Education and Practice 2013;98:99-105
(2)Dewan PK., Grinsdale J., Kawamura M
Low sensitivity of a whole blood interferon gamma release assay for
detection of active tuberculosis
Clinical Infectious Diseases 2007;44:69-73
(3) Metcalfe JZ., Cattamanchi A., McCulloch CE et al
Test variability of the QuabtiFERON-TB-Gold in-Tube assay in clinical
practice
Am J Respir Crit Care Med 2013;187:206-2011
(4) van Zyl Smit RN., Zwerling A., Dheda K., Pai M
Within-subject variability of interferon-gamma assay results for
tuberculosis and boosting effect of tuberculin skin testing: A systematic
review
PLoS ONE 2009;4:e8517
As part of the team that undertook review of the paper prior to
publication I would like to thank Alan for picking up this
misinterpretation and to apologise to our readers for the mistake.
It's entirely correct that a negative ADOS will be right - the
patient will not have autism - about 88% of the time.
The table 3 is misleadingly titled "prob that the test rules out
autism" and should be "post test...
As part of the team that undertook review of the paper prior to
publication I would like to thank Alan for picking up this
misinterpretation and to apologise to our readers for the mistake.
It's entirely correct that a negative ADOS will be right - the
patient will not have autism - about 88% of the time.
The table 3 is misleadingly titled "prob that the test rules out
autism" and should be "post test probability of autism with a negative
test" and this mistake is repeated in the text.
I think there's something in the way we describe the 'output' of a
diagnostic test.
Sometimes the value of a negative test is given as NPV ie the % with
a negative test who are negative for the condition.
Sometimes it's given as the predictive value of a negative test ie
the % of those with a negative test that DO HAVE the disorder
Personally, I prefer this latter way of presenting the information as
it highlight the negative test 'failures' who you may have 'dismissed'.
So - while it's true that a negative ADOS is right ~88% of the time,
that's the same as saying about 12% of the time a patient with negative
ADOS actually does have an autistic spectrum disorder.
Carter and colleagues have done a superb job in summarising the
theory and practice of tools used in assessing children for autism.
Unfortunately their paper is marred by a mathematical error which, if left
unchallenged, could undermine trust in the use of one such tool, the ADOS.
According to the paper, the positive predictive value (ppv, i.e. the
proportion of those who test positive who actually have the cond...
Carter and colleagues have done a superb job in summarising the
theory and practice of tools used in assessing children for autism.
Unfortunately their paper is marred by a mathematical error which, if left
unchallenged, could undermine trust in the use of one such tool, the ADOS.
According to the paper, the positive predictive value (ppv, i.e. the
proportion of those who test positive who actually have the condition) of
the ADOS is 80.4% in a neurodevelopmental clinic population, whilst the
negative predictive value (npv, proportion of those who test negative who
do not have the condition) in the same population is only 11.9%. If this
were true it would mean that the proportion of those in the test negative
group who have the condition would actually be higher than in the test
positive group- 88.1% against 80.4%. Fortunately it is not true.
Using the population prevalence of 53% quoted, and the figures of 91%
sensitivity and 75% specificity the true figure for ppv is as given, but
the npv is actually 87.5%. Carter et al's conclusion, therefore, that
tests should be interpreted in the light of history and information from
other sources stands, but the ADOS is not as hopeless as their paper might
have suggested.
Although it may be difficult to make a distinction between
retropharyngeal abscess, and retropharyngeal cellulitis attributable to
organisms such as Group A bete-haemolytic Streptococcus, Staphylococcus
Aureus, and Group B Streptococcus(1), retropharyngeal abscess should
remain high in the differential diagnosis because Fusobacterium
necrophorum(F necrophorum), the gram negative culprit pathogen,although
initially givin...
