bluuebunny/crossref_metadata_2025 huggingface dataset:
Los recursos de poder de la reina Leonor de Castilla (1241-1290): un estado de la cuestión
Authors: Bergaz Álvarez Andrea
Published: June 2021

El presente trabajo tiene como objetivo presentar un estado de la cuestión o repaso historiográfico de los recursos de poder con los que contó la reina de Inglaterra Leonor de Castilla (1241-1290). Se analizan temáticamente los recursos relacionales y los materiales, base fundamental de su reginalidad y el aspecto más trabajado de esta reina en la historiografía anglosajona. Nuestra conclusión es que el estudio de los recursos de poder de Leonor de Castilla presenta aún muchas posibilidades, por lo que se hace necesario continuar investigando los componentes que hicieron posible su reginalidad.
Álvar García de Illas: servicios diplomáticos y aspiraciones señoriales bajo el reinado de Alfonso XI de Castilla
Authors: Carriazo Rubio Juan Luis
Published: June 2021

Se analizan en este artículo los escasos testimonios documentales conservados sobre Álvar García de Illas, personaje mal conocido que obtuvo el señorío de la torre del Bao (Los Molares, Sevilla) en 1336, participó en la embajada enviada por Alfonso XI a Clemente VI en Aviñón en junio de 1342 y fue nombrado alcalde mayor de la Algeciras recién conquistada. Se estudian la experiencia previa de García de Illas en tareas negociadoras de carácter internacional, su condición de alcalde del rey y sus vínculos con la familia real y con el estamento nobiliario.
Effect of a joint policy statement by nine UK shooting and rural organisations on the use of lead shotgun ammunition for hunting common pheasants Phasianus colchicus in Britain
Authors: Green Rhys , Taggart Mark , Pain Deborah , Clark Nigel , Clewley Louise , Cromie Ruth , Elliot Bob , Green Ros , Huntley Brian , Huntley Jacqui , Leslie Roderick , Porter Richard , Robinson James , Smith Ken , Spencer Jonathan , Stroud David
Published: June 2021

There are significant negative effects of exposure to spent lead ammunition on wildlife and human health. A joint statement was issued by nine UK shooting and rural organisations on 24th February 2020 intended to encourage a voluntary transition to non-lead shotgun ammunition within five years “in consideration of wildlife, the environment and to ensure a market for the healthiest game products”. We dissected carcasses of wild-shot common pheasants Phasianus colchicus sold or offered for human consumption in Britain in the shooting season between 1st October 2020 and 1st February 2021 to recover shotgun pellets. The principal metallic element composing one pellet from each bird was identified using inductively coupled plasma atomic emission spectrometry. The results showed that 99% of the 180 pheasants from which shotgun pellets were recovered had been killed using lead shotgun ammunition, compared with 100% in a much smaller study conducted in the 2008/2009 shooting season. We conclude that the shooting and rural organisations’ joint statement, and their subsequent promotional actions, have not yet had a detectable effect on the ammunition types used by shooters supplying pheasants to the British game market.
Analysis of Factors Affecting the Quality of the Annual Development Plan of Aceh Tamiang Regency
Authors: Anwar Yohny , . Ismayani
Published: June 2021

This study aims to find out and analyze the influence of internal and external factors on the quality of the annual development plan of the region in Aceh Tamiang Regency partially and simultaneously. The sample of this study is that all employees in the office of Regional Development Planning, Research and Development Agency (BAPPEDA) Aceh Tamiang district numbered 30 people. The results of the study obtained mathematical equations that are Y = 9.468 + 0.262 X1 + 0.215 X2. The correlation coefficient value (R) of 0.673 means a strong and positive relationship and significant (real) between internal and external factors with the quality of the regional annual development plan in Aceh Tamiang Regency. The coefficient of determination (R2) of 0.453 or 45.3% indicates that 45.3% of the quality of the regional annual development plan in Aceh Tamiang Regency is influenced by internal and external factors. The remaining 54.7% was influenced by other factors. T test results for internal factors t calculated > t table value of 2,277 > 2.05183 and significant in  = 0.05 obtained figures of 0.031 < 0.05 means internal factors significantly affect the quality of the regional annual development plan in Aceh Tamiang District, which is the contribution of the variable of 0.262. External factors have a t count value of > t table and a significant t that is far from the significant value of tolerance of 5% which is 2,155 > 2.05183 and significant 0.040 < 0.05 and the contribution of these factors is the amount of the regression value with the number 0.215. F is worth 3.35. The calculated F value is above F table which is 11,160 > 3.35 and also the significant F value is 0.000 < 0.005. So that from the results of the F test can be analyzed that internal and external factors together the two free variables have a significant and significant / tangible effect on the quality of the annual development plan of the region in Aceh Tamiang District. Thus, the hypothesis that reads internal and external factors simultaneously affects the quality of the annual development plan of Aceh Tamiang District can be accepted and theoretically proven.

