bluuebunny/crossref_metadata_2025 huggingface dataset:
Direct and delayed admissions to ICU in older medical patients
Authors:   Maastricht University Medical Centre, Maastricht University, Maastricht, the Netherlands, Bosch Milou , Zwietering N Anne ,   Maastricht University Medical Centre, Maastricht University, Maastricht, the Netherlands, Borggreve Hella F. ,   Department of Internal Medicine, division of General Medicine, section Acute Medicine, Maastricht University Medical Centre, Maastricht University, School of CAPHRI, Maastricht, the Netherlands, Pijpers Evelien ,   Department of Internal Medicine, division of General Medicine, section gerontology, Maastricht University Medical Centre, Maastricht University, Maastricht, the Netherlands, Stassen Patricia M. ,   Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, 6229 ER Maastricht, the Netherlands.
Published: June 2021

The aims of this retrospective cohort study were to retrieve characteristics and outcomes of older (65+) medical patients who are directly admitted to ICU from the ED and to compare these with those admitted to ICU from a ward. Of 1396 patients, 21 (1.5%) were directly admitted to ICU and 54 (3.9%) after a delay. Blood pressure was lower and respiratory rate higher in the direct than in the delayed group. The direct group had lower mortality (28-day: 19.0 vs. 38.9%, p=0.14; 1-year: 42.9 vs. 66.7%; p=0.06), shorter length-of-stay and returned more frequently to independent living than the delayed group. Only a fraction of older patients are admitted to ICU; directly admitted patients tend to have better outcomes.
Iliofemoral deep vein thrombosis and the problem of post-thrombotic syndrome
Authors:   Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Denny Nicholas , Musale Shreshta ,   Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Edlin Helena ,   Department of Vascular Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Thachil Jecko ,   Department of Haematology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Serracino-Inglott Ferdinando ,   Department of Vascular Surgery, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
Published: June 2021

Deep vein thrombosis (DVT) is an important cause of short-term mortality and long-term morbidity. Among the different presentations of DVT, thrombus in the iliofemoral veins may be considered the severest form. Although anticoagulation is the mainstay of the management of iliofemoral thrombosis, despite adequate anticoagulant treatment, complications including post-thrombotic syndrome is not uncommon. The latter is often overlooked but can cause considerable morbidity to the affected individuals. Preventing this condition remains a challenge but recent clinical trials of catheter directed thrombolysis and elasticated compression stockings provide some advance in this context. In this article, with the aid of a clinical case, we review the particular considerations to take into account when managing patients with an iliofemoral DVT.
Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography
Authors:   William Harvey Hospital (East Kent Hospitals University NHS Foundation Trust), Parulekar Prashant , Harris Tim ,   Hamad Medical Centre Doha, Qatar
Published: June 2021

Both hyper and hypovolaemia have been associated with poor outcomes. Assessment of fluid responsiveness is challenging in the acute medical patient, due to time constraints, limited evidence and quite often the lack of accurate assessment tools on the Acute Medicine Unit (AMU). This article explains how focused echo assessment is quick and easy to use for this purpose on the acute medical take and highlights key principles to bear in mind when assessing for hypovolaemia and whether to administer fluid therapy. The increasing familiarity with focused echo such as Focused Intensive Care Echocardiography (FICE) and Point Of Care Ultrasound (POCUS) makes extension of these skill sets to assess for fluid responsiveness a relatively straightforward next step for acute physicians.
Abnormal cardiac conduction in a septic patient: incidental finding or cause for concern?
Authors:   The James Cook University Hospital, Middlesbrough, United Kingdom, TS4 3BW, Jackson M , Balasubramaniam K ,   The James Cook University Hospital, Middlesbrough, United Kingdom, TS4 3BW
Published: June 2021

The initial ECG (figure 1A) demonstrates a regularly irregular rhythm at approximately 80bpm. There is a profound first-degree atrioventricular(AV) block with a PR interval of over 400ms. There is monomorphic ventricular ectopy in a right bundle branch pattern. The baseline QRS complexes are narrow.
Sub-acute herpes simplex virus myelitis in a patient with esophageal cancer on chemo-radiation with 5-fluorouracil: a case report
Authors:   Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, Samudrala Pavani , T Cruz-Carreras Maria ,   Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, Blum Murphy Mariela ,   Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, Rice Terry ,   Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
Published: June 2021

No reported cases to date describe herpes simplex virus (HSV) myelitis in association with cancer and chemo-radiation. We report a case of sub-acute HSV myelitis in a 54-year-old man receiving chemo-radiation with 5-flourouracil for esophageal cancer who presented to the emergency department with increasing numbness in both lower limbs that gradually spread to waist level. Magnetic resonance imaging with gadobutrol contrast 1 week later showed transverse myelitis involving the dorsal columns. Radiation-induced myelitis was suspected, and the patient was initially treated with dexamethasone; however, CSF analysis revealed HSV myelitis. Treatment with antivirals resolved much of the numbness. HSV myelitis can be confused with complications of radiation or malignancy in patients presenting with focal neurological deficits.
A case of Osmotic demyelination syndrome despite normal rate of Sodium correction with good recovery
Authors:   Department of Diabetes & Endocrinology, Hull Royal Infirmary, Mongolu Shiva
Published: June 2021

