bluuebunny/crossref_metadata_2025 huggingface dataset:
Into the Night: Factors affecting response to abnormal Early Warning Scores out-of-hours and implications for service improvement
Authors:   Glangwilli Hospital, Carmarthen, UK, Yiu C J , Khan S U ,   Department of Gastroenterology, Ysbyty Gwynedd, Bangor, UK, P Subbe Christian ,   Acute, Respiratory & Critical Care Medicine, Bangor University & Ysbyty Gwynedd Hospital Bangor, Wales, Tofeec K ,   Diabetes and Endocrinology, Royal Blackburn Hospital, United Kingdom, Madge R A ,   Midcentral DHB, Palmerston North, New Zealand
Published: June 2021

Background: Early Warning Scores alert staff to preventable deterioration. Raised scores should lead to escalation of care. Aims: To establish response of staff to patients scoring National Early Warning Score (NEWS) of six or above and to identify patient and environmental factors affecting escalation by nursing staff. Methods: Service evaluation with prospective review of patient records of 118 beds on four medical wards during 20 night-shifts. Results: During 2360 observed bed days 109 patients triggered NEWS >=6 at least once during the observation period. Nursing staff escalated only 18 (17%) of these patients; nearly all of them had predefined chronic health conditions, the majority fulfilled criteria for frailty. Despite their higher 30-day mortality patients with COPD had lower escalation rates. Additionally wards that had more patients with a NEWS >=6 had lower escalation rates. Conclusion: Alarm fatigue and clinical judgement of staff might result in deviation from escalation protocols.
A giant cause of stroke
Authors:   Atkinson Morley Regional Neuroscience Centre, St Georges Hospital, Blackshaw Road, Tooting, London, Yin Kong Kelvin Ka , Mackinnon Andrew D ,   Atkinson Morley Regional Neuroscience Centre, St Georges Hospital, Blackshaw Road, Tooting, London, R Bridges Leslie ,   Atkinson Morley Regional Neuroscience Centre, St Georges Hospital, Blackshaw Road, Tooting, London, Cloud Geoffrey C ,   Atkinson Morley Regional Neuroscience Centre, St Georges Hospital, Blackshaw Road, Tooting, London
Published: June 2021

An 80 year old man presented subacutely with drowsiness and confusion. Subsequent MRI brain imaging demonstrated multiple posterior circulation infarcts. Extracranial vasculitis was suspected when his ESR was found to be high and vascular imaging showed multifocal irregular narrowing of both vertebral arteries. This was confirmed by targeted temporal artery biopsy, which showed chronic granulomatous inflammation typical of giant cell arteritis (GCA). The patient made a significant recovery following treatment with prednisolone.
Reversible Cerebral Vasoconstriction Syndrome: an important cause of thunderclap headache
Authors:   University of Manchester Medical School, Manchester, UK, Montague Emily , Murphy Christopher ,   Greater Manchester Neuroscience Centre, Salford Royal Hospital, Salford, UK
Published: June 2021

Reversible cerebral vasoconstriction syndrome (rCVS) is an important cause of acute severe headache that is poorly understood and under-recognised. It typically presents with recurrent thunderclap headaches and is characterised by multifocal, segmental constriction and dilatation of the cerebral arteries, shown by a ‘string of beads’ appearance, on cerebral angiography. We describe a case of rCVS in a 39-year-old male presenting with post-coital thunderclap headaches following a whiplash-type injury.
Can someone call my PA?
Authors:   Acute Geriatrics, George Eliot Hospital NHS Trust and President of the UK Association of Physician Associates, Dowsing Teresa , Chellamuthu Palanichamy ,   Acute Medicine, George Eliot Hospital NHS Trust, Powell Natalie ,   Acute Medicine and Geriatrics, Surrey and Sussex Healthcare NHS Trust, Forbes-Pyman Rachel ,   Acute Medicine and Secretary of the UK Association of Physician Associates
Published: June 2021

The aim of this paper is to outline the background of the Physician Associate (known in the USA as physician assistant1) role in the USA and follow its recent journey to the UK where it is becoming a rapidly developing new healthcare role. Through the use of two case studies from UK Hospital Trusts who are currently utilising Physician Associates (PAs) in their workforce we describe the implementation and development opportunities for the role, with particular reference to their role in Acute Medicine teams of the future.
British Society of Echocardiogaphy Adult Accreditation: An Unrealistic Expectation for Acute Physicians?
Authors:   Acute Medicine, Musgrove Park Hospital, UK, Sanusi Idrisu
Published: June 2021

Acute medicine trainees can chose to pursue a specialist interest as part of their training. I decided to train in echocardiography and I’m currently close to attaining the BSE Adult Transthoracic Echocardiography Accreditation. I have found echocardiography a useful tool to rapidly answer important clinical questions and aid management of the acutely unwell patient. For example, an 85 year old was admitted with acute shortness of breath, hypoxia despite high flow oxygen and a normal CXR. A bedside echocardiogram revealed thrombi in the right atrium with mild right ventricular strain. A CTPA confirmed a saddle embolus and she was admitted to CCU as a precaution in case thrombolysis was required. In another case, a 75 year old was admitted to the emergency department after successful DC cardioversion for VF arrest 10 days post primary PCI for anterior STEMI. The post arrest ECG did not show new acute ischaemia. He had 2 further VT arrests with successful DC cardioverison to sinus rhythm. An echocardiogram revealed an acutely dilated right ventricle and he was thrombolysed for a high risk pulmonary embolus.
Problem based review: The patient presenting with hyponatraemia
Authors:   Acute and General Medicine, Walsall Hospitals NHS Trust, Walsall, West Midlands, A M Saeed Saad , Ahmad Saad ,   General Medicine, Alexandra Hospital, Redditch, West Midlands, Hayat Amer ,   Acute and Renal Medicine, Walsall Hospitals NHS Trust, Walsall, West Midlands, Saeed Marwa ,   The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, West Midlands
Published: June 2021

