Clinical Reviews

Isolated paracetamol-induced acute kidney injury: a systematic review

Clinical Reviews, Volume 21, Issue 2, Pages 65-120 (2022)

Aim: We sought to characterise the syndrome of isolated paracetamol-induced acute kidney injury (AKI), whose incidence and mechanisms are poorly understood.
Methods: Using systematic review methodology, fifty-six papers relating to paracetamol-induced AKI were identified.
Results: 24 cases of isolated paracetamol-induced AKI were identified and compared to 87 identified cases of concurrent renal and hepatic injury.
Paracetamol-induced AKI became detectable 3-4 days after exposure; liver injury, where it occurred, preceded AKI detection by 1 day.
Risk factors affecting hepatotoxicity risk do not appear to influence isolated AKI, with no clear associated factors except younger age (mean 18.8 versus 33.1 years).
Conclusions: Isolated paracetamol-induced AKI appears commoner in younger patients. Paracetamol-induced AKI occurs late and may go undetected by current treatment guidelines.

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Potential therapies for sodium azide intoxication; a case report and review of the literature

Clinical Reviews, Volume 21, Issue 2, Pages 65-120 (2022)

Intoxications with sodium azide are rare and in almost all cases lethal in doses above 700 mg or 10mg/kg. We report a case of a patient who ingested 2 grams of sodium azide as a suicide attempt. Sodium azide irreversible blocks cytochrome C oxidase by inhibiting oxidative phosphorylation leading to cell death. There is currently no antidote available. Our patient was treated with a range of therapies, on site, in the emergency department and in the intensive care unit, such as sodium thiosulphate, methylene blue, intralipid, extensive gastric lavage, whole bowel irrigation combined with pro-kinetics, hydroxocobalamin and exchange transfusion. During the clinical course the patient developed cardiac failure, for which veno-arterial ECMO and an intra-aortic balloon pump was placed. However, cardiac function did not recover, leading to discontinuation of treatment after 7 days. As literature on sodium azide intoxication is scarce, we conducted a review to present potential treatment options.

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Communicating diagnostic uncertainty in the acute and emergency medical setting: A systematic review and ethical analysis of the empirical literature.

Clinical Reviews, Volume 20, Issue 3, Pages 157-248 (2021)

Background: diagnostic uncertainty is ubiquitous. Its communication to patients requires further investigation.
Aims: To determine: 1) What is known about how and why diagnostic uncertainty is communicated in acute care; 2) evidence of the effects of (not) communicating diagnostic uncertainty in the acute setting; 3) associated ethical issues.
Methods: systematic review of Medline, Web of Science and SCOPUS for (acute or emergency care) AND (diagnostic uncertainty) AND (ethics OR behaviours). Critical interpretive synthesis and ethical analysis were conducted.
Results and conclusion: Nine studies (primarily surveys and interviews) were identified. Doctors are not trained in communicating diagnostic uncertainty and perceive it to have negative effects on patients; however not communicating diagnostic uncertainty can disempower patients, resulting in delayed/missed diagnoses or inappropriate use of resource.

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Quality: What does it mean in Acute Medicine and how do we measure it?

Clinical Reviews, Volume 20, Issue 2, Pages 89-156 (2021)

Acute Medicine is a specialty that is not defined by a single organ system and sits at the interface between primary and secondary care. In order to document improvements in the quality of care delivered a system of metrics is required.

A number of frameworks for measurements exist to quantify quality of care at the level of patients, teams and organisations, such as measures of population health, patient satisfaction and cost per patient. Measures can capture whether care is safe, effective, patient-centred, timely, efficient and equitable. Measurement in Acute Medicine is challenged by the often-transient nature of the contact between Acute Medicine clinicians and patients, the lack of diagnostic labels, a low degree of standardisation and difficulties in capturing the patient experience in the context.

In a time of increasing ecological and financial constraints, reflecting about the most appropriate metrics to document the impact of Acute Medicine is required.