The Osmotic demyelination syndrome (ODS) primarily occurs with rapid correction of severe hyponatraemia that has been present for more than two or three days. Some patients are, however at risk and can develop ODS at higher sodium concentration and lower rates of correction. A case of Osmotic demyelination Syndrome which developed despite an ‘optimal’ rate of correction of serum Sodium with good clinical outcome is described. The risk factors that contribute to development of ODS and strategies to prevent this complication are discussed, along with recommendations on how to manage this condition in hospital inpatients.
Exploring the value of routinely measured hematology parameters for identification of elderly patients at high risk of death at the Emergency Department
Authors:   Emergency Department, University Hospital of Basel, Switzerland., Nickel CHl
Published: June 2021

Emergency Department, University Hospital of Basel, Switzerland.
The prognostic implication of the SOFA score on acutely admitted medical patients
Authors:   Department of Surgery, Vejle Hospital, Holm Louise , Brabrand Mikkel ,   Department of Emergency Medicine Odense University Hospital
Published: June 2021

Objectives: To investigate the prognostic implication of the SOFA score on all acutely admitted medical patients, to see how well it could predict 30-day mortality and ICU- admission. Main outcome measures: Discriminatory power was calculated as AUROC. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit. Results: AUROC for 30-day mortality was 0.68, (95% CI, 0.64 to 0.71) and ICU admission 0.71, (95% CI, 0.66 to 0.76). Goodness of fit for 30-day mortality and ICU admission was acceptable. Conclusions: The SOFA score showed average ability to predict 30-day mortality and ICU admission with acceptable calibration. When substituting GCS with AVPU the performance of the SOFA score was unacceptable.
Delayed onset pulmonary edema following toxic smoke inhalation; a systematic review
Authors:   Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark, Björkbom Daniel M. , Brabrand Mikkel ,   Department of Emergency Medicine Odense University Hospital
Published: June 2021

Background: Fire smoke inhalation cause a wide range of symptoms immediately or after a relatively asymptomatic period. In this review, we will focus on delayed onset pulmonary edema (DOPE); the incidence and duration of potential delay. As the symptoms may not present immediately, seemingly healthy patients could be inadvertently be sent home. Therefore, many authors recommend observation for 6-24 hours depending on the extent of inhalation injury. Methods: A systematic literature search in Embase, Medline, and Cochrane library was performed on 14 April 2016. All studies describing smoke exposure and delayed pulmonary edema were included. Additional relevant studies were identified snowballing based on included studies. Results: We included seven studies, with a total of 135 patients, describing pulmonary edema. Symptoms generally developed after a relatively asymptomatic period (up to 36 hours post-injury) until mechanical ventilation was needed. However, pulmonary edema developing after 36 hours was most likely due to other factors related to burn injury (excessive intravenous fluids, de novo heart failure, infection or problems related to intubation). Conclusion: Delayed onset pulmonary edema can develop as late as 36 hours postinjury after a relatively uneventful phase. But it would have been rare to have been completely asymptomatic before developing pulmonary edema.
Early Supported Discharge for patients with febrile neutropenia – Experience at a large district hospital in the UK
Authors:   Taunton and Somerset NHS Foundation Trust, Brunner Clair I. W. , Botten Joanne ,   Taunton and Somerset NHS Foundation Trust, Wennike Nic ,   Taunton and Somerset NHS Foundation Trust, Ford Lucy ,   Taunton and Somerset NHS Foundation Trust, Michaels Kathryn ,   Taunton and Somerset NHS Foundation Trust, Stephens Anna ,   Taunton and Somerset NHS Foundation Trust, Baker Robert ,   Taunton and Somerset NHS Foundation Trust
Published: June 2021

Neutropenic sepsis can be life threatening, with mortality 2-21%. The heterogeneity of patients referred with “suspected neutropenic sepsis” has led to strategies being developed to risk-stratify patients and identify those with a low risk of septic complications that could be managed in the outpatient setting, such as The Multinational Association for Supportive Care in Cancer score (MASCC). Outcomes for patients referred with suspected neutropenic sepsis were assessed before and after use of MASCC guided early-supported discharge. 50/123 (41%) patients over 24 months were eligible for early-supported discharge. 26/50 patients had same-day discharge, 14 had overnight admission, 8 stayed 2 nights and 2 stayed 3 nights. Patients received on average 2 follow-up telephone consultations. There were 5 readmissions (10%) and no adverse events. In comparison group; 8 patients over 3-months would have been suitable, potentially saving 40 bed-days. This shows MASCC guided early-supported discharge is safe and cost-effective.
Case based review: Toxicology on the Acute Medical Unit
Authors:   Acute Internal Medicine and Intensive Care Medicine Trainee in London Deanery, Achilleos A , Collas Oliver ,   London Deanery, Murch Nicholas ,   Royal Free Hospital, Pond Street, London, NW3 2QG
Published: June 2021

