Archives: BETs

I report the use of oral sildenafil in a male preterm of 28 weeks gestation, born with congenital hydrops secondary to maternal parvovirus. He received maximal ventilatory and inotropic support. His neonatal course was complicated with pulmonary hypertension refractory to inhaled nitric oxide treatment. Sildenafil was administered via an orogastric tube to the neonate. Forty-eight hours after treatment commenced, echocardiography revealed that the contractility of both ventricles had improved and evidence of tricuspid incompetence had decreased, resulting in a marked reduction in pulmonary arterial pressure. Low dose oral sildenafil was initiated at 250 to 500 micrograms/kg/dose once a day to 3 times a day for 6 to 8 weeks until complete resolution of pulmonary hypertension. This helped the neonate wean from the ventilator and subsequently discharged home on low flow oxygen. There was no major adverse effect noted during the treatment period, except for a small drop in blood pressure post dose administration which was short lived. He had a normal cranial ultrasound. Had oral sildenafil contributed to the reduction in pulmonary vascular resistance and therefore successful extubation? Should it be considered as a second line treatment for severe pulmonary hypertension?

A 50 year old man presents to accident and emergency department after an assault and has injuries to his hand. On examination you are not sure if it needs plastic surgery, you try your best to relay the relevant information to plastic surgeon in the regional centre and transfer the patient to the centre. At the centre he is evaluated and it is found that he does not need plastic surgery. Could we have avoided this scenario by using teleconsultation.

A child presents to your developmental clinic at 30 months old. His mother reports developmental regression of previously acquired developmental milestones. He has now lost his previously acquired language skills and only makes incomprehensible babbles. He is otherwise clinically well and does not have any clinical seizures. From his early history and current behaviour your clinical diagnosis is autism. You wonder whether an electroencephalogram (EEG) should be performed to rule out possible underlying subclinical epilepsy that may contribute to his developmental regression.

Your last evening shift in the emergency department was particularly busy. The charge nurse remarked, "There must be a full moon out tonight." You wonder if there is truly any link between ED census and the lunar phases, or is this belief simply a myth.

An 11-year-old boy is struck by a car and sustains an acquired brain injury (ABI). He is admitted with a Glasgow Coma Scale score of 6/15. Cranial imaging reveals evidence of diffuse injury. Approximately 12 months later following discharge, the patient is seen for a planned review. The patient and his family report poor attention with hyperactive and impulsive behaviours. The school has reported to parents that there has been a change in his ability to concentrate at school and he is being disruptive in class. This represents a clear departure from the patient's preinjury behaviour. Parental and school management of this concerning conduct is structured and consistent. You have heard that stimulant medication may be of benefit in managing difficulties with attention, hyperactivity and impulsivity (attention deficit hyperactivity disorder (ADHD) type behaviours) following an ABI.

You are about to operate on a 32 year old i.v. drug abuser who has been under the care of your cardiologists for 8 weeks with Tricuspid valve endocarditis. She has successfully undergone 6 weeks of antibiotic therapy and 3 blood cultures off antibiotics have all been negative. However she has severe tricuspid regurgitation with hepatic congestion and peripheral oedema and requires tricuspid replacement. You wonder whether to use a biological or mechanical valve.

You are asked to see a patient with deep sternal wound infection following coronary artery bypass surgery. You feel that a wound debridement with closure will probably be the best approach. However, your consultant wants this patient's wound to be managed with vacuum-assisted closure (VAC) therapy. You manage the patient as desired by the consultant but decide to review the literature to see if there is any evidence to back up this strategy.

You are about to perform a coronary arterial bypass graft on a 47-year-old ex-smoker who has triple vessel disease requiring three grafts. You elect to use both mammary arteries, but he is a manual labourer with many scars and tattoos on both his arms, and Doppler ultrasound and Allen's testing of his radials show poor flow on both sides. You wonder whether selecting the gastroepiploic artery would give him better long-term patency then using a saphenous vein.

