bluuebunny/crossref_metadata_2025 huggingface dataset:
Active flap control with the trailing edge flap hinge moment as a sensor: using it to estimate local blade inflow conditions and to reduce extreme blade loads and deflections
Authors: Perez-Becker Sebastian , Marten David , Paschereit Christian Oliver
Published: June 2021

Abstract. Active trailing edge flaps are a promising technology that can potentially enable further increases in wind turbine sizes without the disproportionate increase in loads, thus reducing the cost of wind energy even further. Extreme loads and critical deflections of the blade are design-driving issues that can effectively be reduced by flaps. In this paper, we consider the flap hinge moment as a local input sensor for a simple flap controller that reduces extreme loads and critical deflections of the DTU 10 MW Reference Wind Turbine blade. We present a model to calculate the unsteady flap hinge moment that can be used in aeroelastic simulations in the time domain. This model is used to develop an observer that estimates the local angle of attack and relative wind velocity of a blade section based on local sensor information including the flap hinge moment of the blade section. For steady wind conditions that include yawed inflow and wind shear, the observer is able to estimate the local inflow conditions with errors in the mean angle of attack below 0.2∘ and mean relative wind speed errors below 0.4 %. For fully turbulent wind conditions, the observer is able to estimate the low-frequency content of the local angle of attack and relative velocity even when it is lacking information on the incoming turbulent wind. We include this observer as part of a simple flap controller to reduce extreme loads and critical deflections of the blade. The flap controller's performance is tested in load simulations of the reference turbine with active flaps according to the IEC 61400-1 power production with extreme turbulence group. We used the lifting line free vortex wake method to calculate the aerodynamic loads. Results show a reduction of the maximum out-of-plane and resulting blade root bending moments of 8 % and 7.6 %, respectively, when compared to a baseline case without flaps. The critical blade tip deflection is reduced by 7.1 %. Furthermore, a sector load analysis considering extreme loading in all load directions shows a reduction of the extreme resulting bending moment in an angular region covering 30∘ around the positive out-of-plane blade root bending moment. Further analysis reveals that a fast reaction time of the flap system proves to be critical for its performance. This is achieved with the use of local sensors as input for the flap controller. A larger reduction potential of the system is identified but not reached mainly because of a combination of challenging controller objectives and the simple controller architecture.
Karakteristik Limbah Cair Pasar Kedondong, Kelurahan Karang Asam Ilir, Kecamatan Sungai Kunjang, Kota Samarinda
Authors: Hadidjah Kemala
Published: June 2021

Limbah cair yang dihasilkan dari kegiatan Pasar Kedondong dapat menimbulkan efek buruk untuk lingkungan sekitar. Penelitian ini bertujuan untuk mengetahui karakteristik limbah cair yang dihasilkan, dan dapat memberikan suatu informasi tentang dampak limbah cair yang telah dihasilkan dari Pasar Kedondong, serta membandingkan limbah cair yang dihasilkan oleh Pasar Kedondong dengan baku mutu air limbah domestik menurut Kep.No P.68/Menlhk-Setjen/2016.

Metode pada penelitian ini menggunakan metode survei. Pengambilan sampel menggunakan botol gelap dan grab sample. Pengambilan sampel air limbah cair dilakukan dengan mengacu pada SNI 6989.59:2008 Bagian 59 tentang metode pengambilan contoh air limbah. Pengambilan sampel dilakukan sebanyak 3 kali ulangan dalam satu titik dengan ukuran 250 mL yang ditempatkan pada botol gelap dan didinginkan dalam coolbox

Hasil penelitian ini menunjukkan warna sampel terlihat coklat, memiliki bau yang menyengat dan tidak sedap. Sedangkan nilai rata-rata parameter air limbah cair Pasar Kedondong menunjukkan rata-rata pH di lapangan 6,94 dengan suhu 28 °C dan pH di laboratorium menunjukkan rata-rata pHnya 7,00. Analisis pH limbah cair Pasar Kedondong masih memenuhi baku mutu lingkungan domestik menurut Kep.No P.68/Menlhk-Setjen/2016. Limbah cair Pasar Kedondong yang dianalisis di Laboratorium menunjukkan hasil rata-rata parameter TSSnya 246 mg/L, yang artinya melebihi baku mutu lingkungan air limbah domestik menurut  Kep.No P.68/Menlhk-Setjen/2016.
Pembuatan Kompos Ampas Tebu dengan Bioaktivator MOL Rebung Bambu
Authors: Mentari F. Silvi Dwi , Yuanita  , Roby
Published: June 2021

Penelitian ini bertujuan memperoleh kompos yang memenuhi syarat untuk digunakan sebagai pupuk organik dalam waktu yang tidak terlalu lama. Penelitian ini menjadikan limbah berupa ampas tebu sebagai bahan baku utamanya. Pembuatan kompos dilakukan menggunakan perlakuan mencampur ampas tebu dengan bioaktivator mikro organisme lokal dari rebung bambu yang terlebih dahulu diolah dengan mencampurkan bahan-bahan rebung bambu, gula merah dan air beras untuk selanjutnya difermentasikan sehingga terbentuk MOL yang siap untuk diaplikasikan pada bahan dasar yang akan diolah menjadi kompos. Hasil penelitian menunjukkan bahwa setelah didekomposisi selama 27 hari, kompos berbahan dasar ampas tebu mempunyai  kandungan unsur hara N 0,3%, P 0,15 %, K 0,53 %, KA 13,21%, nisbah C/N 20,45, BO 34,54% serta pH 6,6 yang menunjukkan kompos telah matang dan siap digunakan.
Analisis Kinerja Pegawai Kantor Desa Dalam Memberikan Pelayanan Administrasi Kepada Masyarakat
Authors: Ropi Pransiska , Wijaya Agustinus Fritz , Papilaya Frederik Samuel
Published: June 2021

