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Opinion surveys on family participation in care in non-Western countries are rare. This study aims to assess the opinions of patients, families, and healthcare professionals regarding family involvement in care to identify their preferences and the associated factors. A cross-sectional survey was conducted over eight months involving 717 participants, using structured questionnaires at the Acute Assessment Unit of a university hospital in Morocco. Comparative analyses examined the association between participant characteristics and the preferences of care categories. Poisson regression was applied to determine factors associated with participant preferences. Attitudes toward family participation in care were positive, with an average score of 3.62 ± 0.43 on a 4-point Likert scale. Healthcare professionals were more favorable towards family participation, with an average of 10.6 ± 2.44 types of care, compared to 7.17 ± 1.96 for families and 5.71 ± 2.16 for patients. Participants' opinions converged on a set of simple and less technical care tasks. Factors significantly associated with patient preferences in the final adjustment model (p < 0.05) included frailty, loss of autonomy, length of stay, and regular and continuous (day and night) family presence. This study highlights the strong support of health professionals, patients, and families for family participation in care. Understanding these preferences and related factors is essential to maximize family participation and develop a model of Patient And Family Centered Care adapted to the Moroccan context. [ABSTRACT FROM AUTHOR]

Background Acute medical unit (AMU) is a dedicated facility to treat patients with acute medical conditions requiring a short hospital stay (< 72 hours) with the support of a multidisciplinary team led by a medical consultant. We aim to present a study of the AMU model of care from Qatar to provide insight into its effects on patient care and management.

Same-day emergency care (SDEC) in unplanned and emergency care is an NHS England (NHSE) priority. Optimal use of these services requires rapid identification of suitable patients. NHSE suggests the use of one tool for this purpose. This systematic review compares studies that evaluate the performance of selection tools for SDEC pathways. Nine studies met the inclusion criteria. Three scores were evaluated: the Amb score (seven studies), Glasgow Admission Prediction Score (GAPS) (six studies) and Sydney Triage to Admission Risk Tool (START) (two studies). There was heterogeneity in the populations assessed, exclusion criteria used and definitions used for SDEC suitability, with proportions of patients deemed 'suitable' for SDEC ranging from 20 to 80%. Reported score sensitivity and specificity ranged between 18-99% and 10-89%. Score performance could not be compared due to heterogeneity between studies. No studies assessed clinical implementation. The current evidence to support the use of a specific tool for SDEC is limited and requires further evaluation. [ABSTRACT FROM AUTHOR]

Background: Point-of-Care Ultrasound (POCUS) consists of a range of increasingly important imaging modalities across a variety of specialties. Despite a variety of accreditation pathways available in the UK, lung POCUS training remains difficult to deliver and accreditation rates remain suboptimal. We describe a multidisciplinary, multi-centre, and multi-pronged approach to lung POCUS education within a region. Methods: A survey was conducted in a region. From these results, bottlenecks were identified for improvement. We utilised key stages in an established accreditation pathway, and the Action Learning process. Analysing participant feedback, consensus amongst the team, regional educational needs, and leveraging the expertise within the faculty, we implemented several solutions which were multidisciplinary, multi-centre, and multi-pronged. We also set up a database across several accreditation pathways to facilitate supervision and assessment of rotational trainees. Results: Utilising the Action Learning process, we implemented several improvements at elements of the lung ultrasound accreditation pathways. An initial regional survey identified key barriers to accreditation: lack of courses (52%), lack of mentors (93%), and difficulty arranging directly supervised scans (73%). A multidisciplinary team of trainers was assembled. Regular courses were organised and altered based on feedback and anecdotal educational needs within the region. Courses were set up to also facilitate continuing professional development and exchange of knowledge and ideas amongst trainers. The barrier of supervision was removed through the organisation of regular supervision sessions, facilitating up to fifty scans per half day per trainer. We collected feedback from courses and optimised them. Remote mentoring platforms were utilised to encourage asynchronous supervision. A database of trainers was collated to facilitate triggered assessments. These approaches promoted a conducive environment and a commitment to learning. Repeat survey results support this. Conclusion: Lung ultrasound accreditation remains a complex educational training pathway. Utilising an education framework, recruiting a multidisciplinary team, ensuring a multi-pronged approach, and fostering a commitment to learning can improve accreditation success. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Among the multitude of causes for acute abdomen patients presenting with free intraperitoneal air, one almost never finds infected pancreatic necrosis as one of the culprits. In patients with risk factors for acute pancreatitis presenting with generalized peritonitis with free intraperitoneal air, consideration should be given to this often deadly entity. Acute pancreatitis is a morbid acute abdominal pathology that has been increasing in incidence in recent years. Most patients have a mild disease and treated medically, while a few proportion require interventional procedures. We present the case of a 39‐year‐old male patient who presented with progressive abdominal pain, vomiting, and yellowish discoloration of the eyes. The abdominal condition progressed to the point where clinical signs became consistent with generalized peritonitis and an x‐ray finding of free intraperitoneal air. The patient underwent exploratory laparotomy with intraoperative findings of intraperitoneal rupture of infected pancreatic necrosis with intraperitoneal purulent collection. He was managed with necrosectomy and discharged improved after intensive care and general ward stay. [ABSTRACT FROM AUTHOR]

