Volume 16

Characteristics and outcome of acute medical admissions with hyponatremia: even mild hyponatremia is associated with higher mortality

Abstract

Hyponatremia is a common finding in hospitalized patients. In this retrospective cohort study we assessed the characteristics and outcome of acute medical admissions with hyponatremia. Compared to the normal sodium group, those with hyponatremia were significantly older and the Charlson Comorbidity Index (CCI) was higher. The number of admissions to MCU/ICU between both groups was similar, but hyponatremic patients had a longer length of stay and both 28-day and one-year mortality were higher, even in patients with mild hyponatremia. Hyponatremia was independently associated with mortality after adjustment for age, CCI and polypharmacy, as was found in the subgroup with mild hyponatremia.

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Editorial Volume 16 Issue 4

My time has come. After 15 years and over 50 editions it is time for me to hang up my metaphorical red biro, and hand over the role of Editor. It has been an interesting job, and I am extremely grateful to everyone who has contributed and supported the journal over this period. When I took on the position in 2002, this journal was very different to how it is today. Some readers may recall its original incarnation as the CPD journal of Internal Medicine, part of a series of publications produced at that time by Rila. Initially this was comprised predominantly of commissioned review articles, running over a 5 year cycle which was designed to cover the common conditions managed by ‘general’ physicians. As time progressed, the number of unsolicited submissions grew steadily – initially (and continually) dominated by case reports, but with a slowly increasing number of research-based articles as the readership expanded. The quality of these submissions improved further when we finally attained indexing in PubMed, which also attracted more international submissions. I am delighted that the current edition features research papers from the Netherlands and Singapore, both of which have a growing community of Acute Physicians. I remain hopeful that the number of acute medicine-related research submissions from the UK will rise as the speciality grows. The number of high quality abstracts presented at the Society for Acute Medicine (SAM) meetings is indicative of the amount of work that is going on, but it is disappointing that so few of these turn into publications in peerreviewed journals. Acute Physicians are busy people with constant and year-round operational pressures, which may mean that writing up  research is continually pushed down the list of priorities. Perhaps also the fact that the number of consultant posts across the continues to exceed the number of Acute Internal Medicine trainees removes some of the ‘pressure to publish’ which is felt by trainees in other hospital specialities.

My hopes for the future of this journal have been boosted by the appointment of Tim Cooksley as my replacement ‘Editor in Chief’, who will take over from the Spring 2018 edition onwards. Tim has been a hard working member of the editorial team over recent years, and prior to this was a regular contributor to the journal. He has a strong research background and is a leading member of the SAMBA academy and SAM research committee. I would also like to thank the other members of the editorial board without whose support and contributions this job would have been completely untenable. I understand that Tim plans to keep many of these colleagues in post, as well as bringing in some ‘new blood’ to create a fresh new vision for the future. I wish them all well, and will look forward to reading (as opposed to writing) these editorials.

Thanks, finally, to all of the loyal readers who have stuck with the journal over the past 2 decades. I hope that we have managed to keep you entertained and educated on those occasional moments of respite during the acute medical on-call. I wish you all well for the future.

Editorial Volume 16 Issue 4 Read More

Measuring impact of telephone triage in Acute Medicine

Abstract

The Society for Acute Medicine’s Benchmarking Audit (SAMBA) was undertaken for the 5th time in June 2016. For the first time, data on telephone triage calls prior to admission to Acute Medical Units were collected: 1238 patients were referred from Emergency Departments, 925 from General Practitioners (GPs), 52 from clinics and 147 from other sources.

Calls from Emergency Departments rarely resulted in admission avoidance.

Calls from Primary Care resulted in avoidance of an admission in 115 (12%) patients; the percentage of avoided admissions was highest if the call was taken by a Consultant.

Consultant triage might result in admission avoidance but the impact of local context on the effectiveness is not clear.