Accidental and intentional poisoning from prescribed, illicit and organic substances remains a major cause of morbidity and mortality worldwide and accounts for just under 1% of the total number of NHS hospital admissions, or around 170,000, a year in the UK. A knowledge of the constellation of signs and symptoms that constitute specific poisonings (referred to as toxidromes) may enable early empirical decontamination, antidote administration, enhanced elimination and supportive care, and may also help to predict the clinical course. This paper presents a series of clinical vignettes to demonstrate emerging presentations in toxicology to help inform the practice of Acute Physicians, who alongside colleagues in Emergency Medicine and Critical Care, are at the front line of diagnosing and treating poisoned patients.
Cerebral Nocardiosis: A Rare Cause of Hemiplegia in the Acute Medicine Unit
Authors:   Department of Medicine, Mater Infirmorum Hospital, Belfast, Liu HuaJian , Simms H Neil ,   Neurosurgery Unit, Royal Victoria Hospital, Belfast, Herron Brian ,   Neuropathology Department, Royal Victoria Hospital, Belfast, Hedderwick Sara ,   Infectious Disease Service, Royal Victoria Hospital, Belfast, Loughrey Anne ,   Department of Microbiology, Royal Victoria Hospital, Belfast, Lindsay John R ,   Department of Medicine, Mater Infirmorum Hospital
Published: June 2021

Nocardiosis, a rare infection occurring mostly in immunosuppressed patients can present with neurological complications including cerebral abscess formation, and is associated with high morbidity and mortality. We describe the case of a 54-year-old immunocompetent man with cerebral nocardiosis, who presented with sudden onset hemiparesis in an acute medicine unit. He required three craniotomies with excision, following failure to respond to antimicrobial therapy, with subsequent clinical improvement and radiological resolution of multiple cerebral abscesses. Challenges in diagnosis and management of hemiparesis in the acute medical unit are discussed. Successful management of cerebral nocardiosis require early communication with a neurosurgical unit, neuropathology and microbiology services to optimise management with targeted antimicrobial therapy.
Case Report: Brachial Neuritis in a Patient with Epstein Barr Virus
Authors:   Barnet Hospital, Royal Free London NHS Foundation Trust, Downing Lindsay , Cane Isobel ,   Barnet Hospital, Royal Free London NHS Foundation Trust, Jacobs Philip ,   Barnet Hospital, Royal Free London NHS Foundation Trust
Published: June 2021

A 41 year-old man, recently returned from Thailand, presented with bilateral shoulder pain and weakness, fever greater than 38 degrees and coryzal symptoms. He had no significant past medical history. He had abnormal liver function tests and an abnormal electromyogram of his right upper limb. He was diagnosed with acute Epstein Barr virus infection, however cerebrospinal fluid was negative for the virus. At follow up after three months, the patient had persistent weakness of his right upper limb. The literature suggests neurological features present in up to 7.5% of patients with Epstein Barr virus, although argues this is underestimated with the virus often being overlooked as a cause of neurological symptoms.
The Source of the Problem
Authors:   Queen Elizabeth University Hospital, Glasgow, Moffitt Peter , Williamson Adam ,   Queen Elizabeth University Hospital, Glasgow, Stenhouse Peter ,   Queen Elizabeth University Hospital, Glasgow
Published: June 2021

The portable chest x-ray (Figure 1) shows a widened cardiac silhouette. An endotracheal tube is in situ, indicating the patient is now intubated. The ECG (Figure 2) shows sinus rhythm with widespread mixed convex and concave ST elevation, most notable in V4, V5 and the lateral leads. There is a suggestion of PR depression in the inferior leads.
Death after Discharge – Every heart beat counts (probably)!
Authors:   Acute, Respiratory & Critical Care Medicine Bangor University & Ysbyty Gwynedd Hospital Bangor, Wales, P Subbe Christian
Published: June 2021

The assumption would be that patients who are discharged from an emergency or acute medicine department have been thoroughly assessed and are good to return to the safety of their own home. An unplanned death after discharge from hospital is the worst-case scenario for patients, families and indeed clinicians. In order to prevent adverse events after patients leave hospital most units have a multi-layered system to capture risk that includes triage, recording of vital signs, basic blood tests, understanding of existing past medical history and assessment by a senior clinician to add experience and intuition. Discharge decisions depend on a balanced review of all these parameters and a discussion with patients about residual risks. Only after this will patients go home. Despite this a small percentage of patients pass away unexpectedly within days after leaving hospital.
Acute management of cellulitis: A review
Authors:   Acute Medicine, Medical Assessment Unit, Queen Alexandra Hospital, Featherstone Peter , Brindle Richard , Williams O Martin
Published: June 2021

Cellulitis is an acute localised skin infection, usually accompanied by symptoms such as fever and rigors, nausea, and vomiting. It most commonly affects the lower limbs, although it can involve any part of the skin. It presents as area of redness and inflammation of the skin, with associated pain and swelling.
A Chest X-Ray causing confusion
Authors:   Acute Medicine, Great Western Hospital, Swindon, Novak Timea , Strait Catherine ,   Acute Medicine, Great Western Hospital, Swindon, Severn Deanery
Published: June 2021

