Volume 21, Issue 2, Pages 65-120 (2022)

Antimicrobial neurotoxicity: an under-recognised cause of delirium

Case Reports, Volume 21, Issue 2, Pages 65-120 (2022)

Antimicrobial associated encephalopathy (AAE) is a well-documented, though under recognised, adverse event associated with antimicrobial use.1 Clinical manifestations of AAE are varied, ranging from myoclonus and seizure to an encephalopathy with cerebellar signs.1 The phenotypic presentation of the encephalopathy syndrome is, in general, governed by the antimicrobial in question. Given its apparent rarity in everyday clinical practice, awareness of AAE is crucial for physicians. We describe a reversible encephalopathy characterised by confusion, myoclonus and stupor in a 76 year old gentleman on antimicrobial therapy for a peri-rectal abscess.

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Acute abdominal pain: chameleon presentations of acute myelitis

Case Reports, Volume 21, Issue 2, Pages 65-120 (2022)

Patients with acute abdominal pain typically undergo urgent clinical assessment to exclude serious underlying surgical diagnoses. However, a diverse range of less common medical conditions may also present with abdominal pain and their severity can range from benign to life threatening. Here we present a case of myelitis (inflammation of the spinal cord) presenting with acute abdominal pain that was initially diagnosed clinically as biliary pathology. We review the canonical differential diagnosis for medical causes of acute abdominal pain and highlight the clinical features that raise the suspicion of spinal pathology. We argue that awareness of the basic clinical features of structural and inflammatory spinal lesions could improve early recognition of these potentially overlooked diseases.

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‘Just another asthma attack?’ – point of care ultrasound as a game changer in respiratory failure

Case Reports, Volume 21, Issue 2, Pages 65-120 (2022)

Wheeze and shortness of breath are a common reason for admission to hospital but the cause of which is not always immediately apparent. We present a case of a patient with respiratory distress, wheeze and chest tightness on a background of well controlled asthma and androgen deprivation therapy for prostate cancer. The patient was provisionally treated as an asthma exacerbation but point of care ultrasound (POCUS) performed soon after admission revealed severe LV impairment and ‘wet lungs’ in keeping with acute decompensated heart failure. The case highlights the importance of POCUS to differentiate between different causes of wheeze in the acute setting and we discuss the diagnostic approach to the patient with suspected heart failure.

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Shock first, ask questions later…

Case Reports, Volume 21, Issue 2, Pages 65-120 (2022)

A 39-year-old man presented to the Emergency Department following a sudden onset of palpitations an hour earlier. He was clammy and felt generally unwell. He was normally fit and active with no history of cardiac symptoms including palpitations – he mentioned as a teenager he was told that he had an ‘extra bit of wiring in his heart’ but nothing further was done. His only regular medication was Sertraline. He drank alcohol to excess. On examination, he was hypotensive but pain free. Bloods including potassium and magnesium were within normal limits – venous lactate was mildly elevated at 2.8. His ECG can be seen in Figure 1A

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Isolated paracetamol-induced acute kidney injury: a systematic review

Clinical Reviews, Volume 21, Issue 2, Pages 65-120 (2022)

Aim: We sought to characterise the syndrome of isolated paracetamol-induced acute kidney injury (AKI), whose incidence and mechanisms are poorly understood.
Methods: Using systematic review methodology, fifty-six papers relating to paracetamol-induced AKI were identified.
Results: 24 cases of isolated paracetamol-induced AKI were identified and compared to 87 identified cases of concurrent renal and hepatic injury.
Paracetamol-induced AKI became detectable 3-4 days after exposure; liver injury, where it occurred, preceded AKI detection by 1 day.
Risk factors affecting hepatotoxicity risk do not appear to influence isolated AKI, with no clear associated factors except younger age (mean 18.8 versus 33.1 years).
Conclusions: Isolated paracetamol-induced AKI appears commoner in younger patients. Paracetamol-induced AKI occurs late and may go undetected by current treatment guidelines.

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Potential therapies for sodium azide intoxication; a case report and review of the literature

Clinical Reviews, Volume 21, Issue 2, Pages 65-120 (2022)

Intoxications with sodium azide are rare and in almost all cases lethal in doses above 700 mg or 10mg/kg. We report a case of a patient who ingested 2 grams of sodium azide as a suicide attempt. Sodium azide irreversible blocks cytochrome C oxidase by inhibiting oxidative phosphorylation leading to cell death. There is currently no antidote available. Our patient was treated with a range of therapies, on site, in the emergency department and in the intensive care unit, such as sodium thiosulphate, methylene blue, intralipid, extensive gastric lavage, whole bowel irrigation combined with pro-kinetics, hydroxocobalamin and exchange transfusion. During the clinical course the patient developed cardiac failure, for which veno-arterial ECMO and an intra-aortic balloon pump was placed. However, cardiac function did not recover, leading to discontinuation of treatment after 7 days. As literature on sodium azide intoxication is scarce, we conducted a review to present potential treatment options.