Abstract Background Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups. Methods Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019–February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others—remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3–

Background: Currently there are no established benefits from the continuous monitoring of vital signs, and the optimal time period for respiratory rate measurement is unknown. Setting: Low resource Ugandan hospital, Methods: Prospective observational study. Respiratory rates of acutely ill patients were continuously measured by a piezoelectric device for up to seven hours after admission to hospital. Results: 22 (5.5%) out of 402 patients died within 7 days of hospital admission. The highest c-statistic of discrimination for 7-day mortality (0.737 SE 0.078) was obtained after four hours of continuously measured respiratory rates transformed into a weighted respiratory rate score (wRRS). After seven hours of measurement the c-statistic of the wRRS fell to 0.535 SE 0.078. 20% the patients who died within seven days did not have an elevated National Early Warning Score (NEWS) on admission but were identified by the 4-hour wRRS. None of the 88 patients whose average respiratory rate remained between 12 and 20 bpm throughout four hours of observation died within 7 days of admission. A simple predictive model that included the four-hour wRRS, Shock Index and altered mental status had a c-statistic for 7-day in-hospital mortality of 0.843 SE. 0.057. Conclusion: Four hours of continuously measured respiratory rates was the observation period that best predicted 7-day in-hospital mortality. After four hours the discrimination of a weighted respiratory rate score deteriorated rapidly.

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC. The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers. Experts ranked five system-based metrics highest. These focus on optimisation of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples. The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Ankylosing spondylitis (AS) presents with renal failure and proteinuria in a minority of cases, usually due to secondary amyloidosis or IgA nephropathy. While focal segmental glomerulosclerosis (FSGS) is less common, it should still be in the differential regardless of the patient's clinical profile. [ABSTRACT FROM AUTHOR]

