Please click link below to view the PDF. References I Sanusi. British Society of Echocardiography Adult Accreditation: An Unrealistic Expectation for Acute Physicians? Acute Medicine 2014; 13(2): 84-85 Susanna Price, Gabriele Via, Erik Sloth et al and WINFOCUSECHO-ICU Group. Echocardiography practice, Training and accreditation in the intensive care: document for the World Interactive Network Focused […]
I gained a run through number in ACCS (AIM and GIM) in 2007 when Acute Medicine, both as a training programme and a stand alone medical specialty, was in its infancy. As the programme has evolved and developed it has become a curriculum requirement for trainees to attain an acknowledged specialist skill.
Palliative Care – a useful speciality skill for trainees in Acute Medicine Read More
Abstract
Pregnant patients commonly present to the acute medical team with symptoms requiring further investigation. Palpitations are a common reason for presentation on the acute medical take, and most acute physicians will be familiar with the process of investigation. The combination of pregnancy and palpitations raises a broad differential diagnosis and can complicate the management pathway. This problem based review is designed to summarise the key issues which may arise during the management of a typical patient presenting in this way.
Problem based review: The Pregnant Woman Presenting to the AMU with Palpitations Read More
Abstract
A wide variety of conditions can present as acute polyarthritis, ranging from those that are potentially life threatening, to those that are self-limiting, and those that represent the early stages of a persistent and potentially destructive form of arthritis. In this article, we describe the diagnostic approach and initial management of patients with recent onset polyarthritis, with the aid of an illustrative case vignette.
Problem based review: The patient with recent onset Polyarthritis Read More
I hope you have all settled well into your new jobs and a very warm welcome to those that have recently joined the ‘family’ of acute medicine. I would first of all like to thank Ruth Johnson for all her hard work as trainee representative over the last 18 months and wish her all the best as she ventures into consultant territory: her replacement will be announced later in the autumn.
July was a busy month, dominated by our Acute Medicine Awareness Week, during which AMUs across the UK undertook events to raise the profile of the speciality and the important work they were doing locally. Barnsley completed a 25 mile virtual marathon, Crosshouse Hospital made £350 in a cake sale, Salford Royal staff walked around every acute medical unit in Greater Manchester, North Staffordshire staff ran a half marathon and there was more cake on sale in Kings College and Leicester Royal. The AMU staff at Southampton raised over £400 with their cake sale and cycle challenge, during which they were joined by the Trust Chief Executive for a ‘virtual’ 120 miles on an exercise bike situated outside the hospital entrance. The highlight, however was the contribution of Dr Nigel Lane, an acute medicine trainee from Southmead Hospital in North Bristol, who put together an outstanding weekly programme of events. This included a visit from the Chief Executive of the trust, visit from local GPs to the unit, daily MDT teaching, daily ‘messages of the day’ located on the trust website and lots of screensavers, banners and information scattered throughout the hospital. I am delighted to announce that Nigel has received the SAM awareness week prize. This involves the opportunity to join the European School of Internal Medicine and attend the winter EFIM school camp in Latvia.
Nigel will also be joining us as one of the speakers in the trainee session at SAM Brighton. He will be speaking on “Preparing for your PYA”. There will also be talks in the trainee session on “Keeping your e-portfolio updated”, “Choosing your specialist skill” and “Preparing for your consultant job”. The session will be aimed at both junior and senior trainees. The trainee that has produced the best poster at Brighton will also have a chance to win a place to attend the summer EFIM school camp. The day before the conference starts there will be a SCE revision session. I attended last year and found it extremely helpful!
Looking forward to seeing you all in Brighton. In the meantime if you have any problems or suggestions please tweet or email me at the addresses below.
