We thank Dr Gyan and colleagues for their thoughtful critique of our paper and welcome the opportunity to clarify the intended interpretation of our findings. We acknowledge that there are a number of limitations to this service evaluation highlighted in your letter, which are also addressed in the paper itself.
Pulmonary embolism (PE) is a common and potentially life-threatening condition encountered in acute medicine. Clinical prediction rules (CPRs), including PERC, Wells, Revised Geneva, YEARS and LEGEND, have been developed to support rational use of computed tomography pulmonary angiography (CTPA). This study evaluated whether retrospective co-application of Revised Geneva, YEARS or LEGEND alongside an existing PERC/Wells-based diagnostic pathway could reduce CTPA utilisation in a Same Day Emergency Care (SDEC) population. We conducted a retrospective cohort study of all patients who had CTPA for suspected PE in a UK SDEC unit between January and June 2024. CPRs were applied retrospectively using documented clinical data. The primary outcomes were the potential reduction in CTPA utilisation and the proportion of scans that would have contained PE. Of 433 CTPAs identified, 362 patients met inclusion criteria. The prevalence of PE among those scanned was 16.6%. Retrospective co-application of Revised Geneva, YEARS and LEGEND would have reduced CTPA utilisation by 5.5%, 29.0% and 39.2% respectively. No PEs were identified among scans potentially avoided using Revised Geneva, whereas PE was present in 4.8% and 5.6% of avoided scans using YEARS and LEGEND. Missed events occurred in a clinically stable ambulatory cohort and were not associated with radiological evidence of right ventricular strain; however, the clinical significance of these findings remains uncertain. In this selected SDEC population, layering additional CPRs onto an existing diagnostic pathway may have the potential to reduce CTPA utilisation, although strategies achieving larger reductions were associated with missed diagnoses. These findings should be regarded as hypothesis-generating and require prospective validation before informing changes to clinical practice.
We read with interest the service evaluation by Voase and colleagues examining the diagnostic yield of lumbar puncture (LP) in patients presenting with acute severe headache. The authors address an important subject in a time of increasingly sensitive neuroimaging and evolving management pathways for suspected subarachnoid haemorrhage (SAH). We would, however, urge caution in interpreting the findings presented.
INTRODUCTION:Anti-fouling marine paints contain toxic components such as copper-based biocides, organotin compounds, and volatile organic solvents. Acute occupational exposure may result in respiratory, gastrointestinal, hepatic, and neurological manifestations; however, clinical data in emergency medicine regarding such exposures remain limited. CASE PRESENTATION:Five male shipyard workers aged 23-39 years presented to the emergency department following acute occupational exposure during anti-fouling paint application. Three patients experienced inhalational exposure and presented with dyspnoea and throat irritation requiring supplemental oxygen therapy. One patient presented with nausea and vomiting and was found to have a two-fold elevation in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. Another patient reported dizziness, throat burning, and palpitations. Other laboratory parameters were within normal limits. All patients were hospitalised for close observation and received supportive treatment, including oxygen therapy, intravenous fluids, and symptomatic management. No severe systemic toxicity or organ failure developed. Clinical and laboratory findings improved within 72 hours, and all patients were discharged without complications. CONCLUSION:Acute exposure to anti-fouling marine paints may cause heterogeneous clinical presentations, including respiratory compromise and transient hepatic enzyme elevation. Emergency physicians should recognise this occupational hazard and consider extended observation and supportive management when clinically indicated.
BACKGROUND:Deep vein thrombosis (DVT) is commonly managed in ambulatory care. Guidelines recommend reassessment at three months to review anticoagulation duration, but no structured follow-up pathway exists within our Trust. AIM:To evaluate anticoagulation duration, follow-up practices, and outcomes in patients with DVT diagnosed in ambulatory care. METHODS:Retrospective, observational service evaluation across two ambulatory care units in Manchester, UK. Patients with confirmed lower limb DVT were identified between January 2023 and June 2023. Data were collected from electronic patient records including complication rates over a 2-year period. RESULTS:Of 307 patients assessed for suspected DVT, 90 had confirmed DVT. Most cases were unprovoked (77.8%). At discharge, 39% were prescribed 3 months' anticoagulation, 31% 6 months, 11% lifelong, 6% received a duration range of 3-6 months, and 13% had no specified duration. Discrepancies between recommendation at discharge and primary care prescribing were seen in 53%, with nearly half receiving longer treatment. 20% had secondary care follow-up. Recurrent DVT occurred in nine patients, none of whom had received follow-up; no recurrences were seen in the followed-up group, although this difference was not statistically significant (Fisher's exact test, p = 0.195). Bleeding events were seen in 4.4% of cases and were minor. CONCLUSIONS:There is substantial variability in anticoagulation management following DVT in ambulatory care. Although recurrence was not observed in the followed-up group, the study was not powered to detect differences, and this finding should be interpreted cautiously. Further work is needed to establish if a follow-up DVT clinic will improve patient outcomes.
