Volume 20

A Proposal to Establish Acute Medicine Units in Sudan’s Hospitals

Correspondence, Volume 20, Issue 4, Pages 249 – 308 (2021)

This proposal is the first to suggest the establishment of the new specialty of acute medicine in Sudan. Introducing this specialty will ensure that patients receive the best care in a timely fashion from a well-trained workforce and will aid in delivering optimum care to critically ill medical patients and securing faster, safer, and more effective services. It will provide a comprehensive training program for senior and junior doctors and attract employees by creating more jobs for different specialties (nurses, pharmacists, radiologists, etc.). Further, introducing acute care will help reduce the number of patients who require long-term admission, provide more accessible, holistic, emergency medical care for all socio-economic classes, and empower key stakeholders.

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CNS infection with a history of recurrent epistaxis: Streptococcal meningitis as a first presentation of juvenile nasopharyngeal angiofibroma

Case Reports, Volume 20, Issue 3, Pages 157-248 (2021)

An adolescent male with a history of recurrent epistaxis presented with headache and vomiting. Investigations revealed concurrent meningitis as well as the presence of a subarachnoid haemorrhage. Subsequent imaging identified a Juvenile Nasopharyngeal Angiofibroma; a rare but important cause of meningitis that should be considered in the young adult population.

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The experiences of NHS hospital acute medicine departments in England during the first wave of the COVID-19 pandemic

Original Articles, Volume 20, Issue 3, Pages 157-248 (2021)

We conducted a survey exploring the experiences of NHS hospital acute medicine services in England during the 1st wave of the COVID-19 pandemic. Responses were collected from 26th May to 8th July 2020. The results of 91 sites are presented. The total number of patients referred to the medical take for assessment and admitted from the medical take decreased from pre-pandemic levels compared to peak COVID-19 activity. The total number of acute medical beds decreased, however critical care beds increased by 162%. We report the median timeline from first admission of COVID-19 to when baseline critical care capacity was reached. We found regional variation across the results. These findings can assist healthcare leaders prepare for future pandemics.

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Period-Prevalence and Risk Factors for Delirium in a Tertiary Referral ICU: A prospective cohort study

Original Articles, Volume 20, Issue 3, Pages 157-248 (2021)

Background: Delirium is common in intensive care and leads to increases in morbidity, mortality, Intensive Care Unit (ICU) length of stay, and hospital length of stay. Certain risk factors predict the appearance of delirium.
Study Objectives: To determine the rates of delirium, the rate of risk factors, and their relationship to the occurrence of delirium in an adult ICU.
Methods: Single-centre, prospective, observational study. Demographic and treatment data were collected. The Confusion Assessment Method for ICU (CAM-ICU) was performed twice daily to assess for delirium continuously during a 3-week period. Statistical analysis was used to determine the relationship between risk factors and the occurrence of delirium.
Results: 86 patients were screened, 44 patients were included, and 260 patient-days were analyzed. The incidence of delirium was 42.9%, the prevalence of delirium in ICU was 50%. Urinary catheters and use of opioids were the most common factors with a positive association for occurrence of delirium. Exposure to daylight and sleeping for more than 4 hours at night were the factors most commonly associated with a lack of delirium.
Conclusion: The rates of delirium in ICU were high and risk factors occurred frequently. Addressing modifiable risk factors, including the promotion of adequate sleep, could improve outcomes.

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A case report of extensive cerebral venous sinus thrombosis: a sequela of COVID-19?

Case Reports, Volume 20, Issue 3, Pages 157-248 (2021)

Coronavirus disease 2019 (COVID-19) is an infectious respiratory disease that is often the trigger for thrombotic complications. Cerebral venous sinus thrombosis (CVST) represents a small percentage of strokes, frequently proving to be a diagnostic challenge. We report a 31-year-old lady presenting with a persistent headache, 18 weeks after a mild COVID-19 illness. On her second visit, CT venography revealed extensive CVST. She was commenced on low-molecular-weight heparin, and was monitored closely in the neuro-medical intensive care unit. She was discharged 2 weeks later, with no residual neurological deficit, and commenced on a direct oral anticoagulant in the community. CVST should be considered in patients presenting with a refractory headache, with greater suspicion if previously infected with SARS-CoV-2.

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Thrombotic thrombocytopenia following ChAdOx1 nCov-19 vaccination

Case Reports, Volume 20, Issue 3, Pages 157-248 (2021)

Serious thromboembolic events with concurrent thrombocytopenia, sometimes accompanied by bleeding, have occurred very rarely following administration of the ChAdOx1 nCoV-19 vaccine. We report the case of a 59-year-old male with an unremarkable medical history who presented to the emergency department with increasing breathlessness five days after receiving the first dose of ChAdOx1 nCov-19. The patient’s blood results showed mild thrombocytopenia and a very high D-dimer, and a pulmonary embolism was confirmed through a CT pulmonary angiogram, which led to a provisional diagnosis of vaccine-induced immune thrombotic thrombocytopenia. The condition was then treated with immunoglobulin and intravenous argatroban in line with the guidance from the Expert Haematology Panel focussed on Vaccine-induced Thrombosis and Thrombocytopenia before conversion to apixaban.

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Type II Cryoglobulinaemia causing Monoclonal Gammopathy of Renal Significance

Case Reports, Volume 20, Issue 3, Pages 157-248 (2021)

A 53 year old female with a background of hypertension, hypothyroidism and Raynaud’s was admitted with an acute ischaemic stroke and referred to the renal team after a routine urine dip revealed microscopic haematuria and nephrotic-range proteinuria. Blood tests revealed renal impairment, a monoclonal IgM kappa paraprotein, low complement C4 concentration and a positive rheumatoid factor. Active cryoglobulinaemia was suspected and testing demonstrated type II cryoglobulins secondary to the monoclonal IgM kappa paraprotein. Bone marrow biopsy was normal. Renal biopsy revealed cryoglobulinaemia associated membranoproliferative glomerulonephritis. Treatment with steroids and rituximab improved renal function and proteinuria. This case fits within the evolving spectrum of disorders now termed Monoclonal Gammopathy of Renal Significance and highlights the value of biopsying and treating these patients early.

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The pharmacist in same day emergency care: a service evaluation of pharmacy services on the ambulatory assessment unit at the John Radcliffe Hospital

Original Articles, Volume 20, Issue 3, Pages 157-248 (2021)

Same day emergency care (SDEC) is an increasingly important part of urgent care delivery in secondary care. This service evaluation examined the role of the pharmacy service on a busy SDEC unit over a 3 week period.
A total of 634 patients were seen on the unit and 513 pharmacy interventions were made. Patients were taking a mean number of 6.7 medicines and the average age was 59.3. The most common medication type pharmacists intervened in were anticoagulants.
To meet the demands of SDEC service, the pharmacy team is crucial for maintaining medication safety and ensuring patient flow through hospital pathways.

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Clinical thermography at extreme temperatures

Correspondence, Volume 20, Issue 3, Pages 157-248 (2021)

Every day, emergency departments and acute medical units all over the world receive and assess thousands of patients. Most are stable, but a few require immediate stabilization. To identify these, all patients are routinely triaged and have vital signs measured. Our group has shown that thermographic images of the face can be an alternative method for identifying patients at increased risk of 30-day mortality. In our previous studies, the thermographic images were taken after the patients had been inside for at least 30 minutes. However, to identify patients at risk, the images have to be available as quickly as triage, i.e. at the door when the patient arrives. Therefore, we have performed a small study, with the aim of illustrating the effect of such heat-gradients on thermal images of the face.

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