bestBETs

You are looking after a previously healthy 3-year-old girl, who was admitted with radiographically confirmed lobar pneumonia 3 days ago. She was started on intravenous penicillin and remains clinically stable but continues to be febrile. The laboratory informs you that Streptococcus pneumoniae has grown from her blood culture and that the isolate is penicillin-resistant (minimum inhibitory concentration (MIC) 1 μg/ml). You are uncertain whether this has any implications for her clinical course and wonder whether you should change her antibiotic treatment on the basis of this information.

You are the neonatal doctor covering the labour ward. A woman who is 38 weeks pregnant and in early labour reveals a recent history of genital warts. She asks the midwife if this could affect her baby and if it should influence the mode of delivery. The midwife is unsure and so asks you

A 57 years old male complaining of unstable angina was submitted to single Left internal mammary artery (LIMA) to Left anterior descending (LAD) artery on-pump grafted distally to a twice stented, severe proximal stenosis. After weaning from Cardiopulmonary bypass (CPB), LIMA was judged well functioning on the basis of finger palpation. Ventricular tachicardia occurred before sternal closure and patient was transferred to intensive care unit under lidocaine infusion. Few hours later a low cardiac output syndrome with LIMA occlusion diagnosed at angiography led patient to emergent surgery. On cardioplegic arrest LIMA was found totally dissected with LAD occlusion at proximal site of anastomosis. A saphenous vein graft was used to revascularize LAD. Intraortic Ballon Pumping was necessary to wean the patient. The anterior myocardial necrosis prolonged hospital stay. On the basis of risk management protocol you carry on a literature survey in order to demonstrate clinical usefulness of Transit-Time flow measurement (TTFM) in coronary graft verification.

An SHO performing a baby check on the postnatal ward feels that one of the hips is “clicky”. There are no risk factors for developmental dysplasia of the hip (DDH). As the Registrar on call, you have to go and examine the baby. If the hips are stable and located on clinical examination, it is hospital policy for no further investigations or follow up. You wonder what the evidence is for performing hip ultrasound scans in all babies and whether or not a policy should be implemented locally to do this.

A thirty year old man is brought to the Emergency Department (ED) having called the ambulance claiming to have taken a massive overdose of amitriptyline. He is noted to be hypotensive and this remains refractory to intravenous fluids and sodium bicarbonate. You know that amitriptyline is lipid soluble and wonder whether lipid emulsion is likely to be of benefit.

A 6-year-old boy presented with ear ache and mild fever. The assessing registrar confidently made the assertion that the diagnosis could not be otitis media as he has read that the presence of wax excludes this. You wonder if this is true.

A shocked multiply injured patient is brought into the emergency department following a road traffic collision. There are a number of open fractures as well as chest, abdominal and pelvic injures. Furthermore, the paramedics report a great deal of blood at the scene. A trauma call is initiated and circulatory resuscitation begins immediately with transfusion of warmed universal donor blood. You have recently been to a presentation by a military surgeon who has just returned from a combat zone. You recall that mention was made of early component therapy in massive transfusion being beneficial and wonder whether you should start such therapy now.

A specialist registrar in a district general hospital receives a call from a health visitor who has seen a 2-week-old baby who is struggling to breastfeed adequately and who has a marked tongue tie. The parents are extremely anxious and after searching the internet are now requesting a tongue division as they are certain that this is the cause of the problem. The health visitor can also recall many success stories after this procedure and is concerned that without it the mother will abandon breastfeeding altogether. She asks you to refer the baby to the ENT specialists with a view to division.

A 72-year-old man with a known history of ischaemic heart disease presents to the emergency department in the early hours of the morning with acute dyspnoea. He is diaphoretic and on examination has crepitations on both middle and lower zones of his chest. A chest radiograph shows cardiomegaly and increased shadowing consistent with pulmonary oedema. He remains unwell despite the administration of oxygen, nitrates, diuretics and opiates and, knowing that ACE inhibitors have proven benefit in chronic heart failure, you wonder if he would receive benefit from this drug in the acute setting.

A 48-year-old man attends the emergency department intoxicated and with a head injury. He is kept overnight and develops symptoms of alcohol withdrawal in the morning. He is a frequent attender to the emergency department with similar presentation and has been treated repeatedly with chlordiazepoxide in the past. You recently attended a postgraduate lecture where the “kindling effect” was discussed. You wonder whether his repeated treatments with chlordiazepoxide are actually having this effect and thereby increasing his risk of alcohol withdrawal seizures.

During a camp trip in a remote area, a 32-year-old man has burned his hand and arm in the camp fire. As he had neither a first aid kit nor bandages or dressings to cover the wounds, he used cooked potato peels for this purpose. When you see him some time later in the emergency department you are very impressed by his innovative use of vegetables, though somewhat less sure of their efficacy and safety in burns. Before you dismiss the idea completely, however, you wonder if there is any published evidence.

You are a physiotherapist working in acute elderly medicine on an acute hospital ward. The team practices a multidisciplinary approach to falls prevention and rehabilitation according to current UK guidelines, consisting of multidisciplinary assessment and multifactorial interventions. A significant part of your caseload consists of patients with dementia who have been admitted following a fall. You wonder which interventions within the scope of physiotherapy practice are effective in improving falls outcomes (number of falls, severity of falls, balance related outcome measures) in patients with dementia who have fallen.