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I was delighted to read the critique of the recent Best Evidence Topic (BET) summary on the reliability of skin turgor as a method for assessing dehydration in children,1 and would like to accept your invitation to respond. My contribution, as third author for this paper, was to check and update the search strategy and to review the final manuscript.
While I am sorry that the BET did not provide Dr Smith with the information he desired regarding the diagnostic accuracy of skin turgor in assessing dehydration in children, I fear that he may perhaps be looking in the wrong place for this answer. Just as we would not criticise a paper published within the Emergency Casebook for not being a randomised controlled trial, it is perhaps wrong to criticise a BET for not being a thorough systematic review of the assessment of dehydration in children.
BETs were designed to “bring the evidence one step closer to the bedside, by providing answers to very specific clinical problems, using the best available evidence” (http://www.bestbets.org/home/betsintro.html). The BET in question asked a very specific three part question regarding the interobserver reliability of skin turgor, as designed by Drs Fayomi and Maconchie. If skin turgor cannot be reliably measured by emergency physicians, it is perhaps of dubious value as a diagnostic test.
The search strategy was also perhaps unfairly criticised. All of the papers cited by Dr Smith were identified using the reported search. None of these papers assessed interobserver reliability and therefore did not answer the three part question that had been posed. All of these papers were also included in the systematic review that we cited.2 It may be of further interest to Dr Smith that, for the detection of 5% dehydration, abnormal skin turgor carried a pooled sensitivity of 58% (95% confidence interval (CI) 40% to 75%) and specificity of 76% (95% CI 59% to 93%) in this well designed systematic review, although the BET in question did not seek to report on diagnostic accuracy.
Finally, Dr Smith states that the usefulness of BETs has been debated and urges caution in the interpretation of their conclusions. While it is true that caution should be exercised in the interpretation of all medical literature, I should like to pass comment for the reader who will infer from this a criticism of BETs as a concept.
Where else within the emergency medicine literature can one easily access an up‐to‐date concise summary of the best available evidence for topics ranging from the use of Buscopan in oesophageal food impaction to the sensitivity of a normal chest x ray for excluding aortic dissection; from the use of oxygen in acute myocardial infarction to the prognostic effect of clopidogrel in head injury? Truly, BETs have revolutionised our approach to emergency medicine both within this country and (increasingly) internationally, as demonstrated by recent publications from the USA and Australia.
Much of the beauty of BETs is in their simplicity. Let us not overcomplicate the issue.
Competing interests: None declared.