Acute Medicine Research Articles

Penyuluhan Pengobatan Tradisional ISPA Pada Balita di Gampong Bireuen Meunasah Reuleut Provinsi Aceh

Traditional medicine for acute respiratory tract syndrome is medicine given to acute respiratory tract syndrome clients using spices found in home namely ginger and turmeric.counseling technique can be used to give information to community regarding traditional medicine.this community service activity conducted counseling in Bireuen Meunasah Reuleut Village, Aceh Province.this counseling aims to provide knowledge and ability to using spices as medicine.The counseling using material delivery and demonstration with power point presentation.The result showed increase for knowledge of acute respiratory tract syndrome disease and medicine using the traditional.

Society for Acute Medicine’s Patients: Learning from Experience Report (SAM-PLER) A service evaluation of patient reported experience in Acute Medicine – establishing the feasibility of a quality improvement collaborative

Patient reported experience measures (PREMS) are a key part of measured quality. There is no tool currently used in the UK in Acute Medicine. On the 8th of September 2022 10 units based in England, Scotland and Wales collected data for the validated PREM, alongside the EQ-5D and variables from the Society for Acute Medicine’s Benchmarking Audit (SAMBA) dataset. 365 patients were screened, 200 were included (55%): 159 patients from AMUs and 41 from SDEC units. Overall experience of patients was rated 8.5/10, patients rated their experience of safety, trust and listening highly. Collection of PREMS was feasible. Further research is required to link experience to clinical outcome and explore tools that capture experience of patients with altered mental status.

Acute Medicine: How will we grow? - An analysis of organisational capabilities for quality improvement, research & education from SAMBA 2021

Background: Education, research, and Quality Improvement (QI) are key enablers for high quality care. We aimed to map the capability of Acute Medical Units (AMUs) to facilitate excellence in these areas. Methods: AMUs were surveyed in an organisational questionnaire within the Society for Acute Medicine Benchmarking Audit 2021. Results: 143 units participated. 80 units had a QI lead, 24 had a research lead and 99 had a medical education lead. 15 units had all three leadership roles. Most QI work considered service structure rather than changes in processes or care outcomes. Conclusion: The organisational capability of AMUs in the strategic areas considered is variable. Improving leadership and disseminating learning could help build a strategic foundation for acute medicine to grow.

P36 Using the Australian National Antimicrobial Prescribing Survey portal (NAPS) to benchmark antibiotic prescribing within an Integrated Care Board (ICB): a pilot point prevalence survey (PPS) of two NHS Trusts

Abstract Background PPS is useful in evaluating volume and appropriateness of antimicrobial prescribing to guide specific antimicrobial stewardship (AMS) interventions. Integrated care systems enable collaboration within an ICB and benchmarking of antimicrobial prescribing in constituent trusts to identify disparities and learn from sharing best practice. NAPS is a web-based qualitative auditing platform which is used to conduct an annual Australia-wide PPS. To assess the suitability of NAPS in benchmarking antimicrobial prescribing practices, we piloted the NAPS platform in the acute admission ward areas in two NHS Trusts within an ICB. Methods In OUHFT, admissions to 2 acute medicine wards on a single day were extracted using the Cerner electronic prescribing system. Antimicrobial prescriptions were anonymized, reviewed using NAPS protocol and uploaded to the NAPS platform. In BHT, antimicrobial prescriptions on 2 admission wards were collected manually using the NAPS parameters and audit standards and entered directly into Excel®. Ethical approval was not required due to the anonymized nature of this audit. Results A total of 124 patients at OUHFT and 53 patients at BHT were included. The proportion of patients prescribed antimicrobials varied, with a prevalence of 23% (n = 29) at OUHFT and 54% (n = 28) at BHT. The total number of antimicrobial prescriptions was approximately 40 per trust. Compliance with guidelines for OUHFT and BHT (88% versus 83%) and stewardship appropriateness (73% versus 80%) were similar. The main indication for antimicrobials was pneumonia. The most common reasons for inappropriateness were ‘incorrect duration’ and ‘spectrum too broad’. The most prescribed antimicrobials differed, with co-amoxiclav and amoxicillin (43%) at OUHFT and metronidazole and clarithromycin (24%) at BHT. Non-compliance with guidelines was frequently associated with the use of doxycycline and co-amoxiclav (47%) at OUHFT and amoxicillin and piperacillin/tazobactam (72%) at BHT. Conclusions Benchmarking of antimicrobial prescribing was possible as both PPSs were conducted using the NAPS parameters and standards. Focusing efforts on antibiotic prescribing for pneumonia, the use of broad-spectrum antimicrobials and reducing duration of courses will be taken forward as a key focus for AMS efforts. NAPS is a suitable tool for benchmarking, sharing best practice and facilitating discussion of AMS interventions across an ICB. This model should be considered as a template for national benchmarking of antimicrobial prescribing.

