Volume 19

EDITORIAL VOLUME 19 ISSUE 4: COVID-19: Exemplifying the importance and challenges of Acute Medicine

Editorials, Volume 19, Issue 4, Pages 173 – 252 (2020)

COVID-19 has challenged healthcare providers and systems. It has dominated the international news agenda for the majority of 2020; arguably opinion becoming more fractured and disparate as the pandemic has evolved. The changing tone of discourse is concerning, although perhaps not surprising. As the majority of the population become increasingly baffled, bored and betrayed desperate for their lives return to “normal”, progressively binary, toxically expressed and opposing scientific views as to how to manage the “second wave” of the pandemic permeate. The initial failings of personal protective equipment (PPE) and a lack of preparedness to face a viral pandemic against the background of a strained acute care sector must not be forgotten and lessons learned.

In the UK, COVID-19 has highlighted both the challenges and importance of Acute Medicine. Acute Medicine teams have provided innovative and rapidly adaptive models of care in response to the pandemic. The fundamental tenets of Acute Medicine – MDT working, rapid initiation of treatment, sound use of diagnostics, early senior clinician input and recognition of those in whom ambulatory care is appropriate – are essential components in the management of all acute medical care and demonstrably equally apply to COVID-19. Our increasing global community of Acute Physicians and Acute Medicine teams have once again demonstrated the importance of our specialty.

The innovative practice of Acute Medicine teams and the impact of COVID-19 features prominently in this issue of Acute Medicine. There has been wide commentary regarding the impact of COVID-19 on both mental health issues and non-COVID-19 presentations. Riley et al. report an important analysis of presentations to AMU during the first wave of COVID-19 demonstrating a significant change in patient case mix.1 There were increased numbers of presentations potentially associated with social isolation such as falls, alcohol-related pathologies and overdoses alongside smaller numbers of traditionally lower risk presentations, such as non-cardiac chest pain.

Ambulatory management of low risk patients with suspected COVID-19 is fundamental to the safety and sustainability of acute care services during the “second wave” and moving forward. Nunan et al. report the experience of the TICC-19 – a virtual ward monitoring oxygen saturations for COVID-19 triaged using a 30 metre rapid walk test.2 This strategy appears safe and feasible with high levels of patient satisfaction and similar models are being utilised across many organisations. The role of POCUS in the diagnosis and management of COVID-19 is increasingly recognised.4 Knight et al. describe a simple aggregated score formed by summating the degree of pleural and interstitial change within six anatomical lung zones showing good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.4 This may form an important addition to COVID-19 ambulatory pathways.

SAMBA, the Society for Acute Medicine’s Benchmarking Audit, initially focused on the Society’s key quality indicators, continues to flourish and grow. It now not only benchmarks performance but is being used to guide the development of UK clinical quality measures. Colleagues in the Netherlands are commencing similar work and describing international standards of acute medical care, an iterative process, is one of the ultimate goals of this work. SAMBA 19 continues to demonstrate the evolving complexity of acute medical pathways and highlights the need to define optimal quality indicators for acute medical care.5 The inaugural winter SAMBA adds further evidence to the concerns that during this period there is an unfortunate cocktail of both sicker patients and poorer performance.6 Adapting acute medical services to meet this challenge requires innovation and investment.

Those working in Acute Medicine should feel proud of their continued contribution to managing the acutely unwell patient and their impact on the sustainability of acute care services, particularly during this most challenging of years. The Society for Acute Medicine has tremendous pride in representing this brilliant workforce. Alongside, the fantastic work of teams this year, there have been multiple emotional and physical stressors. Many AMUs have experienced large numbers of patient deaths, often having to support their loved ones by telephone. The seroprevalence of SARS-CoV-2 was greatest among colleagues working in Acute Medicine.7 Tragically, some AMUs have lost valued colleagues from COVID-19. We remember these friends for their fantastic work they have done, thank them for their contributions to Acute Medicine and on behalf of all the patients they served, we express thanks; their dedication resulted in the ultimate personal sacrifice. They will never be forgotten.