Keywords: Internal Factors, External Factors, Quality of Regional Annual Development Plans.
Laîche de Host (Carex hostiana DC.) et un de ses hybrides en Aveyron
Authors: Biais Lucas , Klesczewski Mario
Published: June 2021

Notre article présente un inventaire actualisé de la Laîche de Host (Carex hostiana DC.) et de son hybride Carex ×fulva en Aveyron. Leur synonymie est clarifiée et la cartographie des stations aveyronnaises est mise à jour. Quelques stations sont décrites plus précisément à l’aide de relevés phytosociologiques accompagnés de mesures du pH. Des critères d’identification hiérarchisés sont proposés à partir d’une synthèse bibliographique et d’une comparaison biométrique des deux taxons.
The effects of production and operational costs, capital structure and company growth on the profitability: Evidence from manufacturing industry
Authors: Istan Muhammad , Husainah Nazifah , Murniyanto Murniyanto , Suganda Asep Dadan , Siswanti Indra , Fahlevi Mochammad
Published: June 2021

The purpose of this research is to analyze the effects of production and operational costs, capital structure and company growth on profitability. The method used in this research is quantitative method, data collection is performed by distributing questionnaires among employees of packaging industry. The population in this study are industrial employees in Jabodetabek whose numbers have not been identified with certainty. The questionnaire is distributed electronically using a simple random sampling technique. The results of the questionnaire returned are 180 respondents. Based on the results of data analysis, it is concluded that Capital structure has a significant effect on profitability. An increase in the capital structure variable will be followed by an increase in profitability and a decrease in variable capital structure will be followed by a decrease in profitability. Company growth has no significant effect on profitability. An increase in the company growth variable will not be followed by an increase in profitability and a decrease in variable company growth will not be followed by a decrease in profitability. Operational cost has a significant effect on profitability. An increase in the operational cost variable will be followed by an increase in profitability and a decrease in variable operational cost will be followed by a decrease in profitability. Production cost has no significant effect on profitability. An increase in the production cost variable will not be followed by an increase in profitability and a decrease in variable production cost will not be followed by a decrease in profitability.
Detecting fraudulent financial statements in pharmaceutical companies: Fraud pentagon theory perspective
Authors: Ariyanto Dodik , Jhuniantara I Made Gilang , Ratnadi Ni Made Dwi , Putri I Gusti Ayu Made Asri Dwija , Dewi Ayu Aryista
Published: June 2021

A fraudulent financial statement is an issue that continues to be discussed as a form of deviation from corporate governance. Covid-19 pandemic has also demanded management to uphold the company's performance to have a good public image. Thus, the present study sets out to scrutinize the fraud pentagon theory on fraudulent financial statements. Each element is not able to be tested directly. However, there are proxies. The pressure element is proxied as a personal financial need. The opportunity is becoming the nature of industry. Each of the qualities of the external auditors as well as the change of directors propose rationalization and competence. The frequent number of CEO’s appearances in photos is a proxy of arrogance. The testing was carried out on the registered pharmaceutical companies of the Indonesian stock exchange in the span of the 2015-2019 period. The samples were selected by the means of sampling technique which is purposive. Data are scrutinized by the means of panel data regression. The analysis results show that the characteristics of the industry positively affects financial reports which are fraudulent. Changing top management positions such as directors can be an indication of financial reports which are fraudulent. The personal financial need variables, the caliber of external auditors and the quantity of CEO’s appearance in photos pose no effects on the fraudulent financial statements of the Indonesian's pharmaceutical companies.
Success predictors of village financial systems
Authors: Wulandari Dewa Ayu Eny , Suprasto Herkulanus Bambang , Dwirandra A.A.N.B. , Astika Ida Bagus Putra
Published: June 2021

SISKEUDES is a financial system used by the village government aimed at improving accountability, creating common perceptions in the delivery and application of various laws and regulations in the form of village financial management systems and procedures. Implementation of SISKEUDES helps us improve good corporate governance of village government in Indonesia. However, in the Village Assistance Report in Badung Regency in 2018 and 2019, there were input errors from planning, budgeting, administration and financial reporting. Based on this phenomenon, this study tested the predictor of successful application of the system. The measurement of SISKEUDES success is based on DeLone and McLean information system success model. This study examines the direct effect of system quality, information quality, service quality and quality of human resource on use, user satisfaction and net benefits. The sample determination technique uses purposive sampling with criteria of all SISKEUDES users in Badung Regency Village Government with a minimum of 1 year working experience. Data analysis uses Partial Least Square with SmartPLS 3. The results show that only system quality, information quality, and service quality have positive effects on user satisfaction, while the quality of human resources has no effect on user satisfaction. The quality of information, the quality of service, and the quality of human resources have positive effects on the use, while the quality of the system has no effect on the use. The quality of information, service quality, use and user satisfaction have positive effects on net benefits.
Internal auditor reports a fraud: Courage and pressure
Authors: Rosdini Dini , Mita Aria Farah , Setyaningrum Dyah
Published: June 2021

