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Acute Medicine

Mark Lander
I read with interest the Viewpoint article by Dr Chadwick regarding the future of Acute Internal Medicine (AIM) training, particularly the development of Capabilities in Practice (CiPs( and their potential to promote a greater identity within the specialty training. Dr Chadwick highlights the struggle we face in asserting why our specialty is so vibrant and vital. In my experience, Acute Internal Medicine training suffers from an identity crisis whereby the specialty is seen as being permanently on call, with trainees working more shifts as the Duty Medical Registrar (DMR) than on other specialty training programs, without the variability of outpatient and skill-based training...
2018: Acute Medicine
Nicola Cooper
I read the article, 'Is the AIM curriculum, for higher specialty training, fit for purpose' with interest. However, I disagree with the author on a number of points. First, a curriculum is 'everything that happens in relation to an educational programme', not a document setting out intentions and expectations. Issues with the quality of training in medical specialties are often addressed by re-writing documents. But the root causes of problems are often to do with the quality of posts 'on the ground' (e.g. timetable, experience and learning opportunities) and the quality of supervision and feedback (nonexistent in some cases)...
2018: Acute Medicine
P Parulekar, T Harris
Both hyper and hypovolaemia have been associated with poor outcomes. Assessment of fluid responsiveness is challenging in the acute medical patient, due to time constraints, limited evidence and quite often the lack of accurate assessment tools on the Acute Medicine Unit (AMU). This article explains how focused echo assessment is quick and easy to use for this purpose on the acute medical take and highlights key principles to bear in mind when assessing for hypovolaemia and whether to administer fluid therapy...
2018: Acute Medicine
N Denny, S Musale, H Edlin, F Serracino-Inglott, J Thachil
Deep vein thrombosis (DVT) is an important cause of short-term mortality and long-term morbidity. Among the different presentations of DVT, thrombus in the iliofemoral veins may be considered the severest form. Although anticoagulation is the mainstay of the management of iliofemoral thrombosis, despite adequate anticoagulant treatment, complications including post-thrombotic syndrome is not uncommon. The latter is often overlooked but can cause considerable morbidity to the affected individuals. Preventing this condition remains a challenge but recent clinical trials of catheter directed thrombolysis and elasticated compression stockings provide some advance in this context...
2018: Acute Medicine
M Jackson, K Balasubramaniam
A 64-year-old male presents to the emergency department in acute respiratory distress. He gives a limited history of progressive shortness of breath of one week's duration and several episodes of sudden unexplained syncope. There was no history of chest pain, palpitations or localising symptoms of infection. He takes no regular medications.
2018: Acute Medicine
S Yeniocak, A Kalkan, D D Metin, A Demirel, R Sut, I Akkoc
Olanzapine is an antipsychotic drug used in psychiatric diseases. At high doses it exhibits cardiovascular and neurological sideeffects in particular. Lipid emulsion therapy for the removal of medication from plasma in high-dose lipophilic drug use has recently become very widespread. In the light of current literature, this report discusses the successful treatment of a patient within 4 hrs of olanzapine overdose as an attempted suicide, who presented with agitation and clouded consciousness.
2018: Acute Medicine
T W Rice, P A Brock, C Gonzalez, K W Merriman, Z Shelal, H Bazerbashi, B P Granwehr
Treatment of human immunodeficiency virus(HIV) in cancer patients improves outcomes and reduces transmission of this oncogenic virus. HIV testing rates of cancer patients are similar to the general population (15-40%), despite the association with cancer. Our aim was to increase HIV screening in the Emergency Department(ED) of a comprehensive cancer center through a quality initiative. Testing increased significantly during the intervention (p<0.001; 0.15/day to 2.69/day). Seropositive HIV rate was 1.4% (12/852), with incidence of 0...
2018: Acute Medicine
M Bosch, N A Zwietering, H Borggreve, E Pijpers, P M Stassen
The aims of this retrospective cohort study were to retrieve characteristics and outcomes of older (65+) medical patients who are directly admitted to ICU from the ED and to compare these with those admitted to ICU from a ward. Of 1396 patients, 21 (1.5%) were directly admitted to ICU and 54 (3.9%) after a delay. Blood pressure was lower and respiratory rate higher in the direct than in the delayed group. The direct group had lower mortality (28-day: 19.0 vs. 38.9%, p=0.14; 1-year: 42.9 vs. 66.7%; p=0.06), shorter length-of-stay and returned more frequently to independent living than the delayed group...
2018: Acute Medicine
R S Nannan Panday, C P Subbe, L S van Galen, J Kellett, M Brabrand, C H Nickel, P W B Nanayakkara
Readmissions are treated as adverse events in many healthcare systems. Causes can be physiological deterioration or breakdown of social support systems. We investigated data from a European multi-centre study of readmissions for changes in vital signs between index admission and readmission. Data sets were graded according to the National Early Warning Score (NEWS). Of 487 patients in whom NEWS could be calculated on discharge and again on re-admission, 39.6% had worse vital signs with a NEWS score difference ≥ 2 points while only 7...
2018: Acute Medicine
K A Lockman, W H Lee, R Sinha, W L Teoh, C Bickler, S Dummer, A Veiraiah
Time and resource constraints have often led to the use of assessment records as discharge communications from acute and emergency departments. However, whether this addresses the primary care needs has not been demonstrated. This study examined the optimal structure that can impart key discharge information effectively using feedback from general practitioners (GP). We implemented an electronic assessment template that focused on the most relevant headings. Prespecified process measures were examined and qualitative thematic analysis of free-text comments from GP surveys were conducted to optimise the document...
