bluuebunny/crossref_metadata_2025 huggingface dataset:
Tricyclic Antidepressant Overdose causing Acute Respiratory Distress Syndrome
Authors:   St. James’ University Hospital, Beckett Street, Leeds, Heaps Tom , Hoye Sarah ,   St James’s University Hospital, Beckett Street, Leeds, Roy Ruby ,   Leeds General Infirmary Leeds, LS1 3EX
Published: June 2021

We report two recent cases of tricyclic antidepressant (TCA) overdose complicated by the development of acute respiratory distress syndrome (ARDS). The previous literature documenting an association between TCAs and ARDS is reviewed. We propose that the respiratory complications of TCA overdose should be more widely publicised and included in national toxicology databases.
https://staging.acutemedjournal.co.uk/providing-better-care-for-patients-with-complex-needs-in-acute-medicine/
Authors:   Queen Elizabeth II Hospital, Hertfordshire, MacFie Caroline , Wall Emma ,   University College London Hospitals NHS Foundation Trust, London, Ash Stephen ,   Ealing Hospital, Southall.
Published: June 2021

There are a number of cases reported in the literature which describe hyperglycaemia in patients following paracetamol overdose. The majority of these occur in conjunction with hepatic failure. Less well known is the occurrence of hyperglycaemia and acidosis following paracetamol overdose in the absence of hepatic failure. This report describes such a case which was initially misdiagnosed as diabetic ketoacidosis (DKA).
Clinical Governance in Acute Medicine
Authors:   Frenchay Hospital, Frenchay Park Rd, Bristol, Ho John
Published: June 2021

We are all responsible for maintaining our standards and improving the way in which we work. However, keeping up to date with the many guidelines/documents published and finding what is relevant to acute medicine can be difficult. This new section of Acute Medicine will hopefully bring together the relevant updates in the world of clinical governance.
Do Patients Really Mind Mixed Sex Bays in an Emergency Assessment Unit?
Authors:   Emergency Assessment Unit, Ansty Unit Poole Hospital Longfleet Road Poole BH15 2JB, Bonner Hayley K , Frost Steven J ,   Poole Hospital, Smith Martin G ,   Poole Hospital, Williams Elizabeth J ,   Poole General Hospital Longfeet Road Poole
Published: June 2021

Mixed sex bays are a reality on most Emergency Assessment Units (EAU). However, they are controversial having recently been the focus of political and media attention. We adapted a validated patient satisfaction questionnaire to seek the views of 1000 emergency admissions regarding mixed sex accommodation. Of 1000 respondents, 925 (92%) had been in bays and 665 (66%) shared with the opposite sex. Most 579/665 (87%) were comfortable with this, 97% (966/1000) feeling there was sufficient level of privacy, all (1000/1000) felt they were given privacy when needed. When asked ‘‘given the nature and function of EAU would you be willing to share with the opposite sex if it meant a shorter stay?’’, 857 (86%) said yes. Our study demonstrates that whilst single sex accommodation is ideal it is not the most important factor to most patients admitted to EAU.
Out-patient detection of deep vein thrombosis using a combination of risk scoring and strain-gauge-plethysmography: a follow-up study
Authors:   City Hospital, Birmingham, Langford Nigel J , Tonks Karl ,   City Hospital, Birmingham, Singh Manjit ,   City Hospital, Birmingham
Published: June 2021

Patients are frequently referred to hospital for exclusion of deep vein thrombosis (DVT); however, the diagnosis is only confirmed in 12% of those undergoing investigation. An effective strategy is required, which minimises the number of negative investigations, while safely excluding or confirming the diagnosis. This study investigates the combination of clinical risk scoring and strain-gauge plethysmography in the initial assessment of patients with suspected DVT. A survey was conducted of 1300 patients referred with suspected DVT over the course of a year. The results of this investigation were comparable to previous clinical trials and supports the use of strain-gauge plethysmography combined with clinical risk score in a busy acute medical unit.
Critical Care Outreach: A Review of Current Practice and Evidence
Authors:   Anaesthesia and Intensive Care Medicine, Broomfield Hospital, Chelmsford, Essex, Rowe Katherine , J Fletcher Simon ,   Anaesthesia and Intensive Care, Norfolk & Norwich University NHS Foundation Trust, Colney Lane, Norwich
Published: June 2021

Critical Care Outreach teams have been developed in most acute hospitals within the UK. This article aims to summarise the evidence behind the development of this service and some of the outcomes which have been demonstrated to-date.
Septic Pulmonary Embolism in an Intravenous Drug User
Authors:   Acute Medicine, St James’s University Hospital, Beckett Street, Leeds, Hoye Sarah , Tolan Damian ,   Department of Clinical Radiology, Leeds General Infirmary, Leeds, Brownjohn Aleck ,   Renal and General Medicine, Leeds General Infirmary, Leeds
Published: June 2021

A recent case of septic pulmonary embolism in an intravenous drug user, complicated by issues of recurrent self discharge and delays in diagnosis yields opportunity to increase awareness of this uncommon yet life-threatening disorder. The literature is reviewed and includes suggested aids to raise clinical suspicion and improve subsequent management.
Not Just A Rash!
Authors:   Liver Unit, Transplant Department, St James University Hospital, Leeds Teaching Hospital’s NHS Trust, Fox MA , Fox JA ,   Geriatric Medicine, Department of Medicine, Royal Bolton Hospital NHS Foundation Trust, S Al-Shamma ,   Gastroenterology, Department of Medicine, Royal Liverpool University Hospital, Royal Liverpool & Broadgreen University Hospitals NHS Trust, K Leiper ,   Gastroenterology, Department of Medicine, Royal Liverpool University Hospital, Royal Liverpool & Broadgreen University Hospitals NHS Trust
Published: June 2021