Income smoothing is basically a management strategy to reduce fluctuating income levels. This study aims to determine the effect of company size, leverage and profitability on income smoothing in companies listed on the LQ45 Index of the Indonesia Stock Exchange for the 2017-2019 period. It was carried out on companies listed on the LQ45 Index of the Indonesia Stock Exchange in 2017-2019. Sampling was conducted by utilizing purposive sampling and obtained 11 companies, from which 33 data were collected. The analysis technique used was multiple linear regression analysis. Results showed that company size, leverage and profitability simultaneously can affect income smoothing of a company. Company size and profitability partially have a positive effect on income smoothing, while leverage has a negative effect on income smoothing.
Pengaruh Penambahan Abu Arang Tempurung Kelapa Pada Tanah Lempung Terhadap Hasil Uji Kompaksi
Authors: Suzanna Brigita , Wong Irwan Lie Keng , Palinggi Monika Datu Mirring
Published: June 2021

The purpose of this research is to determine the physical properties of clay soil and to analyze the effect of adding coconut shell charcoal ash to the clay soil. The soil samples used in this study came from Tanralili District, Maros Regency, two sample points were taken and the variations in the levels of addition of coconut shell charcoal ash is 0%, 4%, 6%, 8%, 10%. The test method used refers to ASTM (American Society for Testing Materials). The tests carried out were testing the physical properties of the soil in the form of moisture content, specific gravity, Atterberg boundaries, filter analysis, and hydrometer analysis, then a compaction test was carried out to determine the maximum soil density. The results of the test obtained a moisture content value of 28.811%, a specific gravity of 2.58 g / cm3 so that it is classified as organic clay. As well as the plasticity index value of 9.926% with moderate plasticity from the 7% -17% interval. Then from the test results of soil compaction testing with the addition of coconut shell ash, the dry density (gdry) equal to 0.862, 0.886, 0.914, 0.943, 0.962, this means that the soil sample experienced an increase in dry density (gdry) of 11.60%. From the research results it can be concluded that the addition of coconut shell charcoal ash can increase the value of soil dry density so that it can be used to increase the value of the carrying capacity of clay soil.
Welcome Message from Editor-in-Chief of Journal of Clinical and Biomedical Investigation
Authors: OJ Castejón
Published: June 2021

This new Journal of Clinical and Biomedical Investigation appears as an expression of the vertiginous and rapid advancements in worldwide in biomedical Sciences and Clinical Research. It will be an online indexed journal in major bibliographic databases and adhere to strict standards of editorial quality in a globalized academic scenario. Our main goal is to publish the most relevant original research and secondly to obtain the broadest possible visibility and the widest dissemination of their scientific contents. We will also publish preliminary research communications, review papers and postgraduate thesis and seminars highly recommended by their mentors or advisors. We will adopt the peer review system and we ask to the authors to send the address and email of three reviewers. The prestige of our journal will be measured by its impact factor and other recent emerging and alternative indicators of research performance. Due to its complex nature modern biomedical research has become increasingly inter- and transdisciplinary and collaborative scientific work. Educational researchers should describe concepts, study design and methods in order to provide transparency, clarity, appropriate ethic guidelines, and a constructive and critical approach. In such a way we can obtain a modern and updated perspective that allows the readers interested to study in depth this emerging field of biomedical research.
How and where police detainees obtain methamphetamine
Authors: Doherty Laura , Sullivan Tom
Published: June 2021

An analysis of 2018–19 Drug Use Monitoring in Australia data suggests 64 percent of police detainees obtained methamphetamine from someone they knew, while 28 percent bought from a dealer. The most common location to obtain methamphetamine was the home of a known person. Detainees reporting methamphetamine dependence were more likely to buy from a dealer and those injecting methamphetamine were more likely to obtain it at an agreed public location. The findings suggest detainees most commonly obtained methamphetamine through closed drug markets using social supply. However, detainees with more harmful patterns of use also commonly used semi-open markets.
Editorial Volume 1 Issue 1
Authors:   Emergency Assessment Unit (Medicine), Norfolk and Norwich University, Jenkins Paul F
Published: June 2021

As you can see, the title of the Journal has changed and this is intended to emphasize its educational direction. It will continue to commission articles covering general medical topics with a particular emphasis on the management of acute medical emergencies, aiming to reflect the challenges that face those physicians responsible for supporting the acute medical intake. The CME component will continue,so helping to facilitate the accumulation of CPD points in General Medicine. As always we welcome submissions for publication and these can take the form of original research in areas of relevance to Acute Medicine or case-reports. We will continue to commission review articles as otherwise it proves impossible to maintain the cycle and the combination of articles we have planned. I am particularly enthused by the combination of topics covered in this Edition and I do hope that you enjoy reading them as much as I have enjoyed my editing duties. Profound thanks as always to those who have so kindly contributed;we do appreciate the extra commitment, especially in these days of inexorably heavier work-load for clinicians. This is my last Journal as Editor and I must extend my gratitude to those who have written articles over the past four years, to the member of the Editorial Board and of course to the Staff at RILA who have self lessly supported the Editor’s task. Unfailingly efficient they have been a complete pleasure to work with and very under tanding of the occasional memory lapse of this particular Editor! Chris Roseveare, Consultant in Acute Medicine in Southampton, takes over and the new editorial board will be announced in the next issue. Chris has some brilliant ideas and will lead this Journal to renewed success I am sure. I wish him the best of luck.
Spinal cord compression
Authors:   Neurology, The Norfolk and Norwich University Hospital, Dick David J
Published: June 2021