2018: Acute Medicine
S M Rombach, G Balke- Budai, J van Galen, R Bekker, S E Smit-Bruineberg, T H Biesheuvel, Mhh Kramer, Pwb Nanayakkara
BACKGROUND: There is an increased influx of patients needing admission. Introducing an acute medical unit (AMU) may increase the admission capacity without increasing the total number of beds. METHODS: Data collected during the first four years after implementation of an AMU in an academic tertiary care center in Amsterdam were analyzed. RESULTS: A 24 bed unit was realized. The total number of admissions increased in the first year with 977 (16%), with an additional 4...
2018: Acute Medicine
P J Newton
Readers may be aware of the need to improve uptake of HIV testing in health care-settings to reduce the number of individuals with undiagnosed infection who later present with advanced disease. Late presentation of HIV infection is associated with a poorer immune response to antiretroviral therapy, an increased morbidity and mortality with a resultant higher cost burden to health-care services. Individuals with undiagnosed HIV infection who inadvertently transmit their infection to others are thought to be responsible for more than half of new HIV infections in the USA...
2018: Acute Medicine
D Lasserson
In the acute care pathway, patients often need to move from home to hospital and for the majority, back again. This movement across care interfaces ensures that assessments and interventions are delivered to reduce risk of harm and enhance recovery. However, information needs to move across interfaces too, which enables the clinician taking over care to understand the problem, what has been done and what remains to be done. This is as important for the journey into hospital as it is for the journey home again and is highlighted in the forthcoming NICE guidance on Emergency and Acute Medical Care...
2018: Acute Medicine
Tim Cooksley, Ben Lovell
As those working in Acute Medicine gather at SAMsterDAM2, the spring conference of the Society for Acute Medicine, the growth, reputation and global representation of the specialty continues to grow. Alongside, the traditional strongholds of the UK, Ireland, Netherlands, Denmark and Australia growth in Asia continues with an AMU now established in Pakistan among other countries.
2018: Acute Medicine
Tim Cooksley, Ben Lovell
Acute Medicine remains a specialty in its infancy and, as such, faces many challenges associated with developing new ways of working. As the Society for Acute Medicine celebrates its 18th birthday the extraordinary role of Acute Medicine in both maintaining and indeed enhancing the care and welfare of patients is increasingly evident. However, scepticism still persists among some colleagues with regards to its effectiveness - a perception heightened by the difficult environment that currently pervades in acute and emergency care in the UK which mirrors the experience of many countries internationally...
2018: Acute Medicine
Zay Myo Htet, Mahzuz Karim
Quinine has long been used for the treatment of conditions such as malaria and leg cramps, and is also present at low levels in some beverages; however, it can cause serious side effects. We describe a patient who developed severe haemolysis, thrombocytopaenia, and acute kidney injury following the ingestion of a single dose of quinine. This case demonstrates the importance of awareness of such potentially life-threatening consequences of exposure to this agent.
2018: Acute Medicine
Adam Williamson, Dan Beckett, Nik Arestis
A 34-year-old gentleman, with a background of osteoarthritis, presented to the Acute Medical Unit with a short history of breathlessness. He had returned from holiday to the United States five days previously. Since return, he had complained of myalgia, sore throat, a non-productive cough, mild anorexia and fevers at home. More acutely, prompting his presentation to hospital, was acute dyspnoea, which was sudden onset, with some central anterior chest discomfort and worse lying flat.
2018: Acute Medicine
C Napier
Thyrotoxicosis is common and can present in numerous ways with patients exhibiting a myriad of symptoms and signs. It affects around 1 in 2000 people annually in Europe1. The thyroid gland produces two thyroid hormones - thyroxine (T4) and triiodothyronine (T3). Thyroxine is inactive and is converted by the tissues and organs that need it into tri-iodothyronine. In health, the production of these thyroid hormones is tightly regulated by the secretion of thyroid stimulating hormone (TSH; thyrotropin) from the pituitary gland...
2018: Acute Medicine
Viyaasan Mahalingasivam, John Booth, Michael Sheaff, Magdi Yaqoob
Nephrotic syndrome is an important presentation of glomerular disease characterised by heavy proteinuria, hypoalbuminaemia and oedema. The differential diagnosis of the underlying condition is wide including primary renal disorders and secondary diseases such as malignancy, infection, diabetes and amyloid. Presentations to acute medicine may be with hypervolaemia, complications of the nephrotic state (such as venous thromboembolism), or complications of therapy (such as infection). Early recognition of nephrotic syndrome is possible through simple urinalysis for protein and testing serum albumin, although a high index of suspicion is sometimes required in patients with comorbidities including potentially distracting cardiac or hepatic diseases...
2018: Acute Medicine
C Dudreuilh, R Aguiar, M Ostermann
Managing kidney transplant patients in an acute medical unit can be challenging, as patients have a single functioning kidney, underlying chronic kidney disease, and are immunosuppressed. Transplant patients develop AKI for all usual reasons but the differential diagnosis is wider and includes specific problems, such as obstruction of a single functioning kidney, vascular thrombosis, rejection, drug toxicity and drug-induced thrombotic microangiopathy. Septic AKI is common but again, the differential diagnosis of sepsis is wider...
2018: Acute Medicine
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