Editorial
Authors:   Acute Medicine, University Hospital Southampton Foundation Trust, Southampton, Roseveare Chris 
Published: June 2021

The arrival of the second edition of this journal is a sign (in case we need one) that summer has arrived – but also a reminder that 2014 is already half over, and the challenges of the autumn and winter are not far over the horizon. Of course, autumn will also bring another International Society for Acute Medicine meeting, this year in Brighton, following on from the success of the recent Spring meeting in Amsterdam. For those who couldn’t be there, we have included some of the abstracts from the oral poster presentations in this edition, along with some reflections in the trainee report. The programme for the autumn meeting is already complete and will include an opening address from the new RCPL president, Professor Jane Dacre, and a closing session including both the NHS Ombudsman and Chief inspector of Hospitals, Professor Mike Richards. There is also a strong line-up of international speakers from the USA, Australasia and Europe, along with a broad range of clinical topics and workshops, designed to appeal to doctors, nurses and allied healthcare professionals. There will be lots of room for posters in the conference venue, so I would encourage you to submit your work via the abstract submission site; further information on how to do this is available via the SAM website. The four case reports in this edition reflect a cardiovascular and neurological theme. Most acute physicians will be familiar with the phenomenon of seizure precipitated by sinus node disease, and it is unsurprising that the clinicians treating the patient in our first case presumed that insertion of a permanent pacemaker would resolve his symptoms, after telemetry revealed sinus arrest. However in this case it appeared that seizure was the precipitant for the arrhythmia, requiring the subsequent addition of anti-epileptic medication to prevent recurrence of the patient’s problem. The mechanism of this unusual phenomenon is described, along with the importance of a careful history. The Reversible Cerebral Vasoconstriction Syndrome (rCVS) is highlighted in the case report by Montague and Murphy from Manchester. The approach for patients with acute severe headache on the AMU is often to ‘exclude subarachnoid’ and then discharge the patient with reassurance. In this case, however, the cerebral angiographic images demonstrated the characteristic ‘string of beads’ appearance of this condition, the symptoms of which can be improved by treatment with nimodipine. The authors rightly recommend that acute physicians need to consider this condition when patients present with recurrent thunderclap headache, following exclusion of subarachnoid haemorrhage. Making this diagnosis also enables advice to avoid certain sympathomimetic drugs, which may precipitate recurrence – including cocaine which is the theme of the case submitted by Rahman Shah from the University of Tennessee. ST segment elevation following cocaine use is a well recognised phenomenon, but the pressure to ensure rapid revascularisation for patients with STEMI might easily lead this piece of history to be over-looked, particularly in an older patient. Rates of cocaine use in the UK may be lower than in the US, so it may be premature to consider this part of our ‘routine questioning’ for all patients with cardiac-type chest pain as recommended by the authors. However their point about maintaining an index of suspicion is well made, given the potential for harm from unnecessary percutaneous intervention or thrombolysis. Enjoy the summer – and I hope to see you all in Brighton in October.