Compression of the spinal cord may present to general physicians, orthopaedic surgeons, neurologists or, if radicular pain is mistaken for intra-abdominal pathology, general surgeons. The causes of spinal cord dysfunction are diverse and range from anterior spinal artery ischaemia through a range of inflammatory insults to structural compressive pathology. The purpose of this article is to discuss the diagnosis of spinal cord compression, how to localise it clinically and how best to manage it.
Acute renal failure
Authors:   Department of Medicine, University College London, Glynne Paul A , Lightstone Liz ,   Faculty of Medicine, Imperial College of Science Technology and Medicine
Published: June 2021

The majority of cases of acute renal failure (ARF)occur in hospital, most commonly due to acute tubule necrosis caused by multiple nephrotoxic insults, particularly hypovolaemia, hypotension and nephrotoxic drugs. In- hospital ARF carries a high mortality rate, and every attempt should be made to identify at-risk patients and prevent its development by suitable hydration and avoidance of nephrotoxins. Out-of-hospital ARF typically presents as single organ disease, and, if the cause is readily identified and treated, often carries a good prognosis. ARF diagnoses that require specific treatment, particularly urinary tract obstruction and rapidly progressive glomerulonephritis,must not be missed. The immediate priority for all patients with ARF is to make them safe from potentially life-threatening metabolic sequelae, with early referral to a nephrologist in case acute dialysis becomes necessary.
Fever in the returned traveller
Authors:   Infectious Diseases, Imperial College, School of Medicine, Department of Infection and Tropical Medicine, Northwick Park Hospital, Harrow, Melzer Mark , Pasvol G ,   Imperial College, School of Medicine, Department of Infection and Tropical Medicine, Northwick Park Hospital, Harrow
Published: June 2021

The diagnosis of fever in the returned traveller is an important challenge to the physician. An accurate travel history and knowledge of the incubation period of common diseases is required to assess the risk of infection with a specific infectious agent. Although many febrile illnesses are benign and self-limiting, failure to diagnose malaria and enteric fevers may have disastrous consequences. All patients returning with fever should have thick and thin blood films for malaria and blood cultures performed. Other haematological and biochemical tests are useful in identifying a group of patients in whom empirical anti-microbial therapy is indicated. Thought must be given to the isolation of patients and notification of certain suspected or proven diseases to the local Consultant for Communicable Disease Control. Preventative measures in those likely to travel again should be discussed.
A Practical Guide to the Management of Diabetic Ketoacidosis in Adults
Authors:   Diabetes and Endocrinology, Cheltenham General Hospital, Evans Alison , Taylor Martin ,   Acute Medicine, Royal Bournemouth Hospital
Published: June 2021

Diabetic ketoacidosis is a life-threatening medical emergency which requires prompt diagnosis and treatment. Understanding the mechanism by which lack of insulin causes dehydration and acidosis is helpful in managing this condition. Numerous guidelines exist to improve management but adherence to guidelines is often poor. This guide aims to provide practical advice for the doctors and nurses involved in the immediate management of these patients.
Principles and Practice of Antibiotic Therapy for Cellulitis
Authors:   Medical Microbiology, Public Health Laboratory, Southampton University Hospitals Trust, Southampton, R Jones Graeme
Published: June 2021

Cellulitis is a common medical emergency. Investigations often fail to establish the specific microbial aetiology and there are few data to support common choices of antibiotic therapy used to treat cellulitis. Potentially unusual pathogens can be predicted from the epidemiological circumstances at presentation, while empirical treatment choices must be based on an understanding of the underlying pharmacokinetic and pharmacodynamic principles that govern antibiotic-microbe interactions. Animal models have established conditions that predict treatment success, taking into account confounding factors such as bacterial inoculum size. Synergistic combinations of antibiotics can improve outcome in difficult cases.
Ventilation for the Asthmatic Patient
Authors:   Anglian School of Anaesthesia, Wolmarans M , Fletcher Simon J ,   Anaesthesia and Intensive Care, Norfolk & Norwich University NHS Foundation Trust
Published: June 2021

Ventilation of the asthmatic is a major challenge with a potential for catastrophic problems that can and should be anticipated. Therapy should be tailored to the individual’s needs. If managed appropriately mortality in these patients is low (less than 1%). Much of the reported morbidity relates to cerebral hypoxia at or immediately before ventilatory intervention. Early use of CPAP in asthmatics that fail or are slow to respond to conventional therapy has been shown to significantly reduce the need for intermittent positive pressure ventilation.
Pulmonary thromboembolism
Authors:   Hinchingbrooke Hospital, Borland Colin
Published: June 2021