Issue 4 of the Acute Medicine Journal (AMJ) reports an interesting exchange between the authors of a service evaluation investigating the prevalence of subarachnoid haemorrhage (SAH) in patients undergoing a lumbar puncture (LP), and readership colleagues evaluating its merit, in light of the current evidence base and clinical recommendations. This discourse highlights the two phases of scientific peer review, which operates as the quality control mechanism for academic publishing.
BACKGROUND:Angioedema is the development of non-pitting edema of the skin and mucosal tissues of the oropharynx, upper respiratory tract, and the gastrointestinal tract. Given the potential for airway compromise, the treatment strategy usually involves a broad approach by addressing multiple underlying possible pathologies simultaneously without knowing the exact mechanism. This is a common and often necessary approach when managing a critically ill patient with incomplete information. Although the current research on TXA use in angioedema centers on ACE-I induced mechanisms, the authors frequently see it used in undifferentiated angioedema. METHODS:This is a retrospective comparative study evaluating the effect of intravenous TXA administration to treat acute angioedema when compared to usual treatment. Hospital admissions, repeat ED visits specifically related to angioedema within 30 days, 30-day all-cause mortality, and need for an advanced airway were assessed as outcomes. RESULTS:After applying inclusion and exclusion criteria, 562 ED encounters were identified for chart review. Matched ED encounters comparing TXA use and no TXA use were well balanced. No statistically significant difference was identified when using TXA or not for angioedema when examining the outcome variables. CONCLUSION:No significant differences were seen between the groups when evaluating ED revisits related to angioedema, hospital admission, the need for an advanced airway, and 30-day all-cause mortality. Prospective analysis of TXA in angioedema is needed to clarify its role in acute treatment.
BACKGROUND:Efficient documentation is essential in Same Day Emergency Care (SDEC) settings to maintain smooth patient flow. Manual typing, although reliable, is time-consuming and can negatively impact clinical efficiency. OBJECTIVES:This Service Improvement Pilot study evaluates the impact of Heidi Health's Ambient Voice Technology on documentation efficiency, clinician workload, and patient satisfaction during clinical consultations. METHODS:An observational analysis was conducted on 100 case notes in an SDEC setting. Documentation times using Heidi Health's Ambient Voice Technology were recorded, while manual documentation times were estimated based on word counts and typical typing speeds. Clinician feedback was gathered on usability and administrative burden, and patient feedback focused on the consultation experience. RESULTS:Ambient Voice Technology reduced documentation time by 85.8%, saving an average of 5.27 minutes (equivalent to 5 minutes 16 seconds) per case compared to manual typing (p < 0.001). Clinicians reported high usability scores (mean = 9.1/10), reduced administrative burden, and improved consultation flow. Additionally, 90% of patients reported an enhanced consultation experience. CONCLUSIONS:Ambient Voice Technology significantly improves documentation efficiency, reduces clinician workload, and enhances patient satisfaction in SDEC settings. Future research should explore its application across a variety of clinical environments.
Transfusion of red blood cells is routine in acute care settings and adverse events are not uncommon. While bleeding protocols are familiar to acute physicians, guidance is less clear for non-bleeding patients. This review offers consolidated guidance on transfusion in the adult acute patient, including restrictive targets and the use of alternatives in anaemia, the role of group O emergency red blood cells (RBC) and important considerations in individuals with childbearing potential, immunosuppressed patients and transfusion-dependent patients.
