bestBETs

An eight year old child presents to the A and E department complaining of abdominal pains and not having passed a stools for two weeks. You wonder whether the use of an osmotic laxative would have a lower risk of recurrence of constipation and if it would mean fewer side effects for the child over the course of the treatment.

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.

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 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.

Joseph, a 4-year-old boy with septic shock, lactic acidosis and multi-organ failure has been admitted to the paediatric intensive care unit. Mechanical ventilation, vaso-active support and renal replacement therapy (CVVHD) are initiated. His haemoglobin level is 8.8 g/dl (5.5 mmol/l). The senior consultant decides to order a red cell transfusion in order to optimise oxygen delivery, but the junior fellow argues that there is no evidence that transfusion improves outcome and that it may potentially be harmful.

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.

A neonate born at 26 weeks and weighing 930 g underwent laparotomy on day 21 of life for perforation secondary to necrotising enterocolitis (NEC). He required fluid resuscitation during the procedure and Gelofusine was given rather than normal saline or blood products. We reviewed the evidence for the use of Gelofusine for volume replacement in neonates.

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.

A 25-year-old man presents to the emergency department with a traumatic laceration to his left index finger. The wound needs a thorough clean and will require suturing and you decide to do this using a digital nerve block technique. A colleague who has recently worked in plastic surgery suggests you use epinephrine (1:100 000) to help with haemostasis, but you have always been told that this can cause finger necrosis and that it should never be done. You wonder whether in fact this is true and decide to look at the evidence for yourself.

A 65-year-old woman presents to the emergency department with signs and symptoms of SBO. She had previously had an abdominal hysterectomy. Plain abdominal radiograph (AXR) is non-specific. You wonder whether abdominal CT would be useful in the management of a patient with presumptive SBO.

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.

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 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 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 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.

On Christmas Eve you intend to circumnavigate the globe stopping at every household containing a child in the space of one night using a dozen reindeer as your means of propulsion. However it is a bit misty out and you feel this will make performing this task a little bit tricky and feel some sort of navigational aid would be helpful. You notice one of the reindeer has a very shiny red nose (you might even say it glows). All of the other reindeer are laughing and calling it names but you wonder whether this may be the answer to your navigational problems.

Your hospital has a policy which states that blood cultures should be taken by dedicated venepuncture, rather than from freshly inserted intravenous cannulae, in order to reduce the risk of contamination. You wonder if this is supported by the literature.

A 2 year-old girl is brought into the Emergency Department with vomiting and watery diarrhoea. She has dry mucous membranes, reduced skin turgor and her central capillary refill time is 3 seconds. You estimate that she is moderately (4-6%) dehydrated. She is refusing oral fluids. Beds on the wards are limited. You wonder whether rapid nasogastric rehydration (RNGR) with an oral rehydration solution (ORS) is an effective and safe strategy to try and avoid the need for hospital admission?

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 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.