A 91-year old female presented to Acute Medical Unit with a 2 week history of shortness of breath and haemoptysis. Her past medical history included osteoporosis, depression, irritable bowel syndrome, asthma, cataracts, and a colonic polypectomy. Her medications: Citalopram 10 mg, Co-codamol, Beclomethasone 200 mcg inhaler, Salbutamol MDI inhaler, Omeprazole 20 mg and Alendronic acid. She was an ex-smoker with a 20-pack year history who had stopped smoking 40-years ago. She did not drink alcohol and lived alone independently.
Malignant renal obstruction without dilatation
Authors:   University College London, Centre for Nephrology, Royal Free Hospital, London, United Kingdom, Mohidin Barian , Bass Paul ,   University College London, Centre for Nephrology, Royal Free Hospital, London, United Kingdom, Salama Alan ,   University College London, Centre for Nephrology, Royal Free Hospital, London, United Kingdom, Hamour Sally ,   University College London, Centre for Nephrology, Royal Free Hospital, London, United Kingdom
Published: June 2021

A 61 year old male presented with a one-week history of abdominal pain and loose stools. He had recently received treatment for cellulitis with flucloxacillin. He was anuric on presentation requiring haemodialysis. His ultrasound scan showed patent vessels with no signs of obstruction. A kidney biopsy revealed tubulointerstitial nephritis, attributed to recent treatment with flucloxacillin. A week later he developed lower limb thromboembolic disease triggering further investigations. A FDG PET-CT scan revealed a large FDG-avid retroperitoneal mass causing non-dilated obstruction of both kidneys. Bilateral retrograde stents were inserted which resulted in a 1.6L diuresis and cessation of haemodialysis. Non-dilated obstruction should be considered in anuric AKI, particularly in the context of malignancy, and may require a therapeutic trial of decompression.
Dealer’s Dytonia (Croupier’s Cramp) – An Unusual Hazard Of Gambling
Authors:   University College London, Newman Hannah , Angus-Leppan Heather ,   Clinical Neurosciences, Royal Free London NHS Foundation Trust, United Kingdom
Published: June 2021

Dystonia takes many forms and often presents acutely to emergency care. The diagnosis is often delayed because it mimics other more common conditions. This report describes a patient with a rare occupational dystonia, the typical clinical features of dystonia in general, and differentials to consider.
Shortness of breath: a common symptom with a rare cause
Authors:   Tameside General Hospital, Ghosh S
Published: June 2021

A 51-year old Caucasian male was admitted to the hospital with a history of breathlessness of one month duration. Prior to this he had been well. He complained that the shortness of breath had worsened over the previous 10 days and was associated with fatigue and fever. The antibiotics from his GP did not relieve his symptoms. He denied any cough, sputum or haemoptysis.
Altered kidney function on the Acute Medical Unit
Authors:   Salford Royal NHS Foundation Trust Division of Cardiovascular Sciences, University of Manchester, Green Darren
Published: June 2021

Reduced kidney function, whether acute or chronic, is a highly significant biomarker of in most clinical settings. This is particularly true on the acute medical take where altered renal function is associated with a worse prognosis, and may also impact on immediate management strategies such as drug choice, dosing and suspension, and the use of contrast agents for imaging. In this edition of the Acute Medical Journal, Yang et al present the results of their study describing the renal function and associated characteristics in 2,070 consecutive patients presenting on the unselected medical take at their hospital over a 40 day period. In this study, the authors provide a wealth of information on the general characteristics of acute medical patients admitted with altered kidney function, be it CKD or AKI. Importantly, both chronic kidney disease (CKD) and acute kidney injury (AKI) are very highly prevalent. Indeed, in this study more than 5% of all medical admissions actually demonstrated evidence of both.
An acute presentation of haemophagocytic lymphohistiocytosis due to visceral leishmaniasis in a British adult returning traveller
Authors:   Microbiology Department, Portsmouth Pathology Service, Queen Alexandra Hospital, Cosham, Hampshire PO63LY, Theodosiou Anastasia A , Hiew Hwai Jing ,   Portsmouth Hospitals NHS Trust, Petridou Christina ,   Portsmouth Hospitals NHS Trust
Published: June 2021

A 62-year old British Caucasian woman normally resident in Spain presented with fever and pancytopaenia after returning to the UK. Her symptoms persisted despite broad-spectrum antibiotics, and she gradually became confused, hypotensive and progressively more pancytopaenic. Imaging demonstrated hepatosplenomegaly, and a bone marrow aspirate confirmed a diagnosis of haemophagocytic lymphohistiocytosis (HLH). Bone marrow polymerase chain reaction (PCR) and blood serology were both positive for Leishmania donovani, consistent with visceral leishmaniasis (VL). Following treatment with dexamethasone and amphotericin, she improved clinically and biochemically, and was able to return to Spain. Fever in the returning traveller is a common acute medical presentation. Although HLH and VL are rare diagnoses, both carry a very high mortality rate if undiagnosed and untreated.
Delayed onset of liver injury after intentional chloroform overdose: a case report and literature review
Authors:   Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, Panetta Maria , Brightmore Alex ,   Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust, Waring W Stephen ,   Acute Medical Unit, York Teaching Hospitals NHS Foundation Trust
Published: June 2021