Hyponatraemia is the most common electrolyte anomaly and is associated with significant morbidity and mortality. Patients with severe hyponatraemia often present to acute medical units with non-specific symptoms which can progress to overt neurological manifestations. There are many causes of hyponatriaemia, the most common being drug-induced causes, particularly thiazide diuretics, and the Syndrome of Inappropriate ADH Secretion (SIADH). Initial assessment should include a careful evaluation of the patient’s volume status, which helps to identify the most likely cause. This article utilises a recent case which presented to our AMU to illustrate the importance of a careful and systematic assessment of patients presenting to hospital with hyponatraemia. The new vasopressin receptor antagonists are explored as an option for the management of severe hyponatraemia.
Successful treatment of massive pulmonary embolism using a pulmonary artery catheter during prolonged normothermic cardiopulmonary resuscitation
Authors:   Reinier de Graaf Gasthuis, Delft, The Netherlands, Dovern Elisabeth , Mende Marlene R. ,   Reinier de Graaf Gasthuis, Delft, The Netherlands, Elderson Niels J ,   Reinier de Graaf Gasthuis, Delft, The Netherlands, Ronner Eelko ,   Reinier de Graaf Gasthuis, Delft, The Netherlands, Visser Steven J Sleeswijk ,   Reinier de Graaf Gasthuis, Delft, The Netherlands
Published: June 2021

Massive pulmonary embolism has a high mortality rate. Standard treatment includes systemic thrombolysis. If this fails, surgical embolectomy or a percutaneous catheter-guided approach is advised in current guidelines. However, these treatment options might not be available in many non-tertiary care hospitals. We describe a case of a 25-year old woman with cardiac arrest from massive pulmonary embolism. She was treated with thrombus fragmentation using a pulmonary artery catheter and intra-pulmonary thrombolysis after failure of systemic thrombolysis along with 90 minutes of cardiopulmonary resuscitation (CPR). Neurological recovery was excellent and pulmonary pressure was normalized after one month. Besides catheter guided thrombus fragmentation and thrombolysis, we contribute the successful outcome to a combination of ultrasound-guided therapy, capnography-guided CPR, and “crew resource management” principles. Our case illustrates that a pulmonary artery catheter can be used successfully in a non-tertiary setting, to perform a percutaneous procedure during CPR and that full neurological recovery is possible after 90 minutes of CPR.
Over-diagnosis and other crises facing evidence-based medicine
Authors:   Aberystwyth University, Aberystwyth, UK, Llewelyn Huw
Published: June 2021

There is a crisis in ‘evidence-based medicine’ (EBM). Reviewers and meta-analysts have become aware that much of their work may be futile because some investigators only publish selected results that favour their own point of view. Such reviews can only be reliable if there is access to all the raw data or if everyone is compelled to publish ‘negative’ results too. This is proving difficult and controversial. The latest example is dabigatran, which was hailed as a safe advance that needs no coagulation monitoring. It seems that the reduced frequency of bleeding if there is coagulation monitoring was not reported. There is also widespread uncertainty about the thresholds for treatment. This has been highlighted in the ‘over-diagnosis campaign’ to address a concern that many patients are subjected to harm without much benefit. Many see the problem as one of vested interest e.g. where those who gain from supplying a treatment will tend to advocate a low threshold for treating whereas those who wish to reduce costs or effort prefer to set high thresholds. The evidence needs to support what is best for the patient and gathered by those who care for them e.g. acute medicine physicians.
A patient with pleuritic chest pain and abnormal blood clotting tests
Authors:   Cardiology SpR, Darlington Memorial Hospital, Vamvakidou Anastasia , Konstantinou Dimitris ,   Bishop Auckland Hospital, Salam Sohail ,   Bishop Auckland Hospital, Mahmoud Mohsen ,   Darlington Memorial Hospital
Published: June 2021

We present the case of a 58 year old man who developed pleuritic chest while an in-patient; investigations revealed pulmonary embolism, despite a significantly raised Activated Partial Thromboplastin Time (APTT), which was subsequently attributed to Antiphospholipid syndrome (APS). The diagnosis and initial management of APS in the acute setting is discussed.
Why I decided to #TakeAIM
Authors:   Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, Skene Hannah
Published: June 2021

I’ve been a consultant Acute Physician for just a few years, but I can honestly say that I have no regrets in choosing AIM as my specialty. In 2005 I applied to be one of the first AIM specialty trainees in my region. At the time, some were very keen to tell me that it was a risky choice to make, and asked me “are you sure you don’t want to do a ‘proper’ specialty”?
A patient with palpitations (Answers)
Authors:   Portsmouth Hospitals NHS Trust, Philip Legate , Longman Kristel ,   Cardiology Queen Alexandra hospital, Portsmouth, Andrews Neil ,   Portsmouth Hospitals NHS Trust
Published: June 2021

Ventricular tachycardias represent an important cause of palpitations. The differentiation of “benign” or “idiopathic” ventricular tachycardias from those which require more aggressive pharmacological and device therapy is an important diagnostic step and requires careful history taking, clinical examination and ultrasound evaluation of both left and right ventricular function.
Ovarian Hyperstimulation Syndrome on the Acute Medical Unit: A problem-based review
Authors:   Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, Carter Rebeca , Petrie Kyle ,   Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, Sadighi Ashkan ,   Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, Skene Hannah ,   Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH
Published: June 2021