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Improving care for patients in the outlying wards: Lessons from patients’ care experience

Original Articles, Volume 21, Issue 2, Pages 65-120 (2022)

Importance: Overcrowding in hospitals and lack of capacity in general medical wards can result in a medical patient being transferred to other specialty wards often referred as ‘outlying’ or ‘boarding’ wards.
Objectives: We explored the experiences of our outlying patients to identify local factors that affect their care experience and inform interventions that could improve their care deliveries and outcomes.
Design, setting, and participants: Qualitative interviews using semi-structured questions were conducted in 21 medical patients from a mixture of specialty wards in a large tertiary NHS hospital.
Main Outcomes and Measures: Perceptions of the factors contributing to the experience of being a patient on a boarding ward, and potential solutions.
Results: Almost all participants reported experiences of good care in an outlying ward. Positive comments highlighted good nursing care, restful environment and a strong focus on patient-centred care. However, none of the participants could identify the team or consultant responsible for their care and this was linked to multiple doctors being involved in the patient’s care. Participants also perceived that the frequency of review was reduced and occurred much later in the day than that experienced in the medical ward. Most felt indifferent about the care ownership, timing and frequency of review but in some cases, this led to confusion and the perception of poor progress. Further, participants felt that they had to actively seek information relating to clinical progress. Negative experience of discharge planning was also reported. The associated themes included conflicting information and delays in social care provision. This led to anxiety, frustration and the perception of being a barrier to patient flow.
Conclusions and Relevance: Patient experience of the outlying ward is positive, and this can provide a foundation for improvement. Our findings suggest that better care processes and improved communication are needed to promote equity and quality of care. However, this should be complemented with efforts to overcome wider challenges that affect the entire continuum of flow within the healthcare system.

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Developing priorities for quality improvement in acute medicine using a modified Delphi method
A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI)

Original Articles, Volume 21, Issue 2, Pages 65-120 (2022)

Introduction: The SAM Quality Improvement Committee (SAM-QI), set up in 2016, has worked over the last year to determine the priority Acute Medicine QI topics. They have also discussed and put forward proposals to improve QI training for Acute Medicine professionals.
Methods: A modified Delphi process was completed over four rounds to determine priority QI topics. Online meetings were also used to develop proposals for QI training.
Results: Same Day Emergency Care (SDEC) was chosen as the priority topic for QI work within Acute Medicine.
Conclusion: The SAM-QI group settled on SDEC being the priority topic for Acute Medicine QI development. Throughout the Delphi process SAM-QI has also developed proposals for QI training that will help Acute Medicine professionals deliver coordinated meaningful improvements in care.

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Developing priorities for quality improvement in acute medicine using a modified Delphi method
A consensus process hosted by the Society for Acute Medicine Quality Improvement Committee (SAM-QI) Read More

The prediction of early mortality by the ROX index of oxygenation and respiratory rate in diverse Canadian and Ugandan cohorts of unselected patient: a post-hoc retrospective analysis of 80,558 patient observations

Original Articles, Volume 21, Issue 2, Pages 65-120 (2022)

Aim: To investigate the association between in-hospital mortality and the ROX index of respiratory rate and oxygenation in diverse cohorts of unselected patient at different prediction windows.
Methods: A retrospective post-hoc analysis of data from a major regional referral Canadian hospital and a low-resource hospital in sub-Saharan Africa.
Results: Four patient cohorts were examined: Canadian medical, surgical and intensive care unit (ICU) patients, and all patients admitted to an African hospital. In all patients in-hospital mortality rose as ROX declined. Apart from ICU patients, ROX had a high discrimination for death within 72 hours. For non-ICU patients the negative predictive value of death within 72 hours for a ROX value <22 ranged from 0.994 to 1.000 Conclusion: In diverse cohorts of unselected patients, the ROX index has a high discrimination for death within 72 hours. However, the index has little or no prognostic value for patient admitted to ICU.

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The prediction of early mortality by the ROX index of oxygenation and respiratory rate in diverse Canadian and Ugandan cohorts of unselected patient: a post-hoc retrospective analysis of 80,558 patient observations Read More

Guest Editorial – Risk Stratification in Acute Medicine

Guest Editorial, Volume 21, Issue 2, Pages 65-120 (2022)

The Nobel-winning physicist Niels Bohr famously said that “prediction is very difficult, especially if it’s about the future.” Nevertheless, the prediction of rapid clinical deterioration has acquired its place in Acute Medicine. Time-urgent medical emergencies can benefit significantly from early detection when treatment delays increase the risk of death. Many Early Warning Systems (EWS) have thus been developed to stratify those at high risk of deterioration. It has been demonstrated that different types of EWS, including the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), and NEWS2, are clinically useful when identifying rapid deterioration. However, as we are inundated with risk stratification tools, it can be hard to decide which we should or should not use.

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