Chloroform is a recognised cause of acute liver injury, although now rarely encountered in clinical practice. We present a case of inhalational chloroform self-poisoning in a 47-year-old man that presented to hospital initially with reduced conscious level and later developed acute liver injury that was treated with intravenous acetylcysteine. This paper reviews the existing literature and presents a summary of the mechanisms of chloroform hepatotoxicity. Published cases show that there is a characteristic delay of 24 to 48 hours between chloroform exposure and elevation of liver transaminase activity. Therefore, clinicians need to provide an appropriate duration of monitoring in order to detect the occurrence of this important toxic effect.
Editorial Volume 18 Issue 4 – Decision-making in acute medicine
Authors:   University College London Hospitals, London, Lovell Ben
Published: June 2021

Acute physicians make patient-centred decisions at the start of the patient’s hospital journey. Dozens more decisions are made by the individual members of the MDT (and, of course, by the patient) during the in-patient period. Decisions are made at every level of seniority and experience and range widely in scope and impact. The original articles in this issue are connected by a common thread: phenomena that inform and influence the decisions made by acute physicians. How do you obtain adequate data to make sound decisions about individual patient care? It is often necessary to collate data around previous admissions and investigations at other healthcare institutions; a process fraught with complications. In this issue Ghelani et al1 undertook the onerous task of calling the main switchboard of all 175 acute hospitals in England on six occasions. Their aim was to identify how long it takes for an outside caller to finally contact a human operative who could put them through to the the correct person or extension. Most healthcare professionals will have some insight into the communication barriers that lie between practitioners in different hospitals, and the inordinate amount of time spent on the phone trying to gain patient information from another institution. The authors’ findings that automated messages and call steering systems impact significantly upon the time required for straightforward datagathering tasks should resonate with many for us. Hopefully, this study will provide substrate for future quality improvement efforts in the UK. How do you decide if your patient is well enough for transfer? The National Early Warning Score (NEWS) is now common currency in acute hospitals. This simple aggregate scoring system uses physiological parameters measures at the bedside and is used to inform assessments about patient acuity. There is currently significant research attention focused on the NEWS’ powers of prognostication. In a previous issues of this journal, we reported how vital sign abnormalities in the Emergency Department are predictors of poor outcomes (although not mortality) 2; monitoring of post-discharge vital signs in the community may predict readmission;3 and minor fluctuations in respiratory rate (in combination with other vital signs) may predicted clinical outcomes several days in advance.4 In this issue Subbe et all5 explore whether patients with low or unchanging NEWS scores are unlikely to deteriorate in future and could therefore be considered for transfer. How do you decide whether your patient requires intravenous fluids? In their qualitative study, Lloyd et al 6thematically analysed data from interviews with clinicians to better delineate the decision-making processes surrounding fluid therapy. They describe how doctors use vital signs, clinical presentation and their own gestalt, and – curiously – these approaches may be affected by the clinical environment and workload, and are not informed by local or national guidelines.
Higher In-Hospital Mortality in Patients with Nonspecific Complaints Presenting to the Emergency Department
Authors:   Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven, the Netherlands., Wachelder JJH , Stassen Patricia M. ,   Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, 6229 ER Maastricht, the Netherlands., Fourmanov RS ,   Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven, the Netherlands., Nickel CH ,   Emergency Department, University Hospital of Basel, Switzerland., Haak HR ,   Department of Internal Medicine, Máxima Medical Centre, 5631 BM Eindhoven, the Netherlands.
Published: June 2021

Background: Nonspecific complaints (NSC) at the Emergency Department (ED) are not well researched yet. Objective: To investigate the number of patients who could be classified as having NSC early after arrival in the ED using an algorithm. Method: Retrospective cohort study was conducted among all hemodynamically stable non-trauma adult patients with MTS category orange/yellow visiting the ED. Patients who had no specific complaints/signs, predefined on a list, were categorized as NSC. Results: In total, 2419 patients, of whom 102 (4.2%) presented with NSC. Hospitalization was more prevalent (85.3% vs. 69.0%, p<0.001) and in-hospital mortality was higher in the NSC-group (11.8% vs. 3.5%, adjusted OR 2.0, 95% CI 1.0-3.9, p=0.04). Conclusion: Using an algorithm it is possible to identify NSC patients who have (worse) outcomes than those classified as SC.
Purple Urine Bag Syndrome in a Patient with an Ileal Conduit and Clostridium Difficile Infection
Authors:   Imperial College London, Sadler Claudia , Brewer Cristopher Felix ,   Imperial College London, Khan Tehmeena ,   Acute Medicine Unit, University College Hospital, Euston Rd, Fitzrovia, London, NW1 2BU, Murch Nicholas ,   Acute Medicine Unit, Royal Free Hospital, Pond Street, London, NW3 2QG
Published: June 2021

Purple urine bag syndrome is a potentially alarming phenomenon caused by bacterial metabolism of urinary tryptophan into indigo (blue) and indirubin (red) pigments. We report the case of a 46-year-old female with an ileal conduit who presented with a 2 week history of abdominal pain and purple discolouration of her urine. In addition, we review the literature on purple urine bag syndrome, and identify potential new risk factors and management considerations.
Patient and Caregiver Experience of Hospital Discharge from an Acute Medicine Unit via the Discharge Lounge: A Qualitative Case Study
Authors:   Acute Medicine Unit, Heartlands Hospital, University Hospitals Birmingham, West Midlands, UK Institute of Clinical Sciences, The University of Birmingham, Birmingham, West Midlands, UK, Lees-Deutsch Liz , Gough Brogan ,   Department of Neurophysiology, St Woolos Hospital, Newport, Yorke Janelle ,   University of Manchester, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Oxford Road, Manchester, Caress Ann-Louise ,   School of Human and Health Sciences, The University of Huddersfield, Queensgate, Huddersfield
Published: June 2021

