bestBETs

You are looking after a 45-year old bricklayer with severe triple vessel disease who underwent urgent CABG using bilateral internal mammary arteries and a radial artery graft. He has progressed well and is awaiting discharge. He was on no medication on admission and asks you why he needs to have 6 weeks of Diltiazem three times per day as prescribed by your consultant. You have some difficulty justifying this medication and thus resolve to look up the literature that night.

An 38 year old male arrives in your emergency department complaining of palpitations and feels slightly light headed. He has never had these symptoms before and is certain that they started 1 hour prior to arrival. He is awake and alert with a blood pressure of 134/82 and a pulse of 128. His physical exam is unremarkable with the exception of tachycardia and an irregularly irregular rhythm.

A 25 week gestation neonate is ventilated for RDS, he develops a haemodynamically significant persistent ductus arteriosus (hsPDA) on day ten of life. The PDA is treated with an initial course of Indometacin and despite initial improvement he remains ventilator dependent. On day seventeen a hsPDA is diagnosed again. How effective is a second course of Indometacin (Indo) at closing the PDA?

A 25 year old science teacher comes into the emergency department with a partial thickness burn to her hand after being careless with a bunsen burner. You wonder if silver sulphadiazine cream is better than normal dressings at reducing the risk of infection and healing time.

A 30 year old woman comes into the Emergency Department having been the victim of a vicious non-sexual assault. She has suffered from depression since the age of 18. The Mental Health liaison nurse says that you should refer her for psychological support straight away as she has a predisposition to develop PTSD. Although it seems likely that someone with a known depressive disorder is more likely to get post assault psychological problems, you wonder whether there is any evidence to show that this really does occur.

A 24 year old man presents to the emergency eye centre with a uniocular red eye. He has a mucopurolent disharge and a follicular (inclusion) conjunctivitis. An initial diagnosis of adenovirus infection is made, but swabs taken show chlamydial infection. He is referred to the GUM clinic but does not test positive for genital infection. You decide to start him on a 10 day course of doxycycline, but are advised that you could treat him with a single dose of Azithromycin.

A middle aged patient is referred to physiotherapy with a 6 months history of CRPS following an innocuous trauma. You usually try hydrotherapy with such a condition but want to know if this is more beneficial than 'dry-land' treatment.

A 4 year old boy in cardiac arrest is brought into the ED as a standby. CPR has been delivered by the ambulance crew en route. Whilst he is being intubated, cardiac compression is carrried out by one of the APLS trained paediatric nurses, but once she tires, it is continued by another staff nurse with no paediatric training. You wonder whether chest compression is more effective in children if delivered by an ATLS trained professional.

A baby is born by spontaneous vaginal delivery at 29 weeks gestation. The infant's mother had a previous child born at 28 weeks gestation, who died due to late onset sepsis. The obstetrician clamps the cord immediately after the baby is delivered. Later the paediatrician, whom was present at delivery, asks why the cord was clamped immediately instead of delaying to 30-45 second. The paediatrician highlights the numerous benefits of delayed cord clamping including the prevention of late onset sepsis. A debate ensues as to the best practise and evidence behind the paediatrician's argument.

A four year old child is brought to the emergency department in moderate to severe pain. You have a protocol for using intra-nasal diamorphine1 in such children, but have been unable to apply it for some time because of a nationwide shortage2. You wonder whether any other opiate could be administered in a similar manner ?

A 30 year old chap presents to the ED following a jump fom height, sustaining a right undisplaced extra-articular calcaneal fracture. He is not severely swollen, and you are happy to discharge him, with out-patient follow up. You wonder whether he should be placed in a below knee POP, or remain NWB without a POP, as then he will not lose movement at the ankle joint.

You are assessing a 7 year old boy with attention and behaviour difficulties, and poor school performance. He has an average IQ and meets the diagnostic criteria for attention deficit hyperactivity disorder (ADHD). There is no evidence of developmental delay, dysmorphism, or other physical abnormalities and no relevant family history. Parents are keen on investigation for a "cause" for his problems. You are aware that some chromosomal and cytogenetic abnormalities may be associated with ADHD. You wonder if you should check karyotype and look for cytogenetic abnormalities with genetic implications for the family.

You see a 12 year old boy with cerebral palsy (CP) in outpatients. His mother is concerned about his drooling. He has tried hyoscine patches with little effect. His mother has heard a radio programme about botulinum toxin (BTX-A) injections and asks you whether it would be beneficial.

Bubble baths are common products used by parents. Medical professionals, from students to consultants, can be heard across clinics throughout the country, advising parents to avoid the use of bubble bath to help prevent another urinary tract infection in their child. In our simple survey we could not find any labels on bubble baths intended for children or babies that reinforced this advice. Are we, as general paediatricians, providing unsubstantiated advice to our patients and parents?

You are about to perform an urgent aortic valve replacement in a 32-year-old male who has been treated for endocarditis with destruction of the native aortic valve, leading to congestive heart failure. The patient has been an i.v. drug user (IVDU) for several years. He has a supportive family and has already been accepted into a methadone program in your community. In order to decide whether you should insert a mechanical heart valve or a tissue valve, you would like to learn about the long-term results of valve replacement in this clinical setting.

An 8-year-old boy presents to the emergency department with an isolated midshaft femoral fracture. You were previously taught to use a combination of lignocaine and bupivocaine, as the lignocaine would have immediate effect followed by the longer action of bupivocaine. The anaesthetic registrar disagrees and wants to use bupivocaine alone.

You are a chest registrar seeing a 55-year-old patient in a rapid access out-patient clinic who has recently presented with cough and hemopytsis. He is a smoker and had these symptoms for just a few weeks before being sent for a chest X-ray. It shows a large lesion in the right upper zone. The patient suspects he has lung cancer, which he probably does. He wants to know why he could not have had a chest X-ray before he was sick to pick up his lung cancer.

A 65 year old male patient is brought in to your department. He is severely short of breath, sweaty and has sats of 91% on a non rebreather. He is an ex smoker and known to have IHD and suffers from LVF. The standard teaching is that Diamorphine (morphine) should be given to these patients as it is an effective treatment for the condition. You wander if that is true and if there is any evidence for this statement.

You are with a 72-year-old patient who is 15 h post emergency Type A dissection repair and CABGx1. It was a difficult operation with a long bypass time. Post-operatively he has been bleeding profusely. He has been reopened but no bleeding points have been found, and he has returned to the CICU packed and with the chest open. He has received 12 units of fresh frozen plasma and 2 pools of platelets and cryoprecipitate, but has still bled 400 ml per hour for the last 3 h. You discuss the patient with the haematologist and he tells you that they now have recombinant activated Factor VII available for use, and asks whether you would like to use it. He has no experience with this post-cardiac surgery and neither have you and you are a little anxious about the patency of the graft that you had to place, but you elect to give it and then search for reports of its use.

A young girl presents in the emergency department with right iliac fossa pain, anorexia, nausea and vomiting for the past 12hours. On examination she has significant right iliac fossa tenderness but no rebound or guarding. Her temperature is 37.3„aC and the inflammatory markers are normal. You are not entirely certain if she has acute appendicitis and would not like her to go through an unnecessary operation. You are wondering whether Ultrasound or CT is better in confirming the diagnosis of acute appendicitis.