Ovarian Hyperstimulation Syndrome (OHSS) is a spectrum of clinical features typically resulting from assisted conception techniques. With 2.35% of all live births in the UK resulting from in-vitro fertilisation (IVF), OHSS is on the rise. Moreover, there has been an increase in the presentation of its complications to GP surgeries and unscheduled acute care services nationwide. This review will discuss signs and symptoms of the increasingly common and potentially fatal complications of OHSS, namely pleural effusion, ascites and thromboembolic events. With such propensity toward critical, life-threatening events it is not only prudent to recognise the population at risk, but also to be aware of the signs, symptoms and complications to expedite treatment and ensure optimum outcome.
An Unusual Presentation of Lyme Neuroborreliosis
Authors:   General Medicine Victoria Hospital, Kirkcaldy, Kitto Laura , McKenna Chris ,   Victoria Hospital, Kirkcaldy
Published: June 2021

Back pain is a common symptom among patients presenting to the acute medical unit. We describe the case of a 55-year-old man with a brief history of fatigue and severe back pain, unresponsive to escalating doses of opiate analgesia. Blood tests and imaging studies were unremarkable and a functional diagnosis was considered. Several weeks into his admission he developed a lower motor neurone facial nerve palsy. He was treated with antibiotics for an incidental finding of a hospital-acquired pneumonia on imaging, which remarkably led to the resolution of his facial palsy and allowed a dramatic reduction in analgesia. This triggered further investigations; identifying Lyme neuroborreliosis as the cause of his symptoms.
Trainee Update March 2015
Authors:   Acute Internal Medicine Surrey and Sussex NHS Trust, Smallwood Nicholas , Conway Nerys ,   Society for Acute Medicine National Trainees’ Representatives
Published: June 2021

We are trying to build a database of regional Acute Internal Medicine (AIM) trainee reps so we can get a better idea of regional training issues to feedback to the SAC (the national training committee). If any of you could drop us a quick e-mail to the addresses below with the name of your Deanery representative, along with any current issues it would greatly help us on our way!
Doctors’ Knowledge of Viral Haemorrhagic Fevers
Authors:   Barnet Hospital, Royal Free London NHS Foundation Trust, Wellhouse Lane, Barnet, Lisk Clifford , Snell Luke ,   Royal Free London NHS Trust, Haji-Coll Michael ,   Barnet Hospital, Royal Free London NHS Foundation Trust, Wellhouse Lane, Barnet, Ellis Jayne ,   Royal Free London NHS Trust, Sufi Saaidullah ,   Barnet Hospital, Royal Free London NHS Foundation Trust, Wellhouse Lane, Barnet, Raj Rohit ,   North Middlesex University Hospital NHS Trust, Sterling Way, Sharma Avinash ,   Luton and Dunstable Hospital, NHS Foundation Trust, Smith Colette ,   Epidemiology and Medical Statistics, University College London, Royal Free Campus
Published: June 2021

Viral Haemorrhagic Fevers (VHF) such as Ebola Virus Disease (EVD) are of increasing concern of increasing concern to clinicians and public heath bodies across Europe and America due to the on-going epidemic in West Africa. We conducted an online study to assess clinicians’ knowledge of VHF across six hospital sites in London. This showed suboptimal knowledge of Public Health England guidance, EVD epidemiology and the risk factors for acquiring VHF. Knowledge about VHF was dependent on seniority of grade with the most junior grade of doctors performing worse in several areas of the survey. Poor knowledge raises concerns that those at risk of VHF will be inappropriately risk stratified and managed. Education of doctors and other healthcare professionals about VHF is necessary to address these knowledge gaps.
How do junior doctors spend their time in an Acute Medical Unit?
Authors:   Acute Internal Medicine, Clinical Fellow in Leadership and Simulation, Yorkshire and Humber Deanery, V Kasfiki Eirini , Yusaf Mamoon ,   Department of Anaesthesia, Clinical Fellow in Leadership and Simulation, Yorkshire and Humber Deanery, Gosai Jivendra ,   Department of Cardiology, Clinical Fellow in Leadership and Simulation, Yorkshire and Humber Deanery, Purva Makani ,   Hull and East Yorkshire NHS Trusts, Anlaby Road, Hull, East Riding of Yorkshire
Published: June 2021

In the UK, postgraduate training for doctors has undergone significant changes over the past decade general practice, etc. During this period, hospital admission rates and bed occupancy have also increased.
Pleuro-Peritoneal Fistula – An Important Condition to Consider in Patients using Peritoneal Dialysis
Authors:   Acute Medicine, West Middlesex Hospital, Shah Shreena , Robson Natalie ,   Acute Medicine, The Medical Admissions, Unit Queens Hospital, Sajid Salman ,   Physiology and Nephrology, Queens Hospital
Published: June 2021

Pleural effusions are a common finding in patients admitted on the medical take. This case decribes a patient using peritoneal dialysis who presented with progressive dyspnoea. Clinical examination and chest x-ray confirmed the presence of a pleural effusion. Thoracocentesis confirmed a ‘sweet’ effusion (higher pleural: serum glucose content), suggesting a pleuro-peritoneal leak. Optimal management involved switch from peritoneal to haemodialysis and referral to a specialised renal unit. This case highlights the need to consider the diagnosis of pleuro-peritoneal leak in patients using peritoneal dialysis who present to the acute medical unit with pleural effusion.
Problem-Based Review: Non Vitamin K Antagonist Oral Anticoagulants for the Acute Physician
Authors:   Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Thachil Jecko , Gagg James ,   Department of Emergency Medicine, Musgrove Park Hospital, Taunton
Published: June 2021

