We thank Dr Gyan and colleagues for their thoughtful critique of our paper and welcome the opportunity to clarify the intended interpretation of our findings.
We acknowledge that there are a number of limitations to this service evaluation highlighted in your letter, which are also addressed in the paper itself.
Lumbar puncture in patients with acute severe headache – Response to letter Read More
We read with interest the service evaluation by Voase and colleagues examining the diagnostic yield of lumbar puncture (LP) in patients presenting with acute severe headache1. The authors address an important subject in a time of increasingly sensitive neuroimaging and evolving management pathways for suspected subarachnoid haemorrhage (SAH). We would, however, urge caution in interpreting the findings presented.
Lumbar puncture in patients with acute severe headache Read More
Background: Angioedema is the development of non-pitting edema of the skin and mucosal tissues of the oropharynx, upper respiratory tract, and the gastrointestinal tract.1 Given the potential for airway compromise, the treatment strategy usually involves a broad approach by addressing multiple underlying possible pathologies simultaneously without knowing the exact mechanism. This is a common and often necessary approach when managing a critically ill patient with incomplete information. Although the current research on TXA use in angioedema centers on ACE-I induced mechanisms, the authors frequently see it used in undifferentiated angioedema.5,6
Methods: This is a retrospective comparative study evaluating the effect of intravenous TXA administration to treat acute angioedema when compared to usual treatment. Hospital admissions, repeat ED visits specifically related to angioedema within 30 days, 30-day all-cause mortality, and need for an advanced airway were assessed as outcomes.
Results: After applying inclusion and exclusion criteria, 562 ED encounters were identified for chart review. Matched ED encounters comparing TXA use and no TXA use were well balanced. No statistically significant difference was identified when using TXA or not for angioedema when examining the outcome variables.
Conclusion: No significant differences were seen between the groups when evaluating ED revisits related to angioedema, hospital admission, the need for an advanced airway, and 30-day all-cause mortality. Prospective analysis of TXA in angioedema is needed to clarify its role in acute treatment.
Background: Deep vein thrombosis (DVT) is commonly managed in ambulatory care. Guidelines recommend reassessment at three months to review anticoagulation duration, but no structured follow-up pathway exists within our Trust.
Aim: To evaluate anticoagulation duration, follow-up practices, and outcomes in patients with DVT diagnosed in ambulatory care.
Methods: Retrospective, observational service evaluation across two ambulatory care units in Manchester, UK. Patients with confirmed lower limb DVT were identified between January 2023 and June 2023. Data were collected from electronic patient records including complication rates over a 2-year period.
Results: Of 307 patients assessed for suspected DVT, 90 had confirmed DVT. Most cases were unprovoked (77.8%). At discharge, 39% were prescribed 3 months’ anticoagulation, 31% 6 months, 11% lifelong, 6% received a duration range of 3-6 months, and 13% had no specified duration. Discrepancies between recommendation at discharge and primary care prescribing were seen in 53%, with nearly half receiving longer treatment. 20% had secondary care follow-up. Recurrent DVT occurred in nine patients, none of whom had received follow-up; no recurrences were seen in the followed-up group, although this difference was not statistically significant (Fisher’s exact test, p = 0.195). Bleeding events were seen in 4.4% of cases and were minor.
Conclusions: There is substantial variability in anticoagulation management following DVT in ambulatory care. Although recurrence was not observed in the followed-up group, the study was not powered to detect differences, and this finding should be interpreted cautiously. Further work is needed to establish if a follow-up DVT clinic will improve patient outcomes.
Introduction: Anti-fouling marine paints contain toxic components such as copper-based biocides, organotin compounds, and volatile organic solvents. Acute occupational exposure may result in respiratory, gastrointestinal, hepatic, and neurological manifestations; however, clinical data in emergency medicine regarding such exposures remain limited.
Case Presentation: Five male shipyard workers aged 23–39 years presented to the emergency department following acute occupational exposure during anti-fouling paint application. Three patients experienced inhalational exposure and presented with dyspnoea and throat irritation requiring supplemental oxygen therapy. One patient presented with nausea and vomiting and was found to have a two-fold elevation in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. Another patient reported dizziness, throat burning, and palpitations. Other laboratory parameters were within normal limits. All patients were hospitalised for close observation and received supportive treatment, including oxygen therapy, intravenous fluids, and symptomatic management. No severe systemic toxicity or organ failure developed. Clinical and laboratory findings improved within 72 hours, and all patients were discharged without complications.
Conclusion: Acute exposure to anti-fouling marine paints may cause heterogeneous clinical presentations, including respiratory compromise and transient hepatic enzyme elevation. Emergency physicians should recognise this occupational hazard and consider extended observation and supportive management when clinically indicated.
Pulmonary embolism (PE) is a common and potentially life-threatening condition encountered in acute medicine. Clinical prediction rules (CPRs), including PERC, Wells, Revised Geneva, YEARS and LEGEND, have been developed to support rational use of computed tomography pulmonary angiography (CTPA). This study evaluated whether retrospective co-application of Revised Geneva, YEARS or LEGEND alongside an existing PERC/Wells-based diagnostic pathway could reduce CTPA utilisation in a Same Day Emergency Care (SDEC) population.
We conducted a retrospective cohort study of all patients who had CTPA for suspected PE in a UK SDEC unit between January and June 2024. CPRs were applied retrospectively using documented clinical data. The primary outcomes were the potential reduction in CTPA utilisation and the proportion of scans that would have contained PE.
Of 433 CTPAs identified, 362 patients met inclusion criteria. The prevalence of PE among those scanned was 16.6%. Retrospective co-application of Revised Geneva, YEARS and LEGEND would have reduced CTPA utilisation by 5.5%, 29.0% and 39.2% respectively. No PEs were identified among scans potentially avoided using Revised Geneva, whereas PE was present in 4.8% and 5.6% of avoided scans using YEARS and LEGEND. Missed events occurred in a clinically stable ambulatory cohort and were not associated with radiological evidence of right ventricular strain; however, the clinical significance of these findings remains uncertain.
In this selected SDEC population, layering additional CPRs onto an existing diagnostic pathway may have the potential to reduce CTPA utilisation, although strategies achieving larger reductions were associated with missed diagnoses. These findings should be regarded as hypothesis-generating and require prospective validation before informing changes to clinical practice.
Issue 4 of the Acute Medicine Journal (AMJ) reports an interesting exchange between the authors of a service evaluation investigating the prevalence of subarachnoid haemorrhage (SAH) in patients undergoing a lumbar puncture (LP)1, and readership colleagues evaluating its merit, in light of the current evidence base and clinical recommendations2. This discourse highlights the two phases of scientific peer review, which operates as the quality control mechanism for academic publishing.