Pulmonary embolism is common, treatable and often overlooked. Genetic factors such as factor V Leiden and acquired factors such as immobility, pregnancy, surgery and malignancy increase the risk. The clinical features are nonspecific, but dyspnoea and tachypnoea are almost universal. Traditional tests such as electrocardiography, blood gases and chest X ray lack sensitivity and specificity and recently ventilation perfusion scanning and leg ultrasound have been shown to be unhelpful in many cases. Central venous pressure measurement and echocardiography, especially of the right ventricle, are helpful in a collapsed patient. D-Dimer testing is useful in excluding pulmonary embolism provided it is part of a diagnostic pathway that includes clinical risk. Spiral CT scanning is sensitive and specific for proximal pulmonary embolism. Immediate treatment with low molecular weight heparin is indicated, except for the hypotensive patient, when thrombolysis with alteplase should be considered. Warfarin should be started and continued for six months or longer if justified by genetic or acquired factors.
Editorial
Authors:   Acute Medicine, University Hospital Southampton Foundation Trust, Southampton, Roseveare Chris
Published: June 2021

So the brief ‘respite’ of summer is over, and we find ourselves plunging, once more towards the abyss of winter bed pressures. Hopefully those of you working at the coalface will find time to browse through the following pages. The production of a third issue in this ‘shortened’ year, following the launch of the Journal in July, is a credit to the hard work of the editorial and publishing teams. I am, as ever, grateful for their support. Next year will see a return to the planned 4-monthly cycle, with issues anticipated in March, July and November. One casualty of the tight schedule has been a minor adjustment to the cycle of reviews – COPD will now appear next Spring. In its place we have included an interesting paper reviewing the management of Neuroleptic Malignant Syndrome and Serotonin Syndrome, submitted by Consultant Psychiatrist David McNamara. Gastrointestinal haemorrhage and atrial fibrillation will be more familiar to readers, while Dr Joanna Girling’s review of the management of medical emergencies in pregnancy is essential reading for any physician working close to a maternity unit. Myasthenia gravis may not be the commonest medical emergency; nonetheless it is important that physicians are able to suspect, diagnose and initiate treatment for this condition. As I mentioned in my last editorial, I am keen to encourage submissions of case reports, audits, and pieces of original research provided they would appeal to a general medical readership. Cases need not be rare conditions, but must contain a clear teaching message for the reader. In future editions case reports will be categorised as ‘Tales of the Unexpected’, and ‘A Case to Remember’ (a memorable case or one with a message that readers should remember in future). The report on page 106 is an example of the latter – an important reminder that a radiological diagnosis of ‘pneumonia’ does not always imply an infective cause. Finally, I would like to thank those of you who have written with feedback following the previous edition of CPD Acute Medicine. We are clearly attempting to appeal to physicians from a broad range of backgrounds, and I hope that all readers find something which appeals to them in the pages which follow. Please feel free to write with your comments on any issue which you would like to share with the editorial team – depending on the response we may consider including a correspondence section in future editions of the journal.
Acute non – variceal upper gastrointestinal haemorrhage
Authors:   Gastroenterology, Southampton University Hospital, Southampton, Bhandari Pradeep , Patel Priya ,   Norfolk and Norwich University Hospital, Colney Lane
Published: June 2021

Upper gastrointestinal haemorrhage remains a common medical emergency with significant mortality. Management depends on appropriate and timely resuscitation, therapeutic endoscopy and surgery. This is made possible by a multidisciplinary approach incorporating protocols and scoring systems to aid risk stratification. Communication between members of the multidisciplinary team is important in determining the outcome for patients with high predicted mortality.
Management of Medical Emergencies in Pregnancy
Authors:   Obstetrics and Gynaecology, West Middlesex University Hospital, C Girling Joanna
Published: June 2021

Medical emergencies in pregnant women pose many challenges if both the baby and mother are to have an optimal outcome. Multidisciplinary team working is essential to ensure that the correct treatment is offered, and that potentially lifesaving options are not discarded because of unwarranted concerns about safety in pregnancy. Expertise should be sought from doctors with a special interest in obstetric medicine. Clinical problems include those unique to pregnancy such as eclampsia or acute fatty liver of pregnancy, exacerbations of chronic medical diseases some of which can be predicted such as pulmonary hypertension, or conditions which have an increased frequency in pregnancy including thromboembolism, urinary tract infection and Bell’s palsy. Cardiopulmonary resuscitation in pregnancy should be managed in the left lateral position, with early recourse to delivery of the fetus.
The Neuroleptic Malignant and Serotonin Syndromes
Authors:   Psychiatry Department, South London and Maudsley NHS, Belgrave, Kings College Hospital, London, McNamara David
Published: June 2021

The Neuroleptic Malignant Syndrome and the Serotonin Syndrome are two rare but potentially fatal complications of psychopharmacology. This review focuses on the clinical aspects of these conditions, exploring the diagnosis, differential diagnosis, treatment and prognosis.
Editorial
Authors:   Acute Medicine, University Hospital Southampton Foundation Trust, Southampton, Roseveare Chris
Published: June 2021