Non-vitamin K antagonist oral anticoagulants (NOACs), are direct anticoagulants which inhibit specific coagulation factors and function as anticoagulants. Three NOACs are currently licensed in the United Kingdom: dabigatran, a thrombin inhibitor, and rivaroxaban and apixaban, antagonists of factor Xa. They are set to change the anticoagulant landscape, which was previously ruled by warfarin and heparins. Their advantages including oral formulations, rapid onset and offset of action, predictable pharmacokinetics, no requirement for routine blood monitoring or dose adjustment and very few drug interactions. The increasing use of these drugs means the acute medicine physicians are likely to encounter patients who have been taking them. This article reviews some of the challenging clinical situations in which this may arise.
Poor drug history documentation in admission medical notes: clerking prompts and junior doctor education alone do not significantly reduce errors
Authors:   Mid Essex Hospitals NHS Trust, Richards Marie , Espitalier-Noel Dominic ,   Mid Essex Hospitals NHS Trust, Broomfield, Essex, Stacey Hannah ,   Norfolk and Norwich University Hospital, Norwich, UK, Thomerson Jessica ,   Mid Essex Hospitals NHS Trust, Broomfield, Essex., Butt Tehreem ,   Mid Essex Hospitals NHS Trust, Broomfield, Essex.
Published: June 2021

Introduction: Poor drug history documentation on admission may lead to medication errors; a leading cause of avoidable harm. Aims: To assess the quality of drug histories in the notes of patients admitted to an emergency assessment unit and impact of interventions to improve documentation. Methods: Data were collected on the accuracy of documentation in 281 drug histories including errors of omission, frequency and dose. Results: The mean error rate was high at more than five per drug history. Omitted drugs included warfarin and long-term steroids, the consequences of which were potentially serious. Clerking prompts and education alone did not improve errors significantly. Conclusion: The error rate in drug histories is unacceptably high. More research is needed to explore factors involved in such documentation errors.
Acquired haemophilia: an easy diagnosis to miss in a patient taking warfarin
Authors:   Manchester Medical School, Talapatra Avraneel , Nash Michael J. ,   Manchester Royal Infirmary, Hay Charles R. M. ,   Manchester Royal Infirmary, Thachil Jecko ,   Manchester Royal Infirmary, Manchester University NHS Foundation Trust
Published: June 2021

Acquired Haemophilia (AH) is an autoimmune bleeding disorder, which despite being rare, can be fatal. It occurs in patients with previously normal haemostasis who spontaneously develop IgG autoantibodies against factor VIII. Unlike congenital haemophilia, it manifests as spontaneous bleeding into skin and soft tissues. The presentation can be masked in patients who are receiving warfarin where the bleeding is often attributed to warfarin therapy, as in the case described in this report. Consideration of AH is important in patients taking anticoagulants, when coagulopathy and bleeding fails to correct with usual measures.
Can Ambulatory Emergency Care have a positive impact on acute services?
Authors:   Northwest Deanery, Narayan N , Gulliford Stephen Richard ,   Trafford General Hospital, Moorside Road Davyhulme, Manchester M41 5SL
Published: June 2021

Ambulatory Emergency Care is a key component of the service for many Acute Medical units across the United Kingdom. A well-functioning ambulatory care unit facilitiates early senior review by a consultant and may reduce the need for hospital admission by managing patients along alternative safe clinical pathways. In this article, we present 12 months of data (January 2014-January 2015) from our Ambulatory Unit at Wrightington, Wigan and Leigh NHS Foundation Trust (WWL NHSFT), which demonstrates how many different conditions can be safely managed along ambulatory care pathways and how this can significantly contribute to postive patient satisfaction survey results and meeting the A&E 4 hour target for a medium-sized Acute Trust such as WWL NHSFT. We also emphasise that the key factors of co-location of ambulatory care with the Emergency Department along with dedicated medical and nursing staff are essential to the success of this model of care.
Society for Acute Medicine Benchmarking Audit 2015: The Patient Perspective
Authors:   University Hospital of Wales, Heath Park, Cardiff, Wales, Pradhan Sara , Ratnasingham Deysha ,   University Hospital of Wales, Heath Park, Cardiff, Wales, P Subbe Christian ,   Acute, Respiratory & Critical Care Medicine, Bangor University & Ysbyty Gwynedd Hospital Bangor, Wales, Stevenson Stuart ,   North Wales Cancer Forum, Ysbtyty Gwynedd, Penrhosgarnedd, Bangor, Ward David ,   Acute Medicine, Queen Elizabeth Hospital, Woolwich, Cooksley Timothy ,   Department of Acute Medicine, Manchester Royal Infirmary, Oxford Road, Manchester
Published: June 2021

Introduction:The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual national audit in the UK. Methods:In SAMBA 2015 patient feedback questionnaires were introduced to help measure the quality of patient experience on Acute Medical Units (AMUs) over a 24-hour period on 25th June 2015. Results: 55 AMUs submitted data on 945 patients, of these 824 (87.2%) would be extremely likely or likely to recommend the AMU. Patients below the age of 50 were less likely to recommend the admitting unit (p<0.013). Positive comments were three times more common than critical comments (976 vs 323). Categories of staff attitude, quality of communication, timeliness of care and catering were dominant themes. Conclusion:This survey has identified key themes for patients being managed on an AMU that can be used to guide future innovations.
Bad presentations
Authors:   Department of Paediatric Surgery, Sheffield Children’s Hospital, Western Bank, Sheffield, Fisher Ross
Published: June 2021

