Editorials

By the time this is published, summer will be over, “Big Brother” will have evicted its final contestant and, no doubt, many of us will still be waiting for the elusive “lull” in emergency pressures. In practice, most acute medical emergencies occur year-round, and even acute asthma appears to be no exception. Whether it is the high pollen count, atmospheric pollution or ozone, our A&E has been literally ‘buzzing’ with nebulisers throughout recent months. Crighton Ramsay’s review of the ward m a n a gement of this condition is a timely sequel to the intensivist’s perspective published last year. This comprehensive paper includes a useful algorithm, based on the current British Thoracic Society guidelines, as well as an excellent pre-discharge checklist, which I can highly recommend. Chest pain remains at number one in our medical admissions countdown from year to year. The National Service Framework for coronary heart disease emphasised the importance of shortening “pain-to-needle” time for patients requiring thrombolysis, but it is the non-ST elevation patients who make up the majority of the workload. Raybould and Groves’ review summarises the management of the group of these who are determined to have acute coronary syndromes, emphasising the importance of risk stratification for these patients. Merrison and Scolding remind us that multiple sclerosis is a disease of affluent (and no doubt internet-browsing) societies. Armed with their excellent review of its emergency management you should stand a chance of knowing as much as the patient next time he or she presents on your acute medical intake. A shortage of suitable submissions means no “how-to-do-it” section, this time. However, Khakoo and Rosenburg have included a useful guide to Sengstaken tube insertion in their review of management of variceal haemorhage. Our “regular features” section includes a case of an important, but frequently forgotten cause of renal failure, while Andrew Crean presents some more of his controversial “thoughts from the dark room”. Once again, submissions along these lines, as well as original research or audits would be most welcome. I hope you find this edition continues to meet your personal CPD requirement for the coming few months.

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’!

So the brief ‘respite’ of summer is over, and we find ourselves plunging, once more towards the abyss of winter bed pressures. Hopefully those of you working at the coalface will find time to browse through the following pages. The production of a third issue in this ‘shortened’ year, following the launch of the Journal

When I was invited to take over as Editor of this journal, I had little idea of the amount of work which went into its production. I am indebted to Paul Jenkins for staying on in the role of sub-editor, and for helping me up a very steep learning curve over the past few months.

As you can see, the title of the Journal has changed and this is intended to emphasize its educational direction. It will continue to commission articles covering general medical topics with a particular emphasis on the management of acute medical emergencies, aiming to reflect the challenges that face those physicians responsible for supporting the acute medical intake. The CME component will continue,so helping to facilitate the accumulation of CPD points in General Medicine.