Henoch-Schonlein Purpura (HSP) is the most common systemic vasculitis in childhood and can present in adults. It is a self-limiting disease characterised by a tetrad of manifestations including the mandated typical cutaneous hallmark. We present a classic case of HSP complicated by gastrointestinal haemorrhage associated with hidradenitis suppurativa.
Picture Quiz: ‘The Upper Hand’
Authors:   Geriatric Medicine, The Ipswich Hospital, Suffolk, UK, Alsawaf AFB , Sivakumar R ,   Geriatric Medicine, The Ipswich Hospital, Suffolk, UK
Published: June 2021

A 76 year-old right-handed man presented acutely with a sudden onset of weakness affecting his right hand only. This happened while working in the garden. On detailed history taking, he denied any previous symptoms, trauma or prodromal illnesses. He denied any other neurological symptoms.
Minimising delays in commencing therapeutic hypothermia after out-of-hospital cardiac arrest: the importance of a multi-disciplinary team approach
Authors:   Department of Intensive Care, Medway NHS Foundation Trust Kent, Patel Viral Kumar , Hayden Paul ,   Department of Intensive Care, Medway NHS Foundation Trust Kent
Published: June 2021

Therapeutic hypothermia (TH) is now a well established therapy in resuscitation guidelines. We retrospectively analysed our first 18 months’ data for all patients who underwent TH for out-of-hospital cardiac arrest (OHCA), measuring delays incurred during each patient episode, safety, and ICU outcomes. Sixteen patients received TH for OHCA. A mean delay of 248mins occurred following hospital admission to commencing therapy. Seven patients survived to hospital discharge with a 6 month Glasgow Outcome Score of 4-5 in 100%. A questionnaire evaluating 30 first responders’ familiarity and knowledge of TH demonstrated poor awareness and knowledge, with most viewing it with low priority. TH is a safe and easy to achieve therapy, however in practice there are significant delays in commencing treatment.
Patients’ perception of physical aspects of an Emergency Assessment Unit: a questionnaire study
Authors:   Physiology and Gastroenterology, Independent, 92 Long Lane, Ickenham, Middlesex, Mahmood Tariq
Published: June 2021

Objective: To explore patient’s perceptions regarding the physical environment of an Emergency Assessment Unit (EAU). Design/Setting: Questionnaire study at the time of discharge from the EAU of a UK District General Hospital Participants: All patients who were admitted through the EAU for three consecutive days. Results: Availability of modern facilities, close proximity to home and cleanliness were considered important parameters by <75% of patients. More than half of the patients considered presence of quiet space, good ward aesthetics and hospital food, provision of telephone and television facility, good ward security and ample hospital parking to be important aspects of an EAU. Conclusions: Patient views should form a key part of design when considering the physical environment of an EAU.
Correspondence
Authors:   Clinical Lead for Acute Medicine, Department of Acute Medicine, Royal College of Physicians, Trepte Nicola , Mallinson Robert H ,   Acute Medicine, The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk, Akhtar Cheema Ali ,   Acute Medicine, The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk
Published: June 2021

Dear Sir, In the latest edition of the journal, catheter-directed thrombolysis was reviewed (1), and does appear to be an attractive therapeutic option for treatment of deep venous thrombosis, both in prevention of postthrombotic syndrome and avoidance of anticoagulant therapy. I have one concern about the procedure with regards to the quoted bleeding rates. A systematic review reported high bleeding rates at 31% though major bleeding rates were low (2)
Towards ‘Sepsis with Optimal Treatment’: Evaluating the sepsis care pathway in Acute Medicine and identifying scope for systems improvement
Authors:   John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, Meyer Joel , Fritz Zoe ,   Adult Intensive Care Unit, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, Burton Hannah ,   Guy’s and St Thomas’ NHS Foundation Trust, Ward Christopher ,   Guy’s and St Thomas’ NHS Foundation Trust, Simpson Anna ,   Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Ahmed Vazeer ,   Cambridge University Hospitals NHS Foundation Trust
Published: June 2021

Sepsis commonly presents to the acute medicine unit (AMU). Timely recognition and treatment can reduce the significant associated mortality, but United Kingdom AMUs and emergency departments are often inadequately equipped to manage sepsis with early-goal directed therapy. We conducted an observational study of 50 consecutive patients admitted with severe sepsis. Demographic, physiological and microbiological data, and information about the provision and timing of care were collected in real time. Treatment fell below “surviving sepsis” targets with only 28% of patients receiving sufficient fluid, and 64% receiving antibiotics within 3 hours, associated with delays in seeing physicians; however despite this mortality was lower than the nationally quoted average (14% at 90 days).
Assessing the performance of the four question abbreviated mental test in the acute geriatric setting
Authors:   Sheffield Teaching Hospitals, UK, Locke Thomas , Keat Sally ,   Chesterfield Royal Hospital, UK, Tate Matthew ,   Sheffield Teaching Hospitals UK, Bown Alexander ,   North of Scotland Region of NHS Education for Scotland, UK, Ghosh Robin ,   Sheffield Teaching Hospitals, UK, Hart Anthony ,   Sheffield Children’s Hospital, UK
Published: June 2021

