Volume 19, Issue 2, Pages 61 – 112 (2020)

POCUS in Acute Medicine

Editorials, Volume 19, Issue 2, Pages 61 – 112 (2020)

In this edition of Acute Medicine, Knight et al. demonstrate from SAMBA data that access to ultrasound machines and supervision is geographically heterogeneous.1 They raise concerns that this may lead to inequity of provision of Point of Care Ultrasound (POCUS) and the benefits it can provide for patients. This point is well made: Since the development of the Focused Acute Medicine Ultrasound (FAMUS) competencies in 20162 there has been a steady increase in the provision of supervisors to 803 and the number of individuals completing training has increased to 56. Whilst this is to be applauded, our experience concurs with this paper that much of the ultrasound training is concentrated in pockets of expertise in particular hospitals.

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Gaps in point of care ultrasound provision and the cost of ultrasound equipment provision: results of a nationwide audit of acute medical units

Original Articles, Volume 19, Issue 2, Pages 61 – 112 (2020)

Introduction: Advances in ultrasound technology have allowed an investigation previously restricted to the radiology department to be used more liberally in clinical decision making. Point-of-Care-Ultrasound (PoCUS) has superior diagnostic performance to traditional clinical examination across a range of pathologies in the hands of a suitably experienced practitioner. The utilisation of PoCUS has the potential to greatly influence the delivery of acute care, but little is known about the current level of resource provision within the acute medical setting.

Methods: To establish the availability of ultrasound equipment and appropriately trained clinicians within Acute Medical Units (AMUs) in the United Kingdom (UK) we asked specific questions with an annual day of care survey, undertaken by the Society for Acute Medicine. We compared data across two years to assess interval changes.

Results: 58.1% (75/129) of AMUs had access to dedicated ultrasound equipment in SAMBA’19. This represents a small increase from SAMBA’18. Ultrasound expertise is concentrated across a small number of AMUs. Growth in the number of ultrasound trained clinicians is greatest units with established expertise.

Conclusion: The equipment to provide PoCUS is not present on all AMUs and appropriately trained clinicians are not distributed evenly across units. This is likely to affect individual AMUs ability to deliver bedside ultrasound to appropriate patients who may benefit. Bridging the gap to ensure all AMUs have the option to use PoCUS will require planning and investment.

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Correlating pulmonary embolism severity with short term mortality to risk stratify for outpatient management

Original Articles, Volume 19, Issue 2, Pages 61 – 112 (2020)

Aims: We ascertain less than 7-day mortality data in suspected pulmonary embolism (PE) in order to risk stratify patients suitable for outpatient imaging.

Methods: Retrospective identification of patients presenting to two emergency departments over a two-year period, with a radiologically confirmed PE. PESI and sPESI scores correlated with death at 1, 3, 7, 30 and 90 days.

Results: There was significant correlation between all PESI risk classes and death at 3, 7, 30 and 90 days (p<0.01), but not day 1. No deaths occurred within 1 and 3 days in low risk PESI groups or within 90 days in the low risk sPESI. Conclusion: PESI/sPESI could be reliably utilized to risk stratify patients being considered for outpatient investigation of PE.

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A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study

Original Articles, Volume 19, Issue 2, Pages 61 – 112 (2020)

Background: The aim of this study was to investigate 30-day mortality for COPD patients treated by ambulances in the period before and after implementation of a pre-hospital oxygen protocol.

Methods: Prehospital High-flow oxygen was used from April to September 2012 and titrated oxygen from April to September 2013. Primary outcome was 30-day mortality.

Results: 707 patients were included; 209 in the high-flow group and 498 in the titration group. Of these, 56 and 132 arrived with acute exacerbation (AE). Overall 30-day mortality was 11.5% vs. 9.4% (p=0.41), respectively. For patients with AE, it was 19.6% vs. 4.6% (p=0.001).

Conclusion: Change of treatment protocol is associated with a lower 30-day mortality for patients registered with acute exacerbation, but not for all COPD patients.

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A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study Read More

Prognostic Value Of Blood Cultures as an Illness Severity Marker In Emergency Medical Admissions

Original Articles, Volume 19, Issue 2, Pages 61 – 112 (2020)

Background: Positive blood cultures predict mortality. The prognostic value of blood culture performance itself has not been fully defined.

Methods: We evaluated medical admissions from 2002-2017. We defined blood culture category as 1) no culture 2) negative culture 3) positive culture. We employed a multivariable logistic regression model to evaluate outcomes.

