There was, no doubt, a time when the end of winter brought a sense of jubilation at the frontline of hospital medicine. Now, not only do the emergency pressures seem to continue year-round, but spring also brings the challenge of a revised set of Government targets. This April we are greeted with a 20 minute door to needle time for thrombolysis, and a four hour wait target measured from the time of arrival in A&E. Those of you who take a light-hearted view of such things may be may be amused to hear of a local hospital’s appropriately mis-spelt response in the form of a ‘Darft Action Plan’. For the rest of you, good luck – remember, your Trust’s ‘Star Rating’ is dependent on you!

In this edition, John O’Reilly reminds us that chronic obstructive airways disease accounts for up to 25% of the workload of a UK medical ‘Take’, although for the last few months it has probably felt like even more. In contrast, accelerated hypertension is rarely encountered, but nonetheless must be recognised and treated by physicians working at the front door. Two of the reviews approach contrasting presentations of the septic patient. On page 13, Cardy and Poulton have produced a comprehensive overview of the critical care perspective, while Clare Spice reminds us of the non-specific way in which infection can present in the elderly in her paper on delirium.

The ‘Regular Features’ section brings the second in a series of ‘How to do it’ papers from ophthalmologists Beth Edmonds and Peter Francis. Having covered fundoscopy last year, they now turn their attention to the demystifying of pupillary responses. This month’s ‘case to remember’ provides a salutary lesson in the need for lateral thinking in the management of patients taking immunosuppressant medication. Although a recognised complication of methotrexate therapy, the diagnosis of pneumocystis carinii pneumonia can so easily be forgotten, with potentially serious consequences.

As I have mentioned in previous editorials, I am keen to encourage submissions of case reports, audits and original research relevant to the acute medical setting for future publication. Reviews are normally commissioned in line with the cycle on page 35. However, if you have a particular interest in a condition not included in the cycle, with a relevance to other clinicians involved in the acute medical take, please feel free to write and submit to us at the address opposite, or contact me directly by e-mail.

The multiple choice questions are, once again, for self-assessment only. Answers are on the following page, so no ‘external’ CPD points can be accrued for now. However, reading the journal can still count towards your ‘personal’ CPD credit. Hopefully you will find something to interest you in the following pages, along with a little light relief from the pressures (and targets) of the ‘day-job’!


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Emergency management of acute exacerbation of chronic obstructive pulmonary disease

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