Pelayanan adalah upaya membantu mempersiapkan, atau mengurus kebutuhan orang lain. Kinerja aparatur pemerintah desa Siabu dalam memberikan pelayanan administrasi yang baik kepada masyarakat terlihat dari Indikator Kinerja, apakah pelayanan tersebut sudah mencapai indikator ini oleh aparatur kelurahan dalam memberikan pelayanan administrasi kepada masyarakat. Tujuan penelitian ini adalah untuk mendeskripsikan dan menganalisis kinerja pegawai Kantor desa Mayak dalam memberikan pelayanan administrasi yang berfokus pada pelayanan administrasi kependudukan yaitu pembuatan Surat Pengantar KTP (Kartu Tanda Penduduk) kepada masyarakat desa Mayak. Penelitian ini menggunakan pendekatan kualitatif deskriptif dengan melakukan wawancara langsung dengan aparat desa dan masyarakat desa. Berdasarkan hasil penelitian dapat disimpulkan bahwa pelayanan administrasi kependudukan yang dilakukan oleh pegawai Kantor desa Mayak masih belum optimal. Diketahui juga bahwa disiplin pegawai kantor desa Mayak masih kurang baik, aparat desa masih kurang tanggap terhadap keluhan masyarakat dalam memberikan pelayanan. Sehubungan dengan hal tersebut, disarankan agar Pemerintah Kantor desa Mayak Kabupaten Seluas menerapkan sistem SOP (Standar Operasional Prosedur), meningkatkan disiplin, agar kedepannya pelayanan yang diberikan kepada masyarakat lebih baik lagi. Undang-Undang Nomor 6 Tahun 2014 berupaya mengembalikan konsep dan wujud desa ke asalnya, desa atau yang dikenal dengan sebutan desa adalah nama suatu kesatuan masyarakat hukum yang berwenang mengatur dan mengurus kepentingan masyarakat setempat berdasarkan asal usul dan adat istiadat yang diakui dalam sistem pemerintahan nasional dan berada di Kecamatan, Kawasan desa juga dapat dibentuk, dihapus, atau digabungkan dengan memperhatikan asalnya atas prakarsa masyarakat dengan persetujuan Pemerintah Kabupaten dan DPRD. Undang-undang ini secara substansial berimplikasi pada pemberdayaan aparatur pemerintah desa dan juga masyarakat desa. mengatasi keterbatasan fasilitas yang tidak memadai dengan menggunakan sarana lain untuk mengolah data yang mempunyai fungsi sama, meningkatkan kinerja pegawai dengan melatih sikap disiplin, melakukan pelatihan mandiri.
Austria COVID-19 Governmental Response
Authors: S. Abdellatif Omar , Behbehani Ali , Landin Mauricio
Published: June 2021

The International Health Regulations (2005) are legally binding on 196 States Parties, Including all WHO Member States. The IHR aims to keep the world informed about public health risks, through committing all signatories to cooperate together in combating any future “illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans.” Under IHR, countries agreed to strengthen their public health capacities and notify the WHO of any such illness in their populations. The WHO would be the centralized body for all countries facing a health threat, with the power to declare a “public health emergency of international concern,” issue recommendations, and work with countries to tackle a crisis. Although, with the sudden and rapid spread of COVID-19 in the world, many countries varied in implementing the WHO guidelines and health recommendations. While some countries followed the WHO guidelines, others imposed travel restrictions against the WHO’s recommendations. Some refused to share their data with the organization. Others banned the export of medical equipment, even in the face of global shortages. The UN Compliance Research group will focus during the current cycle on analyzing the compliance of the WHO member states to the organizations guidelines during the COVID-19 pandemic.
«Out-of-furnace cast iron processing» subsystem in the solution of tasks for the choice of rational technology for producing quality metal products under the applicable conditions of raw material and technological.
Authors: Togobitskaia D.N. , Vergun A.S. , Molchanov L.S. , Kislyakov V.G , Likhachov Y.M. , Khodotova N.E.
Published: June 2021

The creation of end-to-end technology for the production of competitive metal products in modern conditions puts on the agenda the task of choosing the optimal metal production technology scheme. In solving this problem, a significant role belongs to the development of an information-modeling system for analysis and decision making. An important link in end-to-end technology is the after-furnace treatment of cast iron. As the analysis of various technological solutions for pig iron desulfurization has shown, the process developed at the Institute of Ferrous Metallurgy is currently the most economical, rational and preferred. The process is carried out by blowing through the immersed tuyeres of dispersed granular magnesium without additives. A special dosing and injection system is used. The developed process has undergone numerous industrial testing at domestic and foreign factories. To optimize the process of end-to-end technology and its information-mathematical support, modular mathematical models have been developed. An integrated database has been created that summarizes information on the parameters of cast iron desulfurization technology with granular magnesium. The expert system «Out-of-furnace cast iron processing» is described and presented, which allows to obtain high-quality metal products. The adequacy of the developed model for predicting the specific consumption of magnesium in the after-furnace treatment of cast iron was studied. The completed developments created the prerequisites for building the architecture of the Expert Decision Making System. The replenishment of the database with information on current and other technologies for pig iron desulfurization will make it possible to refine the existing and obtain descriptive models for various reagents, which will serve as the basis for the algorithmic support of the analytical unit of the expert system.Key words: desulfurization, hot metal, magnesium, information system, model.
Development of technological regulation for carbon ironing of iron in 30t ladle. Part 1
Authors: Piptyuk V.P. , Vergun A.S. , Grekov S.V. , Samohvalov S.E. , Krasnikov K.S.
Published: June 2021