Trainee Update September 2014 Read More
Introduction
There is a crisis in ‘evidence-based medicine’ (EBM). Reviewers and meta-analysts have become aware that much of their work may be futile because some investigators only publish selected results that favour their own point of view. Such reviews can only be reliable if there is access to all the raw data or if everyone is compelled to publish ‘negative’ results too. This is proving difficult and controversial. The latest example is dabigatran, which was hailed as a safe advance that needs no coagulation monitoring. It seems that the reduced frequency of bleeding if there is coagulation monitoring was not reported. There is also widespread uncertainty about the thresholds for treatment. This has been highlighted in the ‘over-diagnosis campaign’ to address a concern that many patients are subjected to harm without much benefit. Many see the problem as one of vested interest e.g. where those who gain from supplying a treatment will tend to advocate a low threshold for treating whereas those who wish to reduce costs or effort prefer to set high thresholds. The evidence needs to support what is best for the patient and gathered by those who care for them e.g. acute medicine physicians.
Over-diagnosis and other crises facing evidence-based medicine Read More
Abstract
Left Atrial Ablation for Atrial Fibrillation is safe and effective for most patients. However a rare complication is thermal damage to the integrity of the normal physical barriers between the left atrium and the adjacent oesophagus due to the ablation process. This can lead to formation of an Atrial-Oesophageal fistula with sepsis, haemorrhage and systemic cardioembolism occurring even up to 2 months post procedure. The presentation is similar to endocarditis but localised instrumentation specifically Transoesophageal echocardiography (TOE) can provoke systemic cardioembolism. This is an important differential in those presenting acutely with a Pyrexia of Unknown Origin or endocarditis-like picture within 2 months of ablation therapy.
An avoidable cause of cardioembolic stroke Read More
Abstract
Acute confusion and hyponatraemia are common presentations in acute medicine. We report two cases of anti-voltage gated potassium channel (VGKC) antibody-related limbic encephalitis highlighting the variable presentation of this condition. Both patients were thoroughly investigated with MRI scan of brain, lumbar puncture, EEG as well as infective and autoimmune screens for encephalitis. Anti-VGKC antibodies were positive for both patients and prompt treatment with immunotherapy yielded good recovery. Patients presenting with confusion and seizures who have no demonstrable infectious or metabolic cause should have investigation for an autoimmune cause expedited. In addition, psychiatric presentations with atypical features such as drowsiness should prompt similar investigations. The outcome of anti-VGKCrelated limbic encephalitis is improved with early treatment employing steroids or immunotherapy.
Two different presentations, one diagnosis Read More
Abstract
Massive pulmonary embolism has a high mortality rate. Standard treatment includes systemic thrombolysis. If this fails, surgical embolectomy or a percutaneous catheter-guided approach is advised in current guidelines. However, these treatment options might not be available in many non-tertiary care hospitals. We describe a case of a 25-year old woman with cardiac arrest from massive pulmonary embolism. She was treated with thrombus fragmentation using a pulmonary artery catheter and intra-pulmonary thrombolysis after failure of systemic thrombolysis along with 90 minutes of cardiopulmonary resuscitation (CPR). Neurological recovery was excellent and pulmonary pressure was normalized after one month. Besides catheter guided thrombus fragmentation and thrombolysis, we contribute the successful outcome to a combination of ultrasound-guided therapy, capnography-guided CPR, and “crew resource management” principles. Our case illustrates that a pulmonary artery catheter can be used successfully in a non-tertiary setting, to perform a percutaneous procedure during CPR and that full neurological recovery is possible after 90 minutes of CPR.
Abstract
Aims:
• Evaluate the use of lumbar puncture (LP) in the Acute Medical Department of a typical urban district general hospital.
• Increase the proportion performed on appropriate patients.
Methodology: An observational, single-centre, retrospective examination of patients undergoing LP at Solihull Hospital over four consecutive months. Discussion of findings and LP indications with the Acute Medicine Department. Re-audit over four months.
Results: Total LPs performed fell by 65%. The proportion performed on patients presenting with red flags rose by 19% (p=0.0098). The proportion that yielded positive findings rose by 33% (p<0.0001). 72% of patients with red flags had negative LP. Conclusions: Awareness of indications and observation of practice reduces total LPs performed and increases the proportion performed on appropriate patients.
Lumbar Punctures in the Acute Medicine Department: indications and evaluation of use Read More