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

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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Struggling with the last breath: breathlessness at the end of life on the AMU

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

Breathlessness is one of the most common symptoms experienced at the end of life, affecting all areas of a patient’s life. It is frightening and leads to high rates of emergency hospital attendances. Often, there is no easily reversible cause and patients are admitted to the acute medical unit (AMU) in order to manage their symptoms with little overall benefit – frustrating patients and clinicians alike. This review reminds the generalist of the significance of breathlessness as a symptom. It highlights the management strategies available to effect improvement and gives practical tips on how this can be achieved within the busy and time-pressured environment of the AMU.

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Death after Discharge – Every heart beat counts (probably)!

Guest Editorial, Volume 18, Issue 2, Pages 61 – 136 (2019)

The assumption would be that patients who are discharged from an emergency or acute medicine department have been thoroughly assessed and are good to return to the safety of their own home. An unplanned death after discharge from hospital is the worst-case scenario for patients, families and indeed clinicians. In order to prevent adverse events after patients leave hospital most units have a multi-layered system to capture risk that includes triage, recording of vital signs, basic blood tests, understanding of existing past medical history and assessment by a senior clinician to add experience and intuition. Discharge decisions depend on a balanced review of all these parameters and a discussion with patients about residual risks. Only after this will patients go home. Despite this a small percentage of patients pass away unexpectedly within days after leaving hospital.

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Acute management of cellulitis: A review

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

Cellulitis is an acute localised skin infection, usually accompanied by symptoms such as fever and rigors, nausea, and vomiting. It most commonly affects the lower limbs, although it can involve any part of the skin. It presents as area of redness and inflammation of the skin, with associated pain and swelling.

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Malignant renal obstruction without dilatation

Case Reports, Volume 18, Issue 2, Pages 61 – 136 (2019)

A 61 year old male presented with a one-week history of abdominal pain and loose stools. He had recently received treatment for cellulitis with flucloxacillin. He was anuric on presentation requiring haemodialysis. His ultrasound scan showed patent vessels with no signs of obstruction.

A kidney biopsy revealed tubulointerstitial nephritis, attributed to recent treatment with flucloxacillin. A week later he developed lower limb thromboembolic disease triggering further investigations. A FDG PET-CT scan revealed a large FDG-avid retroperitoneal mass causing non-dilated obstruction of both kidneys. Bilateral retrograde stents were inserted which resulted in a 1.6L diuresis and cessation of haemodialysis.

Non-dilated obstruction should be considered in anuric AKI, particularly in the context of malignancy, and may require a therapeutic trial of decompression.

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Dealer’s Dytonia (Croupier’s Cramp) – An Unusual Hazard Of Gambling

Case Reports, Volume 18, Issue 2, Pages 61 – 136 (2019)

Dystonia takes many forms and often presents acutely to emergency care. The diagnosis is often delayed because it mimics other more common conditions. This report describes a patient with a rare occupational dystonia, the typical clinical features of dystonia in general, and differentials to consider.

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