Diagnostic and prognostic value of deregulated long non-coding RNA RPPH1 in patients with severe community-acquired pneumonia: a retrospective cohort study

BackgroundSevere community-acquired pneumonia (SCAP) is one of the most common critical and acute diseases in the respiratory and acute medicine department. The expression and significance of lncRNA RPPH1 (RPPH1) in SCAP were assessed aiming to explore a biomarker assisting in the screening and management of SCAP.MethodsThis study is a retrospective study enrolled 97 SCAP patients, 102 mild community-acquired pneumonia (MCAP) patients, and 65 healthy individuals. The serum expression of RPPH1 of study subjects was evaluated using PCR. The diagnostic and prognostic significance of RPPH1 in SCAP was evaluated by ROC and Cox analyses. Meanwhile, the correlation of RPPH1 with patients’ clinicopathological features was evaluated by spearman correlation analysis to evaluate its role in assessing disease severity.ResultsA significant downregulation of RPPH1 was observed in the serum of SCAP patients compared with MCAP and healthy individuals. RPPH1 was positively correlated with ALB (r = 0.74) and negatively correlated with C-reactive protein (r = -0.69), neutrophil-to-lymphocyte ratio (r = -0.88), procalcitonin (r = -0.74), and neutrophil (r = -0.84) of SCAP patients, which are associated with the development and severity of SCAP. Additionally, reduced RPPH1 was closely associated with the 28-day development-free survival of SCAP patients and served as an adverse prognostic indicator together with procalcitonin.ConclusionsDownregulated RPPH1 in SCAP could act as a diagnostic biomarker screening SCAP from healthy and MCAP individuals and act as a prognostic biomarker predicting patients’ disease conditions and outcomes. The demonstrated significance of RPPH1 in SCAP could assist the clinical antibiotic therapies of SCAP patients.

Palliative aspects in clinical acute and emergency medicine as well as intensive care medicine : Consensus paper of the DGIIN, DGK, DGP, DGHO, DGfN, DGNI, DGG, DGAI, DGINA and DGPalliativmedizin

The integration of palliative medicine is an important component in the treatment of various advanced diseases. While aGerman S3guideline on palliative medicine exists for patients with incurable cancer, arecommendation for non-oncological patients and especially for palliative patients presenting in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care.

National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration

IntroductionThe Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on...

An Audit of Hypophosphatemia after Intravenous Iron Therapy

Background Due to the gastrointestinal side-effects of oral iron supplementation in patients with iron deficiency anaemia, which impairs tolerance - many acute medical and haematology day units provide intravenous iron replacement therapy as day cases. Hypophosphatemia is a frequent side effect following intravenous iron administration, which can persist for weeks or months, is under-recognised in clinical practice and can lead to patients presenting with typical features to the emergency departments. Aim We designed an audit to measure the incidence of symptomatic hypophosphatemia after intravenous iron therapy to develop monitoring, prevention, and treatment strategy in a secondary care hospital setting. Methods We audited a convenience sample of consecutive patients who attended an acute day-care assessment unit for intravenous (IV) iron infusion (ferric carboxymaltose). All patients had serum phosphate levels checked after IV iron infusion at different intervals, from 1- 6 weeks. The cohort was divided into two groups based on the occurrence of hypophosphataemia - early (1-3 weeks) and late (>3-6 weeks). Results We included 35 patients referred from primary care, gastroenterology, gynaecology, and acute internal medicine. 19 (55%) developed hypophosphatemia after receiving a single IV iron infusion and almost 100% after more than one dose. Hypophosphatemia in some patients lasted up to 12 weeks. Conclusion Hypophosphatemia was frequent after a single dose and almost universal after multiple doses of IV Iron, which can persist for many weeks. Clinicians prescribing ferric carboxymaltose (Ferinject®) should be aware of hypophosphataemia, which could be mild, moderate, or severe and can last for months.