References:

Riley B, Packer M, Gallier S, et al. Acute, non-COVID related medical admissions during the first wave of COVID-19:
A retrospective comparison of changing patterns of disease. Acute Med 2020; 19(4): 176–82.
Numan J, Clarke D, Malakouti A, et al. Triage Into Community for COVID-19 (TICC-19) Patients Pathway – Service evaluation of the virtual monitoring of patients with COVID pneumonia. Acute Med 2020; 19(4): 183–91.
Mort DO, Limbu D, Nunan J, et al. Abnormal Lung Point-of-Care Ultrasound (POCUS) in Suspected Cases of COVID-19 pneumonia with Normal Plain Chest Radiographs – A Case Series. Acute Med. 2020; 19(3): 162–167
Knight T, Edward L, Rajasekaran A, et al. Point-of-care lung ultrasound in the assessment of COVID-19: a retrospective service evaluation with a severity score. Acute Med 2020; 19(4): 192–200.
Holland M, Subbe C, Atkin C, et al. Society for Acute Medicine Benchmarking Audit 2019 (SAMBA19): Trends in Acute Medical Care. Acute Med 2020; 19(4): 209–19.
Atkin C, Knight T, Subbe C, et al. Acute care service performance during winter: report from the winter SAMBA 2020 national audit of acute care. Acute Med 2020; 19(4): 220–29.
Shields A, Faustini SE, Perez-Toledo M, et al. SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study. Thorax 2020; epub ahead of print

EDITORIAL VOLUME 19 ISSUE 4: COVID-19: Exemplifying the importance and challenges of Acute Medicine Read More

Letter to the editor

Correspondence, Volume 19, Issue 3, Pages 113 – 172 (2020)

“Inside the word emerging is emerge, from an emergency new things come forth. The old certainties are crumbling first, but danger and possibility are sisters.’’1

The population burden of SARS-CoV-2, in terms of number of new cases, has declined significantly since the peak of the outbreak. Concerns rightfully persist regarding a possible second wave of infection. We feel the impact upon acute medicine warrants further discussion.

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Editorial Volume 19 Issue 3 – We are all story-tellers

Editorials, Volume 19, Issue 3, Pages 113 – 172 (2020)

Story telling is a human universal1. It is as old as language. Creating and relating narratives form an integral part of how physicians understand and communicate about our patients and their diseases. We ask our patients to help us develop their story (‘tell me about when all of this first started’), and then we tell their story back to them to facilitate our understanding (‘let me just check I understood; this is how things have progressed’). We use individual patients to anchor our learning in medicine; conditions are better recalled when they are attached to a specific people. Thus, we write case vignettes to improve understand when we teach others. When we see an interesting case we advise our medical students to use the opportunity to revise the related conditions, as we know that an individual patient narrative establishes richer meaning and better recall.

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Proteus mirabilis – a rare cause of non-HACEK Gram-negative infective endocarditis

Case Reports, Volume 19, Issue 3, Pages 113 – 172 (2020)

Infective endocarditis caused by Proteus mirabilis is strikingly rare. Here, we describe the case of an 86-year old man with five recurrent septic episodes over a period of three months associated with Proteus mirabilis bacteraemia secondary to underlying Proteus endocarditis. The final diagnosis was made based on clinical findings, blood culture results and transoesophageal echocardiogram. The patient was treated medically with 6 weeks of ceftriaxone and long-term oral ciprofloxacin. On completion of intravenous therapy the patient remained well. We performed a literature review and found this to be only the fourth confirmed case of Proteus mirabilis endocarditis successfully treated with antibiotic therapy alone. This case highlights an important but rare cause of endocarditis, reinforcing the need to consider this diagnosis in recurrent Gram-negative bacteraemia even if by an atypical organism.

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Who is allowed to read and write?

Guest Editorial, Volume 19, Issue 3, Pages 113 – 172 (2020)

What makes us human? In 2015 Jeremy Vine asked this question to a selection of leading British thinkers and writers. The answers were as diverse as the people he interviewed. While you might have your own views about the complexity of being human I would suggest that being able to articulate thoughts and communicate them to others might be one of the characteristics that distinguishes us from other life forms. And if we think more about the achievements of human culture then being able to communicate thoughts in writing and reading other people’s thoughts is one of the unique abilities that humanity has acquired during its evolution: Young humans spend extensive time to learn how to read and write. They write on paper, they read books and they do the same on computers. They become adults. They read and write most days: they e-mail their telephone company, file online forms to the tax office and or write romantic notes to their partner.