Background: Nonspecific discharge diagnoses after acute hospital courses represent patients discharged without an established cause of their complaints. These patients should have a low risk of adverse outcomes as serious conditions should have been ruled out. We aimed to investigate the mortality and readmissions following nonspecific discharge diagnoses compared to disease-specific diagnoses and assessed different nonspecific subgroups. Methods: Register-based cohort study including hospital courses beginning in emergency departments across 3 regions of Denmark during March 2019–February 2020. We identified nonspecific diagnoses from the R- and Z03-chapter in the ICD-10 classification and excluded injuries, among others—remaining diagnoses were considered disease-specific. Outcomes were 30-day mortality and readmission, the groups were compared by Cox regression hazard ratios (HR), unadjusted and adjusted for socioeconomics, comorbidity, administrative information and laboratory results. We stratified into short (3–<12 h) or lengthier (12–168 h) hospital courses. Results: We included 192,185 hospital courses where nonspecific discharge diagnoses accounted for 50.7% of short and 25.9% of lengthier discharges. The cumulative risk of mortality for nonspecific vs. disease-specific discharge diagnoses was 0.6% (0.6–0.7%) vs. 0.8% (0.7–0.9%) after short and 1.6% (1.5–1.7%) vs. 2.6% (2.5–2.7%) after lengthier courses with adjusted HRs of 0.97 (0.83–1.13) and 0.94 (0.85–1.05), respectively. The cumulative risk of readmission for nonspecific vs. disease-specific discharge diagnoses was 7.3% (7.1–7.5%) vs. 8.4% (8.2–8.6%) after short and 11.1% (10.8–11.5%) vs. 13.7% (13.4–13.9%) after lengthier courses with adjusted HRs of 0.94 (0.90–0.98) and 0.95 (0.91–0.99), respectively. We identified 50 clinical subgroups of nonspecific diagnoses, of which Abdominal pain (n = 12,462; 17.1%) and Chest pain (n = 9,599; 13.1%) were the most frequent. The subgroups described differences in characteristics with mean age 41.9 to 80.8 years and mean length of stay 7.1 to 59.5 h, and outcomes with < 0.2–8.1% risk of 30-day mortality and 3.5–22.6% risk of 30-day readmission. Conclusions: In unadjusted analyses, nonspecific diagnoses had a lower risk of mortality and readmission than disease-specific diagnoses but had a similar risk after adjustments. We identified 509 clinical subgroups of nonspecific diagnoses with vastly different characteristics and prognosis. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Care must be taken to mitigate the effect of cognitive bias in times of frequent common presentations. The etiology of bicytopenias and pancytopenias must always be carefully investigated. Blast cells in low count B ALL may not be seen on a peripheral smear and diagnosis often requires confirmational bone marrow aspirate with flow cytometry and molecular typing. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Ibuprofen single dose may rarely induce Stevens–Johnson Syndrome, emphasizing the vital need for heightened vigilance in healthcare and public awareness for safer medication practices. Stevens–Johnson Syndrome (SJS) is a severe and potentially life‐threatening skin disorder associated with certain medications, including ibuprofen. We present a case of a 45‐year‐old woman who developed SJS following a single dose of ibuprofen. Despite its rarity, this case underscores the importance of heightened vigilance in healthcare and public awareness regarding the potential risks of commonly used medications. Prompt recognition of SJS symptoms and immediate medical intervention are crucial for patient outcomes. Healthcare providers should exercise caution when prescribing ibuprofen, particularly in patients with a history of adverse drug reactions. This case emphasizes the need for ongoing monitoring, patient education, and informed decision‐making to promote medication safety and optimal patient care. [ABSTRACT FROM AUTHOR]

Aim: To investigate the predictive value of both mental status, assessed with the AVPUC (Alert, responds to Voice, responds to Pain, Unresponsive, and new Confusion) scale, and mobility assessments, and their interrater reliability (IRR) between triage clinicians and a research team. Method: Prospective study of consecutive patients who presented to an ED. Mental status and mobility were assessed by triage clinicians and by a dedicated research team. Results: 4,191 patients were included. After adjustment for age and sex, patients with altered mental status have an odds ratio of 6.55 [4.09-10.24] to be admitted in the ICU and an odds ratio of 21.16 [12.06-37.01] to die within 30 days; patients with impaired mobility have an odds ratio of 7.08 [4.60-11.12] to be admitted in the ICU and an odds ratio of 12.87 [5.93-32.30] to die within 30 days. The kappa coefficient between triage clinicians and the research team for mental status assessment was 0.75, and 0.80 for mobility. Conclusion: Assessment of mental status by the AVPUC scale, and mobility by a simple dichotomous scale are suitable for ED triage. Both altered mental status and impaired mobility are associated with adverse outcomes. Mental status and mobility assessment have good interrater reliability. [ABSTRACT FROM AUTHOR]