Although it may be difficult to make a distinction between
retropharyngeal abscess, and retropharyngeal cellulitis attributable to
organisms such as Group A bete-haemolytic Streptococcus, Staphylococcus
Aureus, and Group B Streptococcus(1), retropharyngeal abscess should
remain high in the differential diagnosis because Fusobacterium
necrophorum(F necrophorum), the gram negative culprit pathogen,although
initially giving rise to pharyngitis(2)or to tonsillitis(3), may
ultimately mandate an antibiotic regime different from the one typically
used for treatment of gram positive infections(4). Among 14 cases of
bacteriologically confirmed F necrophorum infection diagnosed in a
children's hospital, the organism was isolated from peritonsillar abscess
fluid in eight, from blood cultures in five, and from bronchial-alveolar
lavage fluid in one. Lemierre's syndrome(LS) was a complication in four of
these bacteriologically confirmed cases. Of note, among two of the four
bacteriologically validated cases of LS there was serological evidence
suggestive of co-infection with two of the organisms more commonly
associated with tonsillitis. In one instance, the serological evidence
amounted to elevation in Anti Streptolysin O Titre, and, in the other, it
amounted to documentation of a positive Immunoglobulin M titre for Epstein
-Barr Virus(2), the latter generally beleived to be "virtually diagnostic
of primary EBV infection"(5). Accordingly, to paraphrase one commentator,
these cases "draw attention to an alternative pathogen for
tonsillitis"(4), thereby justifying a high index of suspicion for F
necrophorum. In the event that the oragnism cannot be isolated by culture
from appropriate specimens molecular methods, including broad-range 16S
rDNA PCR should be used. The latter startegy has the advantage that it
also encompasses other bacterial infections, such as Group A Streptococci,
Staphylococcus Aureus, and Streptococcus pneumoniae, presenting with
similar clinical features. Furthermore, because the test dtects molecular
material from bacteria, previous antibiotic treatment does not interfere
with the diagnosis(6).
References
(1)Zacharkiwa A., Williams H
A pain in the neck
Arch Dis Child Ed Pract 2013;98:71-72
(2)Ramirez S., Hild TG., Rudolph CN et al
Increased diagnosis of Lemierre Syndrome and other Fusobacterium
necrophorum infections in a children's hospital
Pediatrics 2003;112:e380-e385
(3)Klug TE., Henriksen J-J., Fuursted K., Ovensen T
Significant pathogens in peritonsillar abscess
Eur J Clin Microbiol Infect Dis 2011;30:619-627
(4)Fourage M., Bourguignat C., Fermond B., Delobel P
A recurrent tonsillitis
Lancet 2013;381:266
(5)Luzuriaga K., Sullivan JL
Infectious mononucleosis
N Engl J Med 2010;362:1993-2000
(6)Patel M
16S rDNA PCR in diagnosis of Lemierre's syndrome
Lancet Infectious Diseases 2013;13:197
.Dear Sir, We read with great interest the accurate paper by Sen et
al. regarding the indications for testing lupus anticoagulants (LA) in
pediatric patients1. We believe that two further considerations might
provide a complete overview on this issue. First, it has to be underlined
the important contribution given by Boffa MC concerning either the
laboratory methods for the detection of LA2 or the association between
an...
.Dear Sir, We read with great interest the accurate paper by Sen et
al. regarding the indications for testing lupus anticoagulants (LA) in
pediatric patients1. We believe that two further considerations might
provide a complete overview on this issue. First, it has to be underlined
the important contribution given by Boffa MC concerning either the
laboratory methods for the detection of LA2 or the association between
antiphospholipid syndrome (APS) and obstetrical complications in women3.
Second, in the article by Sen et al. the authors do not take into
consideration infants born to mothers with APS. To date, it is still
unclear how neonates born to mothers with APS should be evaluated and
which is the true clinical relevance of neonatal antiphospholipid
antibodies (APL). Concerning the indications to LA testing, the authors
suggested two main indications: the presence of thrombosis and/or of
unexplained prolonged aPTT. We agree with the authors concerning the first
indication, i.e. APL testing in all infants with thrombosis even in
neonates born to mothers with negative APL4. Concerning the second
indication, it should be specified that the activated partial
thromboplastin time (aPTT) in neonates is intrinsically longer than in
adults and changes according to postnatal age5. Boffa et al. suggested
that APL should be sistematically tested at birth in neonates born to
mothers with APS6 since unpredictable transplacental passage occurs in
about 30% of cases. The low rate and the unpredictable entity of APL
crossing through the placenta could depend on the absorption of antibodies
by trophoblast cells and by their binding to heparin, administered to
mothers with APS during pregnancy. Interesting data have been recently
provided by the European registry of babies born to mothers with APS7.
First, maternal APL crossing over the placental barrier was confirmed.
Second, the kind of neonatal APL correlated with the same mother's isotype
before 6 months of life and mostly disappeared thereafter. Third, 10% of
children showed persistent APL at 24 months of life. Fourth, de-novo
production of antibodies was reported; in particular, de-novo anti-beta2
glycoprotein-I antibodies synthesis occurred in 16% and LA in 4% of cases.
