Volume 17, Issue 4, Pages 173 – 240 (2018)

Response to: Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography

Correspondence, Volume 17, Issue 4, Pages 173 – 240 (2018)

I read the article, ‘Assessment of Fluid responsiveness in the Acute Medical Patient and the Role of Echocardiography’ by Dr Parulekar and Dr Harris with interest. It rightly highlights the challenges posed when assessing for fluid resuscitation in a pressured setting with limited information. This scenario is a routine one for our speciality, which is why it is a concern that the evidence-base outside of intensive care remains limited. Of particular relevance to the Acute Medical specialist, the article acknowledges that performing a focussed-echocardiogram on all acutely-unwell patients is “impractical”. Developing a quick and straightforward approach to fluid resuscitation assessment should be a high research priority for Acute Medicine.

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The Last Laugh – Reversible myeloneuropathy induced by chronic nitrous oxide use

Case Reports, Volume 17, Issue 4, Pages 173 – 240 (2018)

A previously fit and well 19 year old male presents with a progressive ataxic - sensory neuropathy worsening over 2 - 3 weeks. History and investigations revealed extensive recreational use of nitrous oxide resulting in functional B12 deficiency and consequent subacute combined degeneration of the cord. Abstinence and B12 supplementation resulted in a rapid and full neurological recovery. This case report highlights the importance of considering ni

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Thyroid storm and myxoedema: two reversible causes of acute heart failure

Case Reports, Volume 17, Issue 4, Pages 173 – 240 (2018)

Cardiovascular signs and symptoms can prevail in both hypothyroidism and hyperthyroidism. Case 1: 30-year-old female with acute right heart failure as first manifestation of Graves’ disease. It illustrates some of its cardiovascular complications, particularly pulmonary hypertension, tricuspid regurgitation, atrial fibrillation, mitral valve prolapse and mitral regurgitation. Case 2: 83-year-old-man with a severe primary hypothyroidism/ myxoedema crisis presented to emergency department with extreme bradyarrhythmia with hemodynamic impact and heart failure signs, which led to implantation of definitive pacemaker. Thyroid disorders are treatable entities and most cardiovascular changes are reversible. Early diagnosis is mandatory and can avoid severe complications and, eventually, invasive therapeutics interventions. Pulmonary hypertension and acute heart failure, especially in young adults, should be screened for underlying hyperthyroidism.

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Alcohol-induced Rhabdomyolysis: A Disease With Potential Pitfalls

Case Reports, Volume 17, Issue 4, Pages 173 – 240 (2018)

Non-traumatic rhabdomyolysis induced by alcohol appears to cause serious clinical implications and could result in catastrophic consequences. We describe a patient who developed rhabdomyolysis following acute alcohol intoxication which led to severe kidney injury requiring dialysis therapy. This case also illuminates the fact that deranged liver function can result from a significant skeletal muscle injury in the absence of a concomitant liver pathology.

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Pneumothorax management: are the guidelines all-encompassing for the purpose of Acute Medicine?

Clinical Reviews, Volume 17, Issue 4, Pages 173 – 240 (2018)

Pneumothorax is defined as the presence of air in the pleural space, between the lung and the chest wall. It is a significant global health problem, with considerable morbidity and healthcare costs. Best management strategy remains controversial, with significant variation in practise, both nationally and internationally. The lack of consensus is driven by the paucity of the evidence base. Current research trials, particularly those looking at ambulatory management, are making progress and may help streamline future guidelines. This review presents five case reports of patients treated with methods which are not entirely synchronous with the current British Thoracic Society (BTS) guidelines; providing guidance for acute medical physicians who are routinely presented with such cases and exploring future developments in pneumothorax management.

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The way healthcare is funded is wrong: it should be linked to deaths as well as age, gender and social deprivation

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Background: most spending on health occurs in the last few months of life. This study explored the number of deaths in England and their relationship to healthcare funding.

Methods: post hoc analysis

Results: the number of deaths range from 3.3 to 15.1/1000/year, and the number of deaths per general practitioner from 5.2 to 27.3/year. Hospital deaths range from 12 to 52/1000 admissions. The correlation between the allocation index used for funding and deaths is not perfect and suggests that some regions may get up to17% less and others 14% more funding than is equitable.

Conclusion: there is considerable variation in the prevalence of death throughout England. If healthcare funding considered the local number of deaths it would be more equitable.

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Delayed onset pulmonary edema following toxic smoke inhalation; a systematic review

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Background: Fire smoke inhalation cause a wide range of symptoms immediately or after a relatively asymptomatic period. In this review, we will focus on delayed onset pulmonary edema (DOPE); the incidence and duration of potential delay. As the symptoms may not present immediately, seemingly healthy patients could be inadvertently be sent home. Therefore, many authors recommend observation for 6-24 hours depending on the extent of inhalation injury.

Methods: A systematic literature search in Embase, Medline, and Cochrane library was performed on 14 April 2016. All studies describing smoke exposure and delayed pulmonary edema were included. Additional relevant studies were identified snowballing based on included studies.

Results: We included seven studies, with a total of 135 patients, describing pulmonary edema. Symptoms generally developed after a relatively asymptomatic period (up to 36 hours post-injury) until mechanical ventilation was needed. However, pulmonary edema developing after 36 hours was most likely due to other factors related to burn injury (excessive intravenous fluids, de novo heart failure, infection or problems related to intubation).

Conclusion: Delayed onset pulmonary edema can develop as late as 36 hours postinjury after a relatively uneventful phase. But it would have been rare to have been completely asymptomatic before developing pulmonary edema.

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Exploring the value of routinely measured hematology parameters for identification of elderly patients at high risk of death at the Emergency Department

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Of the warning scores in use for recognition of high-risk patients at the Emergency Department (ED), few incorporate laboratory results. Although hematological characteristics have shown prognostic value in small studies, large studies in elderly ED populations are lacking. We studied the association between blood cell and platelet counts and characteristics as well as C-reactive protein (CRP) at ED presentation with mortality in non-multitrauma patients ≥ 65 years. Comparison between survivors and non-survivors showed small, significant differences with AUROCs ranging between 56.6% and 65.2% for 30-day mortality. Combining parameters yielded an evident improvement (AUROC of 70.4%). Efforts should be pursued to study the added value of hematological parameters on top of clinical data when assessing patient risk.

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The prognostic implication of the SOFA score on acutely admitted medical patients

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Objectives: To investigate the prognostic implication of the SOFA score on all acutely admitted medical patients, to see how well it could predict 30-day mortality and ICU- admission.

Main outcome measures: Discriminatory power was calculated as AUROC. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit.

Results: AUROC for 30-day mortality was 0.68, (95% CI, 0.64 to 0.71) and ICU admission 0.71, (95% CI, 0.66 to 0.76). Goodness of fit for 30-day mortality and ICU admission was acceptable.

Conclusions: The SOFA score showed average ability to predict 30-day mortality and ICU admission with acceptable calibration. When substituting GCS with AVPU the performance of the SOFA score was unacceptable.

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Unscheduled return visits by patients to a german emergency department are a high risk group for initial wrong diagnosis

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

The aim was to classify patients who returned unscheduled to an emergency department within 7 days. We categorized the patients’ cases arbitrarily according to the underlying cause of the return. The main causes for returning unscheduled were: “patient related” (24,2%), “illness related” (35,4%), “physician related” (18,3%), “system related” (3,8%) and “other” (21,7%). We also analyzed missed diagnoses, as the literature describes this special patient population as a high risk group. 15,4% of all return cases had a wrong diagnosis. No typical risk constellation/symptom could be found. Vital signs or blood values were within normal limits as well.

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