INTRODUCTION:Patients with respiratory infection-associated changes on chest X-ray often have follow-up chest X-rays (CXRs) to exclude malignancy. In the UK, same day emergency care (SDEC) units have been developed to manage patients needing urgent hospital care on an ambulatory basis. The yield of findings and benefit from follow-up CXRs in this population is unknown. We report the non-malignant and malignant findings from our cohort of SDEC patients. METHODS:We performed a retrospective service evaluation of CXRs for adult patients who attended our SDEC between 6/1/2020 and 25/9/2023, identifying CXRs arranged as follow-up for infection-related findings and assessing outcomes stratified by lung malignancy-associated risk factors. RESULTS:Of 27,336 CXR requests from our SDEC unit, we identified 419 follow-up CXRs. From these, 341 follow-up CXRs were done to assess resolution of infection-related changes; 304 (89%) showed resolution and 37 (11%) showed persistent changes. Further investigation of persistent changes identified two malignancies and several non-malignant conditions including 7 cases of interstitial lung disease, 2 requiring ongoing respiratory follow up. Both patients with cancer were over 50 with risk factors. CONCLUSIONS:The small number of malignancies detected in follow-up CXRs in SDEC patients support risk factor-based targeting of CXRs although non-malignant findings may benefit some patients.
Acute Medicine Journal is evolving, in a move to prioritize the publication of more randomized controlled trials (RCTs) and large prospective cohort studies, therefore accepting fewer case reports and retrospective studies. This trend reflects a fundamental shift towards stronger, more reliable and more generalisable scientific evidence in clinical research and practice.
BACKGROUND:Sepsis, a devastating syndrome of organ dysfunction triggered by a dysregulated host response to infection, remains a leading cause of global mortality. Statins, renowned for lipid-lowering, also exhibit potent anti-inflammatory and endothelial-stabilizing properties, offering a theoretical advantage in the septic milieu. This study investigated whether adjunctive atorvastatin could improve survival and modulate key sepsis-related outcomes. METHODS:In this open-label, randomized controlled trial conducted in the acute medical unit of a tertiary academic center, adult patients with sepsis (defined as suspected infection plus a SOFA score increment of ≥2) were allocated to receive either standard sepsis management plus daily oral atorvastatin 20mg or standard management alone for up to 28 days. The primary endpoint was 28-day all-cause mortality. Secondary endpoints included requirements for organ support, duration of hospitalization, and kinetic changes in C-reactive protein(CRP), procalcitonin(PCT), and lactate. Analysis adhered to intention-to-treat principles. RESULTS:Sixty-eight patients were randomized(36 atorvastatin, 32 control). While 28-day mortality trended lower in the atorvastatin arm(36% vs. 56% in controls; Risk Difference -20%, 95% CI -45% to 5%), this difference did not achieve statistical significance(p=0.10). Similarly, no significant benefits were observed in organ support needs or hospital stay. Critically, atorvastatin administration led to a significant and more pronounced reduction in both procalcitonin (median change -8 vs 0 ng/ml, p=0.005) and lactate levels(median change -0.95 vs -0.62 mmol/l, p=0.048) by day 7. CONCLUSION:While adjunctive atorvastatin did not demonstrably reduce 28-day mortality in this sepsis cohort, its significant impact on attenuating procalcitonin and lactate levels suggests a beneficial modulation of underlying inflammatory and metabolic derangements.
BACKGROUND:Medical ward rounds are essential to support care delivery, however a lack of multi-disciplinary team rounding may have a knock-on effect on care coordination and may lead to delayed discharges and increased length of stays. METHODS:The aim of this study was to improve patient outcomes by improving communication and coordination surrounding medical ward rounds through bringing disciplines together during medical ward rounds or at post-round operational huddles. The primary outcome measure was to improve the number of patients discharged by noon. RESULTS:At the end of the study there was no impact on our primary outcome measure. Efforts for improvement were redirected from the micro- to the meso- and macrosystem of the organisation. CONCLUSION:While developing this complex project, we found reforms at a macrosystem of how care is provided are needed including ward-based care. Reforms must balance system resilience and efficiency while ensuring 'slack' in the system to support communication, relationship building and coordination of care.