Results: We evaluated 78,568 blood cultures in 106,586 admissions. 30-day in-hospital mortality for no culture was 2.8% (95%CI 2.7, 2.9), culture negative 8.9% (95%CI 8.5, 9.3) and culture positive 16.7% (95%CI 15.5, 17.9). There was significant interaction between blood culture category and illness severity, OR 1.06 (95%CI 1.05, 1.08), and comorbidity, OR 1.09 (95%CI 1.09, 1.10).

Conclusion: Performance and results of blood cultures are independently associated with increased mortality.

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Fentanyl patches: Use and Misuse

Clinical Reviews, Volume 19, Issue 2, Pages 61 – 112 (2020)

Transdermal fentanyl is a well-used and highly effective form of opioid analgesia for patients suffering with severe chronic pain. It is also an opioid that is widely abused. Acute clinicians need to be aware of the methods by which fentanyl patches may be used both therapeutically and illicitly as well as the impact this can have in managing a patient’s period of intoxication.

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A change in perspective to see the bigger picture. A thematic analysis of Audit and Quality Improvement submissions to the last seven UK based SAM Conferences

Research Audit and Clinical Practice, Volume 19, Issue 2, Pages 61 – 112 (2020)

Aims: To create a profile of Society for Acute Medicine (SAM) Audit and Quality Improvement (A&QI) accepted abstracts from the last seven UK based conferences.

Methodology: The profile elements for 380 SAM A&QI abstracts accepted for poster presentation were compiled from their respective conference programme booklets. Abstracts were classified into 30 categories based on key themes. Further sub-categorisation of abstracts was based on secondary detail of the submissions. Data was analysed with Pareto charts.

Findings: The majority of submissions were covered by a small representation of themes, with 30% of category themes covering 80% of A&QI abstracts.

There is a repetitive trend of theme categories across all the conferences.

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Ferric carboxymaltose (Ferinject®) associated hypophosphataemia: case report illustrating the need for increased awareness to minimise incidence and risk

Case Reports, Volume 19, Issue 2, Pages 61 – 112 (2020)

Ferric carboxymaltose (Ferinject®) is an infusion administered for the treatment of iron deficiency anaemia. A number of previous case reports have shown the occurrence of hypophosphataemia after Ferinject® treatment, supposedly managed though high dose phosphate therapy. This case report highlights the risk associated with, and futility of, managing this adverse effect through high dose phosphate infusion. A review of the available literature suggests that if hypophosphataemia develops as a result of Ferinject®, through upregulation of the renal protein Fibroblast Growth Factor-23, it cannot be readily reversed and on average persists for circa 50 days. Acute medical units should be aware of this – likely underreported – adverse effect, and avoid treating these hypophosphataemic patients with high dose phosphate since it can compound symptoms.

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Pericardial Effusion presenting as Cough Syncope

Case Reports, Volume 19, Issue 2, Pages 61 – 112 (2020)

Syncope is a common clinical presentation and accounts for 1-3% of Emergency Department (ED) visits. Cough syncope is a rare type of situational syncope, often caused by respiratory conditions like bronchial asthma and chronic obstructive pulmonary disease. Cough syncope due to pericardial effusion is a rare but treatable condition. Delay in diagnosis can lead to fatal complications due to cardiac tamponade. We present a case of recurrent cough syncope caused by large pericardial effusion.

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Is fake news contributing to increased Covid-19 BAME deaths?

Correspondence, Volume 19, Issue 2, Pages 61 – 112 (2020)

We write this letter as doctors and proud members of the Black, Asian and Minority Ethnic (BAME) community from a South Asian background. Recent Office for National Statistics (ONS) data suggest that the BAME population is disproportionately affected by Covid-19.1 Observations and experiences from within our family and wider community led us to explore how cultural aspects may account for these figures. Both intrinsic and extrinsic factors are likely to contribute to this unfortunate statistic. Intrinsic factors such as pre-existing health conditions and comorbidities e.g. cardiovascular risk factors, diabetes2 and diet are likely to play a role. Extrinsic factors such as living in overcrowded conditions,3 multigenerational households and a large proportion of this population being key/essential workers,4 which are often less likely to be amenable to remote working. Faith also plays a part and the large congregational gatherings in places of worship may add to the risk in this community, as does the tactile nature of greeting in BAME communities.

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