Discharge lounges enable the swift movement of patients imminently awaiting hospital discharge, to free beds without delay. This Qualitative Yin-Style Case Study describes the patient and caregivers experience of transition from an Acute Medicine Unit (AMU) to a discharge lounge and staff perspectives, as organisers of this process. Audiorecorded, interviews and focus groups were undertaken. Data were analysed using Framework Analysis. Lack of patientcenteredness in moving patients to the discharge lounge emerged with three themes: ‘moving the problem’; ‘being moved’ and ‘feeling removed’. Patients were transferred at accelerated speed. Communications between staff, patients and carers were abruptly curtailed. Patient transfer from AMU to a discharge lounge is a transitional stage in the acute discharge process and must be adequately communicated.
An unusual suspect for heart failure
Authors:   Department of Cardiology, The Alfred Hospital, Australia, Tan Christianne , C Patel Hitesh ,   Department of Cardiology, The Alfred Hospital, Australia, Mariani Justin ,   Department of Cardiology, The Alfred Hospital, Australia
Published: June 2021

A 71-year old retired missionary presented with a 2- week history of increasing dyspnoea, orthopnoea, and peripheral oedema. The patient had no previous significant past medical history. On clinical examination, his heart sounds were dual and his jugular venous pressure was elevated to 7cm. On chest auscultation there were bilateral crepitations at his lung bases.
A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study
Authors:   Emergency Department, Odense University Hospital, Bentsen Lasse Paludan , Lassen Annmarie Touborg ,   Emergency Department, Odense University Hospital and University of Southern Denmark., Titlestad Ingrid Louise ,   Department of Respiratory Medicine, Odense University Hospital, Brabrand Mikkel ,   Department of Emergency Medicine Odense University Hospital
Published: June 2021

Background: The aim of this study was to investigate 30-day mortality for COPD patients treated by ambulances in the period before and after implementation of a pre-hospital oxygen protocol. Methods: Prehospital High-flow oxygen was used from April to September 2012 and titrated oxygen from April to September 2013. Primary outcome was 30-day mortality. Results: 707 patients were included; 209 in the high-flow group and 498 in the titration group. Of these, 56 and 132 arrived with acute exacerbation (AE). Overall 30-day mortality was 11.5% vs. 9.4% (p=0.41), respectively. For patients with AE, it was 19.6% vs. 4.6% (p=0.001). Conclusion: Change of treatment protocol is associated with a lower 30-day mortality for patients registered with acute exacerbation, but not for all COPD patients.
Pneumomediastinum, subcutaneous emphysema and pneumorrhachis following cocaine insufflation: a case report
Authors:   Department of Emergency Medicine, York Teaching Hospitals NHS Foundation Trust, Burns Jill , Roby Allen ,   Department of Emergency Medicine, York Teaching Hospitals NHS Foundation Trust, Jaconelli Tom ,   Department of Emergency Medicine, York Teaching Hospitals NHS Foundation Trust
Published: June 2021

A case report on a 36-year-old male patient presenting to the emergency department (ED) with chest tightness, nasal sounding voice and subcutaneous emphysema 72 hours after the nasal insufflation of approximately 0.5g of cocaine. A plain radiograph of the chest demonstrated an extensive pneumomediastinum with subcutaneous emphysema extending into his neck. A computerised tomography (CT) scan confirmed the above findings, along with a pneumorrhachis of the thoracic spine. He was admitted locally for further investigation and observation. Cocaine is the second most used illicit drug in the UK. The associated complications of cocaine can vary from acute coronary syndrome to acute psychosis. Pulmonological trauma secondary to cocaine misuse is commonly associated with inhalation of cocaine; we present this rare case of subcutaneous emphysema, pneumomediastinum and pneumorrhachis secondary to nasal insufflation. It is believed that deep nasal insufflation of cocaine is followed by forceful Valsalva manoeuvre, which allows for the rapid absorption of the drug and increases the euphoric effect. This forceful inhalation can lead to barotrauma and leakage of air into the posterior mediastinum.
Abnormal Lung Point-of-Care Ultrasound (POCUS) in Suspected Cases of COVID-19 pneumonia with Normal Plain Chest Radiographs – A Case Series
Authors:   Acute Medical Unit, Royal Berkshire Hospital, Reading, UK, Owen Mort Daniel , Limbu Dipraj ,   Acute Medical Unit, Royal Berkshire Hospital, Reading, UK, Nunan Joseph ,   Department of Acute Medicine, Royal Berkshire Hospital, Berkshire, P. Walden Andrew ,   Department of Acute Medicine, Royal Berkshire Hospital, Berkshire
Published: June 2021