The results of numerical simulation of the carbonization of low-carbon iron as a by-product of the production of titanium slag for the designed unit ladle-furnace (LF) installation as applied to the conditions of PJSC Zaporizhzhya Titanium-Magnesium Combine are presented. The technological regulations have been developed and a numerical study has been carried out on the carburization of metal in a 30-ton ladle at the LF. For the production of commercial pig iron, associated iron-containing waste is used. The purpose of the work is to identify factors of the influence of out-of-furnace processing on technology optimization. A numerical simulation was performed of the carburization technology of liquid low-carbon (up to 2% carbon) cast iron with lump (fraction up to 50 mm) graphite and coke introduced onto the surface of a ladle bath (excluding slag cover). The material and energy balances of the process were carried out, the properties of carburizing materials were studied, and the diffusion coefficient of carbon in a liquid metal was estimated. The results of studies of the hydrodynamic and thermal conditions in the bucket bath of the LF are estimated from the contour diagrams of the flow rates and temperature fields for different flow rates of argon supplied through the bottom and submerged tuyeres. The optimal fractions of carbon-containing materials were determined. It has been shown that treatment on LF with lump graphite requires a shorter duration (≈ 45%) compared with lump coke. To accelerate the process of diffusion dissolution of carbon, it is necessary to periodically (every 3 portions of 70 kg of graphite and coke) heat the melt to a temperature of 1520-1530 ° C. Injection of powdered graphite and coke contributes to a more efficient absorption of carbon and a decrease in the duration of the process (≈ by 1/3). Research continues in the direction of using flux-cored wire for carburizing cast iron at LF.
Strategy for Enhancing Students’ Entrepreneurship in Reducing Reduction in Knowledge Management's View
Authors: Utama Hendra
Published: June 2021

This study aims to foster student strategies in developing entrepreneurship, which includes learning to do business, creativity in creating products, the promotion process, and innovations in developing business. The method used in this research is a qualitative approach with descriptive analysis to determine the students' strategies in starting and developing their business. This method is considered to be able to obtain as much detail as possible about student strategies in entrepreneurship. Based on the research results, it shows that students have high courage in entrepreneurship and self-taught learning via the internet. Data obtained from a survey conducted using a google form filled with 56 students starting from the 2015-2019 class showed that students' strategies in developing business prefer social media as a means of product promotion because it is more effective and efficient. Based on the results of the study, we found a link between student entrepreneurial strategies and knowledge management. From the data we have collected, most of the students are self-taught, rely on information, and process that information. This is by the concept of knowledge management.

Keywords: knowledge management, entrepreneurship.
HUMAN BARTONELLA INFECTION: A REVIEW OF LITERATURE
Authors:   Maxillofacial Surgery Division, University Multiprofile Hospital for Active Treatment and Emergency Medicine N. I. Pirogov, Sofia, Bulgaria., Blagova Bistra , Yanev Nikolay ,   Maxillofacial Surgery Division, University Multiprofile Hospital for Active Treatment and Emergency Medicine N. I. Pirogov, Sofia, Bulgaria.
Published: June 2021

Cat scratch disease has been reported in the literature for more than half a century as a syndrome of regional lymphadenopathy and fever. However, only a quarter of a century has passed since Bartonella henselae was identified as an etiological agent. As diagnostic techniques have improved, Bartonella has been found to be responsible for a wide range of clinical syndromes. This review summarizes current knowledge about microbiology, clinical manifestations, diagnostic techniques and treatment of Bartonella henselae infection.
Effect of Reconstitution Solvents and Containers on Kinetics and Safety of Cephradine Neutralised with L-Arginine
Authors: Khan Aman ullah , Iqbal Javeid , Khattak Saif-ur-Rehman , Saquib Najam-us- , Qazi Muhammad Saleem
Published: June 2021

The effect of reconstitution solvents such as water, 0.5% metronidazole solution, 0.9% sodium chloride and 5% dextrose injections, have been investigated on the kinetics of degradation of cephradineneutralised with L-arginine contained in glass, polyvinylchloride (PVC) and polyethylene pthalate (PET) containers at 5, 15 and 30 oC. The analytical method described in USP-31 for the analysis of cephradineinjection was employed in this study and validation in respect of specificity, linearity, accuracy and precision was observed. The degradation of the compound showed first-order kinetics and the degradation rate constants kobs were found in the range of 1.84-3.07 ´ 10-3/h (r2 = 0.990-0.999) at 5 oC, 2.3-4.2 ´ 10-3/h (r2 = 0.993-0.999) at 15 oC and 7.18-9.97 ´ 10-3/h (r2 = 0.998-0.999) at 30 oC, respectively. Cephradineshowed maximum stability in dextrose solution followed by water, sodium chloride and metronidazole injections, however, linear effect of containers on degradation rate could not be established. The  extended degradation did not change the kinetics of the reaction. The abnormal toxicity/ safety test on mice for the admixtures in different containers at various temperatures showed no abnormal toxicity.
Downstream Wind Flow Path Diversion and Its Effects on the Performance of Vertical Axis Wind Turbine
Authors: Maganhar Abdul Latif , Rajpar Altaf Hussain , Samo Saleem Raza , Luhur Muhammad Ramzan
Published: June 2021