Background: Cognitive impairment is common amongst acute geriatric hospital admissions but detection is often poor and this is associated with worse outcomes. The four-question abbreviated mental test (AMT4) has previously been promoted nationally in the acute setting as a succinct assessment tool. However, a recent national dementia Commissioning for Quality and Innovation (CQUIN) goal recommends a single screening question followed by the tenquestion abbreviated mental test (AMT10). We aimed to evaluate the negative predictive value of the AMT4 within the acute setting by comparing it to three other validated tools. Methods: We identified 100 acute medical admissions (>60 years old) with a negative AMT4 and administered the AMT10, six-item cognitive impairment test (6CIT) and confusion assessment method (CAM) within 24 hours of admission. Results: Forty-six percent of the participants scored positively on at least one of the additional tests despite a negative AMT4. Forty-four patients had a positive 6CIT, 23 had a positive AMT10 and six had a positive CAM. Using the 6CIT as a diagnostic standard, tests of short-term memory had the greatest sensitivity and specificity for cognitive impairment. Conclusions: Nearly half of the participants had signs of cognitive impairment despite a negative AMT4. Consequently, there is a risk of under diagnosis with potentially serious consequences for morbidity and mortality. Tests of shortterm memory were strongly associated with cognitive impairment. We propose the addition of such a test in order to increase the sensitivity of the AMT4 without compromising its brevity and utility in the acute setting.
Posterior Reversible Encephalopathy Syndrome: ‘A headache’ on the AMU
Authors:   Huddersfield Royal Infirmary, Desai Purav , Bholah Mohammad Hassan ,   St James’s University Hospital, Leeds, Dunn Ed ,   Leeds Teaching Hospitals
Published: June 2021

Headache and seizures are common presentations to the acute medical unit. We report a case of posterior reversible encephalopathy syndrome (PRES) in a 73 yr old woman with a history of uncontrolled hypertension who had recently discontinued one of her antihypertensive drugs; such cases are rare but pose a diagnostic challenge given the nonspecific nature of the clinical presentation. However, early diagnosis and treatment leads to full recovery in the majority of patients.
Spinal epidural hematoma: an important stroke mimic
Authors:   Virginia Tech-Carilion School of Medicine, Schmidley James W. , Mallenbaum Sidney ,   Roanoke Memorial Hospital, Roanoke, VA, Broyles Kevin ,   Carilion Clinic Roanoke Memorial Hospital Roanoke, VA
Published: June 2021

Tissue plasminogen activator (tPA) is, on occasion, given to patients who do not suffer from acute cerebral ischemia. As the underlying conditions often mistaken for acute ischemic stroke tend to produce transient dysfunction, and are generally seen in individuals younger than stroke patients, the outcome of such mistaken treatment is generally benign. We will describe two elderly patients with acute hemiparesis caused by spinal epidural hematomas (SEDH), both of whom were initially considered candidates for tPA. The literature review and discussion will emphasize features allowing the distinction between these unusual hemiparetic presentations of SEDH and acute brain ischemia, and briefly review other cervical lesions that may rarely present with hemiparesis.
Trainee Update – February 2013
Authors:   Society for Acute Medicine Trainee representatives, Freeman Kirk , Daniel Amy ,   Society for Acute Medicine Trainee representatives
Published: June 2021

It has been created to recognise an outstanding contribution made by an individual to the principles or practice of Acute Medicine, on a local, national or international scale and will be awarded at SAM national meeting in Coventry. The prize is free attendance at SAM Glasgow in October.
A review of the clinical and legal issues surrounding refusal of treatment following overdose
Authors:   Leeds General Infirmary Great George Street Leeds, Heaps Charlotte , Bowen Emily ,   Yorkshire Deanery, Cooper Nicola ,   Leeds Teaching Hospitals
Published: June 2021

This article reviews the clinical and legal issues involved in dealing with patients who refuse medical treatment following an overdose. We first describe a real case that has been made anonymous, before discussing a general approach to management. We then review the relevant legislation, including the Mental Capacity Act (2005), the Mental Health Act (1983) and legal issues surrounding the treatment of young people. We discuss how this legislation may be applied in practice and then conclude with the outcome of the case, sources of further information and some key learning points.
Scombrotoxin poisoning: an important differential diagnosis for anaphylaxis
Authors:   ueen Alexandra Hospital Portsmouth Hospitals NHS Trust, Southwick Hill Road, Portsmouth, Numbere Numbere K , Featherstone Peter ,   Queen Alexandra Hospital, Cooper Hywel L ,   St. Mary’s Hospital
Published: June 2021

We report a case of scombrotoxin poisoning, an acute illness that develops within minutes to hours of eating poorly processed oily fish, such as tuna or mackerel. It presents with symptoms that can mimic an anaphylactic reaction. It is presumed to arise due to ingestion of histamine that is formed by contaminating bacteria that have flourished during periods of suboptimal refrigeration, following capture. Knowledge of this underdiagnosed malady as a potential differential diagnosis for patients presenting with symptoms suggestive of histamine release is important. It is a notifiable condition. The alternative diagnosis of anaphylaxis may have significant lifestyle implications for the patient. This article reports on one such presentation and the way that the diagnosis was explored.
Buttock Cellulitis as a Presentation of Psoas Abscess: a clinical reminder
Authors:   Southampton General Hospital, May Denzil
Published: June 2021