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Abnormal Lung Point-of-Care Ultrasound (POCUS) in Suspected Cases of COVID-19 pneumonia with Normal Plain Chest Radiographs – A Case Series

Case Reports, Volume 19, Issue 3, Pages 113 – 172 (2020)

COVID-19 pneumonia produces a heterogeneous array of clinical, biochemical, and radiological findings. Over the last few months of global hurry to optimize a testing strategy, it has been suggested that bedside point-of-care lung ultrasound may have a diagnostic role. We present 3 patients with RT-PCR nasopharyngeal swab-confirmed COVID-19 pneumonia, who had an admission plain chest film reported to be normal by a consultant radiologist, but with significant sonographic abnormalities on bedside ultrasound performed within 24 hours of the chest radiograph. Lung ultrasound may better correlate with the oxygen requirement and overall condition of the patient than chest radiograp

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Abnormal Lung Point-of-Care Ultrasound (POCUS) in Suspected Cases of COVID-19 pneumonia with Normal Plain Chest Radiographs – A Case Series Read More

Total Occlusion of the Left Descending and circumflex Coronary Artery without ST Elevation: the De Winter electrocardiographic pattern

Case Reports, Volume 19, Issue 3, Pages 113 – 172 (2020)

de Winter syndrome, or anterior ST segment elevation myocardial infarction (STEMI), constitutes 2% of acute myocardial infarctions. In contrast to classic ST segment elevation as seen with STEMI, it involves ST depression with precordial derivations and sharp waves. de Winter syndrome indicates critical narrowing of the left ascending coronary artery (LAD). Recognizing this presentation is important in terms of both mortality and morbidity. We present the case of a 71-year old patient presenting at the Emergency Department with chest pain, who had findings of de Winter syndrome on their ECG. Coronary angiography confirmed occlusions in the LAD and circumflex (CX) coronary arteries.

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Pneumomediastinum, subcutaneous emphysema and pneumorrhachis following cocaine insufflation: a case report

Case Reports, Volume 19, Issue 3, Pages 113 – 172 (2020)

A case report on a 36-year-old male patient presenting to the emergency department (ED) with chest tightness, nasal sounding voice and subcutaneous emphysema 72 hours after the nasal insufflation of approximately 0.5g of cocaine. A plain radiograph of the chest demonstrated an extensive pneumomediastinum with subcutaneous emphysema extending into his neck. A computerised tomography (CT) scan confirmed the above findings, along with a pneumorrhachis of the thoracic spine. He was admitted locally for further investigation and observation.

Cocaine is the second most used illicit drug in the UK. The associated complications of cocaine can vary from acute coronary syndrome to acute psychosis. Pulmonological trauma secondary to cocaine misuse is commonly associated with inhalation of cocaine; we present this rare case of subcutaneous emphysema, pneumomediastinum and pneumorrhachis secondary to nasal insufflation. It is believed that deep nasal insufflation of cocaine is followed by forceful Valsalva manoeuvre, which allows for the rapid absorption of the drug and increases the euphoric effect. This forceful inhalation can lead to barotrauma and leakage of air into the posterior mediastinum.

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Pacemaker Lead Perforation Mimicking Symptoms of Acute Pulmonary Embolism

Case Reports, Volume 19, Issue 3, Pages 113 – 172 (2020)

Myocardial perforation is a rare yet serious complication following cardiac pacemaker or defibrillator device procedures.

In this article, the authors describe a case of right ventricular pacemaker lead perforation presenting to our hospital’s medical assessment unit with a clinical presentation suggestive of an acute pulmonary embolism. Treatment dose low molecular weight heparin (LMWH) was commenced while awaiting CT scan. CT images were negative for PE however demonstrated RV lead perforation. Echocardiogram demonstrated pericardial effusion with the tip of RV lead in the pericardial free space. A rapid deterioration in the patient’s haemodynamics prompted an emergency pericardial drain insertion and successful RV lead re-position in the cardiac catheter lab. The patient recovered well and was discharged with routine pacemaker clinic follow-up.

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Limited Prognostic Utility of a Simplified Vital Sign Based Risk Calculator in Acute Medical Admissions

Original Articles, Volume 19, Issue 3, Pages 113 – 172 (2020)

Background: Accurate efficient prognostication in acute medical admissions remains challenging.Methods: We constructed a Vital Sign based Risk Calculator using vital parameters and Major Disease Categories to predict 30-day in-hospital mortality using a multivariable fractional polynomial model.

Results: We evaluated 113,807 admissions in 58,126 patients. The Vital Sign based Risk Calculator predicted 30-day inhospital mortality to increase from 2 points - 3.6% (95%CI 3.4, 3.7) to 12 points - 14.8% (95%CI 14.0, 15.7). AUROC was 0.74 (95%CI 0.72, 0.74). The addition of illness severity and comorbidity data improved AUROC to 0.90 (95%CI 0.89, 0.90).

Conclusion: The Vital Sign based Risk Calculator is limited by its simplicity; inclusion of illness severity and comorbidity data improve prediction.

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