Ethics in acute medicine.

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.

Acute Traditional Chinese Medicine Fuzi Poisoning: A Case Report

Fuzi is lateral root of aconite crowfoot plants of aconite root of processed products, its medicinal sheen, sweet, hot, toxic, authority and by the kidney, spleen, for "back to Yang inverse first to save medicine", there are back to Yang Yang to save inverse, fire, cold analgesic effect, modern pharmacology study anti-inflammatory analgesic, cardiac, anti-aging and other functions, is the doctor of traditional Chinese medicine clinical commonly used drugs, often used in the treatment of cardiovascular diseases, diseases such as rheumatoid arthritis. According to different machining processing technology can be divided into salted aconite root, Heishun tablet, Baishun tablets, Light monkshood tablet, etc. Clinical use of Fuzi is often after processing and attenuation, but poisoning still occurs from time to time. A case of poisoning caused by taking Fuzi in our hospital is reported as follows.

Correspondence - Ultrasound for Lumbar Punctures - An Invaluable tool for the Acute Physician.

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.

Change to hospitalist providers had a minimal influence on overall antibiotic use in a VA long-term care setting

Background: In long-term care settings, practice patterns among practitioners are stronger determinants of antibiotic use than resident characteristics. In July 2021, hospitalists from the acute medicine service replaced geriatricians and assumed the care of residents in a 110-bed community living center (CLC) at a large academic Veterans Affairs (VA) medical center. We assessed changes in antibiotic use associated with that change of practitioners to guide stewardship efforts. We hypothesized that antibiotic use in the CLC would shift, reflecting the practice pattern of practitioners accustomed to treating patients in acute-care settings. Methods: We conducted a retrospective cohort study from July 1, 2020, through June 30, 2022, 1 year before and after the change of practitioners on July 1, 2021. We assessed resident characteristics and the following metrics of antibiotic use at monthly intervals: days of therapy (DOT) per 1,000 bed days of care (BDOC), antibiotic starts per 1,000 BDOC, and mean length of therapy (LOT) in days. We also compared the DOT per 1,000 BDOC for various antibiotics, in groups and individually. Results: In the years before and after the change of practitioners on July 1, 2021, the characteristics of CLC residents were comparable. Before and after July 1, 2021, monthly DOT per 1,000 BDOC (Fig. 1A), antibiotic starts per 1,000 BDOC, and mean LOT (Fig. 1B) were similar. After July 1, 2021, the use of fluoroquinolones decreased (14.31 vs 5.83 DOT per 1,000 BDOC; P < .01), and variations in anti-MRSA, narrow-spectrum, and broad-spectrum hospital agents were small, whereas the use of broad-spectrum community agents increased (29.42 vs 47.81 DOT per 1,000 BDOC; P < .01) (Fig. 2A). Within this group, there was increased use of doxycycline (7.42 vs 19.13 DOT per 1,000 BDOC; P < .01), ertapenem (2.03 vs 4.58 DOT per 1,000 BDOC; P < .01), and, modestly, azithromycin (0.40 vs 1.80 DOT per 1,000 BDOC) (Fig. 2B). Conclusions: The overall use of antibiotics, as measured by DOT, antibiotic starts, and LOT did not change after hospitalists assumed care of CLC residents. However, a notable decrease was observed in the use of fluoroquinolones, and an increase was observed in the use of doxycycline and ertapenem. Stewardship that is tailored to the type of provider and incorporates their practice patterns is needed to reinforce the prudent use of antibiotics.Disclosures: None

Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia.

