As we look forward to the warmer months. Last year saw a dramatic rise in the number of training posts in Acute Medicine, a trend which will continue this August. The Department of Health considers Acute Medicine to be one of the few hospital specialities with the potential for future expansion, and additional funded NTNs have been made available. This is undoubtedly good news for the speciality; however, it is clearly important to ensure that any additional numbers can be accommodated without diluting the opportunities for our existing trainees. From discussions with trainers and trainees alike, it is clear that there remains wide variation in Acute Medicine training programmes across different regions. The recently formed Acute Medicine Programme Directors group has started to address these issues, and has presented proposals for a more formalised training structure to the JRCPTB. Speciality skills training remains one of the most contentious areas, which is likely to increase as trainee numbers rise. The feasibility of providing every acute medicine trainee with suffi cient exposure to a practical procedure such as echocardiography or ultrasound may require a rethink in future training plans. Development of a special interest in Medical Education, management or research may be more appropriate and arguably more useful to future consultants and employers.

A respiratory fl avour fl ows through many of the articles in this edition of the journal. Alistair Proudfoot’s article on the treatment of pulmonary embolism follows on from his review of the diagnosis of this condition in the previous edition. If there were a prize for the most comprehensive referencing this review would certainly win by some margin. Of course this list would have been pruned, were it not for his inclusion of the editors own paper at citation number 106. It clearly pays to save the best until last! In another sequel Mayank Patel follows up the previous review on the management of acute symptomatic hyponatraemia with a comprehensive summary of the more common scenario of the asymptomatic hyponatraemic patient on the AMU. The article on pleural effusion is the fi rst of two papers on management of pleural disease; pneumothorax will follow in a future edition. As usual the case reports have been selected for publication to highlight important teaching messages. Orthodeoxia platypnoea may be unfamiliar to acute physicians, but the case illustrates the importance of apparently minor details in the history in this case the marked variation in symptoms relating to posture. The challenges of risk versus benefi t for anticoagulation in patients with metallic heart valves are highlighted by the case of fatal intra-hepatic haemorrhage; this month’s picture quiz demonstrates the importance of the history when considering intercostal tube insertion for a ‘radiological diagnosis’ of pneumothorax.

‘Viewpoint’ is intended as an opportunity to stir up debate, and the article by Clare et al in the last edition produced a ripple of disquiet amongst some readers. The interface between acute and emergency medicine remains a contentious area, and further contributions to this debate are welcomed for consideration in future editions.


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Initial Treatment of Pulmonary Embolism

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