Cellulitis is a common condition that is frequently managed by the general physicians on an acute medical take. This case report describes buttock cellulitis as a presentation of an iliopsoas abscess and illustrates the importance of considering a deep abscess when there are atypical features, when the cellulitis is in an unusual location or when the patient fails to improve with standard anti-microbial therapy.
Acute Sarcoidosis: 3 Cases in an Acute Medical Clinic
Authors:   Tapas Kumar Chakraborty, Chakraborty Tapas Kumar , Asghar Adam ,   Huddersfield Royal Infirmary, Kumar Asis ,   Huddersfield Royal Infirmary
Published: June 2021

Sarcoidosis is a cryptogenic multisystem granulomatous disorder. We present three patients who presented acutely with erythema nodosum in our Medical Assessment Unit (MAU) or attended our clinic, subsequently diagnosed with acute sarcoidosis. In doing so, we aim to demonstrate that this presentation can easily be seen on the acute medical take, focussing on the management of acute sarcoidosis in association with erythema nodosum. Although patients will often not display florid systemic upset on presentation, we recommend follow-up after initial presentation, to ensure good resolution of symptoms.
A profile of Nurses working in acute medicine units: What is the future?
Authors:   Heart of England NHS Foundation Trust, Birmingham, Leese Liz , Myers Liz ,   Ninewells Hospital, Dundee
Published: June 2021

A survey of registered nurses working in two acute medicine acute medicine units (AMUs) was conducted between May & September 2009 to enable a focussed understanding of nursing recruitment and retention, to guide nurse managers for future workforce planning. The NHS collects national information regarding recruitment, retention and leavers, but this is sporadic and hampered by a lack of feedback to clinical areas. In this study, fifty completed questionnaires were collated, totalling a response rate of 57.5%. The results demonstrate that while recruitment is currently buoyant, nurses with significant experience are becoming dissatisfied through lack of opportunity to advance. It concludes that further national research is required to inform a strategy fit for the future development of nursing in acute medicine.
Picture Quiz: All in the head?
Authors:   Milton Keynes General Hospital, Milton Keynes, UK, Khan Dalia , Wijesurendra Rohan Sajeev ,   Royal Berkshire Hospital, Reading, UK, Orchard Melanie ,   Royal Berkshire Hospital, Reading, UK, Evans Pru ,   Milton Keynes General Hospital, Milton Keynes, UK, Smith Richard William ,   Milton Keynes General Hospital, Milton Keynes, UK
Published: June 2021

A 40 year old previously fit bank executive of Cypriot origin presented to the acute medical take with insidious onset frontal and vertex headaches with features suggesting raised intracranial pressure. He had been under investigation in the outpatient department after developing multiple erythematous lesions on his legs, associated with malaise, occasional mouth ulcers and episodic sweats.
Picture Quiz: Answer
Authors:   Milton Keynes General Hospital, Milton Keynes, UK, Khan Dalia , Wijesurendra Rohan Sajeev ,   John Radcliffe Hospital, Oxford, UK, Orchard Melanie ,   Royal Berkshire Hospital, Reading, UK, Evans Pru ,   Royal Berkshire Hospital, Reading, UK, Smith Richard William ,   Royal Berkshire Hospital, Reading, UK
Published: June 2021

The patient was anti-coagulated with low molecular weight heparin and then warfarin. He was also commenced on a reducing course of prednisolone. Symptoms and signs resolved within two weeks, and this was accompanied by normalisation of inflammatory markers. He remains clinically well and is now on methotrexate.
An unusual cause of bilateral deep vein thrombosis in a young adult patient
Authors:   Core Medicine Acute Medical Unit East Surrey Hospital, Warner Ben , Ceccherini Andrew ,   East Surrey Hospital, Mearns Ben ,   Acute Medical Unit East Surrey Hospital, Patel Viral Kumar ,   Acute Medical Unit East Surrey Hospital Surrey and Sussex NHS Trust, Canada Avenue Redhill, Surrey RH1 5RH
Published: June 2021

We describe the case of a 17 year old male who presented with severe groin pain leading to inability to weight bear on his left leg. Investigation revealed extensive bilateral and proximal deep vein thrombosis, in association with an absent inferior vena cava and anomalous venous drainage system. We present a review of the literature surrounding this association, summarise the typical clinical presentation and common characteristics in this group of patients and discuss its management.
The Patient with Acute Paraplegia: A Problem-Based Review
Authors:   Acute Medicine Princess Alexandra Hospital Harlow, Elegbe Oloruntoba , Wickremaratchi Mirdhu ,   Worthing Hospital Worthing, Hinchcliffe Martyn ,   Worthing Hospital Worthing
Published: June 2021

