Acute Medicine最新文献

During the current SARS-CoV2 pandemic, fear of nosocomial infection could keep neutropenic patients from contacting the healthcare system with infection. We analyzed nationwide hospital contacts for neutropenic fever during the first seven weeks of the Danish shelter at home order. Using national registers, we extracted data on all unplanned hospital contacts due to neutropenic fever. We included 311 admissions, 13-30 per week, and found no difference between 2017-2019 and 2020. The incidence rate ratio varied between 0.68 and 1.11 with no effect on mortality. Thus, our data indicate that Danish neutropenic patients are admitted with fever, even during a pandemic.

In the context of a significant increase in obesity rates, quantifying the relationship between body mass index (BMI) and risk of pulmonary embolism (PE) is an essential component of accurate clinical risk assessment. This observational study is the first to explore this association by clinician-defined cause of the PE. We demonstrate that the association between BMI and PE is driven by patients with otherwise 'unprovoked' PE where there is a strong positive correlation with odds ratios equivalent to well-recognised major risk factors such as cancer, pregnancy and surgery. We make a case for the inclusion of BMI in risk-prediction tools.

Background: The relationship between diagnosis, illness severity, and mortality risk for unselected emergency admissions is poorly defined.

Aim: To define primary ICD-10 diagnostic chapters at discharge, admission illness severity by the National Early Warning Score, and in-hospital mortality for all unselected emergency admissions.

Method: Retrospective, observational, cohort study of 122,259 unselected, adult emergency admissions to Salford Royal Hospital between 2014 and 2022.

Results: In-hospital mortality was 4.3% but most patients had an ICD-10 chapter associated with a lower risk of death. 60% of in-hospital deaths were in four chapters, infections, circulatory and respiratory diseases, or neoplasms. An admission NEWS ≥3 was associated with earlier mortality and an eight-fold increased risk of in-hospital mortality. 45% of all in-hospital deaths occurred in patients with an admission NEWS <3.

Conclusion: Mortality in emergency hospital admissions is associated with illness severity and four diagnostic chapters. NEWS should not be the only arbiter of hospital admission, as for certain diagnostic chapters the risk of death is high even if vital signs on presentation are normal.

Background: The medical registrar is a daunting role to take on for the first time. While studies have explored how preparedness can be improved through simulation, less has been written about how doctors learn to be registrars through clinical practice.

Method: Doctors working as medical registrars were invited to participate in semi-structured interviews. The qualitative data collected underwent thematic analysis.

Results: The clinical environment was considered fertile ground for transformative experiential learning, but opportunities for debriefing and guided reflection were rare. Participants felt they needed additional support from supervisors after difficult experiences and mistakes, but this support was not always forthcoming.

Conclusion: Acute physicians involved in supervising new medical registrars must facilitate meaningful independent practice to encourage the next generation of medical generalists.

We present the case of an 83-year-old female patient with left-side hemichorea and hemiballism associated with poorly controlled type 2 diabetes mellitus. Hyperintensity in the right basal ganglia was evident in T1-weighted brain magnetic resonance. Clinical and radiological findings were consistent with diabetic striatopathy.

Despite still being seen as a relatively 'new' specialty, Acute Internal Medicine (AIM) has reached full adulthood, with its 23rd birthday being celebrated in 2023, and as a new specialty it is somewhat apt that it's the same age as the new millennium. Arguably, the coming of age of the specialty has been its role in helping deal with the increased pressures on the urgent and emergency care system, not least with Covid pandemic. However, AIM still faces challenges in its implementation in certain areas. The specialty continues to innovate with regards to service development including Same Day Emergency Care (SDEC), a new Higher Specialty Training curriculum including innovations such as mandatory Point of Care Ultrasound (POCUS) as well as the guidance for Enhanced Care Units (ECUs) allowing centralised care for those patients needing closer monitoring and specialized care.

Clinical ethics is a core part of the decision-making process. Whilst often reduced to the four principles approach, the situation is more complex. Teaching of ethics frequently focuses on quandary issues, such as assisted-suicide, but there is an ethical component to every clinical encounter. Where differences of opinion arise it is important to understand one's own perspective and that of others. Compassion is an important starting point.

The traditional procedure of identifying anatomical landmarks when performing lumbar punctures can lead to a failure rate of 19%. The Society of Hospital Medicine have published a statement, recommending use of ultrasound (US) guidance for all adult lumbar punctures (LP). A recent meta-analysis found several advantages of point of care US guided LP: higher success rate and diminished pain. US assisted LP is easy to learn, integrating ultrasound guided LP into Acute Medicine curriculum, could lead to better patient outcome.

This syllabus is intended to act as a guide for students and their instructors in medical schools. It describes the range of clinical presentations that they should be able to recognize and the underlying conditions that they should know how to treat. It also includes knowledge of the practice of Acute Internal Medicine and systems of care. The appropriate level of knowledge is that which would be expected of a non-specialist Foundation level doctor.

Background: The incidence of hospital admissions for pulmonary embolism (PE) and associated pleural effusion, and the impact of these effusions on outcomes on a national level is unknown.

Methods: Data from the National Inpatient Sample between 2016 to 2019 was used to conduct a retrospective nationwide cohort study of hospital admissions for PE with and without pleural effusion. Multiple logistic regressions and linear regression analyses were used to determine the independent impact of effusions on in-hospital mortality, length of stay, and cost.

Results: There were 937,744 hospital admissions with PE included in our analysis (median age 64 [interquartile range 50-76] years; 52.5% females). The in-hospital mortality rate overall was 3.7% which was 5.5% for patients with pleural effusion and 3.6% for patients without pleural effusion (p<0.001). The median length of stay was longer in the group with pleural effusion (6 [3-12] days vs 4 [2-6] days, p<0.001) and the median healthcare cost was higher among patients with pleural effusion (13,689 [7,279-30,915] vs 8,855 [5,472-16,531], p<0.001). The factors most associated with pleural effusion were atrial fibrillation (OR 1.89 95%CI 1.78-2.00, p<0.001) and arterial thrombosis (OR 1.48 95%CI 1.19-1.84, p<0.001). Pleural effusion was associated with increased odds of mortality in patients with PE (OR 1.30 95%CI 1.18-1.45, p<0.001). Pleural effusion was associated with increased length of stay (Coefficient 4.15 95%CI 3.99 to 4.32, p<0.001), and healthcare costs (Coefficient 12,164; 95%CI:11,639 to 12,688, p<0.001)).

Conclusion: Concomitant pleural effusion is not uncommon among PE patients which is more common in patients with atrial fibrillation and previous arterial thrombosis. Pleural effusions in patients with PE are associated with higher in-hospital mortality, length of stay and cost.