In the present experimental study efforts have been made to analyse path diversion effect of downstream wind flow on performance of vertical axis wind turbine (VAWT). For the blockage of downstream wind flow path at various linear displaced positions, a normal erected flat wall, semi-circular and cylindrical shapes were tested for path diverting geometries. Performance of VAWT in terms of improved rotor speed up to 45% was achieved.
Estudos linguísticos: (novos)caminhos vol. 2
Authors:   UEFS, Silva Jacson , Lemos Dayane Moreira ,   UEFS
Published: June 2021

A língua sempre foi um objeto de análise para todas as ciências e, desde que Saussure assumiu que a língua é o objeto de análise da Linguística, vemos as correntes linguísticas definindo possíveis formas de compreender a língua, por meio de uma abordagem modular ou não, a partir de diversos fenômenos cognitivos, pragmáticos, textuais, discursivos, sintáticos, semânticos, morfológicos e fonológicos; compreendendo que esses estão presentes na descrição de uma língua e dos fenômenos que nela tomam lugar. Considerando isso, este livro, intitulado Estudos Linguísticos: (Novos) Caminhos, o segundo volume publicado, apresenta fenômenos descritos a partir de vários níveis de análise e descrição, remontando a essa postura modular de descrição, sem, contudo, deixar de assumir que os fenômenos linguísticos estão todos em interação. Interação essa que pode ser percebida com a leitura, fluída, dos capítulos e nas leituras dos dois volumes da coleção.
Abdominal pain and a raised amylase? It’s not always pancreatitis…
Authors:   Department of Clinical Biochemistry, University Hospital Southampton, Oluwatowoju IO , Abu EO ,   Department of Clinical Biochemistry, University Hospital Southampton, Lawson G ,   Department of Clinical Biochemistry, Tunbridge Wells Hospital at Pembury, Kent
Published: June 2021

We report the case of a 72 year old man with a history of COPD and heavy alcohol consumption who was initially diagnosed with acute pancreatitis based on a presentation with epigastric pain and elevated serum amylase. Review of his notes revealed several previous similar admissions and extensive normal investigations apart from persistently elevated amylase. Further analysis showed evidence of macroamylasaemia which accounted for the apparently high serum amylase level.
The patient presenting with ‘Acopia’
Authors:   Elderly Medicine, Pinderfields Hospital, Granger Kate , Ninan Sean ,   Geriatric and General Medicine, Calderdale and Huddersfield NHS Foundation Trust, Stopford Elizabeth ,   Pinderfields Hospital
Published: June 2021

Patients may be referred to Acute Medical Units (AMUs) with a diagnosis of ‘acopia’. This term is offensive and lazy, implying fault on the part of the patient and allowing the assessing doctor to erroneously label the patient as a ‘social admission’ when, in fact, such patients are likely to be frail with co-morbidities and have an acute (potentially reversible) illness. Frail older patients should be assessed using the principles of Comprehensive Geriatric Assessment, informed by an understanding of the concept of frailty and of geriatric syndromes such as falls and delirium.
Sudden loss of vision in an Acute Medical Unit
Authors:   Watford General Hospital, Watford, Arif Muhammad , Jordaan Johan ,   Wexham Park Hospital, Slough, Arias Veronica Garcia ,   Department of Microbiology and Infections, Wexham Park Hospital, Slough
Published: June 2021

We present a case report of young man with Type 1 diabetes who developed acute visual loss after initially presenting with diabetic ketoacidosis. The diagnosis of invasive paranasal sinusoidal aspergillosis was made following CT and biopsy. Although uncommon, visual loss is a recognised complication of disseminated aspergillosis and is more likely in immunecompromised patients and those with diabetes. Early investigation with appropriate sinus imaging and involvement of the Ear Nose and Throat team in recommended when patients with diabetes develop acute visual loss in the context of a non-specific infective illness.
Pause for thought? Syncope and sinus arrest as the presenting feature of temporal lobe epilepsy
Authors:   Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK, Wijesurendra Rohan Sajeev , Carey M ,   Department of Cardiology, Milton Keynes NHS Foundation, Eaglestone, Milton Keynes, Butterworth R J ,   Department of Cardiology, Milton Keynes NHS Foundation, Eaglestone, Milton Keynes, Khiani R ,   Department of Cardiology, Milton Keynes NHS Foundation, Eaglestone, Milton Keynes
Published: June 2021

Some forms of focal epilepsy, including temporal lobe epilepsy, are rarely associated with ictal bradycardia and sinus node arrest. We report a case of a previously healthy man presenting with syncope in whom telemetry revealed sinus arrest. Initial treatment was with permanent pacemaker implantation and it was only following a subsequent grand mal seizure that other symptoms suggestive of temporal lobe epilepsy were documented. Anti-epileptic medication was subsequently commenced with resolution of all symptoms. There are few previously reported cases of syncope and documented sinus node arrest as the presenting feature of temporal lobe epilepsy.
Two different presentations, one diagnosis
Authors:   Altnagelvin Area Hospital, McCluskey Gavin , Rajani Chandni K. ,   Anaesthetics, University College Hospital, London, Lewis Gareth ,   Altnagelvin Area Hospital, Mehta V , Gardiner Philip V ,   Altnagelvin Area Hospital, Jee Pamela ,   Central and North West London NHS Foundation Trust, Trip Anand ,   Northwick Park Hospital and National Hospital for Neurology and Neurosurgery, O McCarron Mark ,   Altnagelvin Area Hospital, de Wolff Jacob F ,   London Northwest Healthcare NHS Trust, Northwick Park Hospital, Watford Road, Harrow
Published: June 2021