Acute paraplegia is an emergency requiring immediate assessment by the acute medical team because of the need to rule out compressive lesions of the cord for which intervention may preserve neurological function and limit persistent disability. In addition acute paraplegia could be complicated by life-threatening problems. These require prompt recognition and treatment to prevent further deterioration. The following clinical scenario, based on a real case of acute paraplegia seen by the authors is aimed at providing a problem-based approach to the management of patients presenting with acute paraplegic weakness.
The Acute Medicine – Speciality Interface: Experience in a large teaching hospital
Authors:   Acute Medicine Unit, Norfolk and Norwich University Hospital Trust, Norwich, Southgate Jo , Ruparelia Prina ,   Respiratory Medicine Department, Norfolk and Norwich University Hospital Trust, Norwich, Phillips Sue ,   Acute Medicine Unit, Norfolk and Norwich University Hospital Trust, Norwich
Published: June 2021

The Norfolk and Norwich University Hospital opened at its present site in 2001. The purpose built Acute Medicine Unit (AMU) is on the ground level, co-located with Emergency Radiology and the Emergency Department (ED). There are, on average, 220 ED attendances and 70 AMU admissions each day, with a split of approximately 30% General Practice referrals and 70% ED referrals. (see table 1) There is no observation ward in the ED, although there is an arrangement for the Emergency Physicians to manage patients with uncomplicated head injury for up to 48 hours.
The Acute Medicine – Speciality Interface: Experience in a District General Hospital
Authors:   Acute Medicine, Swindon Great Western Hospital, Swindon, Cannon Charlotte
Published: June 2021

The Great Western Hospital was opened in 2002. It was built as a PFI hospital, moving services from the old Princess Margaret Hospital situated in central Swindon. The Great Western Hospital is conveniently situated near junction 15 of the M4 and therefore has excellent transport links. The Acute Medical Unit (AMU) was purpose built adjacent to the Emergency Department and in close proximity to Emergency Department Radiology. Details of the Acute Medical Unit layout are summarised in Table 2.
Falls in older people – An overview for the acute physician
Authors:   Geriatric Medicine, Department of Medicine, Royal Bolton Hospital NHS Foundation Trust, Fox JA , Fox MA ,   Liver Unit, Transplant Department, St James University Hospital, Leeds Teaching Hospital’s NHS Trust
Published: June 2021

Falls are common amongst older adults inf licting a substantial socioeconomic burden. Aetiology is often multifactorial. Comprehensive individualised assessment is pivotal to direct effective interventions. We provide an overview of falls and highlight an approach for acute physicians who will increasingly encounter this mode of presentation in an ageing population.
The emergency management of the patient presenting with shock
Authors:   Anaesthesia and Intensive Care Medicine, Broomfield Hospital, Chelmsford, Essex, Rowe Katherine , Fletcher SJ ,   Anaesthesia and Intensive Care, Norfolk & Norwich NHS Trust, Colney Lane, Norwich
Published: June 2021

Shock may not be the commonest scenario encountered within the average clinical take, but unless rapidly recognised and managed appropriately, it carries an extremely high mortality. Shock is defined as inadequate tissue perfusion and is a consequence of a number of different clinical conditions. Hypotension is often, but not always, present. Blood pressure (BP) is a product of cardiac output (CO) and peripheral resistance (PR) as defined in the following equation: BP = CO x PR An inadequate cardiac output with intense vasoconstriction can therefore result in tissue hypoxia in the absence of hypotension. The recognition of shock, its causes and initial management will be discussed in this article.
A traveller with haemoptysis
Authors:   Respiratory Medicine, Salford Royal NHS Foundation Trust, Harris Ann , Newton P ,   Infectious Diseases, University Hospital of South Manchester NHS Foundation Trust and Respiratory Medicine Research Group, School of Translational Medicine, Manchester University, Chaudhry N ,   Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust
Published: June 2021

A 22 year old woman was admitted to hospital after coughing up approximately 500ml of fresh blood. She was a lifelong non-smoker with no significant prior respiratory history; however she described coughing up a small quantity of fresh blood on one occasion during the previous year. She had also been diagnosed with chronic idiopathic urticaria one year earlier.
A traveller with haemoptysis – Answers
Authors:   Respiratory Medicine, Salford Royal NHS Foundation Trust, Harris Ann , Newton P ,   Infectious Diseases, University Hospital of South Manchester NHS Foundation Trust and Respiratory Medicine Research Group, School of Translational Medicine, Manchester University, Chaudhry N ,   Respiratory Medicine, University Hospital of South Manchester NHS Foundation Trust
Published: June 2021

Further investigations revealed a negative autoimmune screen and aspergillus preciptins, but a raised total IgE level of 350ku/l. She underwent a bronchoscopy and lavage which was negative for routine culture and acid-fast bacilli, and revealed a normal cell differential.
Teaching on the AMU ward round
Authors:   University of Nottingham UK, Cooper Nicola
Published: June 2021

Abstract AMU ward rounds can be busy, and many consultants feel they are ‘too busy to teach’. Yet the AMU is a rich learning environment. If we take the starting point that teaching is not the same as learning, how can consultants facilitate learning during a busy AMU ward round? Opportunistic teaching requires some planning but can easily be incorporated in to the business of the working day. Good educational practice requires some knowledge however. This article aims to give physicians some understanding and tips on teaching on the AMU ward round.
A case of haemophagocytic syndrome in HIV-associated disseminated histoplasmosis
Authors:   Chelsea and Westminster Hospital, London, Vaid Nidhi , Patel Parind ,   Hammersmith Hospital, London
Published: June 2021