COVID-19 pneumonia produces a heterogeneous array of clinical, biochemical, and radiological findings. Over the last few months of global hurry to optimize a testing strategy, it has been suggested that bedside point-of-care lung ultrasound may have a diagnostic role. We present 3 patients with RT-PCR nasopharyngeal swab-confirmed COVID-19 pneumonia, who had an admission plain chest film reported to be normal by a consultant radiologist, but with significant sonographic abnormalities on bedside ultrasound performed within 24 hours of the chest radiograph. Lung ultrasound may better correlate with the oxygen requirement and overall condition of the patient than chest radiographs – a pertinent consideration given the imminent advance of the pandemic into resource-poor zones where timely access to roentgenological imaging may be sparse.
Point-of-Care Screening Echocardiograms and their Potential Utility in the Acute Inpatient Medical Setting
Authors:   Australian Society of Ultrasound, Walker Humphrey , Short Nadia ,   British Society of Echocardiography
Published: June 2021

Demands on echocardiography services are increasing annually. This Quality Improvement Project aimed to see whether a point of care screening echocardiography (SE) service in the acute inpatient medical setting might help reduce demand on full trans-thoracic echocardiography services (FE). The indication and results of all FE requests on the admission ward were analysed over a three-month period. Following this, it was considered whether a theoretical SE occurring prior, would have changed the on-going utilisation of FE resources. Of the 67 requests analysed, 57 underwent FE. 25% revealed no abnormality. In 47%, a SE prior may have changed the future use of FE resources. This small retrospective review highlights the potential benefits of a SE service and further work is required.
The evidence for assessing frailty and sarcopenia in an acute medical unit: a systematic review
Authors:   Queen Elizabeth Hospital Birmingham, Mindelsohn way, Birmingham, West Midlands, Kamwa Vicky , Seccombe Adam ,   Queen Elizabeth Hospital Birmingham, Mindelsohn way, Birmingham, West Midlands, United Kingdom, Sapey Elizabeth ,   Queen Elizabeth Hospital Birmingham, Mindelsohn way, Birmingham, West MidlandsQueen Elizabeth Hospital Birmingham, Mindelsohn way, Birmingham, West Midlands
Published: June 2021

Background/objectives: A systematic review was conducted to assess if frailty and sarcopenia were associated with poorer outcomes in older adults admitted to an acute medical unit (AMU). Methods: Eligible studies included older adults with an unplanned admission to an AMU and included a measure of frailty or sarcopenia, completed within 72 hours of admission. Risk of bias was assessed. Results: Of 1659 identified articles, 16 were included (4 on sarcopenia and 12 on frailty). There was significant study heterogeneity. Overall, frailty and sarcopenia were associated with worse outcomes. Targeted interventions appeared to improve outcomes. Conclusion: Current evidence suggests some benefit in screening older adults admitted to an AMU for frailty and sarcopenia. However, further studies are required before clinical adoption.
Editorial Volume 17 Issue 3 - Acute Medicine is invested in patient care, and therefore multiple departments
Authors:   Acute Medicine, Manchester University Foundation Trust and The Christie, Cooksley Tim , Lovell Ben ,   Acute Medicine, University College London Hospitals
Published: June 2021

There is a myth that Acute Physicians only work in Acute Medical Units (AMUs). In fact, they tread a constant path between the AMU, the Emergency Department (ED), ambulatory care, Intensive Care Units (ITUs) and various specialty wards within the hospital. Just as our focus is not tied to a single organ or body system, is it not solely linked to a certain geographical place. As a result, those working in Acute Medicine are invested in the pathways, problems, processes and positive attributes of departments and units outside of the AMU, because they affect our patients.
Elementos de Aliança em Jonas
Authors: Moreira Victor Chaves
Published: June 2021

O livro de Jonas contem uma das narrativas mais famosas, mas também mais controversas do texto bíblico. Dentre as controvérsias, se encontra a discussão sobre a historicidade de tal relato, se é fato histórico ou apenas uma fábula tardia. Diferente,ente dos demais profetas, Jonas não é alvo discussões dentro do tema da teologia da aliança, uma vez que o livro em parece não carregar elementos que tratem do assunto. Todavia, o presente artigo procura mostrar o contrário: partindo do pressuposto de que Jonas é um relato de histórico, o autor destaca elementos da narrativa que possuem auta relação intertextual com os elementos da teologia da aliança, especialmente da aliança davídica, na qual Jonas se encontra historicamente; como também a visão que o Novo Testamentotem do livro.
O ANTIGO MODELO CATEQUÉTICO, O MODERNO ENSINO CONFESSIONAL E A QUESTÃO DA TOLERÂNCIA RELIGIOSA NO ESTADO LAICO
Authors: Castello Branco Gustavo Leite
Published: June 2021

Com a crescente demanda social por uma formação humana integral desde os primeiros anos escolares a educação confessional ganha novo espaço no Brasil. Entretanto, barreiras de preconceito em relação a esta espécie de ensino religioso dentro dos limites do Estado laico ainda precisam ser superadas. Neste artigo, esboça-se e critica-se três destas barreiras: 1- A pressuposição de equivalência entre “ensino confessional” e “ensino catequético”; 2- A pressuposição de que o ensino confessional seria incapaz de promover uma cultura de paz e de respeito à diversidade cultural da nação; 3- A pressuposição de que o “Modelo Fenomenológico / das Ciências das Religiões” de ensino religioso seria o único capaz de promover plenamente os princípios do Estado laico. Ao final do artigo, inclui-se uma análise da experiência da Escola Internacional Cidade Viva, de orientação cristã e reformada, visando-se evidenciar que o ensino confessional cristão também é capaz de promover os princípios norteadores de um Estado verdadeiramente laico.
A INCONGRUÊNCIA DO RELATIVISMO CULTURAL
Authors: BORBA DELGADO ANA BEATRIZ DE ANDRADE
Published: June 2021