Acute confusion and hyponatraemia are common presentations in acute medicine. We report two cases of anti-voltage gated potassium channel (VGKC) antibody-related limbic encephalitis highlighting the variable presentation of this condition. Both patients were thoroughly investigated with MRI scan of brain, lumbar puncture, EEG as well as infective and autoimmune screens for encephalitis. Anti-VGKC antibodies were positive for both patients and prompt treatment with immunotherapy yielded good recovery. Patients presenting with confusion and seizures who have no demonstrable infectious or metabolic cause should have investigation for an autoimmune cause expedited. In addition, psychiatric presentations with atypical features such as drowsiness should prompt similar investigations. The outcome of anti-VGKCrelated limbic encephalitis is improved with early treatment employing steroids or immunotherapy.
Problem based review: The patient with recent onset Polyarthritis
Authors:   Department of Medicine, Ng Teng Fong General Hospital, Singapore., Suresh Ernest , Menon Preetha Venugopalan ,   Alexandra Hospital (Jurong Health), Myint May Zin ,   Alexandra Hospital (Jurong Health)
Published: June 2021

A wide variety of conditions can present as acute polyarthritis, ranging from those that are potentially life threatening, to those that are self-limiting, and those that represent the early stages of a persistent and potentially destructive form of arthritis. In this article, we describe the diagnostic approach and initial management of patients with recent onset polyarthritis, with the aid of an illustrative case vignette.
Palliative Care – a useful speciality skill for trainees in Acute Medicine
Authors:   Tunbridge Wells Hospital UK, Virjee Judith
Published: June 2021

I gained a run through number in ACCS (AIM and GIM) in 2007 when Acute Medicine, both as a training programme and a stand alone medical specialty, was in its infancy. As the programme has evolved and developed it has become a curriculum requirement for trainees to attain an acknowledged specialist skill.
Developing and Evaluating Nurse led Discharge in Acute Medicine
Authors:   Acute Medicine and Intensive Care, Royal Bolton Hospital, Bolton, Gotz Vera Nina , Thompson Andrew ,   Musgrove Park Hospital, Parkfield Drive, Taunton, Somerset., Jones Kevin ,   Acute Medicine, Royal Bolton Hospital, Bolton
Published: June 2021

Aims: To develop and evaluate nurse-led discharge criteria for a clinical decision unit in a large NHS Foundation Trust Method: Criteria for nurse led discharge were developed for patients presenting to hospital via the emergency department with chest pain, headache and deliberate self poisoning. Data on length of stay on CDU and readmission were collected for these patient groups during a 2 month period, during which the nurse-led criteria were introduced. Following introduction of the criteria a survey was conducted to evaluate staff opinions of the new system. Results: A trend towards reduced length of stay was noted during the month after introduction of nurse-led discharge (18.26hrs vs 20 hours p=0.582). Our staff survey indicated that the process was popular and has been continued since the study period. Conclusion: Nurse-led discharge using defined criteria is feasible and popular with staff in an acute medical setting.
A patient with palpitations
Authors:   Portsmouth Hospitals NHS Trust, Philip Legate , Longman Kristel ,   Cardiology Queen Alexandra hospital, Portsmouth, Andrews Neil ,   Cardiologist Portsmouth Hospitals NHS Trust
Published: June 2021

A 52 year old woman presented to the Acute Medical Unit with her 4th episode of palpitations in the past four weeks. Each episode was similar in nature and described as being acute in onset, fast and regular, associated with pre-syncope but never syncope or chest pain. The episodes lasted for 30 – 45 minutes and would self terminate. Of particular note, the episodes were not associated with exertion and she had a normal exercise tolerance.
Trainee update
Authors:   Acute Internal Medicine Surrey and Sussex NHS Trust, Smallwood Nicholas , Conway Nerys ,   Society for Acute Medicine National Trainees’ Representatives
Published: June 2021

First of all, thank you and goodbye to Ruth Johnson who’s leaving the ranks of trainees and joining the Consultant body in Herefordshire imminently; Ruth has worked hard over the last two years representing trainees and we wish her well for the future.
Why I decided to #TakeAIM
Authors:   Acute Internal Medicine Surrey and Sussex NHS Trust, Smallwood Nicholas
Published: June 2021

Having realised early in my medical school training I was a medic not a surgeon, I had long assumed I would end up being a cardiologist or gastroenterologist. I enjoyed looking after acutely unwell patients, liked intervention and procedures and enjoyed being part of a hard-working team. The thing that always worried me was that I would become so specialised in my chosen field, that I would end up forgetting how to manage the vast range of medical conditions present among hospital inpatients.
Viewpoint: What is ‘Training’?
Authors:   Acute Medicine, Leeds Teaching Hospitals, Cooper Nicola
Published: June 2021

