Volume 17, Issue 3, Pages 117 – 172 (2018)

Curriculum mapping for Focused Acute Medicine Ultrasound (FAMUS)

Correspondence, Volume 17, Issue 3, Pages 117 – 172 (2018)

Point of care ultrasound (POCUS) in the hands of the non-radiologist has seen a steady growth in popularity amongst emergency, intensive care and acute medical physicians. Increased accessibility to portable, purpose-built ultrasound machines has meant that clinicians often have access to a safe and non-invasive tool to enhance their management of the unwell.

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Focused Acute Medicine Ultrasound (FAMUS)

Special Article, Volume 17, Issue 3, Pages 117 – 172 (2018)

Point of care ultrasound (POCUS) has seen steady growth in its use and applications in aiding clinicians in the management of acutely unwell patients. Focused Acute Medicine Ultrasound (FAMUS) is the standard created specifically for Acute Medicine physicians and is endorsed by the Society for Acute Medicine and recognised by the Acute Internal Medicine (AIM) training committee as a specialist skill.

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Sub-acute herpes simplex virus myelitis in a patient with esophageal cancer on chemo-radiation with 5-fluorouracil: a case report

Case Reports, Volume 17, Issue 3, Pages 117 – 172 (2018)

No reported cases to date describe herpes simplex virus (HSV) myelitis in association with cancer and chemo-radiation. We report a case of sub-acute HSV myelitis in a 54-year-old man receiving chemo-radiation with 5-flourouracil for esophageal cancer who presented to the emergency department with increasing numbness in both lower limbs that gradually spread to waist level. Magnetic resonance imaging with gadobutrol contrast 1 week later showed transverse myelitis involving the dorsal columns. Radiation-induced myelitis was suspected, and the patient was initially treated with dexamethasone; however, CSF analysis revealed HSV myelitis. Treatment with antivirals resolved much of the numbness. HSV myelitis can be confused with complications of radiation or malignancy in patients presenting with focal neurological deficits.

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An unusual case of dysphagia

Case Reports, Volume 17, Issue 3, Pages 117 – 172 (2018)

A 51-year-old lady, with a background of an arachnoid cyst and ventriculo-peritoneal shunt in situ, presented to the Acute Medical Unit with a 2-day history of neck pain. She awoke from sleep with the pain and it persisted since. She had not been involved in any trauma, had no previous history of neck or back pain and her pain was not controlled with simple analgesia. She also complained of new odynophagia and high dysphagia, particularly to solid foods. There was no history of upper respiratory tract infection.

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What is the evidence base for ambulatory care for acute medical illness?

Review Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Acute ambulatory care is a critical component of the emergency care pathway with national policy support and a dedicated NHS Improvement network. The evidence base for treating acute medical illness outside hospital is a diverse mix of randomised and observational studies with varying inclusion criteria, prognostic stratification, interventions and healthcare setting which limits synthesis of all available evidence and translation to the UK context. There is little consensus on the level of risk for home-based treatment for acute medical illness. Selection tools for referral to acute ambulatory care have been developed but there is limited evidence for their use. There are still research questions concerning optimal staffing, referral mechanisms, point of care diagnostic portfolio and tools for shared decision making.

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Chronic deep vein thrombosis

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Deep vein thrombosis (DVT) is an important cause of short-term mortality and long-term morbidity. Although acute DVT is often well managed, there is uncertainty in the management of chronic DVT which is increasingly being noted among patients presenting with similar symptoms to their initial DVT. The presence of a residual venous clot can be a problem for both physicians and patients fearing the risk of emboli to the same extent as the acute DVT. There are also issues in the accurate diagnosis and appropriate management of chronic DVT, which is the focus of the second part of this review.

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Examining trainee awareness of dermatoses and dermatological assessments during acute admissions (A quality improvement project)

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Studies demonstrate 67% of elderly patients can have dermatoses, which could result in functional and psychological consequences. Elderly presentations are further complicated by comorbidities and polypharmacy. This combined with limited dermatology training at undergraduate and postgraduate levels creates diagnostic challenges. This project investigated dermatology assessments by trainees using the Trust’s acute medical admissions proforma. 100 proforma were reviewed for skin assessments alongside nursing skin care bundles. Subsequently, a skin survey was conducted amongst trainees evaluating knowledge and confidence when diagnosing and managing common dermatoses. Successively, a dermatology teaching series was delivered. Post-intervention the above were reassessed, demonstrating  improvements in most areas. The dermatology teaching series will continue alongside a Trust hospital guideline to sustain improvements in dermatological care on admission.

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Mortality outcomes and emergency department wait times – the paradox in the capacity limited system

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Background: There is concern that undue ED wait times may result in adverse outcomes.

Methods: We studied 30-day in-hospital mortality (2002-2017) for all medical admissions (106,586 episodes; 54,928 patients) focusing on clinical risk profile

Results: Comparing 2002-09 vs. 2010-17, median ED waits > 6 hours (hr) increased 10h (95% CI: 8,13) to 15h (95% CI: 9,19). 30-day mortality declined 6.2% to 4.9%- (RRR- 20.8%/ NNT- 78). 30-day-mortality by ED wait: - < 4hr 6.6% (95% CI: 6.3%, 6.9%), 4-8hr 4.8% (95% CI: 4.6%, 5.0%), 8-12hr 4.3% (95% CI: 4.1%, 4.5%) or >=12hr 4.2% (95% CI: 3.9%, 4.5%).

Conclusion: Admissions with shorter waits are overrepresented with high clinical acuity. Higher Risk Score patient with extended wait times had worse clinical outcomes.

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Screening instruments for identification of vulnerable older adults at the emergency department: a critical appraisal

Original Articles, Volume 17, Issue 3, Pages 117 – 172 (2018)

Abstract

Background: Early detection of vulnerable older adults at the emergency department (ED) and implementation of targeted interventions to prevent functional decline may lead to better patient outcomes.

Objective: To assess the level of agreement between four frequently used screening instruments: ISAR-HP, VMS, InterRAI ED Screener and APOP.

Methods: Observational prospective cohort study in patients ≥ 70 years attending Dutch ED.

Results: The prevalence of vulnerability ranged from 19% (APOP) to 45% (ISAR-HP). Overall there was a moderate agreement between the screening instruments (Fleiss Kappa of 0.42 (p<0.001)). Conclusion: Depending on the screening instrument used, either only a small percentage or almost as many as half of the presenting patients will be eligible for targeted interventions, leading to large dissimilarities in working processes, resources and costs.

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