It was suggested that prolonged APS exposure could represent an
immunological trigger, as well as vaccinations or infections, for de-novo
synthesis of APL. Nevertheless, the exact clinical relevance of neonatal
APL positivity is still poorly understood. Although only few case reports
of thrombosis have been described among children born to mothers with
APS6, this increased prothrombotic risk should not be underestimated. In
addition, the European registry of babies born to mothers with primary APS
reported four cases of neurodevelopmental anomalies during the 5-year
follow-up7. According to the current knowledge on this topic, APL
screening should be performed at birth only in case of thrombosis, and
after 6 months of life in asymptomatic neonates to investigate the
eventual persistence of APL. In this case, a long lasting follow-up is
required to verify the true clinical significance of persisting APL.
References 1. Sen ES, Beresford MW, Avcin T, Ramanan AV. How to use
lupus anticoagulants. Arch Dis Child Educ Pract Ed. 2012 Oct 6. 2. Lambert
M, Ferrard-Sasson G, Dubucquoi S, Hachulla Eet al. Diluted Russell viper-
venom time improves identification of antiphospholipid syndrome in a lupus
anticoagulant-positive patient population. Thromb Haemost 2009;101(3):577-
81. 3. Soulier JP, Boffa MC: Avortements a repetition, thromboses et
anticoagulant circulant anti-thromboplastine: trois observations. Nouv
Presse Med 1980;9:859. 4 De Carolis MP, Salvi S, Bersani I, De Carolis S.
Isolated cerebral sinovenous thrombosis: a rare case of neonatal
antiphospholipid syndrome. Indian Pediatr. 2012 May;49(5):411-2. 5. Andrew
M, Paes B, Milner R, et al. Development of the human coagulation system in
the full-term infant. Blood 1987;70(1):165-72. 6. Boffa MC, Lachassinne E.
Infant perinatal thrombosis and antiphospholipid antibodies: a review.
Lupus 2007;16(8):634-41. Review. 7. Mekinian A, Lachassinne E, Nicaise-
Roland P, et al. European registry of babies born to mothers with
antiphospholipid syndrome. Ann Rheum Dis. 2012 May 15.
The authors state that INH does not prevent the development of active
tuberculosis. However, it is well known that with lower dosage than
15mg/kg daily of INH, we cannot assure therapeutical INH levels,
precluding its efficacy, as it correlates with lower levels than 3g/l in
the pharmacokinetic parameter of response Cmax
Straw and Porter write an important article on Sexual health and
Contraception (Arch Dis Chld Educ Pract Ed 2012; 97:177-184), but there
are some points which I think need clarification or correction. There may
also be missed opportunities for highlighting the most effective methods
of contraception in real life situations for young people.
The statement that 'Levonelle 1500 is an an oral progestogen which can be
obtaine...
Straw and Porter write an important article on Sexual health and
Contraception (Arch Dis Chld Educ Pract Ed 2012; 97:177-184), but there
are some points which I think need clarification or correction. There may
also be missed opportunities for highlighting the most effective methods
of contraception in real life situations for young people.
The statement that 'Levonelle 1500 is an an oral progestogen which can be
obtained over the counter at any pharmacy' is misleading. Levonelle 1500
is a Prescription Only Medicine , whereas Levonelle One Step can only be
sold to women over the age of 16. Levonelle 1500 will be issued free in
some pharmacies on a Patient Group Direction where pharmacists have been
trained and approved for its use. The commissioning arrangements for this
are not universal, nor are the upper age limits.
The table of summary of contraceptive methods available for young
people in the UK (Table 1) again has some strange and sometimes out of
date statements. Combined hormonal contraception (pills, patches and
vaginal rings) are no longer consider to become ineffective if non-liver
enzyme inducing antibiotics are taken concurrently or during the 7 days
after cessation 1. The 'progesterone only pill' for which only one brand
name is appended should more correctly be called 'progestogen only pill'
as the hormone is the synthetic form of progesterone. The Today sponge has
not been available in the UK for several years for prescription (it is not
listed in the British National Formulary) but does appear to be available
for direct sale from pharmacies or via the internet. It's failure rate is
not quoted in Table 1 -perhaps because it this appears to be the same as
for spermicide alone, a method which would not be recommended to young
highly fertilie people.