This edition’s paper on ‘How doctors spend their time on an AMU’ defines ‘training’ as time spent on senior ward rounds. But the idea that senior ward rounds are training and the rest of work is not is a huge assumption that must be challenged. This article explores some false ideas about postgraduate medical education; why teaching and learning activities needs to be made more explicit, and why we need to stop talking about ‘training’ and start talking about learning. The goal of professional education is expertise, not competence. That can only happen through work-based learning, something to which we need to pay much more attention.
The Team at Work – The Society for Acute Medicine’s Benchmarking Audit 2014 (SAMBA’14)
Authors:   Respiratory & Critical Care Medicine Bangor University & Ysbyty Gwynedd Hospital Bangor, Wales, Subbe Christian P , Le Jeune Ivan ,   Nottingham University Hospitals NUH Trust, Nottingham, UK, Burford Caroline , Mudannayake Rahul S
Published: June 2021

Background: The Society for Acute Medicine’s Benchmarking Audit (SAMBA) serves as a tool for Acute Medical Units to compare and improve their quality of care. Aim: To audit the performance of Acute Medical Units against clinical quality indicators, standards by the Royal College of Physicians and Specialist Societies relevant to the practice of Acute Medicine. Methods: An online survey of unit profiles and staffing levels on the audit day was followed by a 24-hour data collection on Thursday the 19th of June 2014 for all patients seen by the local Acute Medicine teams as part of the general medical take. Patients were followed-up for 72 hours. We reviewed the impact of staffing levels on performance indicators. Results: 66 Acute Medical Units admitted 2333 patients during the 24-hour period. Compliance with the quality standards of SAM was as follows: 84% of patients had an early warning score recorded within 30 minutes of admission, 81% of patients had been seen by a competent decision maker within four hours and 73% of patients were seen by a consultant physician within the appropriate period of time. Only 56% of patients received a standard of care compatible with all three quality standards. We found no relation between unit characteristics, staffing and performance indicator. Conclusion: There remains a gap between the standard described by the quality indicators and the performance of Acute Medical Units during a one-day audit.
‘Take AIM’ – Raising awareness of Acute Internal Medicine
Authors:   Tauranga Hospital, Private Bag 12024 Bay of Plenty District Health Board New Zealand, Kennedy Adrian , Masterton-Smith Charlotte ,   St Thomas’ Hospital, London, Wheeler Joe , Threlfall Lynsey , Prinja Paarul , Jones Zoe
Published: June 2021

Acute Internal Medicine (AIM) may be the ‘new kid on the block’ as a medical specialty but it lies at the heart of our health service. Recognition of the importance of early senior review in managing medical patients admitted to hospital in an emergency has led to a dramatic expansion in the number of consultant posts being created in acute medical units across the UK. This has been matched by a similar rise in the number of higher speciality training positions, with over 100 posts being advertised every year. Although the majority of these posts have been filled, this expansion, combined with a relative lack of awareness of the speciality, has meant that vacancies remain in many Deaneries. This needs to be addressed in order for the speciality to continue to expand, and deliver high quality, consultant-led acute medical care in every hospital in the UK.
A rare cause of secondary hypertension
Authors:   Departments of Cardiology and Acute Medicine, Queen’s Hospital, Rom Valley Way, Romford, Essex, Dulai Rajdip , Oshodi Marek ,   Departments of Cardiology and Acute Medicine, Queen’s Hospital, Rom Valley Way, Romford, Essex
Published: June 2021

Severe hypertension is a well-recognised cause for acute medical admission, and can have serious consequences if untreated. We present a 48 year old patient in whom coarctation of the aorta was identified following the finding of severe hypertension at the time of routine preoperative assessment, and subsequent finding of absent lower limb pulses. The patient had a past history of Apert syndrome, a rare autosomal dominant inherited condition characterised by craniosynostosis, facial dysmorphia, syndactyly of the hands and feet and cardiac abnormalities. This case report highlights the importance of a careful clinical examination in adults with severe hypertension, without which coarctation of the aorta may go undiagnosed.
Ambulatory Outpatient Management of patients with low risk febrile neutropaenia
Authors:   Department of Acute Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, Cooksley Timothy , Holland Mark ,   Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, United Kingdom, Klastersky Jean ,   Department of Medical Oncology, University of Brussels and Chief of Medicine Service, Institut Jules Bordet, Department of Internal Medicine
Published: June 2021

Patients with febrile neutropenia are a heterogeneous group with only a minority developing significant medical complications. Scoring systems, such as the Multinational Association for Supportive Care in Cancer (MASCC) score, have been developed and validated to identify low risk patients. Caring for patients with low risk febrile neutropenia in an ambulatory setting is proven to be safe and effective. Benefits include admission avoidance, cost savings and reduced risk of nosocomial infections, as well as improved patient experience and satisfaction. Implementation of an ambulatory pathway for low risk febrile neutropenia provides an excellent opportunity for Acute Physicians and Oncologists to collaborate in delivering care for this group of patients.
Implementation of NICE recommendations on abdominopelvic CT, following unprovoked venous thromboembolism, in a UK teaching hospital: no additional detection of occult malignancy and high numbers of incidental findings
Authors:   Royal Liverpool University Hospital, UK, Garwood David , Renton Bryan ,   Royal Liverpool University Hospital, UK, Joekes Elizabeth ,   Royal Liverpool University Hospital, UK
Published: June 2021