There was, no doubt, a time when the end of winter brought a sense of jubilation at the frontline of hospital medicine. Now, not only do the emergency pressures seem to continue year-round, but spring also brings the challenge of a revised set of Government targets. This April we are greeted with a 20 minute door to needle time for thrombolysis, and a four hour wait target measured from the time of arrival in A&E. Those of you who take a light-hearted view of such things may be may be amused to hear of a local hospital’s appropriately mis-spelt response in the form of a ‘Darft Action Plan’. For the rest of you, good luck – remember, your Trust’s ‘Star Rating’ is dependent on you! In this edition, John O’Reilly reminds us that chronic obstructive airways disease accounts for up to 25% of the workload of a UK medical ‘Take’, although for the last few months it has probably felt like even more. In contrast, accelerated hypertension is rarely encountered, but nonetheless must be recognised and treated by physicians working at the front door. Two of the reviews approach contrasting presentations of the septic patient. On page 13, Cardy and Poulton have produced a comprehensive overview of the critical care perspective, while Clare Spice reminds us of the non-specific way in which infection can present in the elderly in her paper on delirium. The ‘Regular Features’ section brings the second in a series of ‘How to do it’ papers from ophthalmologists Beth Edmonds and Peter Francis. Having covered fundoscopy last year, they now turn their attention to the demystifying of pupillary responses. This month’s ‘case to remember’ provides a salutary lesson in the need for lateral thinking in the management of patients taking immunosuppressant medication. Although a recognised complication of methotrexate therapy, the diagnosis of pneumocystis carinii pneumonia can so easily be forgotten, with potentially serious consequences. As I have mentioned in previous editorials, I am keen to encourage submissions of case reports, audits and original research relevant to the acute medical setting for future publication. Reviews are normally commissioned in line with the cycle on page 35. However, if you have a particular interest in a condition not included in the cycle, with a relevance to other clinicians involved in the acute medical take, please feel free to write and submit to us at the address opposite, or contact me directly by e-mail. The multiple choice questions are, once again, for self-assessment only. Answers are on the following page, so no ‘external’ CPD points can be accrued for now. However, reading the journal can still count towards your ‘personal’ CPD credit. Hopefully you will find something to interest you in the following pages, along with a little light relief from the pressures (and targets) of the ‘day-job’!
Emergency management of acute exacerbation of chronic obstructive pulmonary disease
Authors:   Victoria Hospital, Blackpool, UK, O’Reilly John F
Published: June 2021

Current management of exacerbation of chronic obstructive pulmonary disease (COPD) takes into account new understanding of the factors contributing to morbidity, hospital admission and mortality. An evidence-based approach to management is outlined based on national and international guidelineds. Particular reference is made to use of oxygen, drug therapy, and non-invasive ventilatory support, as well as development of hospital at home and early supported discharge services.
Accelerated Hypertension –management in the acute setting
Authors:   Renal Unit, Ninewells Hospital, Dundee, Henderson Andrew , Jones Matthew ,   Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust
Published: June 2021

Accelerated hypertension is a rare but life threatening disease. The commonest cause is poorly controlled essential hypertension but other causes exist. Diagnosis is made by the finding of severe hypertension with associated end organ disease affecting brain, eyes, heart or kidney. Treatment should be tailored to the individual patient and usually should be given orally. There is no clear evidence that one class of antihypertensives is more effective than another and the main aim of therapy should be a controlled fall in Blood Pressure.
Emergency assessment and management of the septic patient
Authors:   Department of Anaesthesia, Norfolk & Norwich University Hospital, Colney Lane, Norwich, Cardy J D , Poulton B ,   Department of Anaesthesia, Norfolk & Norwich University Hospital, Colney Lane, Norwich
Published: June 2021

Sepsis is a common problem in hospital practice. As well as being an important precipitant of hospital admission many patients develop the problem after arrival in hospital, including in excess of 500,000 patients in critical care units across each year. Over one-half of all infections in critical care units are associated with severe sepsis or septic shock.1 Despite major research effort in this area and the introduction of new therapeutic agents, mortality from septic shock remains high (50-70%). With the ageing population, emerging antibiotic resistance, and increasing use of immunosuppressive healthcare, sepsis is set to become an even greater drain on healthcare resources. The early recognition and appropriate management of sepsis is important. There is increasing evidence that an immediate, proactive approach has prognostic significance.
Acute exacerbation of asthma in adults
Authors:   Norfolk and Norwich University Hospital Colney, Ramsay Crichton
Published: June 2021

Acute asthma remains an important cause of morbidity adults. The recognition, assessment and appropriate management of acute asthma are essential to avoid unnecessary morbidity and also mortality, which unfortunately still occurs. This article will present an overview of the hospital management of acute asthma exacerbations in adults. The British Thoracic Society(BTS) conjunction with the Scottish Intercollegiate Guidelines Network(SIGN) published the latest British Guidelines on all aspects of asthma management in February of this year .1 This article is a précis of these latest British guidelines as they relate to acute asthma in adults.
Acute management of multiple sclerosis
Authors:   Frenchay Hospital Bristol, Merrison A FA , Scolding Neil J ,   Frenchay Hospital Bristol
Published: June 2021

