The challenges and uncertainties of working in the developing field of Acute Medicine have been a regular theme for editorial comment in this journal since I took the helm in 2002. Almost four years on, with sub-specialty status confirmed, over 200 consultants and many SpRs enrolled in higher specialist training programmes throughout the UK, Acute Medicine finds itself in a much stronger position than any could have predicted at that time. Enthusiasm for the field is clear from the numbers of applicants for training programmes at SpR level, as well as the dramatic rise in attendances at acute medicine meetings across the country in the last year. However, on-going challenges remain. Eighteen months from now, Modernising Medical Careers will send shockwaves throughout hospital medicine. The exact nature of the change to our training programmes remains unclear, and will probably have changed again between my writing this and its publication. However it is essential that Acute Medicine is ready for whatever comes our way. We must work closely with our colleagues in Emergency Medicine and Critical Care to develop common stem training schemes which allow doctors to choose the area of ‘front door’ medicine which suits them best. Where possible we should seek to encourage dual accreditation in two or more of these areas. But most of all we need to maintain the momentum which has carried us so far in such a short space of time, and which has the potential to make Acute Medicine one of the largest hospital specialties. This edition’s review articles cover a varied mix of common and less common conditions on the acute medical ‘take’. Most medical admission units will be faced with at least one patient presenting with a seizure in each 24 hour period. Dr Kinton emphasises the importance of a good history in the management of this problem, but also provides some useful tips to help distinguish seizures from other causes of blackout. Distinction from syncope can be a particular challenge, not least because of the differing implications for driving, the loss of which can have devastating consequences. Acute ischaemic stroke is another common problem, the management of which is comprehensively reviewed by David Jarrett and Hemang Dave. As well as summarising some of the major trial data for thrombolytic and antiplatelet therapy, this review includes some advice on some of the common clinical challenges which don’t usually feature in text book descriptions of this condition. Less common, but no less important, Acute liver failure must be distinguished from decompensated chronic liver disease – the former often requiring discussion with a regional liver unit. Phil Berry has included a useful checklist to have to hand before making this phone call. Headache, palpitations and sweating is a common problem on the post-take ward round – particularly amongst the junior staff completing a night shift. Fortunately most junior doctors do not have a phaeochromocytoma – in common with every patient for whom I have ever requested 24 hour urinary catecholamine measurement. Having read Dr Solomon’s thorough review of the acute management of this condition I will now feel equipped to manage this condition when I finally get a positive result back from the laboratory!
Apologies that this edition has been a little delayed – I hope you consider it to have been worth waiting for….