The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC. This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC. The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI. The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.

Acute Medicine: A New Horizon

Background: Acute medicine is concerned with the immediate and early management of adult patients suffering from a wide range of medical conditions requiring urgent care. It is a new concept in the context of our country. Given the current situation of the burden of patients against available resources, management of acute conditions under the umbrella of acute medicine may have a promising result. Methods: All the information was collected from the department of Acute Medicine of Square Hospitals Limited since it started its journey on the 15th October, 2022. Data of first 175 days (15th October, 2022 to 7th April, 2023) were compiled and the outcome was observed. Results: Among 615 patients of department of Acute Medicine, 50% were male and 50% were female. Among them 84% were managed within 72 hours; 92.4% improved and 7.2% needed treatment escalation. Among the patients who got improved, 76% were shifted to cabin and 13% were discharged home after management of acute condition. Conclusion: The observation revealed better patient outcome with less hospital stay. J Medicine 2023; Vol. 34, No. 2(1) Supplement: 218

Prevention of Acute Respiratory Failure Due to Administration of Polymyxins by Intravenous Calcium Gluconate in Critically Ill Patients for Treating Carbapenem Resistant Infections in Acute Medicine Unit: A Quality Improvement Project (Qip)

Background: Polymyxin B and colistin are most potent antibiotics for treating carbapenem resistant infections due tomultidrugs resistant organisms that are currently rising remarkably and alarm signs for global health. These are last resorts options for bacteremia during crisis time when pathogens are only sensitive to polymyxins. Most common life threatening complication is respiratory muscle paralysis due to neuromuscular blockage that lead to apnea, acute type 2 respiratory failure and death. Main aim of this quality Improvement project (QIP)was to demonstrate therapeutic effectiveness and outcomes of I/V calcium gluconate during administration of polymyxins. Methods: This QIP was conducted at acute medicine and HDU of a tertiary care hospital for 2 months in Bangladesh. Patients who got I/V calcium gluconate with polymyxins in January and February, 2023 were compared with similar data without calcium gluconate for prior 4 months. Data analysis and interpretation done by unpaired t test. Results: Primary outcome shows statistically significant decrease dintubation and mechanical ventilation due to sudden respiratory failure and ICU transfer after getting I/V calcium gluconate during polymyxins(30.8%,n=13 and 88.9% ,n=9 and p= &lt;0.005). Conclusion: This study showsstrongly visible positive outcome in prevention of acute respiratory failure by polymyxins in critically ill patients. We feel that all physicians may practice this study in acute medicine and critical care setup. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 216

Docimological Analysis of Written Acute Medicine Examinations at a Medicine School

Introduction:The docimology or "science of examinations" is a scientific discipline devoted to the study of the examination in all its dimensions. The main objective is the development of standards guaranteeing valid, reliable and objective tests. It was adopted within a Medical School in 2007.Our aim was to analyze results of docimological survey results of written acute medicine examinations through a global approach, by discipline and by item.Method:This was a retrospective study analyzing the notes of acute medicine examinations (January and May sessions) of Second Cycle Medical Studies 3). We have calculated docimological parameters allowing three levels of assessment: global, by discipline, and items analysis.Results:We analyzed 407 scripts, 99 questions and 6,919 pieces of data. The overall success rate was 97.6%. Highest success rates were found in Medical resuscitation (87%). The lowest rate was found in emergency medicine (53%). The difficulty index for the January session was 0.53 and 0.61 for the May session. For the January session: 24% of questions were easy, 14% of questions were difficult and 61% were of acceptable difficulty. For the May session: 40% of questions were easy, 6% of questions were difficult and 54% were of acceptable difficulty. The discrimination index was 0.27 for the January session and 0.24 for the May session. Discrimination was very good in 18% of items and good in 25%. Useless and bad discrimination items were about 35% for both sessions. Average Cronbach’s Alpha was 0.84, showing good internal-consistency.Conclusion:Overall, acute medical examinations have joined docimological recommendations and had an acceptable internal consistency and a good level of difficulty and discrimination. However, some weaknesses had been revealed specially for the discipline with low weighting. A reflection on the integration of questions would make up for these weaknesses. This would ensure better assessment and training.