Multiple sclerosis is one of the commonest causes of disability in young adults. This review highlights some of the acute presentations of this condition, and how these may be managed in the emergency setting. The role of corticosteroids is discussed, along with the value of other drugs in symptom control during an acute relapse.
Emergency Management of Variceal
Authors:   Southampton General Hospital Tremona Road Southampton, Khakoo Salim I , Rosenberg William MC ,   Southampton General Hospital Tremona Road Southampton
Published: June 2021

Variceal haemorrhage is a life-threatening condition requiring prompt emergency therapy. This paper summarises the key aspects of management of this condition in the acute setting, including airway management, fluid resuscitation, and pharmacotherapy. The value of therapeutic endoscopy, balloon tamponade and radiological shunt procedures are also highlighted.
Milk-Alkali Syndrome: An Unusual Cause of Acute Renal Failure
Authors:   Southampton General Hospital Southampton, Ahmad Azhar , Dathan Rodney ,   Southampton General Hospital Southampton
Published: June 2021

Milk–alkali syndrome is described as a triad of hypercalcaemia, metabolic alkalosis and renal impairment, resulting from the ingestion of calcium and absorbable alkali1. It was more common in the early part of the century when antacids were used for the symptomatic treatment of peptic ulcer disease. The use of antacids has since been overtaken by H2- receptor antagonists and proton pump inhibitors. More recently, there have been various case reports of milk-alkali syndrome due to the increasing use of calcium carbonate as part of the management of osteoporosis and chronic renal failure, and also the increasing availability of calcium carbonate ‘over the counter’. We describe a case of milk-alkali syndrome due to self-medication with calcium carbonate.
Thoughts from the darkroom…
Authors:   Hinchingbrooke Hospital, Huntingdon, Crean A
Published: June 2021

One of the commonest requests for out of hours imaging is for cranial CT in patients with possible meningitis. Telephone conversations like this may be familiar: “Hello I’m the medical SHO on call….I’d like to request a CT brain please…to rule out raised intracranial pressure before lumbar puncture…no we couldn’t get a good look at his fundi….they didn’t have any tropicamide in A and E…well, perhaps you’d like to do the LP if you don’t think a CT is necessary…” This type of request in fact may or may not be justified depending on the clinical scenario. The perception of radiologists is that few patients with possible meningitis require head CT before lumbar puncture; the perception of physicians is that the majority do. Pole-positions like this invariably generate conflict between our specialities. Can we use the available literature to guide us to a more evidence-based approach which both groups will find acceptable ?
Editorial
Authors:   Acute Medicine, University Hospital Southampton Foundation Trust, Southampton, Roseveare Chris
Published: June 2021

It could be said that the past 12 months have been an exciting time in the field of acute medicine. In addition to the high profile afforded by the publication of Reforming Emergency Care and the ongoing Emergency Services Collaborative, the significance of the recent acquisition of subspecialty status for Acute Medicine cannot be understated. This, in turn has enabled approval of a new competency-based training curriculum by the JCHMT. Hopefully within the next few months, specialist registrars in General Internal Medicine with Acute Medicine will be appointed to the first few numbered posts in this discipline. Clearly a rapid expansion in posts of this nature will be required in the next few years in order to meet the enormous demand for consultants in Acute Medicine. Recently, in common with other medical specialties, hospitals have experienced difficulties in recruiting suitable applicants for such posts resulting in many vacancies across the UK. One challenge for those of us already working in the field is to maintain enthusiasm for the concept, while we are waiting for the trainees to mature into competent consultants. This edition includes another varied selection of reviews. Community acquired pneumonia may be of particular relevance over the remaining winter months, although hopefully the brief mention of SARS in this paper will now only be of historical significance. Patients with hypercalcaemia, dysphagia and Guillan Barre syndrome may be less frequent attenders, but nonetheless often create management dilemmas with which the admitting physician needs to be familiar. In a departure from our previous format, we have included two case reports this time, both highlighting an important clinical scenario. Power kite flying may not be a familiar activity for many readers, but the outcome described by Merrison and colleagues justifies its inclusion as ‘a case to remember’. Mark Mallett, on the other hand, reminds us that syncope can, on occasions, reflect significant underlying pathology, even in an apparently healthy member of the hospital portering staff. Once again we would like to encourage similar submissions for future editions of the journal. After several years of association with CPD Acute Medicine and its predecessor, it is with great sadness that this edition is Paul Jenkins ’last as sub-editor. We wish him well as he moves on to new challenges in his role as President of the Society for Acute Medicine, and gratefully acknowledge all of his hard work in establishing the journal.
Community-Acquired Pneumonia
Authors:   Kings Mill Hospital, Mansfield Road, Sutton, Ashfield, Nottinghamshire, Mabeza George F. , Ward Mike J. ,   Kings Mill Hospital, Mansfield Road, Sutton, Ashfield, Nottinghamshire
Published: June 2021

Pneumonia causes more deaths than any other infectious disease in the developed world. Patients who develop pneumonia in the community therefore require early recognition, targeted investigation and specific treatment. We outline a practical approach to assessing and managing the immunocompetent adult presenting with a community- acquired pneumonia to the emergency department.
Dysphagia for the acute physician
Authors:   Royal Hampshire County Hospital, Romsey Road, Winchester, Followfield Jonathan , Shepherd Hugh ,   Gastroenterology, Royal Hampshire County Hospital, Romsey Road, Winchester
Published: June 2021

