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This week's Practice section has a trio of interesting and useful articles.
Giuseppe Lauria and Raffaella Lombardi review recent advances in the use of skin biopsy to diagnose and monitor peripheral neuropathy (doi: 10.1136/bmj.39192.488125.BE). An easy to perform 3 mm punch biopsy can make the diagnosis of small nerve fiber neuropathies, which can be associated with diabetes and other metabolic disorders, sarcoidosis and other immune-mediated disorders, and viral and hereditary diseases. Commonly recommended nerve conduction studies only evaluate large myelinated fibers. Sural nerve biopsies, used to diagnose peripheral neuropathies, are invasive and sometimes dangerous procedures. Punch biopsy is worth thinking about in patients—especially those with chronic diseases—who complain of burning, prickling sensations or deep and aching foot pains.
In a 10-minute consultation on sinusitis, Neil Chadha and Rashmi Chadha emphasize that the diagnosis of rhinosinusitis is a clinical one, at least in primary care (doi: 10.1136/bmj.39161.557211.47). Characteristic signs and symptoms include nasal congestion and discharge, facial pain, and decreased sense of smell. Sinus x rays are not indicated. Bacterial etiology, and thus antibiotic treatment, is more likely if the condition has lasted more than a week, purulent discharge is present, and there are systemic symptoms (fever and malaise). Referral is indicated for chronic or recurrent cases or if complications are suspected.
The UK National Institute for Health and Clinical Excellence (NICE) has released guidance on the assessment and initial management of young children with feverish illness (doi: 10.1136/bmj.39218.495255.AE). Based on evidence when it is available and consensus when it is not, the recommendations follow a “traffic light” system that directs management decisions based on whether the risk of serious illness is low (green), intermediate (amber), or high (red). High risk children should receive a face to face assessment within two hours and urgent referral to specialty care. Children at intermediate risk should be followed up closely. Low risk children may be managed at home.