Which is more painful: an unsolicited PPI telephone call during clinic? Your hospital email on returning from two weeks annual leave? The strong realisation on waking at 3am that you have contracted norovirus like the rest of the team? Or a 10 minute powerpoint presentation? It’s the powerpoint. That is the most painful. And, painful as it might be and unlike the others, it is all your fault.
Trainee Report Winter 2015
Authors:   Acute Internal Medicine, Surrey and Sussex NHS Trust, Smallwood Nicholas , Krishnamoorthy Sanjay ,   Chelsea and Westminster Hospital
Published: June 2021

You will hopefully be aware that the first national takeAIM conference was run in Manchester on Saturday November 14th. It was attended by around 150 Foundation and Core trainees who had a morning of lectures followed by an afternoon of small group workshops, all for only £50. Feedback was very positive and will be used to shape future takeAIM events. These are likely to include regional and/or national conferences, alongside teaching workshops and possibly simulation events. For further information or to contact the fellows, please tweet (@take__AIM – remember there’s two underscores), or e-mail takeaim@acutemedicine.org.uk.
‘Non Surgical’ jaundice- how to manage on the medical take
Authors:   University Hospital Bristol, U.K., Portal AJ ,   University Hospital Bristol, U.K.
Published: June 2021

Malignancy and alcoholic hepatitis are cited as the most common causes of jaundice seen in secondary care. A patient with non-alcohol related jaundice, however, may require extensive investigations and early involvement of specialists. This article utilises a case presenting to the Acute Medical Unit, (AMU) to illustrate the importance of a careful and systematic assessment of non-alcoholic related jaundice.
Legal Highs, Lethal Lows
Authors: Shah Bhavini , Heaps Tom ,   Acute Medicine, St. James’ University Hospital, Beckett Street, Leeds
Published: June 2021

Novel Psychoactive Substances (NPS), sometimes referred to as Legal Highs, are newly available drugs with psychoactive properties that are not currently prohibited by United Nations Drug Conventions. Despite many of these compounds still being ‘legal’ and readily available via online mail-order companies and high-street ‘headshops’, their rapid emergence in the UK has been associated with increasing hospital admissions, enquiries on TOXBASE® and fatalities. It is therefore vital that Acute Physicians have a good understanding of the issues in recognizing, investigating and managing patients presenting to the AMU with toxicity due to legal highs. This article outlines the classification and effects of various novel psychoactive substances and presents a strategy for management according to the prevailing toxidrome.
A simple intervention to improve antibiotic treatment times for neutropenic sepsis
Authors:   Musgrove Park Hospital, Parkfield Drive, Taunton, Somerset, Botten Joanne , Beard J ,   Musgrove Park Hospital, Parkfield Drive, Taunton, Somerset, Zorzi A ,   Musgrove Park Hospital, Parkfield Drive, Taunton, Somerset, Thompson Andrew ,   Musgrove Park Hospital, Parkfield Drive, Taunton, Somerset
Published: June 2021

Objectives: Patients with suspected Neutropenic sepsis require rapid antibiotic administration, but despite extensive education, only 67% of patients received antibiotics within 60 minutes. Methods: A Neutropenic Sepsis Alert Card was created, as a Patient Specific Directive – this allows nurses to administer antibiotics to specific patients without prior medical review. Results: Since the intervention, 301 patients presented with suspected neutropenic sepsis. 277 patients (92%) received their first dose of intravenous antibiotics within 1 hour of arrival into hospital, compared to 95 out of 143 patients (67%) presenting between January and June of 2014 (p=0.036). Conclusion: The Neutropenic Sepsis Alert Card can significantly improve door to antibiotic needle time for chemotherapy patients with suspected neutropenic sepsis. This intervention is inexpensive and easily replicable in other health care organisations.
The Relationship between Resource Utilization, Clinical Risk and Hospital Costs for Emergency Medical Admissions
Authors:   St. Vincent’s University Hospital, Dublin 4., Cournane Seán , Byrne Declan ,   St James’s Hospital, Dublin 8, Ireland., O’Riordan Deirdre ,   St James’s Hospital, Dublin 8, Ireland., Fitzgerald Brian ,   St James’s Hospital, Dublin 8, Ireland., Silke Bernard ,   St James’s Hospital, Dublin 8, Ireland.
Published: June 2021

There has been little study of the relationship between resource utilisation, clinical risks and hospital costs in acute medicine with the question remaining as to whether current funding models reflect patient acuity. We examined the relationship between resource use for investigations/allied professional and patient episode costs in all emergency medical admissions admitted to our institution during 2008-2013. Univariate estimates were compared with a multivariate model adjusted for major cost predictors. Interestingly, the model adjusted cost estimates changed considerably when compared with univariate analysis. We used both linear and non-linear (quantile regression) methods due to the highly skewed nature of hospital costs. The data suggested that hospital episode costs were predictable and driven by objective measures of clinical complexity. The use of expensive investigations and healthcare professional time was secondary to the clinical acuity. Thus, cost was heavily weighted towards higher complexity, and lower resource utilisation associated with lower risk patient groups. However, the non-linear nature of the costings would caution against simple predictor models and non-linear techniques such as quantile regression may, as we have demonstrated, prove superior in defining the underlying relationships.
Measurement of generic patient reported outcome measures (PROMs) in an acute admission unit: A feasibility study
Authors:   VU University Medical Center, Amsterdam, The Netherlands, van Galen LS , van der Schors W ,   NIVEL Netherlands Institute for health services research, Utrecht, The Netherlands, Damen NL ,   NIVEL Netherlands Institute for health services research, Utrecht, The Netherlands, Kramer Mark H H ,   VU University Medical Center, Amsterdam, The Netherlands, Wagner C ,   VU University Medical Center, Amsterdam, The Netherlands, Nanayakkara Prabath WB ,   VU University Medical Center, Amsterdam, The Netherlands
Published: June 2021

