bestBETs

A very low birth weight baby is born at 27 weeks gestation.She is now fully stable and 10 days old requiring low flow oxygen via the nasal prongs, is on full enteral feeds. Her Hb is slightly low at 13, her biochemistry is otherwise normal. Her saturation alarm limits are kept at mid 80s to low 90s, which is the local policy. Is there good evidence that this reduces complications to her eyes and future development of chronic lung disease or may actually be harmful by inducing an element of chronic hypoxia?

An adult male is brought to the Emergency Department following a significant tricyclic antidepressant overdose. While in the Emergency Department he has several seizures. You wonder whether to load with intravenous phenytoin or simply manage prolonged seizures with benzodiazepines.

Fraser is an 8-year-old boy well known to everyone in A&E and the hospital. He has severe dystonic cerebral palsy as a result of his premature birth at 26 weeks' gestation. Although he was ventilated for 5 weeks he did not develop chronic lung disease. He is gastrostomy fed and had a Nissen's fundoplication 5 years ago. He has copious secretions and a poor cough reflex. These are made worse by nitrazepam which he requires for his dystonia. Evidence from previous barium studies and swallow assessments show that he chronically aspirates his secretions. He has no symptoms of upper airway obstruction. Over the last year, he has had increasingly frequent lower respiratory tract infections, requiring admission and intra-venous antibiotics. His weight and height have fallen from the 10th to the 3rd percentile. A chest x ray shows chronic changes suggestive of underlying bronchiectasis and he is now colonised with Pseudomonas aeruginosa. Immune function and a sweat test are normal. He has not had a recent pH study or barium swallow. He awaits a CT scan of his chest. He has daily physiotherapy and regular suction and usually produces copious muco-purulent secretions. He is on maximal anti-reflux medication already. Would prophylactic azithromycin reduce his risk of further lower respiratory tract infections? Or might it increase growth of multi-resistant organisms within his sputum?

A 15-year-old girl with acute renal failure was found to have class IV systemic lupus erythematosus (SLE) nephritis on renal biopsy. A decision was taken to start her on the routine National Institute of Health protocol of pulsed methyl-prednisolone and monthly intravenous cyclophosphamide (CYC) (0.5–1.0 g/m2 of body surface area). With her post-pubertal status and the possibility of CYC induced gonadal toxicity, the question was raised as to whether she should be put on gonadotropin releasing hormone analogue (GnRH-a) therapy for ovarian protection.

As part of a bench-marking exercise in your neonatal network, the length of stay (LoS) for babies born at 30+0 to 34+6 weeks' gestation was measured over a 12-month period (only babies who were inborn and admitted within the first 24 h and had their care on the same unit were included). Corrected gestational age at day of discharge was compared between the seven units. The bench-marking results show variation of LoS in these babies from 35.5 weeks to 36.7 weeks with a network average LoS of 36.2 weeks. Although this is less than the UK mean LoS of 36.3 weeks, it is higher than the California average of 35.9 weeks.1 You decide to review the LoS in your own unit for this same defined group for the years 1995, 1998, 2001 and 2004. The median LoS for these years is fairly constant at 36.4, 36.6, 36.8 and 36.1 weeks, respectively. You note that 60% of all neonatal admissions comprise babies in this group and that they account for 6000 cot days per year. You wonder whether you can implement any changes locally to reduce the LoS, safely, for these babies.

70 years old patient has been brought in to the resuscitation area with an exacerbation of COPD. Nebulizers and steroids have been given and had little effect. You wonder if you could use intravenous magnesium sulfate to improve his airflow.

A 52 year old patient 36-hours after mitral valve repair and grafts arrests with an asystolic ECG. He had been on increasing doses of adrenaline and a TOE had shown a poor LV but no tamponade. After 2-minutes of external cardiac massage and 1mg of adrenaline you elect to perform an emergency re-sternotomy with the intention of putting the patient back on bypass. Once commencing internal massage you are surprised at the significantly better arterial pressure that you are able to achieve performing internal massage.

A 3 year old boy presents to the Emergency Department not using his left arm after a fall. He has a bruise over his left clavicle and is clinically tender over this area. X-ray reveals a mid-clavicular fracture. From your experience in adult Emergency Departments you wish to put him in a collar and cuff, however this seems to distress him. You wonder if it is necessary to immobilise him at all.

A 60yr old lady presents to A and E complaining of wrist pain following a mechanical fall. X rays reveal a Colles fracture. You wonder if manipulation of the fracture will actually improve her functional outcome?

A 39 year old man referred to the PT clinic with a 3 weeks history of low back pain. There is no history of back pain or work-related back injury. At the L4-L5 level, there is herniated nucleus pulposus without nerve root compromise as shown in the MRI images. He has limitation of lumbar spinal mobility without red flags. He is normally fit and well. He is extremely afraid that any physical activity might damage his back. You wonder how to plan a rehabilitation program that will help to reduce his fear along with pain and risk of disability.

You are seeing a 60-year-old man who has been referred for multivessel coronary artery bypass grafting (CABG). He is an insulin-treated diabetic with a body mass index of 27 and no previous myocardial infarction. His father also died of a heart attack when he was 65 years old. You tell him that the grafts with the best long-term patency are the internal thoracic arteries. You would like to perform CABG using bilateral internal thoracic arteries (BITA) and a vein graft. You inform the patient that this configuration of the procedure carries higher risk for mediastinitis, which is associated with about 20% in-hospital mortality and higher long-term mortality [Toumpoulis]. He is not that keen on the idea and asks if there are any other configurations that could have the same long-term results without the risks of mediastinitis. You wonder whether BITA would be performed in diabetics with low risk of mediastinitis

A patient who has suffered a traumatic brain injury (TBI) is admitted to your rehabilitation hospital. Other therapists have used body weight supported treadmill training (BWSTT) with patients post stroke. What evidence supports the use of BWSTT in a TBI population?

A 28 year old male attends at 7.30am having dislocated his shoulder again, this time when making the bed that morning. He states he is awaiting an elective orthopaedic procedure planned later this year. This is his 3rd non traumatic dislocation in the last 2 months. The shoulder is clinically relocated with ease using morphine and entonox only. A pre-reduction x-ray was not taken as the diagnosis was clinically obvious. You are confident that the shoulder is relocated and wonder if a post reduction film is still required.

You are seeing a patient at lunch-time 4 days after his coronary artery bypass grafts. He is well and has been walking around the wards. You are aware that he only gave up smoking three weeks ago, when he was admitted with a non-ST myocardial infarction. He thanks you for doing his operation and asks if it is okay to have some salt on his chips for lunch. You tell him that you are sure that it's okay and that he has to have a few pleasures in life. On walking away from the patient, your nurse practitioner tells you off. She had just told him that high salt intake is bad for him and that he should cut down. You sheepishly promise your nurse practitioner that you will look up the evidence.