Volume 15, Issue 3, Pages 109 – 164 (2016)

Trainee Report Autumn 2016

Training and Education, Volume 15, Issue 3, Pages 109 – 164 (2016)

New Trainee Representative

After providing years of sterling representation, Nick Smallwood will be moving on to a consultant job. Neil Patel takes his place formally at SAMEdinburgh. Neil is an ST5 trainee in Thames Valley with special interest in medical education and medical leadership. He has been working on projects to improve GIM recruitment and training, establishing trainee networks, and developing strategies to improve trainee morale over last few years with various local to national organisations. He is looking forward to bringing this project experience to his new role with SAM to improve and develop the trainee experience in Acute Medicine.

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Improving acute care for adolescents and young adults on medical admission units: The interventions that matter

Viewpoint, Volume 15, Issue 3, Pages 109 – 164 (2016)

It had become a familiar routine. My seventh admission with diabetic ketoacidosis (DKA) in a year. Each time I was admitted it was the same; a DKA protocol, a diabetes specialist nurse visit, and a few questions from the doctors checking if “everything is okay?” On each admission, I would be discharged home after a couple of days. We all knew I’d be back again within a month or two.

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Pneumomediastinum as a complication of MDMA (3,4-methylenedioxymetamfetamine, Ecstasy) ingestion

Case Reports, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

MDMA (3,4-methylenedioxymethamfetamine, Ecstasy) is a widely used recreational drug. We present a case of pneumomediastinum as a complication of MDMA use in a 21-year-old man with no previous history of lung or gastrointestinal pathology. We have performed a literature review, and summarised the symptoms, signs, and prognosis for this under-recognised complication of a commonly used recreational drug. We recommend enquiring about illicit drug use in any patient presenting with spontaneous pneumomediastinum.

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Fever, delirium and incontinence: not always a UTI

Case Reports, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

Unexplained fever and confusion is a common reason for emergency medical admission. When this occurs in the context of new urinary incontinence, a urinary tract infection may be considered to be the most likely cause. However it is also important to consider spinal pathology when this combination of symptoms arises. We present a case of a retropharygeal collection presenting in a patient with this combination of symptoms.

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Pheochromocytoma presenting as a mimic of acute coronary syndrome

Case Reports, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

Chest pain with elevated serum troponin is a common clinical presentation and is normally managed as suspected myocardial infarction or acute coronary syndrome (ACS). We report a 49 year old man who presented with central chest pain sweating and breathlessness. He had a significantly elevated serum troponin I level and a subsequent angiogram showed near normal coronary arteries. He was subsequently investigated for fever and found to have a 3cm right sided adrenal mass consistent with a pheochromocytoma. After confirmation and appropriate blockade laparoscopic adrenalectomy was performed.
Pheochromocytoma may present as a mimic of acute coronary syndrome but this is often unrecognized and leaves the patient at risk of future pheo crisis events which may be fatal.

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Acute generalised exanthematous pustulosis (AGEP)-a potential pitfall for the acute physician

Case Reports, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

Acute generalised exanthematous pustulosis is a rare drug-induced dermatosis with an incidence of 1-5 cases per million cases per year, characterised by the appearance of hundreds of sterile pustules over erythematous and oedematous skin. Fever and neutrophilia are usually present. It has a rapid course and usually resolves following discontinuation of the precipitating drug or as a result of topical corticosteroid treatment. A patient with AGEP, who presented with generalized pustulosis lesions after the use of Flucloxacillin for cellulitis is described, along with the management and differential diagnosis of this condition.

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Frailsafe: from conception to national breakthrough collaborative

Research Audit and Clinical Practice, Volume 15, Issue 3, Pages 109 – 164 (2016)

Introduction

The number of people aged over 60 years worldwide is projected to rise from 605 million in 2000 to almost 2 billion by 2050, while those over 80 years will quadruple to 395 million. Two-thirds of UK acute hospital admissions are over 65, the highest consultation rate in general practice is in those aged 85–89 and the average age of elective surgical patients is increasing. Adjusting medical systems to meet the demographic imperative has been recognised by the World Health Organisation to be the next global healthcare priority and is a key feature of discussions on policy, health services structures, workforce reconfiguration and frontline care delivery.

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The diagnostic yield of CTPA: pulmonary embolism, alternative diagnoses and incidental findings

Research Audit and Clinical Practice, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

Aims: In this retrospective study we assess the diagnostic yield of computed tomography pulmonary angiogram (CTPA) and the incidence of alterative and incidental diagnoses.

Methods: The results of all CTPA scans performed in our trust over a period of 18 months were reviewed and all diagnoses noted. Data collected was descriptively analysed.

Results: A total of 1138 scans were performed (56.5% men, mean age 59 years). A diagnosis of pulmonary embolism (PE) was made in 20.2%, an alternative aetiology for presenting symptoms in 26.4% and incidental findings in 19.5%. The commonest alternative diagnosis was pneumonia (9.5%).

Conclusions: Significant numbers of CTPA yield unexpected findings, which may provide an explanation for the clinical presentation. Furthermore substantial numbers of incidental pathologies are also diagnosed which may lead to inappropriate resource utilization and increased patient anxiety.

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The Relationship Between Social Deprivation and a Weekend Emergency Medical Admission

Research Audit and Clinical Practice, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

Background: Deprivation increases admission rates; the specific effect of deprivation with regard to weekend admissions is unknown.

Methods: We calculated annual weekend admission rates for each small area population unit and related these to quintiles of Deprivation Index from 2002-2014. Univariate and multivariable risk estimates were calculated using truncated Poisson regression.

Results: There were 30,794 weekend admissions in 16,665 patients. The admission rate was substantially higher for more deprived areas, 12.7 per 1000 (95%CI 9.4, 14.7) vs 4.6 per 1000 (95%CI 3.3, 5.8). More deprived patients admitted at the weekend had a significantly lower 30-day in-hospital mortality (10.3% vs 14.5%, p<0.001). Conclusion: Deprivation is a powerful determinant of weekend admissions, however these comprise a group of patients with better outcomes.

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Can we predict Acute Medical readmissions using the BOOST tool? A retrospective case note review

Research Audit and Clinical Practice, Volume 15, Issue 3, Pages 109 – 164 (2016)

Abstract

Background: Readmissions within 30-days of hospital discharge are a problem. The aim was to determine if the Better Outcomes for Older Adults through Safe Transitions (BOOST) risk assessment tool was applicable within the UK.

Methods: Patients over 65 readmitted were identified retrospectively via a casenote review. BOOST assessment was applied with 1 point for each risk factor.

Results: 324 patients were readmitted (mean age 77 years) with a median of 7 days between discharge and readmission. The median BOOST score was 3 (IQR 2-4) with polypharmacy evident in 88% and prior hospitalisation in 70%. The tool correctly predicted 90% of readmissions using two or more risk factors and 99.1% if one risk factor was included.

Conclusion: The BOOST assessment tool appears appropriate in predicting readmissions however further analysis is required to determine its precision.

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