Same-day emergency care (SDEC) in unplanned and emergency care is an NHS England (NHSE) priority. Optimal use of these services requires rapid identification of suitable patients. NHSE suggests the use of one tool for this purpose. This systematic review compares studies that evaluate the performance of selection tools for SDEC pathways.Nine studies met the inclusion criteria. Three scores were evaluated: the Amb score (seven studies), Glasgow Admission Prediction Score (GAPS) (six studies) and Sydney Triage to Admission Risk Tool (START) (two studies). There was heterogeneity in the populations assessed, exclusion criteria used and definitions used for SDEC suitability, with proportions of patients deemed ‘suitable’ for SDEC ranging from 20 to 80%. Reported score sensitivity and specificity ranged between 18–99% and 10–89%. Score performance could not be compared due to heterogeneity between studies. No studies assessed clinical implementation.The current evidence to support the use of a specific tool for SDEC is limited and requires further evaluation.

Key Clinical Message Among the multitude of causes for acute abdomen patients presenting with free intraperitoneal air, one almost never finds infected pancreatic necrosis as one of the culprits. In patients with risk factors for acute pancreatitis presenting with generalized peritonitis with free intraperitoneal air, consideration should be given to this often deadly entity. Abstract Acute pancreatitis is a morbid acute abdominal pathology that has been increasing in incidence in recent years. Most patients have a mild disease and treated medically, while a few proportion require interventional procedures. We present the case of a 39‐year‐old male patient who presented with progressive abdominal pain, vomiting, and yellowish discoloration of the eyes. The abdominal condition progressed to the point where clinical signs became consistent with generalized peritonitis and an x‐ray finding of free intraperitoneal air. The patient underwent exploratory laparotomy with intraoperative findings of intraperitoneal rupture of infected pancreatic necrosis with intraperitoneal purulent collection. He was managed with necrosectomy and discharged improved after intensive care and general ward stay.

Hypercapnia is commonly encountered by general and specialist respiratory clinicians. Patients at risk of developing hypercapnic respiratory failure include those with chronic obstructive pulmonary disease (COPD), obesity and neuromuscular disease. Such patients may present to clinicians acutely unwell on the acute medical take or during an inpatient deterioration, or be identified in the stable outpatient setting. In this review, we provide a practical guide to develop clinicians' knowledge, skills and confidence in promptly recognising and managing hypercapnic respiratory failure, and to promote national ventilation quality standards to encourage consistent delivery of high-quality care and optimise outcomes for patients. [ABSTRACT FROM AUTHOR]

Copyright of Medizinische Klinik: Intensivmedizin & Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