Abstract Disseminated histoplasmosis is an opportunistic infection which is commonly associated with HIV. Haemophagocytic lymphohistiocytosis (HLH) has been described as a secondary phenomenon to infection, collagen – vascular disorders and malignancies. In patients with HIV, cases of reactive haemophagocytic syndrome associated with disseminated histoplasmosis have been reported with CD4 counts of less than 50 cells/μl (450-1660 cells/μl). We report a case of a 25 year old man with HIV who presented with a CD4 count of 153 cells/μl and would suggest that this diagnosis should be considered at higher CD4 counts than previously reported.
Problem-Based Review: Calcium Channel Blocker (CCB) Poisoning
Authors:   St. James University Hospital Leeds, Heaps Tom
Published: June 2021

A 56-year-old female presents to the emergency department 6h after taking an overdose of verapamil MR 120mg x 28 capsules. She has a past medical history of hypertension and atrial flutter. On admission her GCS is 15, HR 50/min, BP 100/64, Capillary blood glucose (CBG) 10.2. ECG shows sinus bradycardia with prolongation of the PR interval. You estimate her weight to be 60kg.
The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix
Authors:   Division of Internal Medicine St James’s Hospital, Dublin, Ireland, Mikulich Olga , Callaly Elizabeth ,   Division of Internal Medicine St James’s Hospital, Dublin, Ireland, Bennett Kathleen ,   Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, O’Riordan Deirdre ,   MED Directorate, St James’s Hospital, Dublin, Ireland, Silke Bernard ,   MED Directorate, St James’s Hospital, Dublin, Ireland
Published: June 2021

Background: A weekend emergency medical admission has been associated with a higher mortality. We have examined all weekend admissions to St James’ Hospital, Dublin between 2002 and 2009. Methods: We divided admissions by weekday or weekend (Saturday or Sunday) presentation. We utilised a multivariate logistic model, to determine whether a weekend admission was independently predictive of 30 day outcome. Results: There were 49337 episodes recorded in 25883 patients; 30-day inhospital mortality at the weekend (9.9% vs. 9.0%) had an unadjusted Odds Ratio of 1.11 (95% CI 0.99, 1.23: p=0.057). In the full risk (unlike the univariate) model, a weekend admission was not independently predictive (OR 1.05; 95% CI: 0.88, 1.24). The case-mix for a weekend admission differed; with more neurological diagnoses (22.8% vs 20.4% : p = 0.001) and less gastrointestinal disease (18.3% vs 21.1% : p = 0.001). A biochemistry only illness severity score predicted a higher mortality for weekend admissions. Conclusion: Patients admitted at the weekend had an approximate 11% increased 30-day in-hospital mortality, compared with a weekday admission. However, admission at the weekend was not independently predictive in a risk model that included Illness Severity (age and biochemical markers) and co-morbidity. Sicker patients, with a worse outcome, are admitted over the weekend; these considerations should inform the allocation of healthcare resources.
Periodic Paralysis: An Unusual Presentation of Thyrotoxicosis
Authors:   Acute Medicine, North Shore Hospital, Auckland, New Zealand, Chapman Laura , Miller Steven ,   Endocrinology, Diabetes & General (Internal) Medicine, North Shore Hospital, Auckland, New Zealand
Published: June 2021

Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis and is up to 20 times more common in males. Cases usually present with painless muscle weakness precipitated by heavy exercise, fasting, an alcohol binge or large carbohydrate meal. Serum potassium is low in the majority, but normokalaemic (or even hyperkalaemic) TPP is recognised. Acute treatment of any electrolyte disorder, administration of a beta-blocker and treatment of the thyrotoxicosis leads to complete resolution. This rare diagnosis should be considered by the Acute Physician when confronted with any case of muscle weakness.
Serotonin Syndrome: An unusual cause of acute confusion and fever in the elderly
Authors:   Acute and General Internal Medicine and Intensive Care Medicine, Hampshire Hospitals NHS Foundation Trust, Misselbrook Gary Peter , Shekhar Raj ,   Stroke Physiology, Queen Elizabeth Foundation Hospital Kings Lynn NHS Trust
Published: June 2021

Delirium is a common cause for hospital admission among elderly patients. Although infection is the most common explanation, there is a large number of other potential causes. We present a case of acute delirium due to serotonin syndrome, precipitated by concomitant prescription of clarithromycin and fluoxetine. The symptoms improved following treatment with a benzodiazepine and discontinuation of the fluoxetine. The diagnosis and management of serotonin syndrome is discussed.
Problem-Based Review: Paracetamol Overdose
Authors:   Acute Medicine, St. James University Hospital, Leeds, Heaps Tom
Published: June 2021

A 29-year old male presents to the emergency department 1h after an overdose of cocodamol. He admits to taking approximately 60 x 8/500mg tablets, with alcohol, over a 20 minute period. He has a past history of depression, treated by his GP with citalopram 20mg OD. He has no previous history of deliberate self-harm. His past medical history is otherwise unremarkable and he is not on any additional medications. He drinks approximately 40 units of alcohol per week. Physical examination is unremarkable, his pupils are normal diameter and his Glasgow Coma Scale is 15. He weighs 82kg.
Management of Atrial Fibrillation with Preexcitation Syndrome
Authors:   Royal United Hospital, Bath, Kamour Ashraf , Dayer Mark ,   Cardiology, Musgrove Park Hospital
Published: June 2021