You have performed a coronary artery bypass graft on a 72 year recent ex-smoker with triple vessel disease and hypercholestrolaemia, who has done very well post-operatively. You usually prescribe dispersible aspirin on discharge, but this gentleman has taken enteric-coated aspirin for 3 years and he tells you that he got terrible indigestion with dispersible aspirin but that the enteric-coated aspirin tablets were no problem at all. You wonder if you should prescribe enteric-coated aspirin to all your patients if it is so 'good to your stomach' instead of your usual dispersible aspirin.

You are seeing a 72 year old man 8 days post-CABG. He had some melaena on day 2 and endoscopy showed a duodenal ulcer, which was injected. He has had no more symptoms or signs of continued bleeding and you would like to resume anti-platelet therapy. You have heard that clopidogrel is better for your stomach and decide to restart this instead of aspirin, but later that day the endoscopist reviews the patient and suggests that aspirin and lansoprazole would be safer and cheaper too. You resolve to check this in the literature.

You perform a right pneumonectomy for a T2 N1 M0 non-small-cell lung cancer, in a 77-year old diabetic with a history of ischaemic heart disease. On the sixth postoperative day he deteriorates, with a copious productive cough, worsening gas exchange, pyrexia and rising inflammatory markers. Chest X-ray shows a fall in fluid level, and fibreoptic bronchoscopy confirms a bronchopleural fistula(BPF), with dehiscence of one third of your staple line. The intercostal drain you site recovers 700ml of purulent fluid. You feel that he would not survive a repeat thoracotomy and wonder if a bronchoscopic approach might work?

You have just completed a right upper lobectomy in a 67 year old smoker for non-small cell carcinoma. He had multiple adhesions and an incomplete fissure and on testing there were many air leaks. A colleague has been trying out a spray-on glue to reduce air leaks and thus you ask for this glue to be brought into theatre and apply it liberally. The air leak stops on day one, the drains are all removed on day 3 and he is discharged on day 5. You wonder whether you should use this glue for all your lobectomy patients and thus resolve to look this up in the literature.

You have inserted a mechanical prosthetic mitral heart valve into a 60-year-old man. He subsequently has a GI bleed while on warfarin so you decide to review the literature to confirm optimal therapeutic INR which minimises long-term thromboembolic and haemorrhagic complications.

As a paediatric registrar you are presented with a 4-month-old baby in paediatric outpatients. His mum describes him as having large vomits up to 30 min after most feeds, and recently he has seemed reluctant to feed. He is exclusively breast fed, and is gaining weight appropriately and otherwise thriving. He has previously been investigated for his vomiting and you conclude that he has gastr­oeosphageal reflux without complications (GOR). In the first instance, positioning and thickened, small frequent feeds would be advised. The latter suggestion is not without difficulty for mothers exclusively breast feeding. As the mother is describing vomiting at least six times per day, but no signs suggestive of pain at present, could a pro-kinetic alone such as domperidone improve these symptoms?

You are referred a 55 year old woman for a mobility assessment. She was diagnosed with an uncomplicated calf DVT and started anticoagulation therapy yesterday. You wonder if there is any evidence contraindicating an immediate mobility assessment.

A 32 year old altitude-naïve man is planning to join a trek to Makalu Base Camp (5000m altitude). He is concerned about the possibility of altitude sickness and wants to know whether taking acetazolamide would reduce this risk.

A 65 year old patient presents with osteoarthritis of the knee in the outpatient department. After trying several more traditional treatments with little improvement in symptoms, you questioned whether it would be helpful to try acupuncture to improve his pain and function.

A five year old child presents to the Emergency Department complaining of abdominal pains and not having passed a stool for at least two weeks. After an abdominal examination you diagnose faecal impaction. After the child has been successfully disimpacted, you are about to decide on the maintenance treatment you wonder whether there would be any difference in efficacy of the treatment if you used Movicol instead of Lactulose.

A patient presents to your A&E with signs of obstructive uropathy. You are reaching for the ultrasound machine, but then wonder if this accepted method of diagnosis is actually backed up by evidence. Perhaps another form of imaging would be better? You take it upon yourself to answer this question.

A patient presents to your emergency department following an acute knee injury. You exclude a fracture and any acute significant meniscal or ligamentous injury and diagnose a knee sprain. You provide the patient with analgesia and RICE advice and wonder whether the application of a tubigrip will also help reduce their pain and lead to a quicker recovery.