• Performance of admission pathways for medical patients are not routinely reported. • We evaluated clinical quality indicators specific to acute internal medicine services. • Quality indicators were associated with time of patient arrival to hospital. • Higher performance was seen within same day emergency care services. • Performance in all clinical quality indicators was lower than in previous years. Urgent and emergency care services face increasing pressure, impacting patient care. We evaluated the performance of acute medicine services, assessing clinical quality indicators for unplanned medical admissions to acute hospital services. 152 acute UK hospital services accepting unplanned admissions to acute and general internal medicine completed a day-of-care survey incorporating organisational structure questionnaire and patient-level data over a pre-defined 24-hour period in June 2022. Clinical quality indicators were: Early Warning Score (EWS) measurement within 30 min of hospital arrival; clinician assessment within 4 h; assessment by consultant physician within 6 h (daytime) or 14 h (night-time). Results were compared with 2019, 2020, 2021. 7293 sequential patients were included (and compared with 19,817 patients across 2019–2021). In 2022, 69% of patients (95%CI 67.7–69.9%) had an EWS documented within 30 min. 79% of patients (95%CI 77.8–79.7%) were reviewed by a clinical decision maker within 4 h of hospital arrival. Patients assessed in Same Day Emergency Care services were more likely to meet this target than those assessed in Acute Medical Units or Emergency Departments (OR 2.4, 95%CI 2.02–2.87, p <0.001). Overall, 50% of patients received consultant physician review within the target time (3065/6161, 95%CI 48.5–51.0%); performance varied with time of arrival and location of initial assessment. Performance against all three clinical quality indicators was lower than 2019, 2020 and 2021 (p <0.001 for all). Performance against all quality indicators within acute medicine services is deteriorating. However, performance in Same Day Emergency Care Units is greater than in Acute Medical Units or Emergency Departments. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Hemothorax is a rare and potentially fatal condition characterized by pleural effusion containing over 50% of the patient's hematocrit. A massive hemothorax involves blood loss exceeding 1.5 L. Common causes include chest trauma, invasive thoracic procedures, anticoagulant medications, vascular anomalies, malignancies, and hematologic abnormalities. Spontaneous hemothorax may be seen in conjunction with pulmonary infarction and spontaneous pneumothorax. Anticoagulation is a key therapeutic strategy for certain thromboembolic events, such as pulmonary embolism. Historically, these events were treated with vitamin K antagonists (VKAs), which have demonstrated variable plasma concentrations and an increased risk of hemorrhage. With the advent of direct oral anticoagulants (DOACs), treatment has become as effective as VKAs while significantly reducing the risk of hemorrhage. However, some researchers have speculated that hemorrhagic complications in certain cases could be worse with DOACs than with VKAs. In the case presented here, we identified a genuine association between the use of rivaroxaban and spontaneous hemothorax following the initiation of treatment for pulmonary embolism. [ABSTRACT FROM AUTHOR]

Key Clinical Message Ankylosing spondylitis (AS) presents with renal failure and proteinuria in a minority of cases, usually due to secondary amyloidosis or IgA nephropathy. While focal segmental glomerulosclerosis (FSGS) is less common, it should still be in the differential regardless of the patient's clinical profile.

Key Clinical Message Care must be taken to mitigate the effect of cognitive bias in times of frequent common presentations. The etiology of bicytopenias and pancytopenias must always be carefully investigated. Blast cells in low count B ALL may not be seen on a peripheral smear and diagnosis often requires confirmational bone marrow aspirate with flow cytometry and molecular typing.

Key Clinical Message Ibuprofen single dose may rarely induce Stevens–Johnson Syndrome, emphasizing the vital need for heightened vigilance in healthcare and public awareness for safer medication practices. Abstract Stevens–Johnson Syndrome (SJS) is a severe and potentially life‐threatening skin disorder associated with certain medications, including ibuprofen. We present a case of a 45‐year‐old woman who developed SJS following a single dose of ibuprofen. Despite its rarity, this case underscores the importance of heightened vigilance in healthcare and public awareness regarding the potential risks of commonly used medications. Prompt recognition of SJS symptoms and immediate medical intervention are crucial for patient outcomes. Healthcare providers should exercise caution when prescribing ibuprofen, particularly in patients with a history of adverse drug reactions. This case emphasizes the need for ongoing monitoring, patient education, and informed decision‐making to promote medication safety and optimal patient care.

Key Clinical Message Hemothorax is a rare and potentially fatal condition characterized by pleural effusion containing over 50% of the patient's hematocrit. A massive hemothorax involves blood loss exceeding 1.5 L. Common causes include chest trauma, invasive thoracic procedures, anticoagulant medications, vascular anomalies, malignancies, and hematologic abnormalities. Spontaneous hemothorax may be seen in conjunction with pulmonary infarction and spontaneous pneumothorax. Anticoagulation is a key therapeutic strategy for certain thromboembolic events, such as pulmonary embolism. Historically, these events were treated with vitamin K antagonists (VKAs), which have demonstrated variable plasma concentrations and an increased risk of hemorrhage. With the advent of direct oral anticoagulants (DOACs), treatment has become as effective as VKAs while significantly reducing the risk of hemorrhage. However, some researchers have speculated that hemorrhagic complications in certain cases could be worse with DOACs than with VKAs. In the case presented here, we identified a genuine association between the use of rivaroxaban and spontaneous hemothorax following the initiation of treatment for pulmonary embolism.