Dear Editor: We read with interest the picture quiz ‘’A young man with palpitation’’ by Shaukat and Grey in Acute Medicine Journal, and we would like to make some comments regarding the management of pre-excited atrial fibrillation.
Magnesium and the Acute Physician
Authors:   Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, Allan Russell , Mara Neil ,   Crosshouse Hospital, Kilmarnock, KA2 0BE, Ayrshire
Published: June 2021

Magnesium deficiency, and to a lesser extent magnesium excess, is commonly encountered in patients admitted to the Acute Medical Unit. It is important that acute physicians are able to identify those at risk of these states and initiate appropriate investigation and treatment. This article aims to provide the reader with a sound understanding of magnesium physiology and its effect at a cellular level. The causes, symptoms and treatment of magnesium disorders are discussed along with a review of evidence regarding the therapeutic use of magnesium.
Viewpoint: Norovirus Outbreak on the AMU – A Lesson In Shared Clinical Leadership
Authors:   Chelsea and Westminster Hospital, Krishnamoorthy Sanjay , Murch Nicholas ,   Royal Free Hospital, Pond Street, London, NW3 2QG
Published: June 2021

Three times a year, the first Wednesday of the month heralds a changeover of junior doctors within our hospital. This year, the first Wednesday in December provided a different kind of challenge. The voice on the phone confirmed the words that no one wanted to hear: “You have three confirmed cases of Norovirus and you have to close to new admissions”.
Journal Watch: February-May 2012
Authors:   Acute Medicine, University Hospitals Southampton, Tremona Road, Southampton, Ladorola M , Matsa Ramprasad ,   Acute Internal and Intensive Care Medicine, Royal Stoke University Hospital, Ellis S ,   University Hospitals Southampton, Tremona Road, Southampton
Published: June 2021

Assessing gait speed in acutely ill older patients admitted to an acute care elders hospital unit.
Problem based review: Alcohol-use disorders on the Acute Medical Unit
Authors:   Acute Medicine, Royal London Hospital, Reynolds Toby , Cooke Fiona ,   Alcohol Liaison Service, Royal London Hospital, Murch Nicholas ,   Acute Medicine Unit, Royal Free Hospital, Pond Street, London
Published: June 2021

Alcohol-use disorders including acute intoxication and withdrawal are common in the acute medical setting. Acute physicians should be aware of the indications for inpatient detoxification, and be able to liase with specialist alcohol services in the hospital and in the community to determine those patients for whom community-based detoxification may be beneficial. Additionally, it is important to recognise the benefit of Brief Interventions for higher-risk drinkers who are not yet dependent. For patients with confusion and a possible history of high alcohol intake and malnutrition, acute physicians should maintain a high index of suspicion for Wernicke’s Encephalopathy and treat appropriately with parenteral thiamine.
Should systematic risk assessment and immediate intervention of the acutely ill patient replace the traditional management paradigm?
Authors:   Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark, Kellett John
Published: June 2021

The outcome of the traditional diagnostic history and physical depends entirely on the availability, ability and diligence of an individual doctor. An alternative is a team-based approach that performs the following tasks: a focused assessment, monitoring of the response to initial treatment, and then determining what further management is appropriate (calling for urgent help if it is required). This concept is based on risk prediction rather than diagnosis, and is captured by the mnemonic FAITH3 (Focused Assessment, Initial Treatment, hAssessing response, calling for Help and Handing over care)...
Problem based review: The patient with ‘palpitations’
Authors:   Bradford Royal Infirmary Bradford, Crossland Sue , Berkin Liz ,   Leeds General Infirmary, Leeds
Published: June 2021

Palpitations, or the sensation of a rapid or heavy heartbeat, are a common symptom in both primary and secondary care settings. Here we use a common presentation of palpitations to explore the best ways to assess and treat patients who present in this way. We hope that by using a structured approach to our assessment we will reduce the use of the ‘scattergun’ approach to diagnosis, thus preventing unnecessary investigation and hospital stay.
Intra-abdominal abscess in older patients: two atypical presentations to the Acute Medical Unit
Authors:   Rotherham General Hospital, Moorgate Road, Rotherham, Hensey Nicola , Ahmed Shameela ,   Rotherham General Hospital, Moorgate Road, Rotherham, Minchin Joanna ,   Rotherham General Hospital, Moorgate Road, Rotherham, Athavale Nandkishor ,   Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, Abdelhafiz Ahmed ,   Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham
Published: June 2021

An abscess is a localised collection of necrotic tissue, white cells and bacteria, collectively forming pus. Intra-abdominal abscesses can occur viscerally (e.g. hepatic abscess), retroperitoneally (e.g. psoas abscess) or intraperitoneally (e.g. subphrenic abscess).1, 2 Clinical presentation is variable and largely depends on the site of abscess. Fever and abdominal pain are the classic symptoms although in older people presentation can be non-specific. Prompt diagnosis and early intervention are vital for good outcomes.3 We present two cases of older women whose presentation with atypical symptoms resulted in a delay in diagnosis.
Exertional Syncope as a presenting feature in Guillain-Barré syndrome
Authors:   Acute Medicine, Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire, Shalaby Tamer , Papoutsos Constantinos ,   Neuroscience, Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire, Tiemens Louise ,   Department of Radiography, East Lancashire Hospital NHS Trust, Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire, Crossingham Iain ,   Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire, Williamson Catherine ,   Acute Medicine, Royal Blackburn Hospital, Haslingden Road, Blackburn, Lancashire
Published: June 2021

