Volume 18

An acute presentation of haemophagocytic lymphohistiocytosis due to visceral leishmaniasis in a British adult returning traveller

Case Reports, Volume 18, Issue 3, Pages 137 – 204 (2019)

A 62-year old British Caucasian woman normally resident in Spain presented with fever and pancytopaenia after returning to the UK. Her symptoms persisted despite broad-spectrum antibiotics, and she gradually became confused, hypotensive and progressively more pancytopaenic. Imaging demonstrated hepatosplenomegaly, and a bone marrow aspirate confirmed a diagnosis of haemophagocytic lymphohistiocytosis (HLH). Bone marrow polymerase chain reaction (PCR) and blood serology were both positive for Leishmania donovani, consistent with visceral leishmaniasis (VL). Following treatment with dexamethasone and amphotericin, she improved clinically and biochemically, and was able to return to Spain.

Fever in the returning traveller is a common acute medical presentation. Although HLH and VL are rare diagnoses, both carry a very high mortality rate if undiagnosed and untreated.

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Diabetic ketoacidosis, a common disease with life-threatening pitfalls

Case Reports, Volume 18, Issue 3, Pages 137 – 204 (2019)

Diabetic ketoacidosis (DKA) is a common cause for admission in Emergency Department. Its treatment is well defined. Nevertheless, in some cases, type I diabetes combines with auto-immune polyendocrine syndrome, which can carry life-threatening consequences. Here we report the case of a young man with inaugural DKA who exhibited ventricular fibrillation and cardiac arrest due to significant hypokalaemia, following undiagnosed thyrotoxicosis with periodic paralysis.

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Delayed onset of liver injury after intentional chloroform overdose: a case report and literature review

Case Reports, Volume 18, Issue 3, Pages 137 – 204 (2019)

Chloroform is a recognised cause of acute liver injury, although now rarely encountered in clinical practice. We present a case of inhalational chloroform self-poisoning in a 47-year-old man that presented to hospital initially with reduced conscious level and later developed acute liver injury that was treated with intravenous acetylcysteine. This paper reviews the existing literature and presents a summary of the mechanisms of chloroform hepatotoxicity. Published cases show that there is a characteristic delay of 24 to 48 hours between chloroform exposure and elevation of liver transaminase activity. Therefore, clinicians need to provide an appropriate duration of monitoring in order to detect the occurrence of this important toxic effect.

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Life threatening pembrolizumabinduced myositis in a patient treated for advanced adenocarcinoma of the lung

Case Reports, Volume 18, Issue 3, Pages 137 – 204 (2019)

The advent of immunotherapy in oncology has led to the emergence of a new spectrum of adverse effects. A number of these have the potential to contribute to life-threatening outcomes; and therefore require prompt identification and aggressive treatment to optimise management. In this report, we describe a case of pembrolizumab-induced CTCAE (common toxicity criteria for adverse events) grade 4 myositis in a non-small cell lung cancer patient.

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Pardon My French

Correspondence, Volume 18, Issue 3, Pages 137 – 204 (2019)

Cama et al’s review of pneumothorax management was excellent, especially their elegant depiction of chest tube diameter in comparison to the intercostal space, as measured in French gauge. The use of gauge is medicine is confusing due to differing systems and seemingly random increments. This diagram neatly shows that French gauge (Fr) is directly proportional to diameter, as the external diameter of the tube in millimetres is the gauge multiplied by three. For example, a 15 Fr chest tube has an external diameter of 5mm.

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Socio-Economic Status and MultiOriginal morbidity – Fact or Fiction?

Original Articles, Volume 18, Issue 2, Pages 61 – 136 (2019)

Background: Areas of low socio-economic status (SES) have a disproportionate number of emergency medical admissions; we quantitate the profile of multi-morbidity related to SES.

Methods: We developed a logistic multiple variable regression model, based on over 15 years of hospital data, to examine the effect of socio-demography on hospital outcomes.

Results: Admissions from low SES cohort were a decade younger, and had a shorter hospital stay, and lower 30-day episode mortality outcome. The number of morbidities was equivalent between groups, but the more disadvantaged were more likely to have a respiratory diagnosis or diabetes.

Conclusion: Low SES emergency admissions present > 10 yr. earlier than the high SES population; their equivalent multimorbidity, despite a lower age, could reflect accelerated disease progression.

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Feasibility of measuring psychological resilience in hospitalized patients with acute illness: The Resilience After the Trauma of Acute Illness (RAFT) study

Original Articles, Volume 18, Issue 2, Pages 61 – 136 (2019)

Resilience is the ‘ability to bounce back’. We want to investigate whether measurement of resilience during an acute hospital admission is feasible. We conducted a feasibility study. Resilience was measured using the Brief Resilience Scale. Results were contextualized by measuring chronic disease burden, anxiety, depression, coping strategies and personality traits. 56 or 103 patients approached took part in the study. A group of 12 patients undergoing pulmonary rehabilitation served as a control group. We found evidence of low resilience in 4/44 (9%) patients admitted as medical emergencies. Low resilience was statistically related to the Hospital Anxiety and Depression Scale and a number of coping strategies and personality traits. We found no relation between measures of resilience and previous admissions to hospital. The concept of resilience might be applicable to unscheduled admissions to hospital. Larger studies are required to establish whether low resilience is common and amenable to intervention. REC number 17/WA/0024.

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SAMBA18 Report – A National Audit of Acute Medical Care in the UK

Original Articles, Volume 18, Issue 2, Pages 61 – 136 (2019)

SAMBA18 took place on Thursday 28th June 2018 with follow up data at 7 days.
Acute medical teams from 127 Acute Medical Units (AMUs) across the UK collected data relating to operational performance, clinical quality indicators and standards from NHS Improvement.
Data was collected from 6114 patients.

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Are vital sign abnormalities associated with poor outcomes after emergency department discharge?

Original Articles, Volume 18, Issue 2, Pages 61 – 136 (2019)

To examine association between vital sign abnormalities in the emergency department (ED) and early death after ED discharge, we performed a matched case-control study. Conditional logistic regression showed that presence of any vital sign abnormality at ED discharge was significantly associated with over three-fold increase in likelihood of death within 15 days of ED discharge (OR: 3.06, 95%CI: 2.81-4.48). Even small changes were associated with increased risk: every additional beat increase in heart rate conferred additional risk (OR: 1.04, 95%CI: 1.02-1.06), while every additional oxygen saturation percentage point was protective (0.89, 0.80-0.98). However, none of these vital sign abnormalities was a good predictor of early death; there was poor discrimination and substantial overlap in values between cases and controls.

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Management of Acute Admissions of Heart Failure Patients with Kidney Disease

Clinical Reviews, Volume 18, Issue 2, Pages 61 – 136 (2019)

Acute heart failure (HF) admissions are common. They are often associated with prolonged hospitalisations and poor outcomes. One-third of chronic HF patients also suffer from chronic kidney disease (CKD). Hence, acute admissions of HF with CKD are common and are associated with longer length of stay and increased mortality. Hyperkalaemia and acute on chronic renal impairment are important challenges in the management of these cases. Cautious introduction of high-dose diuretic therapy, followed by the re-commencement of renin-angiotensin-aldosterone (RAAS) inhibitors, improves length of stay, quality of life, and prognosis. During an admission on to the medical assessment unit careful monitoring and management of the patient’s clinical condition and biochemistry is essential.

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