It is a shame that space was not given to emphasising the differing
rates of failure between perfect use of a method when compared to typical
(every day real life) use. Trussell 2 has published updated tables showing
(at the end of 1 year of use in the USA) that user-dependent methods (such
as combined hormonal contraception, POP, and to a lesser degree the
injectable methods) have a much higher failure rates than those quoted in
Table 1 of the article. For this reason, long acting reversible
contraception (such as implants, IUDs and IUS), with additional use of
condoms to decrease transmission of STIs, are encouraged particularly
amongst young women where life styles may make 100% adherence difficult.
References
1. Drug interactions with Hormonal Contraception. Clinical Effectiveness
Unit of Faculty of Sexual and Reproductive Healthcare Jan 2011,
http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf accessed
30.9.12
2.Trussell,J Contraceptive Failure in the United States. Contraception 83
(2011) 397-404 accessed 30.9.12
Yours sincerely
Dr Alyson Elliman B Sc(Hons) MBBS DCH FFSRH MIPM
Consultant in Sexual and Reproductive Healthcare
2 Edridge Rd, Croydon, CR9 1PJ
Alyson.elliman@nhs.net
Conflict of Interest:
I receive educational grants from Durbin Sales and Bayer Schering
Surprisingly, especially in view of a recent article highlighting the
importance of including a history of recent travel when evaluating
neurological symptoms and signs(1), such an inquiry was not mentioned as a
fundamental requirement in the 15 minute consultation on facial
paralysis(2). In the anecdotal report of a patient with multiple cranial
nerve involvement(inclusing facial nerve paralysis) in whom the diagnosis
of...
Surprisingly, especially in view of a recent article highlighting the
importance of including a history of recent travel when evaluating
neurological symptoms and signs(1), such an inquiry was not mentioned as a
fundamental requirement in the 15 minute consultation on facial
paralysis(2). In the anecdotal report of a patient with multiple cranial
nerve involvement(inclusing facial nerve paralysis) in whom the diagnosis
of neuroborreliosis was initially missed, it was only after an inquiry
abour recent travel was made that the "penny" dropped, and progress was
made towards the correct diagnosis(1). Facial nerve paralysis arguably has
greater relevance in paediatric neuroborreliosis than in adult cases,
having been documented in as many as 71% of chidren with
neuroborreliosis(3). In a review of 66 paediatric cases of central nervous
system infection covering the period January 1, 2004 to December 31, 2006,
in a university hospital in Helsinki, facial nerve paralysis was a
presenting feature in 19 patients with a variety of central nervous system
infections. Thirty two percent of those CNS infections characterised by
facial nerve paralysis were attributable to Lyme disease(4). In the United
Kingdom itself, the true incidence of Lyme disease is unknown but,
according to one view, "it is more common than is thought", as shown by an
audit of a "highly aware" GP parctice in Scotland which found "an
incidence of 370/100,000 population, based on clinical diagnosis of the
erythema migrans rash..."(5). The rash may be on the back of the body and
not seen, or may be present behind the hair line in children, or may have
been forgotten by the time later symptoms develop(5). The latter may have
been the case in the instance of a 12 year old Canadian girl admitted to
hospital with a 10 day history of unilateral facial weakness and
midscapular pain after returning from a holiday in rural France. She did
not recall any insect bites, and the family did not recall a preceding
rash. On examination she had a right sided lower motor neurone facial
nerve palsy, but the unusual additional feature was the coexistence of
spinal cord involvement in a patient of her age(3). Progressive motor
weakness with universal arreflexia is another unusual presenting feature
of neuroborreliosis(6), and this can simulate Guillain- Barre syndrome.
The presence of cerebrospinal fluid(CSF)pleocytosis is one of the
important features which distinguishes this presentation from Guillain-
Barre syndrome(7)(8), given the fact that it is highly exceptional for
Guillain-Barre sysndrome to be characterised by CSF white cell counts(WCC)
of the order of 25-197/microlitre as was the case in 3 patients aged 77,
82, and 82, respectively, who were the subject of one report(9).Lower CSF
white cell counts were documented in the other 2 patients, aged 78 and 82,
who were the subjects of the same report(9).