Guillain-Barré syndrome (GBS) is an acute demyelinating disorder of the peripheral nervous system that results in motor weakness, absent reflexes and autonomic nervous system dysfunction. Autonomic failure is reported in approximately 65 % of patientswith GBS and usually follows extensive motor involvement. In this case our patient presented with syncope and other signs of autonomic failure before the motor weakness developed. Few cases in the literature have reported features of autonomic failure before established weakness in GBS; to our knowledge, syncope has not been described previously as a presenting feature of GBS.
Picture Quiz: An Acute, Blue, Swollen, Painful Leg
Authors:   Department of Medicine & Elderly Care, Royal Hampshire County Hospital, Honney R , Bhullar J ,   Department of Medicine & Elderly Care, Royal Hampshire County Hospital, Swales P ,   Department of Medicine & Elderly Care, Royal Hampshire County Hospital
Published: June 2021

A 55 year old male presented to the Acute Medical Unit with a one hour history of pain and swelling of his right leg with resultant inability to weight bear. He denied any preceding history of trauma. Previous medical history was unremarkable. He was taking no regular medications, and did not use recreational drugs. There was no prior weight change, or alteration in bowel habit, no associated chest pain or dyspnoea and there were no risk factors for venous thromboembolism or arterial thrombotic disease. He was a lifelong non-smoker.
Trainee Update – December 2012
Authors:   Society for Acute Medicine, Freeman Kirk , Daniel Amy ,   Society for Acute Medicine
Published: June 2021

It was great to see so many of you in SAM Manchester. We hope you found the conference worthwhile and found the trainee session really useful. With the trainee session we have tried to get a balance of something for trainees of all stages and thought a summary would be useful for those who couldn’t make it.
Journal Watch: August-October 2012
Authors:   Acute Medicine, St Marys Hospital, Newport, Isle Of Wight, Prescott Craig , Edwards Penelope ,   St Marys Hospital, Newport, Isle Of Wight
Published: June 2021

In this article we are presenting 4 articles of interest to acute physicians. We reviewed literature covering the period August to October 2012 in The New England Journal of Medicine, The BMJ and affiliated journals and JAMA and performed a medline search.
Instruments of Positive Transcultural Psychotherapy as a Model for Systemic Constellations
Authors: Kyrychenko Svitlana
Published: June 2021

The article is dedicated to methodological features of constellations in the positive psychotherapy method. Models of Positive Transcultural Psychotherapy determine the structure of personal differentiation, which could be used in constellations. According to the three levels of work in positive psychotherapy (situational, notional and basic), we could discuss constellations on the three different levels. This article represents a generalization of practical experience of using the constellations on the three levels of work in positive psychotherapy in group and individual psychotherapy as well.
The encyclopedia of agroecology and Indigenous wisdom: Reflections on McFadden’s Deep Agroecology
Authors: Boochever Alissa
Published: June 2021

Presenting an array of facts and an encyclopedia of ideas, Deep Agroecology: Food, Farms, and Our Future, by journalist Steven McFadden, urges the reader to activate their ‘spiritual understanding’ of agriculture in order to elevate all life on Earth. The author calls for nothing short of a spiritual awakening of all human beings to prevent further deterioration of the planet. As our climate falls into chaos, oceans warm, deserts grow, and the ice poles melt, McFadden argues, infusing and sustaining greater spirituality in farming practices is essential for the food system and farmers, for our culture, and for the health of the planet. McFadden’s goal with this book is not just to explore agroecology but to advocate for an additional “realm of critical mystery” (p. xiii) in our conception of farming. . . .
Evaluación del control interno como instrumento de gestión del inventario en las MIPYMES; farmacias veterinarias, distribuidoras y misceláneas en el municipio de Juigalpa, Chontales durante el año 2019
Authors: Urbina Arana Eveling Yahoska , Guevara Ruíz Álvaro José
Published: June 2021

El objetivo esencial de este artículo es relacionar el control interno como instrumento de gestión del inventario; farmacias veterinarias, distribuidoras y misceláneas de la cuidad de Juigalpa del departamento de Chontales. Los instrumentos que se utilizaron en el estudio: la entrevista, cuestionario que se aplicaron al contador, auxiliar de contabilidad y responsable de bodega acorde a las funciones contables, administrativas de las MIPYMES en referencia, para una muestra de nueve funcionarios que laboran en dichas empresas. Como deducción de los planteamientos los propietarios reconocen la utilidad de un buen manejo de los productos en sus almacenes para obtener un eficiente registro de las mercancías que se encuentran en resguardo bajo la custodia del personal encargado, para evitar daños, deterioro e irregularidades que ocasionen pérdidas significativas en su situación financiera.

Se determina que en estas entidades sus transacciones lo realizan de manera manual o automatizada: se lleva un reporte diario de los ingresos del día, las compras la efectúan a base de pedidos de acuerdo a las necesidades requeridas, aplican el sistema de inventario periódico adoptando el método promedio por lo que esto no ha sido suficiente para controlar las entradas y salidas de los productos es por eso que al final del cierre contable siempre se identifican faltantes, sobrantes y cruces de mercancías por lo tanto realizan ajustes respectivos para tener información oportuna, comparativa que permita determinar errores o  inconsistencia en el inventario como medida de control establecen realizar el levantamiento físico por lo menos una vez al año.