Objective: Measuring patient-reported outcome measures (PROMs) is a challenge in Acute Admission Units (AAUs), where patients present with a variety of pathologies. Generic PROMs may be used to measure the quality of care in this population. The main objective of this study was to assess the feasibility of measuring generic PROMs in a Dutch AAU. Design: Longitudinal cohort study Setting: An AAU of a tertiary hospital in Amsterdam, the Netherlands Participants: 123 patients admitted to the AAU during 5 weeks in May and June 2015 Methods: Patients admitted to the AAU were asked to fill out a questionnaire relating to three time points: 7 days before, during, and within 2 weeks after admission. Additionally, patients were asked to report on their experienced level of safety on the AAU and the contribution of the AAU to their recovery. Results: There were significant trends in generic PROMs for all three domains. Physical functioning decreased during hospital admission and almost fully returned to the previous level after discharge. Satisfaction with social role and anxiety significantly decreased over time. Conclusions: Measuring generic PROMs in the AAU is feasible. The analysis of the PROMs took little effort and results could be reported back to the healthcare workers on the AAU quickly. Patients appreciated being asked about their own perceived health and the quality of care. Given that this is the first study focusing on PROMs in AAU patients in the Netherlands, future studies with larger sample sizes, and from other nations are needed to further investigate PROMs in this patient group to establish International reference values.
Acute Mitral Regurgitation: an important cause of respiratory distress
Authors:   Portsmouth Hospitals NHS Trust, Philip Legate , Andrews Neil ,   Portsmouth Hospitals NHS Trust
Published: June 2021

Acute mitral regurgitation (acute MR) is a rare cause of acute respiratory distress, which can present diagnostic challenges. We present the case of a 57 year old man who developed acute shortness of breath subsequently associated with fever, raised white cells and elevated CRP. Chest x-ray revealed unilateral shadowing and he was treated for pneumonia, despite the finding of severe mitral regurgitation on echo. Failure to respond to antibiotic treatment following 3 weeks on ITU led to the consideration of acute MR as the cause of his symptoms and he responded well to diuretics. He subsequently underwent mitral valve repair. The causes and clinical presentations of this condition are discussed.
On increasing the power of presentations (p cubed)
Authors:   Dept of Paediatric Surgery Sheffield Children’s Hospital, Western Bank, Sheffield S10 2TH, Fisher Ross
Published: June 2021

In Medicine we believe our practice is evidence based and effectual. We review our results, keep abreast of the literature and make changes as knowledge evolves. Most presenters believe the same for their presentations. The majority of presentations directly contradict well established psychological principles, aspire to a level around them only of mediocrity and are almost uniformly ineffectual. Worse than this, we instruct our colleagues to present in the same way.
So you want to talk about sex? – a brief guide to taking a sexual history for Acute Physicians
Authors:   Sexual Health & HIV medicine Wrexham Maelor Hospital Betsi Cadwaladr University Health Board North Wales, Williams Olwen E
Published: June 2021

It’s a Monday morning; the week-end has seen the re-admission of a retired teacher with a dry cough, increasing dyspnoea and no physical signs. His chest X-ray ten days previously didn’t show any abnormalities. The course of amoxicillin given by his GP has not helped. He has an oxygen saturation of 89% at rest. Something doesn’t add up?
Persistent dysphagia and drowisness following collapse in an alcohol-dependent patient (Answers)
Authors:   University of Hull and the Hull York Medical School, Department of Respiratory Medicine, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ., Bodington Richard , Werpachowska Anna ,   Hull and East Yorkshire Hospitals NHS Trust, Department of Respiratory Medicine, Hull, United Kingdom, Faruqi Shoaib ,   Department of Respiratory Medicine, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefiled, WF1 4DG, Maliakal Paul ,   Hull and East Yorkshire Hospitals NHS Trust, Department of Radiology, Hull, United Kingdom
Published: June 2021

This T2 weighted MRI scan demonstrates a hyperintense trident shaped lesion extending from the pontomedullary junction to the midbrain with peripheral sparing (figure 2 – abnormality indicated by white arrows).
https://staging.acutemedjournal.co.uk/investigating-for-pulmonary-embolism-in-pregnancy-five-year-retrospective-review-of-referrals-to-the-acute-medical-unit-of-a-large-teaching-hospital/
Authors: Brougham T , Gillett C , Powter L ,   Southmead Hospital Southmead Way Bristol Avon BS16 1LE
Published: June 2021