O objetivo deste artigo é investigar de maneira crítica as relações culturais, diante de uma perspectiva filosófica, sociológica e antropológica da pós-modernidade e a  incongruência do relativismo cultural. Para isso, serão abordadas questões sobre o conceito de verdade nas relações culturais, sugerindo uma resposta para o relativismo. Nesse aspecto,considera-se que o uso da perspectiva múltipla não promove ou entra em contrapartida com a verdade, mas a reconhece.  Além disso, há uma abordagem no âmbito do  Direito e da moralidade, haja vista que o tema do presente artigo envolve, de maneira integral, a dignidade humana. Sendo  assim, foi utilizada a pesquisa bibliográfica e descritiva, a luz de grandes intelectuais, a fim de chegar a uma conclusão fidedigna acerca do conceito de verdade e da problemática do relativismo.
PENGARUH KOMPETENSI KERJA DAN PENGARAHAN TERHADAP TINGKAT PELAYANAN KARYAWAN CV. MEGA DUTA COMPUTINDO PAMEKASAN
Authors: Djaja Moh. Herman
Published: June 2021

This study aims to determine and analyze how true the effect simultaneously or partially on job competence anda direction on service levels and determine the more dominant influence on service levels. The model used in this research is the mothed of observation, interview, questionnaires, and literature study using a likertslale with the sample collection method used is accidental sampling of 30 samples. The analysis method used is multiple linier regression method. The result showed the job competence anda direction simultaneously or partially had a partially significant effect on service levels CV. Mega Duta ComputindoPamekasan.  The value of the coefficient of determination (R square) obtained 0,866, this suggests that the levels of service can be explained by twu independent variables, namely (Job Competence and Direction) CV. Mega Duta Computindo Pamekasan amounting 86,6% and the rest of 13,4% explained by other factors not included in this study.Keyword : Job Competence; Direction; Level of Service.
Sintomatología no respiratoria de COVID-19
Authors: Oliva Marín José Eduardo
Published: June 2021

La sintomatología usual de COVID-19 incluye fiebre, dolor de garganta, tos seca, fatiga, dolores musculares, anosmia e hipogeusia. Al desarrollar neumonía los pacientes usualmente presentan disnea. La sintomatología atípica de la enfermedad, la cual es basta, no se ha narrado ampliamente. Esta incluye sintomatología del sistema nervioso, como agitación, confusión e incluso convulsiones; de aparato ocular, como la conjuntivitis y la epífora; del sistema auditivo, como la sordera neurosensorial. La piel también se ve comprometida, con hallazgos como el eritema con vesículas o pústulas (pseudo eritema pernio o pseudo-sabañones), otras erupciones vesiculares, lesiones urticariales, erupciones maculopapulares y la livedo o necrosis; del sistema cardíaco, como el daño agudo al miocardio y las arritmias; del sistema gastrointestinal, como las náuseas, el vómito y la diarrea. El hecho epidemiológico importante que el 50 % de los individuos con diarrea excretan al virus en sus heces, es un problema de salud pública. Otras áreas corporales afectadas son: el sistema renal, donde del 3 al 44 % de los individuos con neumonía grave por COVID-19 presentan daño renal agudo; el sistema hematológico, el cual presenta un estado de hipercoagulabilidad que pone en riesgo de trombosis a los pacientes con neumonía por COVID-19 y finalmente, el síndrome inflamatorio multisistémico en niños.
Women Shellfish Collectors: Economic and Social Implications of the Shellfish Extractivism Perna perna (Linnaeus) in Paraná Coast, Brazil
Authors: Anacleto Adilson , Oliveira Alcione Mariano Pires de , Maia Ana Paula , Rodrigues Karen Alice de Castro , Silva Thais Mendes Da
Published: June 2021

This study aimed to elaborate a diagnosis of the situation experienced by women who practice the collection of shellfish from Paraná Coast, revealing the economic and social implications of shellfish collection that may be limiting the activity. The study showed that women are predominant in the activity, and they are developing the activities related to the extraction of mollusks since adolescence. The study also revealed that women shellfish collector had an average of 4 children and had a low level of education and high levels of illiteracy. The average income obtained was on average of USD 107.90, with the majority of the interviewees (n = 93%) having in the activity the only source of income. It should be noted in relation to the income obtained, these women can be classified in the group of people living on the “poverty line” who are the people who receive an income of up to US$ 5.5 (approximately R$ 22.00) per day. 86% of the interviewees reported that, due to the humidity in the workplace and the repetitive movements, they already had some health problem. The main implications of the activity were associated to the low income measured with the activity and the unhealthy environment, and the potentialities such as income generation and the possibility of reconciling professional activities with domestic ones were the most positively highlighted. The collective organization can be considered the main alternative of this group of women in the fight for better remuneration, work environment and quality of life.