bestBETs

A preterm baby on the neonatal intensive care unit develops anaemia of prematurity, requiring a blood transfusion. The parents of the baby are Jehovah's Witnesses and do not believe in blood transfusions. They do agree to allow their baby to have recombinant human erythropoietin (rHuEPO) treatment instead. However, the clinical staff are unsure whether giving coexisting iron supplementation with rHuEPO treatment will further reduce the requirement for transfusion, and if so in what dose and form should the iron supplement be given?

A newborn baby born at 37 weeks is noted to be unwell at 18 h postnatally. The mother gives a history of prolonged rupture of membranes for 36 h. The baby is feeding poorly and is jittery, with a temperature of 38°C. A clinical diagnosis of early sepsis is made and lumbar puncture is suggested on the ward round as a part of sepsis evaluation. Several publications on the use of lumbar puncture in late-onset sepsis, including a recent review article by Malbon et al,1 suggest that lumbar puncture is an important method of investigation and should be considered in babies for >48 h old, with suspected sepsis. We wonder whether there is sufficient evidence to justify lumbar puncture in early sepsis.

A 2-year-old girl presents with chickenpox. The girl has typical vesicular lesions but has no evidence of complications on examination. Her mother reports that she is scratching continuously and has had very little sleep over the past few days as a result of the pruritus. Considering the therapeutic options, we wonder whether there is any evidence to support the use of either calamine lotion or antihistamines to alleviate pruritus in varicella zoster infection.

A 7 year old boy attends the emergency department following a fall in school. Clinically he has sustained closed fracture of his distal radius and ulna. The patient definitely needed manipulation under anaesthesia for reducing the fractures. You wonder whether below arm cast is as effective as above arm cast for these fractures.

A 3 year old child attends the Accident and Emergency Department with a 2 day history of vomiting and diarrhoea. You wish to estimate the child's hydration status to determine whether rehydration therapy is needed but wonder how reliable is the clinical sign of skin turgor.

A 16 year old male arrives at the ED having sustained a head injury after falling over whilst intoxicated. You have heard about the recent institution of an Alcohol Health Service in the department comprising two designated Alcohol Health Workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol-related events. Having assessed and treated the patient, you wonder whether you should refer him on to them...

A 57 year old woman attends the Emergency Department with newly diagnosed atrial fibrillation of uncertain duration. You decide to treat her by ventricular rate limitation and wonder whether you should use digoxin or a calcium channel blocker.

A 50 years old man attends the Emergency department with a 12 hours history of palpitations. He denies any history of previous ischaemic heart disease. He complains of no other symptoms other than mild dizziness. On clinical examination he has a normal BP, no signs of heart failure and an ECG shows him to be in AF with a rate of 140/min. You wonder if flecainide is better than placebo at cardioversion.

A 57 year old woman attends the Emergency Department with newly diagnosed atrial fibrillation of uncertain duration. You decide to treat her by ventricular rate limitation and wonder whether you should use digoxin.

A 45-year-old man has been diagnosed with non-gonococcal urethritis. He needs antibiotics, and you wonder whether he should be given azithromycin or doxycycline.

A 26 week gestation premature neonate is born with a birthweight of 650g. He is intubated and ventilated from birth. Both arterial and venous umbillical catheters are inserted. He is at risk of sepsis from maternal chorioamnionitis and prolonged rupture of membranes and is therefore commenced on broad spectrum antibiotics. Invasive candidiasis is an increasingly recognised problem in such infants. Would intravenous antifungals be effective and safe at preventing this?

A 21-year-old man has been diagnosed with gonococcal urethritis. You are advised to give treatment to cover chlamydia infection as well and you wonder if this is necessary.

A man attends the Emergency department with a 12 hours history of palpitations. He denies any history of previous ischaemic heart disease. He complains of no other symptoms other than mild dizziness. On clinical examination he has a normal BP, no signs of heart failure and an ECG shows him to be in AF with a rate of 140/min. You have read some studies that have shown both intravenous and oral flecainide is effective at converting AF to sinus rhythm, but wonder which route is more effective and safe.

A middle age male presents to emergency department with sudden onset of painful, swollen, red and tender joint at the base of big toe. Blood test showed normal serum uric acid level. There is no previous history of gout. The patient asks if he suffers from gout. Does normal serum uric acid level rules out gout?

A 4 year old child presents to the paediatric accident and emergency department with a history of fever for 12 hours and clinical signs of an upper respiratory tract infection. The temperature on assessment is 39.5°C. There is a past medical history of asthma. The attending emergency doctor prescribes ibuprofen. The mother is not willing to give ibuprofen to her child, as she was told in the past that it is contraindicated in children with asthma.

A 12 year old girl with primary generalised epilepsy comes to clinic for review. She has been seizure free for two years on sodium valproate 600 mg twice daily. Following discussion with her and her mother, an agreement is reached to withdraw the medication. You advise that the medication should be tapered off over a six week period. At this point the mother informs you that when she had her own anticonvulsant medication withdrawn, this was reduced over a six month period. She questioned whether it was appropriate to reduce the medication so quickly and requested evidence to support the recommendation, raising concerns about the possibility of a higher risk of seizure recurrence.

You are consenting a 64-year old lady for AVR. She is quite keen to go for a bioprosthesis as her mother was on warfarin in the past and it had 'never agreed with her'. She is then quite disappointed when you tell her that she will actually have to be on warfarin for 3-months after the operation, and asks what would happen if she didn't take it. You can't quote her a figure of increased risk and therefore resolve to look up the answer.

A patient presents to the emergency department with a unilateral, red, painful eye. Visual acuity is reduced in the affected eye. The pupil is normal and the cornea is clear. There is some cillary flush around the iris. You can't decide if the diagnosis of iritis is correct or not. The other features of iritis (i.e unilateral, red, painful, decreased visual acurity) are present but the pupil remains a normal size and shape. Is this a common presentation?

A 35-year-old man presents to the emergency department with a history of burning pain radiating from his epigastric area up through his mediastinum that started after dinner. The patient had a history of gastro-oesophageal reflux disease and was placed on prilosec treatment last year, but has stopped taking this for 3 months. You decide to treat this probable case of dyspepsia with a gastrointestinal cocktail, a mixture of lidocaine and antacid, but wonder if adding the lidocaine yields any benefit.

A 39y old woman presents with a one day history of suprapubic pain, dysuria and urinary frequency. She is systemically well but dipstick testing confirms blood, protein and leucocytes in her urine sample. You send the sample to the microbiology department for culture and write a prescription for antibiotics. The patient states that she does not like to use conventional medicines and asks if cranberry juice is effective for the treatment of UTIs.