Aims: To create a system to co-ordinate the medical take, bed management and track patient flow. To use the system to continuously audit against Society for Acute Medicine Quality Indicators. To use the data to model patient flow and optimize working patterns to improve waiting times. Method: An online whiteboard and underlying database system were designed, tested and implemented. Data from this system were used to audit against SAM Quality Indicators and then analysed to optimise both trainee and consultant working patterns. Results: The online whiteboard proved effective and popular as a working tool. Data collection improved using the electronic system. Optimising junior doctor working patterns to match demand led to a reduction of average waiting time to see a doctor from 190 minutes to 71 minutes (p < 0.0001), and a reduction in the proportion of patients waiting over 4 hours from 40% to 10% (p < 0.0001). Optimising consultant working patterns did not produced significant changes in waiting times. Conclusions: The online whiteboard improved day-to-day working and data collection, when compared to the previous paper-based system. Better data facilitated analysis of working patterns leading to a significant improvement in patient waiting times.
Investigating for pulmonary embolism in pregnancy: Five year retrospective review of referrals to the acute medical unit of a large teaching hospital
Authors: Hamilton Elizabeth Janette , Green Alistair Quentin ,   James Paget University Hospital NHS Foundation Trust, Cook Jennifer Ann ,   Norfolk and Norwich University Hospital NHS Foundation Trust, Nash Henry ,   West Suffolk NHS Foundation Trust
Published: June 2021

This was a retrospective review of five years’ data relating to patients referred to the Acute Medical Unit (AMU) of a large teaching hospital with suspected Pulmonary Embolism (PE) during pregnancy or 6 weeks postpartum. During this period, 210 patients in this group underwent half-dose perfusion scanning as investigation for possible PE and were managed via our ambulatory pathway. Pulmonary embolism was diagnosed in 5.2% of patients compared to 18% of non-pregnant patients identified in a previous audit. Half-dose Q scanning enabled exclusion of PE in almost 90% of patients without the need for further imaging. A new local pathway for the investigation and management of PE during pregnancy has now been developed.
Unscheduled care admissions at end-of-life – what are the patient characteristics?
Authors: Mason Emma , Jenkins Debbie ,   Royal Gwent Hospital, Williams Meg ,   Nevill Hall Hospital, Davies James ,   Wales Deanery
Published: June 2021

Unscheduled acute hospital admissions and subsequent deaths in hospitals of patients considered palliative are increasing, despite many patients’ preference to die at home. A large proportion of these patients are admitted via acute medical units or emergency departments. The integration of primary and secondary care within Wales should enhance the delivery of end-of-life care at home but unscheduled admission for patients with palliative care needs remains prevalent. The aim of our study was to explore the characteristics amongst patients who die shortly after unscheduled hospital admission. A retrospective, observational study was conducted in all unscheduled admissions at end-of-life at a single health board in South Wales, UK over a period of one month. The result showed that 47% of patients who died within 48hrs of unscheduled admission are considered to be palliative. The majority of these patients were admitted via 999 ambulances and out of normal working hours (65%). They were elderly (median age 80) and had a poor performance status (78%). Over 1/3 (39%) were admitted from a nursing or residential home. Less than a quarter (22%) had an advance care plan in place.
An Acute Severe Headache
Authors:   Royal Bournemouth Hospital, Bournemouth, BH7 7DW, Azim Adnan , Spake C ,   Royal Bournemouth Hospital, Bournemouth, BH7 7DW, Raza T ,   Royal Bournemouth Hospital, Bournemouth, BH7 7DW
Published: June 2021

A previously fit and healthy 57 year old gentleman presented to hospital 2 weeks after a previous admission with acute severe headache. At the time of his previous admission the patient had reported that the headache was preceded by an unprovoked sharp pain in his back which had quickly resolved. The headache developed a few hours later and was noted to be markedly worsened by any attempt to sit upright, accompanied by intense nausea, and relieved by lying flat.
An unusual pathogen in ambulatory care: two cases of Scedosporium soft tissue infections presenting as “unresponsive cellulitis”
Authors:   University Hospitals Southampton NHS Foundation Trust, Lillie Patrick , Misselbrook Gary Peter ,   Hampshire Hospitals NHS Foundation Trust, Thomas Claire P ,   Hampshire Hospitals NHS Foundation Trust
Published: June 2021

Soft tissue infections with Scedosporium spp. are an uncommon but serious and emerging cause of infection in immunocompromised patients. Acute Medical Units (AMUs) in the UK are increasingly managing patients with cellulitis in an outpatient setting, therefore acute physicians should be aware of some of the more uncommon causes of soft tissue infection, particularly in patients not responding to initial antibiotic therapy. We present two cases of Scedosporium presenting to the AMU as cellulitis not responding to initial antibiotic therapy and outline the assessment and management of this important condition.
Acute Internal Medicine Trainee Survey 2016
Authors:   Surrey and Sussex NHS Trust, Smallwood Nicholas , Krishnamoorthy Sanjay ,   Chelsea and Westminster Hospital
Published: June 2021

Objectives: To ascertain the views of current Acute Internal Medicine (AIM) trainees on the strengths and weakness of the specialty, their training programmes, practical procedures and the provision of training days. Methods: Online electronic survey circulated to all Higher Specialty Trainees (HST) in AIM. Participation was voluntary and all answers confidential. A total of 108 trainees responded. Results: There were respondents from across the United Kingdom. The majority of respondents are happy or quite happy with their training (61%), with 11% unhappy or very unhappy. The variety of workload (68%), specialty exposure (69%) and practical procedures (67%) were strengths while lack of respect from other specialties (55%) and rota gaps (59%) remain significant problems. 53% of respondents feel they are expected to cover more rota gaps than their GIM colleagues, and 54% trainees feel they do not get a session a week allocated to them for specialist skill training/admin. Only 33% of trainees expect to get dedicated leadership and/or management training during their programme, and a large proportion of trainees (78%) feel that some form of ultrasound training should be a core part of the curriculum. Despite the difficulties, 85% of respondents would recommend AIM as a specialty. Conclusions: This survey highlights some of the positives and negatives of training in AIM, and highlights areas where potential improvements to programmes could be made. Comparison of the data with 2015 shows small improvements in a number of areas, but still some significant concerns remain. The findings were fed back to the Training Committee in March.
Providing a navigable route for acute medicine nurses to advance their practice: a framework of ascending levels of practice
Authors:   University Hospitals Birmingham, West Midlands, UK Institute of Clinical Sciences, The University of Birmingham, Birmingham, West Midlands, UK, Lees-Deutsch Liz , Christian Jan , Setchfield Ian
Published: June 2021