Association of circulating histone H3 and high mobility group box 1 levels with postoperative prognostic indicators in intensive care unit patients: a single-center observational study.

Damage associated molecular patterns (DAMPs) levels are associated with sepsis severity and prognosis. Histone and high mobility group box 1 (HMGB1) levels are also potential indicators of prognosis. We investigated the relationship between serum histone H3 and HMGB1 levels and the illness severity score and prognosis in postoperative patients. Postoperative serum histone H3 and HMGB1 levels in 39 intensive care unit (ICU) patients treated at our institution were measured. The correlation between peak histone H3 and HMGB1 levels in each patient and clinical data (age, sex, surgical time, length of ICU stay, and survival after ICU discharge), which also included the patients' illness severity score, was examined. Histone H3 but not HMGB1 levels were positively correlated with surgical time, the Sequential Organ Failure Assessment score, the Japanese Association for Acute Medicine acute phase disseminated intravascular coagulation diagnosis score, and the length of ICU stay. Both histone H3 and HMGB1 levels were negatively correlated with age. However, survival post-ICU discharge was not correlated with histone H3 or HMGB1 levels. Histone H3 levels are correlated with severity scores and the length of ICU stay. Serum histone H3 and HMGB1 levels are elevated postoperatively. These DAMPs, however, are not prognostic indicators in postoperative ICU patients.

Position paper of the working group Urological Acute Medicine

Emergency patients with acute genitourinary system diseases are frequently encountered in both outpatient and clinical emergency structures. It is estimated that one-third of all inpatients in a urology clinic initially present as an emergency. In addition to general emergency medicine knowledge, specialized urologic expertise is a prerequisite for the care of these patients, which is needed early and specifically for optimal treatment outcomes. It must be taken into account that, on the one hand, the current structures of emergency care still lead to delays in patient care despite positive developments in recent years. On the other hand, most hospital emergency facilities need urologic expertise on site. In addition, politically intended changes in our health care system, which drive an increasing ambulantization of medicine and condition a further centralization of emergency clinics, become effective. The aim of the newly established working group "Urological Acute Medicine" is to ensure and further improve the quality of care for emergency patients with acute genitourinary system diseases and, in consensus with the German Society of Interdisciplinary Emergency and Acute Medicine, to define precise task distributions and interfaces of both specialities.

Recognising and managing eating disorders in the emergency department.

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Vascular access device type for systemic anti-cancer therapies: a scoping review protocol

Vascular access devices (VADs) are the most common invasive procedure performed in acute medicine and cancer patients undergo multiple invasive vascular access procedures. Our aim is to identify the type of evidence available regarding the best choice of VAD for cancer patients undergoing systemic anti-cancer therapy (SACT). In this article, the authors frame the scoping review protocol used, which will systematically report all published and unpublished literature around the use of VADs for the infusion of SACT in oncology. For studies to be included, they must focus on people or populations aged 18 years or older and report on vascular access in cancer patients. The concept is the variety of VAD use in cancer and reported insertion and post-insertion complications. The context surrounds the intravenous treatment of SACT whether in a cancer centre or non-cancer setting. The JBI scoping review methodology framework will guide the conduct of this scoping review. Electronic databases (CINAHL, Cochrane, Medline and Embase) will be searched. Grey literature sources and the reference lists of key studies will be reviewed to identify those appropriate for inclusion. No date limits will be used in the searches and studies will be limited to the English language. Two reviewers will independently screen all titles and abstracts and full-text studies for inclusion, and a third reviewer will arbitrate disagreements. All bibliographic data, study characteristics and indicators will be collected and charted using a data extraction tool.