Volume 17

A Catastrophic Consequence of Cramp

Case Reports, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

Quinine has long been used for the treatment of conditions such as malaria and leg cramps, and is also present at low levels in some beverages; however, it can cause serious side effects. We describe a patient who developed severe haemolysis, thrombocytopaenia, and acute kidney injury following the ingestion of a single dose of quinine. This case demonstrates the importance of awareness of such potentially life-threatening consequences of exposure to this agent.

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A young breathless patient

Picture Quiz, Volume 17, Issue 1, Pages 1 – 56 (2018)

A 34-year-old gentleman, with a background of osteoarthritis, presented to the Acute Medical Unit with a short history of breathlessness. He had returned from holiday to the United States five days previously. Since return, he had complained of myalgia, sore throat, a non-productive cough, mild anorexia and fevers at home. More acutely, prompting his presentation to hospital, was acute dyspnoea, which was sudden onset, with  some central anterior chest discomfort and worse lying flat.

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Acute kidney injury in kidney transplant patients

Review Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Managing kidney transplant patients in an acute medical unit can be challenging, as patients have a single functioning kidney, underlying chronic kidney disease, and are immunosuppressed. Transplant patients develop AKI for all usual reasons but the differential diagnosis is wider and includes specific problems, such as obstruction of a single functioning kidney, vascular thrombosis, rejection, drug toxicity and drug-induced thrombotic microangiopathy. Septic AKI is common but again, the differential diagnosis of sepsis is wider. Transplant patients are at higher risk of developing both community and opportunistic infections, especially in the first year after the transplant or after any increase in immunosuppressive medication. In addition, there is always a risk of rejection, especially in case of reduction of immunosuppressive medications. Therefore, any change in the immunosuppressive therapy should to be discussed with the transplant team to achieve an appropriate balance between avoiding rejection and preventing opportunistic infections.

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Nephrotic syndrome in adults

Review Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Nephrotic syndrome is an important presentation of glomerular disease characterised by heavy proteinuria, hypoalbuminaemia and oedema. The differential diagnosis of the underlying condition is wide including primary renal disorders and secondary diseases such as malignancy, infection, diabetes and amyloid. Presentations to acute medicine may be with hypervolaemia, complications of the nephrotic state (such as venous thromboembolism), or complications of therapy (such as infection).
Early recognition of nephrotic syndrome is possible through simple urinalysis for protein and testing serum albumin, although a high index of suspicion is sometimes required in patients with comorbidities including potentially distracting cardiac or hepatic diseases.

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Managing thyrotoxicosis in the acute medical setting

Review Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Thyrotoxicosis is common and can present in numerous ways with patients exhibiting a myriad of symptoms and signs. It affects around 1 in 2000 people annually in Europe1. The thyroid gland produces two thyroid hormones - thyroxine (T4) and triiodothyronine (T3). Thyroxine is inactive and is converted by the tissues and organs that need it into tri-iodothyronine. In health, the production of these thyroid hormones is tightly regulated by the secretion of thyroid stimulating hormone (TSH; thyrotropin) from the pituitary gland. The term ‘thyrotoxicosis’ refers to the clinical manifestations of hyperthyroidism.

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Relationship of the clinical acuity & complexity to the outcome of an emergency medical admission

Original Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

Background: An Illness Severity and Co-morbidity composite score can predict 30-day mortality outcome.

Methods: We computed a summary risk score (RS) for emergency medical admissions and used cluster analysis to define four subsets

Results: Four cluster groups were defined. Cluster 1 – RS 7 points (IQR 5, 8) Cluster 2 - 9 (IQR 8, 11), Cluster 3 - 12 (IQR 11, 13) and Cluster 4 - 14 (IQR 13, 15). Clusters predicted 30-day in hospital mortality OR 1.86 (95%CI: 1.82, 1.92); respective rates 1.4% (95% CI: 1.3%, 1.6%), 3.4% (95% CI: 3.1%, 3.6%), 7.8% (95% CI: 7.5%, 8.1%) and 16.5% (95% CI: 15.7%, 17.2%).

