Archives: BETs

A 14-year-old girl is seen in the paediatric outpatient department. She was referred by her general practitioner (GP) with persistent tinea versicolor. The GP had previously treated her with topical clotrimazole over the last few years with varying degree of success. The girl has recently returned from a trip to South America during which she experienced an exacerbation of her symptoms. On examination you find multiple oval to round shaped lesions which are hypopigmented with superficial scaling, that appear particularly prominent in the axillary region and around the neck. The girl tells you that these areas had previously been darker than the surrounding skin, which was more obvious during the winter months. Under Wood's light examination the lesions appear fluorescent yellow. You obtain samples for microbiological confirmation but concur with the GP that this is tinea versicolor. The girl expresses her distress about her external appearance and is very keen to finally get rid of this problem. You wonder whether oral antifungal agents may provide a more effective alternative to topical treatment and consult the British National Formulary for Children (BNFC 2006). The formulary states that oral itraconazole should be considered if topical treatment has failed. It also mentions that fluconazole may be used as an alternative. You wonder which of these treatment options is more effective in tinea versicolor.

You have noticed the appearance of numerous dispensers for alcohol based hand gel within your emergency department. This is accompanied by a poster campaign to make staff aware of the importance of hand hygiene. You wonder what evidence lies behind the campaign.

A 67 year-old presented to the emergency department following a head injury. He has no significant medical history apart from osteoarthritis for which he takes regular NSAIDs. He denies any intake of Aspirin. You wonder if the use of regular NSAIDs increases the risk of intracerebral bleeding post head injury.

You are evaluating an immunosuppressed patient in the emergency department. As you auscultate his chest, you wonder if your stethoscope could present a significant source of MRSA contamination

Evidence for the effectiveness of circuit class therapy (CCT) in patients post stroke has concentrated on lower limb parameters, walking tasks and balance. There is some research emerging on the effects of participation in CCT on upper limb recovery post stroke. This BET will help to inform class structure and content.

An elderly gentleman is brought in with a reduced GCS following an unfortunate high speed accident involving several reindeer and a sleigh. You decide that he requires intubation in order to protect his airway. A colleague suggests that the presence of his full, white beard suggests that he will be difficult to intubate. You wonder if there is any truth in this statement.

A child presents to the ED with ulcers in their mouth causing significant pain and difficulties with eating and drinking. You wonder if they may have Herpes gingivostomatitis and whether antiviral therapy may speed their recovery.

A 2 year old boy attends the Emergency Department after pulling a pot of tea over himself. Using the hand method (child's palm including fingers equals 1%) you estimate he has a 12% burn. Using a Lund-Browder chart results in estimation of a 9% burn. You wonder how accurate the hand method is.

A 4-month old child is presented at the emergency department with coryza,cough and wheeze. You see an alert, well hydrated wheezing infant with mild respiratory distress and oxygen-saturation 93%. You wonder wether it is safe to send this child with bronchiolitis home.

You're having a bad day! You've just seen your third neonate in 2 hours with a sticky eye and the senior nurse informs you that you dispensed the final bottle of chloramphenicol eye drops in the Emergency Department to the last child. In a rapidly deteriorating mood, you ring pharmacy, who suggest fucidic acid (Fucithalmic) eye drops. You wonder if it is comparable to the standard treatment with chloramphenicol.

A 28 year old male presents to the AED knee review clinic two weeks after a twisting injury whilst playing football. The history and his symptoms make you suspicious of a meniscal injury, but you are unsure of the best test to confirm this. You wonder if there is any evidence to help you choose.

A three year old girl with the first episode of a febrile unilateral otitis media with purulent discharge and otalgia is brought to Children's Emergency. As usual you would prescribe oral amoxicillin but the consultant who happens to stand next to you when filling out the prescription advises you to use antibiotic eardrops instead. They would just be better.

A patient presents to the Emergency Department (ED) breathless, distressed and complaining of pain with a pulsating mass in the abdomen. You wish to investigate for an abdominal aortic aneurysm (AAA) using the portable ultrasound unit at the bedside. You recall that peers on a recent ED ultrasound refresher course feared that sufficient compression of the AAA with the transducer in order to get a good image would precipitate a deterioration of the clinical course. You wonder whether there is any evidence surrounding this perception.

An Emergency Department Registrar presented a paper at our journal club showing the efficaciousness and cost effectiveness of home treatment with unfractionated heparin (UFH) in comparison to low-molecular-weight heparin (LMWH). We decided to look at the possibility of altering our outpatient treatment guidelines for DVT and low risk PE as a way of lowering the cost of treatment. As part of the process this BET was produced.

A 59 year old lady with a 22 year history of Multiple Sclerosis where truncal ataxia is a major feature has become increasingly less able to carry out all activities of daily living. Lycra suits have been used in children with cerebral palsy where ataxia is a feature, to improve postural stability. Would the same benefit be gained in adults?

You are the specialist registrar in paediatrics doing the ward rounds. There has been a recent outbreak of Escherichia coli (E coli) O157:H7 gastroenteritis in the community. A 5-year old girl was admitted 3 days ago with bloody diarrhoea, abdominal cramps and vomiting. Her stool has grown E coli O157:H7. She is now stable and her parents are keen to take her home but are understandably anxious and ask you about possible complications. You are aware of the risk for progression to haemolytic uraemic syndrome (HUS). However, you are not sure if all such patients should be closely monitored. You note that the patient now has a normal platelet count and renal function and wonder if there are any simple parameters to predict the risk of HUS, which may take up to 2 weeks to develop. You talk to the consultant in public health medicine, who kindly directs to you to the national guidelines by the Health Protection Agency (HPA) on the management of E coli O157:H7 infections. Unfortunately, the guidelines do not answer your question. Your consultant has come across anecdotal evidence that leukocytosis may be a predictor for HUS in such children. You decide to do a literature search and critically appraise the evidence.

An 8-month-old infant is admitted with fever and vomiting. Urinary tract infection (UTI) is diagnosed. You decide to commence IV treatment with gentamicin. In your paediatric ward, gentamicin is routinely administered in three times daily dose (TD) regimens but you look up gentamicin administration in the BNF for children and find that it can be given once daily (OD). This prompts debate amongst staff as to whether the same can be done on your ward. Everyone wonders whether there is any supportive evidence for efficacy and safety when OD gentamicin is used in the treatment of UTI.

A 6-year-old boy presents to the paediatric emergency department complaining of pruritus affecting his scalp. On examination you notice several nits attached to his hair as well as a few adult head lice. You are considering treatment with pediculocides, but his mother is rather reluctant to use "chemicals". You consult the BNF for children, which apart from listing three classes of pediculocides – carbaryl, malathion and pyrethroids (permethrin and phenothrin) – outlines the option of using wet combing as an alternative. You wonder whether there is good evidence to support the sole use of this intervention in head lice infestation.

A 27 year old man presents to the ED after being bitten by a dog on his right palm. The wound is contaminated and needs a good clean before referral on to plastics for more formal repair. It is very painful and you elect to use a median nerve block to facilitate good wound toilet. You use a landmark technique and infiltrate a mixture of lignocaine and bupivicaine. However, you are dissapointed to find that it has not worked. You ask a colleague to help and they suggest getting the Ultrasound machine out to help localise the nerve more precisely. You are familiar with this technique for other nerve blocks but have not seen it done at the wrist before.