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Evaluation of systemic vasoconstriction and prognosis using thermography: a systematic review

Clinical Reviews, Volume 20, Issue 2, Pages 89-156 (2021)

Purpose: This systematic review investigates whether infrared thermography (IRT) can measure systemic vasoconstriction and addresses the value of IRT in assessing circulatory deficiency and prognoses.

Methods: Design was based on the PRISMA criteria and a systematic search of 6 databases was performed.

Results: Of 3,198 records, five articles were included. Three clinical studies were identified; two found significant correlations between IRT obtained temperatures and mortality. An experimental study found an association between peripheral temperature and stroke volume. An animal study found that central-peripheral temperature differences correlated with shock index, mean arterial pressure, and disease progression.

Conclusions: Data from the most valid study suggests that central-peripheral temperature differences should be investigated further, both on its own, and integrated with other variables.

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The evidence for assessing frailty and sarcopenia in an acute medical unit: a systematic review

Clinical Reviews, Volume 20, Issue 1, Pages 1-88 (2021)

Background/objectives: A systematic review was conducted to assess if frailty and sarcopenia were associated with poorer outcomes in older adults admitted to an acute medical unit (AMU).

Methods: Eligible studies included older adults with an unplanned admission to an AMU and included a measure of frailty or sarcopenia, completed within 72 hours of admission. Risk of bias was assessed.

Results: Of 1659 identified articles, 16 were included (4 on sarcopenia and 12 on frailty). There was significant study heterogeneity. Overall, frailty and sarcopenia were associated with worse outcomes. Targeted interventions appeared to improve outcomes.

Conclusion: Current evidence suggests some benefit in screening older adults admitted to an AMU for frailty and sarcopenia. However, further studies are required before clinical adoption.

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Evaluating quality in acute care using patient reported outcome measures: a scoping review

Clinical Reviews, Volume 20, Issue 1, Pages 1-88 (2021)

The aim of this scoping review is to identify patient reported outcome measures (PROMs) in acute care settings, assess their psychometric properties and provide recommendations for their use in daily practice. We performed a search in the PubMed database to identify publications concerning PROMs in an acute care setting. The COSMIN checklist was used to assess the psychometric properties of the reported PROMs. We found 1407 publications and included 14 articles, describing 15 measures. Most publications provided limited information on psychometric properties. Three generic PROMs were deemed of adequate quality for use in acute care. We recommend future development and evaluation of PROMs focussing on acute care to further evaluate and improve the quality of acute care.

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Fentanyl patches: Use and Misuse

Clinical Reviews, Volume 19, Issue 2, Pages 61 – 112 (2020)

Transdermal fentanyl is a well-used and highly effective form of opioid analgesia for patients suffering with severe chronic pain. It is also an opioid that is widely abused. Acute clinicians need to be aware of the methods by which fentanyl patches may be used both therapeutically and illicitly as well as the impact this can have in managing a patient’s period of intoxication.

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Overview of acute renal manifestations in cancer patients

Clinical Reviews, Volume 19, Issue 1, Pages 1 - 60 (2020)

Acute kidney injury is frequently encountered in patients with malignancy and is associated with prolonged hospitalization, significant morbidity, and increased mortality. Thorough evaluation is required to identify possible contributing factors, which may range from relatively easily reversible pre-renal causes to complex cancer-specific aetiologies. This review will serve as a practical guide for acute care physicians on the acute medical unit to the assessment and initial management of cancer patients presenting with acute kidney injury.

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Non-Cardiac Chest Pain: management in the Ambulatory Clinic setting

Clinical Reviews, Volume 18, Issue 3, Pages 137 – 204 (2019)

Non-cardiac chest pain (NCCP) is a common presenting complaint which can be better managed. This requires the recognition of clinical sub-groups with investigation and treatment tailored accordingly. The aim of this paper is to encourage more accurate diagnoses and the better recognition of the source of chest pain. We discuss the appropriate investigations and management of each clinical sub-group.

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