RICKETS—A RE-EMERGING PROBLEM

In recent months we have received a series of papers detailing authors’ concerns over the increasing number of UK children they are seeing with rickets, particularly amongst certain ethnic minority groups. For various reasons, we rejected most of the submissions but since it is clear this is currently a subject of concern, we invited a group from Newcastle to summarise how best to investigate these children. The authors recommend that all paediatric units prepare a protocol to deal with the problem; we hope their review may provide the necessary template.See page 403

THE LONG TERM EFFECTS OF MENINGITIS

The immediate sequelae of bacterial meningitis, including neurodisability and sensorineural hearing loss have been repeatedly highlighted in scientific papers. What is less well documented are the possible long term effects in children previously assumed to have escaped major damage.

This month we report what has happened to 1175 children recruited to a national study of infantile meningitis carried out from 1985–7. The authors were able to trace and question parents (and many teachers) of 739 of their original cohort 13 years later and compare them with a control group, previously recruited when the index cases were 5 years old.

Just over 7% of the children were attending a special school and a further 5% were receiving extra help within mainstream schooling. Parents and teachers of patients were twice as likely as those of controls to report behavioural problems, whichever type of school they attended. Social skills were adjudged normal by the parents of 91% of controls but only 71% of cases.See page 395

IMPORTED FEVERS—TROPICAL OR TEMPERATE?

A favourite exam question is to test participants’ grasp of the likely causes of fever in children just returned from tropical countries. The potential list of exotica is a gift for the small print specialist. In fact, of course, life is more mundane. This month we report on the final diagnoses of 153 children with fever prospectively studied at Birmingham (UK) Heartlands Hospital within 12 months of their return. We are reassured that an appropriate history and examination with investigations such as blood film and culture, stool culture, and chest x ray diagnosed most cases (see ISABEL below). Fourteen percent had malaria and 27% diarrhoea (but just a quarter of those had something worth treating with an antibiotic). As has been previously reported a low platelet count was often a marker for malaria. Indeed the authors suggest a platelet count above 190 × 10⁹/l may serve to rule it out.See page 432

CAUSATION OR COINCIDENCE?

Ruud and his colleagues in Oslo were confronted with a disturbing problem: two of 14 children in whom they had implanted cardiac xenografts developed acute myeloid leukaemia. Readers can imagine the possible consequences, ranging from parental distress, hostile media attention, hardly less hostile legal attention to a major setback for the xenotransplantation programme. A working group set about dealing with the issue. We do not normally encourage the publication of anything produced by a body as amorphous as a working group, but we have made an exception.

Dr Ruud describes the successful way in which the hospital managed what could have been a very tricky situation. Any of our readers in clinical or academic paediatrics could be faced with a similar crisis, literally overnight. Not for nothing was the telegraphic address of the Medical Defence Union, “Damocles”. Keeping a copy of this paper may prove a valuable investment. And what was the true nature of the association? Read the paper to find out.See page 435

CAN ISABEL KEEP YOU OUT OF TROUBLE?

There are other ways of dealing with uncertainty. ISABEL is a web-based differential diagnostic aid for paediatricians, run by a charity and currently hit 100 000 times a month. Text from major UK and US textbooks are incorporated in its database. We now report an assessment of its utility in assisting diagnosis in 200 real and hypothetical cases when their presenting features were notified. The outcome measured was whether ISABEL included the expected (hypothetical) diagnosis or final (real) diagnosis in its differential list. It succeeded in 91% of the hypothetical cases and 95% of the real cases. With regard to the latter, it failed on just 4 occasions, missing Stevens-Johnson syndrome, RSV bronchiolitis, erythema multiforme and staphylococcal cellulitis. The authors conclude that this tool has the potential to remind doctors of diagnoses they might otherwise discount. The next step is for independent clinicians to test it in real time. Older readers may remember (and the authors of this paper cite) a paper on computer-assisted diagnosis of acute abdominal pain which caused many of us anguish when it was published over 30 years ago.¹ Please don’t write if I am wrong but I recall that de Dombal showed that his computer was better at diagnosing appendicitis than consultants. Thankfully for my amour-propre, the consultants were better than the registrars who were better than the SHOs.See page 408