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Electronic Prompts Can Reduce The Number Of Unnecessary Clotting Screens Ordered For Patients

Abstract

In an attempt to reduce the number of inappropriate clotting screens being performed in our Trust, an electronic prompt was introduced to our haematology requesting system. Over the six month period after introduction of this prompt the number of clotting screen requests reduced by 7001, representing a 21% reduction when compared to the same 6 month period one year earlier. This represented a cost saving of over £98,000 without any increase in adverse incidents being reported related to bleeding complications.

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Research Protocol: Intravenous Access during Resuscitation: the IVAR trial

Summary

Objective: To compare the effects of central versus peripheral drug administration on the rate of return of organised electrical activity and/or spontaneous circulation during CPR.

Study design: Randomized clinical trial.

Study population: Hospitalized patients and patients presenting at the emergency department, older than 18 years, requiring CPR.

Intervention: Central venous access

Main study parameters/endpoints: Combined primary endpoint: rate of appearance of organised electrical activity or return of spontaneous circulation.

Nature and extent of the burden and risks associated with participation, benefit and group relatedness: All patients are treated according to the guidelines of the European Resuscitation Council, which are endorsed by the local VUMC CPR-committee. Central access will be obtained by cannulation of the external or internal jugular vein. To avoid interference with initial management, central venous access will be obtained after initiation of chest compressions, first attempt at defibrillation (if applicable), securing the airway and obtaining a peripheral access.

All resuscitated patients require vascular access and almost all successfully resuscitated patients require central venous access. Obtaining central access during CPR may be associated with a slightly higher complication rate, such as arterial puncture and pneumothorax. Possible benefits for study subjects are a higher success rate of CPR.

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Medical High Dependency Unit series, Article 3: Respiratory Support in the MHDU

Abstract

Acute respiratory failure is a life threatening condition encountered by Acute Physicians; additional non-invasive support can be provided within the medical high dependency unit (MHDU). Acute Physicians should strive to be experts in the investigation, management and support of patients with acute severe respiratory failure. This article outlines key management principles in these areas and explores common pitfalls.

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Abstracts from Oral Presentations at the Society for Acute Medicine Autumn Conference

Birmingham International Centre, 11-12th September 2017

As usual a large number of abstract submissions were received for the autumn meeting of the Society for Acute Medicine, which was held this year in the Birmingham International Centre on 11th-12th September. A large number of these were displayed as posters throughout the meeting, and twelve were selected for oral presentation. The abstracts from the oral presentation session are published here.

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Disseminated intravascular coagulation in an under-recognised zoonotic infection

Abstract

A 51 year old man presented with severe sepsis, disseminated intravascular coagulation (DIC) and multiorgan dysfunction after a 24 hour history of diarrhoea and malaise. Despite fluid resuscitation and receiving a platelet transfusion, freshfrozen plasma and intravenous broad-spectrum antibiotics, he remained anuric with a worsening metabolic acidosis. He was transferred to critical care for organ support including renal replacement therapy. He subsequently developed purpura fulminans. Blood cultures were positive for Captocytophaga carnimorsis, a gram-negative canine zoonosis that is an underdiagnosed cause of severe sepsis, for which DIC at presentation is characteristic. Treatment is with penicillins and fluoroquinolones. Identification of risk factors for unusual organisms and recognition of DIC allowing prompt treatment is critical for the acute physician.

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Third cranial nerve palsy: an unusual manifestation of Mycoplasma pneumoniae

Abstract

Mycoplasma Pneumoniae (M.pneumoniae) is a well-known cause of atypical pneumonia, however it is also associated with many extra pulmonary manifestations. This report highlights a patient with gastroenterological, haematological and neurological complications, including a third cranial nerve palsy which developed after her initial treatment and discharge from hospital.

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Not just a simple sore throat

Abstract

The presentation of a ‘sore throat’ is common and often requires only symptomatic treatment. This is the case of a 20-year-old female who presented with persistent symptoms of a sore throat. On admission she had raised inflammatory markers and a subsequent blood culture demonstrated a fusobacterium necrophorum and arcanobacterium haemolyticum bacteraemia. Further investigations established an internal jugular vein thrombosis, confirming the diagnosis of Lemierre’s syndrome. This case highlights the importance of further investigation when a sore throat fails to improve, and to remember this often-forgotten syndrome.

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