Dysphagia (subjective difficulty in swallowing) is a common clinical problem, particularly in the elderly population. Ideally, patients should be assessed promptly in the appropriate outpatient setting, but frequently they will be admitted on an acute medical take due to ‘total’ dysphagia, dehydration, debilitation or possible aspiration. A careful history and examination can usually elucidate the site of the lesion and its possible cause, and thus direct initial management. This article will concentrate on the role of the acute physician in the assessment of patients with dysphagia within the first 48 hours of presentation.
Acute Management of Guillain-Barré Syndrome
Authors:   Department of Neurology, Royal Gwent Hospital, Cardiff Road, Newport, Lawthom Charlotte , Llewelyn J Gareth ,   Department of Neurology, Royal Gwent Hospital, Cardiff Road, Newport
Published: June 2021

Guillain-Barré Syndrome (GBS) is an acute inflammatory polyneuropathy. Typical presentation is one of ascending tetraparesis with aref lexia. Variant forms of GBS include ataxia and ophthalmoplegia with aref lexia; patients with preserved ref lexes may mislead the unwary. Diagnostic dilemmas may be solved with neurophysiology and lumbar puncture. Emergency management requires assessment of airway, breathing and circulation. Regular monitoring of respiratory, and bulbar function is essential and any deterioration in neurological function should prompt treatment. Treatment with intravenous immunoglubulin shortens the length of illness.
A guide to the initial management of hypercalcaemia
Authors:   General Medicine, Ninewells Hospital, Dundee, Macklin J.P. , Green F.C. ,   Endocrinology, Ninewells Hospital, Dundee
Published: June 2021

With the widespread use of multiple channel biochemical auto analysers hypercalcaemia has become a common incidental finding. The approach to managing a patient with hypercalcaemia requires an understanding of the principles of calcium homeostasis, knowledge of the potential differential diagnoses and the clinical judgement to know when therapy is appropriate. This article aims to provide a guide to the initial investigation and management of patients presenting with hypercalcaemia.
Syncope in the Hospital
Authors:   Medical Assessment Unit, Royal United Hospital, Bath, UK, Mallet Mark
Published: June 2021

A case is presented in which a man with anomalous coronary artery anatomy and thrombotic oronary stenoses had an episode of syncope. Further subsequent presyncopal events coincided with ventricular tachycardia on ambulatory ECG; stenting of the lesions eliminated further symptoms. The importance of seeking prognostically significant cardiac causes of syncope is discussed.
Neurological perils of power kites
Authors:   Department of Neurology, Frenchay Hospital, Bristol, Merrison Andria F.A. , Dougan Charlotte F. ,   Department of Neurology, Frenchay Hospital, Bristol, Lhatoo Samden D. ,   Department of Neurology, Frenchay Hospital, Bristol
Published: June 2021

A 38 year old man spent several hours flying a power kite, towing himself along a beach on a buggy. The wind generated sufficient force for this to be vigorous exercise. An hour later he developed a frontal headache, left-sided periorbital pain and neck pain. This persisted and two days later he noticed drooping of the left eyelid and difficulty focussing on near objects with that eye. He presented to hospital eight days later.
The Management of ST-segment Elevation Myocardial Infarction
Authors:   Dpt. of Cardiology University Hospital of Wales, Wallis Helen L
Published: June 2021

The definition and management of ST-segment elevation myocardial infarction (STEMI) has changed considerably over the past few years. This article has been written as an update to encompass the National Service Framework (NSF) for coronary heart disease (published in England in March 2000 1 and in Wales in July 20012), the Scottish Intercollegiate Guidelines Network 3 and the recent Task Force Report by the European Society of Cardiology (January 2003).
Coma – emergency management of the unconscious patient
Authors:   Peterborough Hospitals, Booth Stuart A , Leary Tim S ,   Norfolk & Norwich University Hospital, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
Published: June 2021

The acute presentation of an unconscious individual is a common scenario and it indicates a severe pathological insult. Aetiology may not be apparent at initial assessment and maximal use of available resources should be made to identify the cause. Initial management should be directed towards resuscitation and stabilisation of the individual, followed by further clinical assessment. The prevention of secondary brain injury is essential and so respiratory, circulatory and metabolic abnormalities should be treated aggressively. Early involvement of critical care physicians may be required. Detailed aspects of acute management and specific care of head injured, intoxicated and post-cardiac arrest patients is discussed.
“Funny Turns” in the Elderly
Authors:   Dept. Medicine for Elderly People Queen Alexandra Hospital Portsmouth PO6 3LY, Bacon M T
Published: June 2021

‘Funny turns’ are a common cause of hospitalization, particularly of elderly patients. The term may be used to define a wide variety of conditions, and to provide a detailed description of all possible causes would be beyond the scope of a single review. Instead this article aims to provide the reader with an overview of the common presentations, suggest a working framework for the admitting physician and guide judicious use of the investigations available.