Introduction: NICE Clinical Guideline 144 recommends that patients with an unprovoked VTE, who do not have signs or symptoms of cancer on initial investigation, be considered for further investigation with an abdomino-pelvic CT to exclude occult malignancy. This study aimed to evaluate numbers of scans performed in a UK teaching hospital and outcomes, following this recommendation. Methods: Retrospective review of CT scans performed before and after publication of the NICE guidance in 2012. CT reports and case notes were analysed. Type and stage of malignancy, treatment and other relevant findings were documented. For the 2014 data set, all incidental radiological findings and follow-up recommendations were reviewed. Results: The annual number of CT scans requested for “unprovoked VTE”, rose by 142% following publication of NICE Clinical Guideline 144. In the 2011 – 2012 data set, 21 patients were included, one of which was found to have a malignancy, which was clinically overt at the time of diagnosis i.e. not occult. Five patients (23.8%) had incidental findings requiring further investigation. In the 2014 –2015 data set, 51 patients were included, five (9.8%) of which were found to have malignancy. In retrospect, all showed signs/symptoms of potential malignancy on initial investigation. No occult malignancies were detected in the patients correctly referred. Incidental findings warranting further investigation were reported in ten cases (19.6%). On review, follow-up advice was deemed incorrect in four of these. Conclusion: Addition of an abdomino-pelvic CT scan in patients with a first unprovoked VTE and no signs or symptoms of cancer on initial investigation, significantly increased the number of scans and incidental findings, but did not pick up any additional occult malignancies.
When is a stroke not a stroke? An unusual mimic presenting to AMU
Authors:   Croydon University Hospital, Croydon, Surrey, UK, Patel Shyamal , Smallwood Nicholas ,   Surrey and Sussex NHS Trust, Abu Hyacinth-John ,   East Surrey Hospital, Redhill, Surrey, UK, Abousleiman Youssif ,   East Surrey Hospital, Redhill Surrey, UK
Published: June 2021

Introduction: Creutzfeldt-Jakob disease (CJD) is a rare prion disease classically manifesting with rapidly progressive dementia, abnormal movements and typical electroencephalographic (EEG) changes. Case Report: A 74 year-old Caucasian man was recently discharged from another centre diagnosed with a stroke. He re-presented to our acute medical unit with worsening symptoms, and stroke remained the working diagnosis. Collateral history revealed a progressive cognitive decline and unilateral myoclonus. Further investigations supported the diagnosis of probable CJD, confirmed by the national CJD surveillance centre. Discussion: Signs and symptoms atypical of stroke should raise the possibility of alternative diagnoses, including prion disease. CJD can present with unilateral symptoms, EEG and MRI changes. Early diagnosis prevents unnecessary investigations and treatments, allowing early palliative care input, where appropriate.
Persistent dysphagia and drowisness following collapse in an alcohol-dependent patient
Authors:   Department of Respiratory Medicine, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ., Bodington Richard , Werpachowska Anna ,   Department of Respiratory Medicine, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ., Faruqi Shoaib ,   Department of Respiratory Medicine, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefiled, WF1 4DG
Published: June 2021

A 58 year old man was brought to the emergency department with acute confusion after being found unconscious on his floor at home. He had a background of alcohol misuse with alcoholic liver disease. He was not taking any regular medications. On examination he smelt of alcohol and was tachycardic at 96 bpm with BP 110/70. The patient’s Glasgow Coma Score was 14, being drowsy but responsive with bilateral lower zone crepitations on auscultation of the chest. Neurological examination revealed generalized reduced muscle bulk but no focal deficits.
Trainee Report, Spring 2016
Authors:   Chelsea and Westminster Hospital, Krishnamoorthy Sanjay , Smallwood Nicholas ,   Acute Internal Medicine Surrey and Sussex NHS Trust
Published: June 2021

Acute Medical registrars across the country have continued to drive the enthusiasm to Take AIM! Following the success of the first national takeAIM conference in Manchester in November, the takeAIM fellows are organising regional conferences to drum up interest. The first of these conferences was held in London on February 25th, followed by conferences in Bristol, Bradford, Birmingham, Durham and Newcastle. We are looking forward to an exciting program of clinical updates from specialists followed by break out groups where interested trainees can engage with current AIM trainees to talk about AIM as a career and the opportunities to broaden their clinical practice through specialist skills. Further details on the different projects under development can be found on the takeAIM website (takeaim.org.uk). If you would like to run a session in your area or have any careers events, please contact the takeAIM team and they can help you with materials and assistance!
Epidemiology, recognition and documentation of sepsis in the pre-hospital setting and associated clinical outcomes: a prospective multicenter study
Authors:   Departments of Internal Medicine and Section Acute Medicine, VU University Medical Center, Amsterdam, The Netherlands, Alam Nadia , BNS Doerga Kirtiedevi ,   Departments of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Hussain Tahira ,   Departments of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Hussain Sadia ,   Departments of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands, Holleman Frits ,   Departments of Internal Medicine and Section Acute Medicine, Academic Medical Center, Amsterdam, The Netherlands, H H Kramer Mark ,   Section Acute Medicine, Department of Internal Medicine, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, The Netherlands, WB Nanayakkara Prabath ,   Department of Internal Medicine, Section Acute Medicine, Amsterdam University Medical Centre, VU University, The Netherlands
Published: June 2021