This article conveys concerns raised by delegates at the International SAM Conference (Manchester, 2015) regarding how to advance nursing practice in acute medicine. It endeavours to capture the essence of ‘how to advance practice’ and ‘how to integrate advanced practice’ within the workforce structures of an acute medicine unit (AMU). It addresses the production of tacit knowledge and the recognition and integration of this to developing the nursing workforce. The current context of NHS efficiencies and recruitment issues emphasize the value of retaining tacit knowledge. Uniquely, this article offers an early conceptual framework through which levels of advancement and potential transition points to advance nursing practice in acute medicine are articulated. Determining how to advance requires identification of prior accomplishments such as, tacit knowledge, experiential learning, CPD, specialist courses and management experience. This requires nurses to make judicious decisions to advance their practice and the distinction between ‘amassing experience’ and ‘career progression’. It aims to stimulate thinking around the practicalities of advancement, the value of tacit knowledge and potential realization through the framework trajectory.
An Acute Severe Headache
Authors:   Royal Bournemouth Hospital, Bournemouth, BH7 7DW, Azim Adnan , Spake C ,   Royal Bournemouth Hospital, Bournemouth, BH7 7DW, Raza T ,   Royal Bournemouth Hospital, Bournemouth, BH7 7DW
Published: June 2021

Severe headaches are a frequent presentation to the Emergency Department, accounting for around 1% of presentations. Of these, 13-16% will have a sinister underlying pathology but accurate diagnosis of headaches on the medical take remain difficult for non-specialists. A retrospective study from the UK found that, of those presenting to Emergency Department with sudden onset severe headaches, only 60% were given a specific headache diagnosis, with one third of these given their diagnoses despite an inadequate history.
Variation in Acute Medicine Units: Measuring it, understanding it, and reducing it
Authors:   Acute Medicine, NHS Forth Valley and National Clinical Lead, Whole Systems Patient Flow Programme, Scottish Government, Beckett Daniel J , Thomson Elaine ,   NHS Forth Valley, EM Reid Lindsay ,   Acute Medicine and Clinical Research Fellow, Royal College of Physicians of Edinburgh, C Lloyd Robert ,   Institute for Healthcare Improvement, Boston, USA
Published: June 2021

Although there are national recommendations on the function of Acute Medicine Units (AMUs), there is no single agreed best model of care. Additionally, robust data is not always available to determine whether system changes have resulted in improvement. We designed an Excel file to interface with the hospital patient management system to provide real-time data on a number of metrics including AMU length of stay (AMULOS), mortality and readmissions. This demonstrated that improving consultant continuity of care was associated with a reduction in AMULOS and reduced variation in AMULOS. Additionally, the Excel file provides timely access to consultant and individual patient-level data. These data are clinically owned, and critical for both unit governance and quality improvement work. We would encourage all AMUs to develop a similar dataset to allow standardised comparisons between units, and better understanding of the association between models of care and patient outcomes.
Can we predict Acute Medical readmissions using the BOOST tool? A retrospective case note review
Authors:   King’s College London, London, A Lee Geraldine , Freedman D ,   Acute Medicine, King’s College Hospital Department of Trauma, Emergency and Medicine 4th Floor, Hambleden Wing (North) King’s College Hospital Denmark Hill, London, Beddoes Penelope ,   Acute Medicine, King’s College Hospital Department of Trauma, Emergency and Medicine 4th Floor, Hambleden Wing (North) King’s College Hospital Denmark Hill, London, Lyness Emily ,   Acute Medicine, King’s College Hospital Department of Trauma, Emergency and Medicine 4th Floor, Hambleden Wing (North) King’s College Hospital Denmark Hill, London, Nixon Imogen ,   Acute Medicine, King’s College Hospital Department of Trauma, Emergency and Medicine 4th Floor, Hambleden Wing (North) King’s College Hospital Denmark Hill, London, Srivastava Vivek ,   Acute Medicine, King’s College Hospital Department of Trauma, Emergency and Medicine 4th Floor, Hambleden Wing (North) King’s College Hospital Denmark Hill, London
Published: June 2021

Background: Readmissions within 30-days of hospital discharge are a problem. The aim was to determine if the Better Outcomes for Older Adults through Safe Transitions (BOOST) risk assessment tool was applicable within the UK. Methods: Patients over 65 readmitted were identified retrospectively via a casenote review. BOOST assessment was applied with 1 point for each risk factor. Results: 324 patients were readmitted (mean age 77 years) with a median of 7 days between discharge and readmission. The median BOOST score was 3 (IQR 2-4) with polypharmacy evident in 88% and prior hospitalisation in 70%. The tool correctly predicted 90% of readmissions using two or more risk factors and 99.1% if one risk factor was included. Conclusion: The BOOST assessment tool appears appropriate in predicting readmissions however further analysis is required to determine its precision.