AIM:To determine the in-hospital mortality of eight physiological categories based on shock index, pulse pressure and ROX index, and to compare each category according to admission level of consciousness and National Early Warning Score. METHOD:A non-interventional observational study of 122,262, unselected, adult emergency admissions between 2014 and 2022. RESULTS:In-hospital mortality increases according to physiological category and whether the admission NEWS was<3 or ≥3. For NEWS ≥3, patients were more likely to die when not alert. Irrespective of total NEWS, patients with a low ROX index <22 are more likely to die. CONCLUSION:Patients with the same NEWS value can have different physiological derangements. Level of consciousness also provides greater insight than NEWS alone regarding the risk of in-patient mortality.
BACKGROUND:Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of high-mortality severe drug reactions. This study aimed to develop an in-hospital mortality risk calculator for SJS based on comorbidities for early risk prediction. METHODS:SJS/TEN patients were identified in National/Nationwide Inpatient Sample between Q4 2015-2020. Weight for each comorbidity was determined from a multivariable logistic regression to develop SJS Index. RESULTS:SJS Index had good discrimination power (c-statistic=0.704) and was well-calibrated (Brier score=0.049). SJS index had significantly better discriminative power than Elixhauser Comorbidity Index (p-value=0.001). SJS Index has good applicability in SJS-TEN and TEN. After adjusting for demographics, SJS Index had improved performance in all groups. CONCLUSIONS:SJS Index effectively discriminates and predicts in-hospital mortality in SJS/TEN.
Research has shown an association between body temperature, heart rate and respiratory rate. We speculated that antipyretics could influence this. We performed this study with the aim of clarifying the association. We included 1,612 acutely admitted medically ill patients and registered their use of antipyretics. We performed crude and adjusted linear regression analyses. In adjusted analysis, we found that heart rate increased with 7.3 (95% CI: 4.5, 10.1) beats/min/℃ in patients who were not on antipyretics and 10.0 (95% CI: 6.2, 13.9) beats/min/℃ in patients who were. Respiratory rate increased 0.4 (95% CI: -0.2, 0.9) and 1.5 (95% CI: 0.6, 2.3), respectively. Our data shows that use of antipyretics affect the association between temperature, heart rate and respiratory rate positively.
A man in his 50s with a history of end-stage kidney disease on haemodialysis and chronic mental health issues underwent thoracoabdominal CT to characterise a prolonged lower respiratory tract infection. A single metallic density foreign object was noted within the lower oesophagus. (Figure 1).
We present the case of an 81 year old man, admitted with ataxia and hyponatraemia. Biochemical analysis was suggestive of Syndrome of Inappropriate ADH (SiADH) which was initially attributed to a recent respiratory infection or treatment with omeprazole. Neurological symptoms worsened despite normalisation of sodium levels and further examination revealed generalised areflexia; subsequent investigation by the Regional Neurology team led to a diagnosis of Guillan Barre syndrome, and symptoms improved following treatment with Intravenous Immunoglobulin and prolonged in-patient rehabilitation. Guillan Barre syndrome is a recognised cause of SiADH and this case highlights the importance of considering this diagnosis along with full neurological examination when patients with hyponatraemia present with neurological symptoms.
The training of Acute Physicians is crucial for future delivery of high-quality urgent care. The 2024 Acute Medicine Trainee Survey gathered 124 responses, assessing training satisfaction, challenges, and progress since the 2022 curriculum update. Most trainees (66.2%) reported satisfaction, with access to training in Point-of-Care Ultrasound (POCUS) improving (74.7% vs. 63% in 2023). Disparities in training provision and burnout remain significant concerns, with 29.1% experiencing burnout and 40% feeling at risk of this. Key challenges included patient flow issues, rota gaps, and limited respect from colleagues. Despite this, trainee satisfaction is rising, with the majority (88.7%) recommending a career in Acute Medicine. Continued efforts are essential to ensure equitable access to training opportunities and supporting well-being in this demanding specialty.
Acute dyspnea represents one of the most common presentations to the emergency department. Identifying the cause of this non-specific symptom among patients with complex medical histories can be challenging. This case report describes a patient in their 60s with worsening dyspnea on exertion, fatigue and orthopnea on the background of a single chamber pacemaker. Our case demonstrates an often-missed diagnosis of pacemaker syndrome which can be identified on the bedside electrocardiogram (ECG). This is a disease with high morbidity and yet is easily treated once diagnosed.
