BackgroundSeptic arthritis is an uncommon but potentially significant diagnosis to be considered when a child presents to the emergency department (ED) with non-traumatic limp. Our objective was to determine the diagnostic accuracy of clinical findings (history and examination) and investigation results (pathology tests and imaging) for the diagnosis of septic arthritis among children presenting with acute non-traumatic limp to the ED.MethodsSystematic review of the literature published between 1966 and June 2019 on MEDLINE and EMBASE databases. Studies were included if they evaluated children presenting with lower limb complaints and evaluated diagnostic performance of items from history, physical examination, laboratory testing or radiological examination. Data were independently extracted by two authors, and quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool.Results18 studies were identified, and included 2672 children (560 with a final diagnosis of septic arthritis). There was substantial heterogeneity in inclusion criteria, study setting, definitions of specific variables and the gold standard used to confirm septic arthritis. Clinical and investigation findings were reported using varying definitions and cut-offs, and applied to differing study populations. Spectrum bias and poor-to-moderate study design quality limit their applicability to the ED setting.Single studies suggest that the presence of joint tenderness (n=189; positive likelihood ratio 11.4 (95% CI 5.9 to 22.0); negative likelihood ratio 0.2 (95% CI 0.0 to 1.2)) and joint effusion on ultrasound (n=127; positive likelihood ratio 8.4 (95% CI 4.1 to 17.1); negative likelihood ratio 0.2 (95% CI 0.1 to 0.3)) appear to be useful. Two promising clinical risk prediction tools were identified, however, their performance was notably lower when tested in external validation studies.DiscussionDifferentiating children with septic arthritis from non-emergent disorders of non-traumatic limp remains a key diagnostic challenge for emergency physicians. There is a need for prospectively derived and validated ED-based clinical risk prediction tools.
IntroductionContinuous positive airway pressure (CPAP) is the standard treatment for
obstructive sleep apnoea (OSA), with limited data about the prevalence of
respiratory infections and microbial colonization in these patients.ObjectivesThe aim of this study was to determine if CPAP use is associated with
respiratory infections and to identify the organisms that colonize or infect
these patients.MethodA retrospective, case-controlled study in patients diagnosed with OSA was
carried out. 137 patients were recruited and interviewed using a
questionnaire. A nasal swab was taken from each patient. Patients using CPAP
machines had swabs taken from masks and humidifiers.Results66 (48.2%) patients received CPAP treatment with 60.6% of them having a
heated humidifier. 78.8% were male, with the majority using a full face mask
(63.6%). No significant difference was seen in the prevalence of
rhinosinusitis, lower respiratory tract infections and hospital admissions
for pneumonia between CPAP and non-CPAP treated patients. The presence of a
humidifier did not influence the prevalence of infections. Commensal flora
was predominantly cultured from nasal swabs from both patient groups.
Coagulase Negative Staphylococci and Diphtheroids were the main organisms
cultured from masks and humidifiers respectively.ConclusionsThis study shows that the use of CPAP, choice of mask and humidifier have no
significant impact on the prevalence of infections and micro-organisms
isolated. This is very reassuring to the physician prescribing CPAP therapy
and users.
SUMMARY'Painful tic convulsif' (PTC) describes the co-existence of hemi-facial spasm and trigeminal neuralgia. In this report, we describe a unique presentation of bilateral PTC in a gentleman with bilateral hemi-facial spasm and trigeminal neuralgia secondary to neurovascular conflict of all four cranial nerves. Following failed medical and radiofrequency therapy, microvascular decompression of three of the four involved nerves was performed, where the offending vessels were mobilised and Teflon used to prevent conflict recurrence. He continues to respond to Botox for right hemi-facial spasm. Since surgery he remains pain-free bilaterally and spasmfree on the left.
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