Conclusion: Cluster grouping of Risk Score was age related; strongest outcome determinant was Acute Illness Severity

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The predictive value of leucocyte progression for one-week mortality on acutely admitted medical patients to the emergency department

Original Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

Objective: To clarify if leucocyte count progression can predict one-week mortality in unselected medical patients admitted to the emergency department. Additionally, we investigated the importance of leucocyte count progression for admission to the intensive care unit and length of stay.

Method: This retrospective cohort study uses data collected in two phases from patients admitted through the emergency department at Hospital of South West Jutland. Upon admission, a nurse recorded the primary complaint and vital signs and registered these along with demographic information. Blood test results were subsequently extracted from the hospital’s computer systems. Patients were separated into three groups according to the development in their leucocyte count from the day of admission to the day after.

Results: The total cohort was 5894 patients; 30.5% remained after exclusion. Median age was 71, and 50.3% were female. Using logistic regression, we found significantly lower one-week mortality with falling leucocyte count progression, even when controlling for confounders.
A decreasing leucocyte count had a sensitivity for one-week mortality of 65%, specificity of 62%, positive predictive value of 4%, and negative predictive value of 99%.
Difference in admission to the intensive care unit was non-significant between the three groups. Difference in length of stay was significant, but with one day difference, the clinical significance is questionable.

Conclusion: Leucocyte count progression is not sensitive enough to predict one-week mortality, nor specific enough to discount it. It is important for physicians to be aware of this to avoid faulty assessments based on imprecise assumptions.

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Can an acute admission to hospital be an opportunity for healthcare professionals to provide physical activity advice? A qualitative study of patients’ perspectives

Original Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

Physical inactivity causes morbidity, mortality and healthcare expenditure. A minority of people undertake sufficient physical activity to meet the DoH recommendations. NICE has determined that brief advice in primary care is costeffective in increasing physical activity levels but there is no current recommendation for secondary care. Acute medical admissions represent “teachable moments” where patients might be receptive to advice. Qualitative methodology was used to determine the perspectives of acute medical in-patients on their willingness to receive physical activity advice and on its format and delivery. Most participants thought physical activity should be discussed by health care professionals if it related to the reason they were admitted to hospital but wanted individually-tailored advice on overcoming their specific barriers to physical activity.

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Continuous Monitoring of Respiratory Rate on General Wards What might the implications be for Clinical Practice?

Original Articles, Volume 17, Issue 1, Pages 1 – 56 (2018)

Abstract

A high respiratory rate is a significant predictor of deterioration. The accuracy of measurements has been questioned.

We performed a prospective observational study of automated electronic respiratory rate measurements and compared measurements with electronic counts obtained in the 10 minutes prior to the manual measurement.

For 182 patients 1331 matching measurements could be compared. The mean age of these patients was 68 (SD 14) years. 96 (53%) of patients were female.

While mean and median measurements were similar frequency distributions were significantly different. Manual measurements were markedly lower than electronic measurements in patients with higher respiratory rates.

While electronic measurements are likely to be more reliable clinical implications require further investigation to clarify whether existing algorithms including Early Warning Scores will need adjustment.

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Editorial Volume 17 Issue 1

Editorials, Volume 17, Issue 1, Pages 1 – 56 (2018)

Acute Medicine remains a specialty in its infancy and, as such, faces many challenges associated with developing new ways of working. As the Society for Acute Medicine celebrates its 18th birthday the extraordinary role of Acute Medicine in both maintaining and indeed enhancing the care and welfare of patients is increasingly evident. However, scepticism still persists among some colleagues with regards to its effectiveness – a perception heightened by the difficult environment that currently pervades in acute and emergency care in the UK which mirrors the experience of many countries internationally.

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