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Problem or pathological gambling is persistent and recurrent maladaptive gambling behaviour despite its detrimental effect (disruption of personal, family or work life). It is undoubtedly a dependence disorder similar to alcohol and other drugs with a similar approach to management.


Prevalence: 0.5–1.5% of adult population

++ Dangers

  • Suicide risk (high)

  • Major depression (up to 75%)

  • Stress-related problems

  • Domestic violence

++ Key warning signs

  • Gambling >$200 wk

  • Chasing losses

++ Other telltale signs

  • Spending many hours gambling

  • Placing larger, more frequent bets

  • Lying about behaviour

  • Being secretive

  • Promising cutting back but not doing it

  • Impulsive activity

  • Mood swings

  • Gambling at expense of other pleasant social activities

  • Growing debts

  • Excessive drinking

++ Management

  • Ask (as part of social history)

  • Consider South Oaks Gambling screen

  • Firm confrontation if suspected

  • Consider using the Prochaska and Di Clemente model of change

  • Give education and basic counselling

  • Look at family? domestic violence

  • Advise family not to provide ‘rescue money’

  • Refer for specialist counselling if necessary

  • Drug treatment inadvisable




Firm cystic lumps associated with joints or tendon sheaths.

++ Management

  • Can be left to wait and see.

  • Do not ‘bang with a Bible’.

  • Needle aspiration and steroid injection:

    • insert 21 g needle with 5 mL syringe

    • aspirate some of contents and change syringes

    • inject 0.5 mL corticosteroid (depot)

    • can be repeated with 0.25 mL in a few wks

  • Surgical excision (can be difficult)



In children

An illness of acute onset, of less than 10 days duration associated with fever, diarrhoea and/or vomiting, where there is no other evident cause for the symptoms.


Prevention: Rotavirus vaccine <6 mths

++ Causes

  • Viral (80%): mainly rotavirus, norovirus and adenovirus

  • Bacterial: C. jejuni & Salmonella sp. (two commonest), E. coli & Shigella sp.

  • Protozoal: Giardia lamblia, Entamoeba histolytica, Cryptosporidium

  • Food poisoning—staphylococcal toxin


Note: Dehydration from gastroenteritis is an important cause of death, particularly in obese infants (esp. if vomiting accompanies the diarrhoea).


Exclude acute appendicitis and intussusception in the very young.

++ Symptoms

  • Anorexia, nausea, poor feeding, vomiting, fever, diarrhoea (fever and vomiting may be absent)

  • Fluid stools (often watery) 10–20/d

  • Crying due to pain, hunger, thirst or nausea

  • Bleeding uncommon (usually bacterial)

  • Anal soreness

++ Assessment of dehydration

The simplest way is by careful clinical assessment (e.g. urine output, vomiting, level of thirst, activity, pinched skin test). The most accurate way is to weigh the child, preferably without clothes, on the same scale each time. It is usual to classify dehydration as:



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