Introduction: General practitioners (GPs) and the emergency medical services (EMS) personnel have a pivotal role as points of entry into the acute care chain. This study was conducted to investigate the recognition of sepsis by GPs and EMS personnel and to evaluate the associations between recognition of sepsis in the pre-hospital setting and patient outcomes. Methods Design: prospective, observational study during a 12 week period in the emergency department (ED) of two academic hospitals. Study population: Patients >18 years presenting with sepsis at the ED. The information available in the ED discharge letter and the ED charts was used to make a definite diagnosis of sepsis, severe sepsis and septic shock Outcome measures: primary: recognition/documentation of sepsis. Secondary: ED arrival time to antibiotic administration, in-hospital mortality, hospital length of stay (LOS) and intensive care unit (ICU) admission. Results: A total of 301 patients were included in the study. GPs and EMS personnel correctly identified and documented 31.6% (n=114) and 41.4% of all sepsis patients (n=140) respectively. Recognition and documentation of sepsis improved with increasing severity. The mean time to administration of antibiotics (TTA) was nearly halved for the group of patients where sepsis was documented (GP: 66,4 minutes, EMS: 65,6 minutes) compared to the group in which sepsis was not documented (GP: 123,9 minutes, EMS: 101,5 minutes; p= 0.365 and p= 0.024 respectively). Conclusions: There is room for improvement in the recognition of sepsis, severe sepsis and septic shock by practitioners working in the pre-hospital setting. Documentation of sepsis prior to arrival in hospital led to a reduced time delay in administration of antibiotics.
The Challenges of Conducting Research on the Acute Medical Unit
Authors:   Anaesthetics, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, O’Dell Thomas , Zalin Anjali ,   Diabetes, Endocrinology and Bariatrics, Chelsea and Westminster Hospitals NHS Foundation Trust, Chelsea and Westminster Hospital, London, Vaughan Louella ,   Centre for Health Improvement Research, Chelsea and Westminster Hospital, London
Published: June 2021

Conducting research on the Acute Medical Unit (AMU) poses unique challenges; the environment is one that sees a diverse range of patient groups and pathologies and holds the potential for easy patient recruitment to research studies, however is geared towards a specific set of triage and discharge goals. We conducted a study into Stress Hyperglycaemia (SH) on a busy AMU, which involved profiling glycaemic changes using specialist equipment and interventions in patients with unscheduled medical admissions, and experienced a number of challenges. This article discusses these challenges and proposes potential solutions. Conducting research on a busy AMU was complicated by factors including rapid patient and staff turnover, the differing goals of the AMU system and suboptimal staff engagement in labour intensive research. We endeavored to follow patients up in further visits after discharge but found they lacked engagement after the resolution of the acute illness requiring initial admission. In this article, we discuss these issues in more detail and suggest approaches for future AMU researchers.
Medical High Dependency Series 2: Haemodynamics and Shock: Assessment, Interventions and Support
Authors:   Queen Elizabeth University Hospital, Glasgow, Allan Russell Morton , Wright Christopher John ,   Queen Elizabeth University Hospital, Glasgow
Published: June 2021

Shock is a life-threatening state commonly encountered by the acute physician. As such those practicing and training in the specialty should strive to become true experts in this field by going beyond even the learning provided by generic life support courses when involved with identifying and managing the shocked state. This article explores the current evidence, where it exists and provides a framework for approaching such patients along with common pitfalls.
Being SAM President – A Long Journey in a Short Time
Authors:   University of Bolton, United Kingdom, Holland Mark
Published: June 2021

My first piece of advice for all aspiring medical leaders would be this, ‘don’t bother’ with a leadership course, as nothing can fully prepare you for the role. That said, please continue reading as I will try and provide an honest review of my time as President to the Society for Acute Medicine (SAM).
Medical High Dependency Unit series, Article 3: Respiratory Support in the MHDU
Authors:   Critical Care, Queen Elizabeth University Hospital, Glasgow, Wright Christopher John , Morton Allan Russell ,   Critical Care, Queen Elizabeth University Hospital, Glasgow, A Gillon Stuart ,   Critical Care, Queen Elizabeth University Hospital, Glasgow
Published: June 2021

Acute respiratory failure is a life threatening condition encountered by Acute Physicians; additional non-invasive support can be provided within the medical high dependency unit (MHDU). Acute Physicians should strive to be experts in the investigation, management and support of patients with acute severe respiratory failure. This article outlines key management principles in these areas and explores common pitfalls.
Society for Acute Medicine Trainee Update, Autumn 2017
Authors:   Society for Acute Medicine, Patel Neil , Khan Tehmeena ,   Acute Internal Medicine, Acute Medicine Unit, University College Hospital, Euston Rd, Fitzrovia, London
Published: June 2021

Tehmeena Khan has replaced Sanjay Krishnamoorthy as a Trainee Representative for SAM. We would like to thank Sanjay for all his hard work and contribution during his tenure as Rep. Tehmeena is a final year trainee from North East & Central London. Tehmeena’s specialist skills are Leadership, Management and Quality Improvement. She has previously been a Darzi Fellow and has undertaken a Winston Churchill Fellowship. She has recently joined the Health Foundation Q Community.
Is the Acute Internal Medicine (AIM) curriculum, for higher specialty training (HST), fit for purpose?
Authors:   University of Brighton campus, Falmer, BN1 9PH, Brereton Andrew
Published: June 2021

This review will critically appraise the AIM curriculum from a trainee’s perspective. The author will focus on the curriculum’s aims and objectives, availability of learning opportunities, adopted assessment and evaluation strategies and finally make recommendations to aid curriculum development.