References
(1) Hobson J., Weatherall MW
A patient's journey. Lyme borreliosis
BMJ 2012;344:46-47
(2) Malik V., Joshi V., Green KMJ., Bruce IA
15 minute consultation: A structured approach to the management of facial
paralysis in a child
Arch Dis Child : Education and Practice 2012;97:82-85
(3)Makhani N., Morris SK., Page AV et al
A twist on Lyme: the challenge of diagnosisng European Lyme
neuroborreliosis
J Clin Microl 2011;49:455-457
(4) Huttunen P., Lappalainen M., Salo E et al
Differential diagnosis of acute central nervous system infections in
children using modern microbiological methods
Acta Paediatrica 2009;98:1300-1306
(5) Pearson S., Huyshe-Shire S
Re: Tick bite and early Lyne borreliosis
BMJ rapid response 25th June 2012
(6) Sterman AB., Nelson S., Barclay P
Demyelinating neuropathy accaompanying Lyme disease
Neurology 1982;32:1302-1305
(7) Hartung H-P., van der Meche FGA., Pollard J
Guillain-Barre syndrome
Current Opinion in Neurology 1998;11:497-513
(8) Burns TEM
Guillain-Barre syndrome
Semin Neurol 2008;28:152-167
(9) Rauschka H., Jellinger K., Lassmann H., Braier F., Schmidbauer M
Guillain-Barre syndrome with marked pleocytosis or a significant
proportion of polymorphonuclear granulocytes in the cerebrospinal fluid:
neuropathological investigation in five cases and review of differential
diagnoses
European Journal of Neurology 2003;10:479-486
I read with interest "The Fifteen-minute consultation on the infant with a large head" published recently by Arnab Seal. Clinicians should also be aware of 'Benign Enlargement of Subarachnoid Space (BESS)'. It is described under various names in literature including benign extra-axial collections of infancy, external hydrocephalus, subdural effusions, etc (1). It presents in infancy with rapid enlarged of head circumferen...
The Fifteen-minute consultation on the infant with a large head just published on line (1) has one major weakness: no mention of which chart the child's head is compared to. Comparison with representative Belgian, Norwegian (2) and British data (3) has shown that European infants' heads appear large compared to the WHO standards. We have undertaken further analyses of the data from the Southampton Women's Survey used fo...
The reservations exepressed about the interpretation of interferon gamma release assays(IGRAs)(1)are underpinned by the following observations:- IGRAs do not reliably identify subjects with active tuberculosis(even in the context of culture positive disease)(2), as shown by a study where 45 subjects received a diagnosis of active tuberculosis characterised, in 37 of those subjects, by positive cultures for mycobacterium...
As part of the team that undertook review of the paper prior to publication I would like to thank Alan for picking up this misinterpretation and to apologise to our readers for the mistake.
It's entirely correct that a negative ADOS will be right - the patient will not have autism - about 88% of the time.
The table 3 is misleadingly titled "prob that the test rules out autism" and should be "post test...
Carter and colleagues have done a superb job in summarising the theory and practice of tools used in assessing children for autism. Unfortunately their paper is marred by a mathematical error which, if left unchallenged, could undermine trust in the use of one such tool, the ADOS.
According to the paper, the positive predictive value (ppv, i.e. the proportion of those who test positive who actually have the cond...
Although it may be difficult to make a distinction between retropharyngeal abscess, and retropharyngeal cellulitis attributable to organisms such as Group A bete-haemolytic Streptococcus, Staphylococcus Aureus, and Group B Streptococcus(1), retropharyngeal abscess should remain high in the differential diagnosis because Fusobacterium necrophorum(F necrophorum), the gram negative culprit pathogen,although initially givin...
.Dear Sir, We read with great interest the accurate paper by Sen et al. regarding the indications for testing lupus anticoagulants (LA) in pediatric patients1. We believe that two further considerations might provide a complete overview on this issue. First, it has to be underlined the important contribution given by Boffa MC concerning either the laboratory methods for the detection of LA2 or the association between an...
The authors state that INH does not prevent the development of active tuberculosis. However, it is well known that with lower dosage than 15mg/kg daily of INH, we cannot assure therapeutical INH levels, precluding its efficacy, as it correlates with lower levels than 3g/l in the pharmacokinetic parameter of response Cmax
Conflict of Interest:
None declared
Straw and Porter write an important article on Sexual health and Contraception (Arch Dis Chld Educ Pract Ed 2012; 97:177-184), but there are some points which I think need clarification or correction. There may also be missed opportunities for highlighting the most effective methods of contraception in real life situations for young people. The statement that 'Levonelle 1500 is an an oral progestogen which can be obtaine...
Surprisingly, especially in view of a recent article highlighting the importance of including a history of recent travel when evaluating neurological symptoms and signs(1), such an inquiry was not mentioned as a fundamental requirement in the 15 minute consultation on facial paralysis(2). In the anecdotal report of a patient with multiple cranial nerve involvement(inclusing facial nerve paralysis) in whom the diagnosis of...
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