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

Fever increases heart rate and respiratory rate; a prospective observational study of acutely admitted medical patients

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

Background: The relationship between increase in body temperature, heart rate, and respiratory rate has only been studied in young, healthy subjects.

Aim: To show the changes in heart and respiratory rate associated with fever in acutely admitted medical patients.

Design: A prospective observational cohort study

Methods: Vital parameters from 4,493 patients were retrospectively extracted. Linear and multiple variable regression analysis was used to calculate the change in heart and temperature rate for every degree rise in temperature (i.e. ΔHR/°C and ΔRR/°C) in the entire study group and in those with low (<36.1°C), normal (36.1-38°C) and high (>38°C) body temperatures.

Results: The ΔHR/°C and ΔRR/°C was 7.2±0.4 beats per minute (bpm) and 1.4 ±0.1 (1.2 to 1.62) breaths per minute (bpm). Adjusting for age, oxygen saturation and mean blood pressure, the results were 6.4±0.4 (5.7 to 7.1) bpm and 1.2±0.1 (1.0 to 1.4) bpm. In low, normal and high body temperature the ΔHR/°C were 2.7±1.9, 6.9±1.9 and 7.4±0.9 bpm, respectively; for ΔRR/°C the values were -0.5±0.5, 1.5±0.5 and 2.3±0.3 bpm, respectively.

Conclusions: We only found a modest association between fever and changes in heart rate and respiratory rate.

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How well are heart rates measured by pulse oximeters and electronic sphygmomanometers? Practice-based evidence from an observational study of acutely ill medical patients during hospital admission

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

Background: heart rates generated by pulse oximeters and electronic sphygmomanometers in acutely ill patients may not be the same as those recorded by ECG

Methods: heart rates recorded by an oximeter and an electronic sphygmomanometer were compared with electrocardiogram (ECG) heart rates measured on acutely ill medical patients.

Results: 1010 ECGs were performed on 217 patients while they were in the hospital. The bias between the oximeter and the ECG measured heart rate was -1.37 beats per minute (limits of agreement -22.6 to 19.9 beats per minute), and the bias between the sphygmomanometer and the ECG measured heart rate was -0.14 beats per minute (limits of agreement -22.2 to 21.9 beats per minute). Both devices failed to identify more than half the ECG recordings that awarded 3 NEWS points for heart rate.

Conclusion: Heart rates of acutely ill patients are not reliably measured by pulse oximeter or electronic sphygmomanometers.

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How well are heart rates measured by pulse oximeters and electronic sphygmomanometers? Practice-based evidence from an observational study of acutely ill medical patients during hospital admission Read More

Altered kidney function on the Acute Medical Unit

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

Reduced kidney function, whether acute or chronic, is a highly significant biomarker of in most clinical settings. This is particularly true on the acute medical take where altered renal function is associated with a worse prognosis, and may also impact on immediate management strategies such as drug choice, dosing and suspension, and the use of contrast agents for imaging. In this edition of the Acute Medical Journal, Yang et al present the results of their study describing the renal function and associated characteristics in 2,070 consecutive patients presenting on the unselected medical take at their hospital over a 40 day period. In this study, the authors provide a wealth of information on the general characteristics of acute medical patients admitted with altered kidney function, be it CKD or AKI. Importantly, both chronic kidney disease (CKD) and acute kidney injury (AKI) are very highly prevalent. Indeed, in this study more than 5% of all medical admissions actually demonstrated evidence of both.

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The appropriateness of current UK training in acute internal medicine

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

Doctors training in Acute Internal Medicine (AIM) need to provide evidence that they can effectively manage 20 ‘top’ and 40 ‘other important’ acute medical presentations. However, the presentations considered important in the AIM curriculum do not have an empirical evidence base. This study compared real-life presentations against those in the AIM curriculum. Data on all presentations to the acute medical service at The Royal Free Hospital, London, were collected retrospectively for five non-consecutive weeks and prospectively for one week. Five frequently encountered presentations viz: cough, nausea and vomiting, dizziness, hyperglycaemia and lethargy were not amongst those listed as ‘top’ or ‘other important’ in the AIM curriculum. Hence, demonstration of competency in these presentations is currently not an explicit requirement.

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Reduced kidney function at presentation in unselected acute emergency medical admissions: incidence, outcome and associated factors

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

We sought to assess the impact of renal impairment on acute medical admissions and to identify potential contributory factors to admissions involving renal impairment at presentation. In a prospective cohort study, 29.5% of all acute medical emergency admissions had an eGFR < 60 ml/min/1.73m2 at presentation. Of these, 19.9 % had definite chronic kidney disease and 8.4 % had definite acute kidney injury. Detailed analysis of a random subset of patients with an eGFR <60ml/min/1.73m2 at presentation demonstrated that the major reasons for admission included falls, dehydration and fluid overload. 46% were on diuretics and 53% were on an ACEI or ARB or both. Gastrointestinal disturbance and recent medication changes were common and diuretic use persisted even with diarrhoea or vomiting.

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Non-Cardiac Chest Pain: management in the Ambulatory Clinic setting

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

Non-cardiac chest pain (NCCP) is a common presenting complaint which can be better managed. This requires the recognition of clinical sub-groups with investigation and treatment tailored accordingly. The aim of this paper is to encourage more accurate diagnoses and the better recognition of the source of chest pain. We discuss the appropriate investigations and management of each clinical sub-group.

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Prediction models for mortality in adult patients visiting the Emergency Department: a systematic review

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

We provide a systematic overview of literature on prediction models for mortality in the Emergency Department (ED). We searched various databases for observational studies in the ED or similar setting describing prediction models for short-term mortality (up to 30 days or in-hospital mortality) in a non-trauma population. We used the CHARMS-checklist for quality assessment. We found a total of 14.768 articles and included 17 articles, describing 22 models. Model performance ranged from AUC 0.63- 0.93. Most articles had a moderate risk of bias in one or more domains. The full model and PARIS model performed best, but are not yet ready for implementation. There is a need for validation studies to compare multiple prediction models and to evaluate their accuracy.

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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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