Acute oncology services (AOS) manage acute cancerrelated presentations alongside acute medical teams. This study assessed AOS provision against national peer review measures and the burden of acute cancer-related admissions. The 2022 Society for Acute Medicine Benchmarking Audit surveyed UK hospitals, collecting hospital-level and patient-level data for all medical admissions over a 24-h period. Logistic regression models were constructed to identify differences in patient outcomes for cancer-related admissions. Most hospitals (n=120 or 91.6%) reported having an AOS. There was heterogeneity in AOS provision, with many failing to meet peer-review measures. Of the 7,116 patients, 542 (7.6%) were cancer-related admissions. Cancer-related admissions had greater clinical acuity (p<0.05), length of stay (p<0.001) and 14-day mortality (adjusted odds ratio (OR)=3.54, 95% confidence interval (CI): 2.41-5.22, p<0.001) compared with other medical admissions. Increasing availability of AOS with integration of ambulatory pathways are vital next steps to improving care for acute cancer-related admissions. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Pulmonary sarcoidosis can manifest in different radiologic patterns. Typical manifestations in high‐resolution computed tomography are bilateral perihilar lymphadenopathy, micronodules, and fibrotic changes. Atypical manifestations are mass‐like or alveolar opacities, honeycomb‐like cysts, miliary opacities, tracheobronchial involvement, and pleural disease. Cystic bronchiectasis in pulmonary sarcoidosis is rare, with only a few reported cases in the literature. We present another case of cystic bronchiectasis with a honeycomb‐like pattern in pulmonary sarcoidosis and with cardiac involvement. This case was presented as an abstract poster at the American Thoracic Society conference in 2022. [ABSTRACT FROM AUTHOR]

Background The effect of the duration of consultant experience on clinical outcomes in the acute medical unit (AMU) model remains unknown. Methods Unscheduled AMU admissions (n=66,929) admitted by 56 consultant physicians between 2017 and 2020 to two large teaching hospital AMUs in Lothian, Scotland were examined. The associations of consultant experience on AMU with patient discharge, mortality, readmission and postdischarge death were calculated adjusting for clinical acuity, pathology and comorbidity. Results Increasing consultant experience was associated with a continuous increase in likelihood of early AMU discharge (odds ratio (OR) 1.08; 95% confidence interval (CI) 1.07-1.10; p<0.001 per 5 years' experience), which persisted after adjustment for confounders (OR 1.06; 95% CI: 1.01-1.11; p=0.01). There was no association with early readmission, death after discharge or 30-day inpatient mortality. The marginal effect estimate translates into 31 (95% CI: 25-36), 41 (95% CI: 30-53) and 52 (95% CI: 35-71) additional safe discharges per 1,000 admissions for clinicians of 15, 20 and 25 years' experience, respectively compared with those recently completing training. Conclusions Increasing consultant physician experience associates with early safe discharge after AMU admission. These data suggest that the support and retention of experienced clinicians is vital if escalating pressures on unscheduled medical care are to be addressed. [ABSTRACT FROM AUTHOR]

Copyright of Die Nephrologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Background There is an emerging consensus that point-of-care ultrasound is an essential skill in acute care. This is reflected in recent changes to the Acute Internal Medicine curriculum in the UK. The need to develop and maintain specific ultrasound competencies is now a mandatory component of training. There is a degree of uncertainty as to how existing training infrastructure can best accommodate these changes. Methods Data were obtained from the latest annual Society for Acute Medicine Benchmarking Audit 2021. All Acute Medical Units in the UK are eligible to participate. Data pertaining to the number of ultrasound machines and number of clinicians that regularly use point of care ultrasound were collected. This was used to develop a series of maps demonstrating variation in provision at the national level. Results In total, 123 AMUs responded to the questions related to ultrasound prevalence and numbers of trained clinicians. Of these, 78.9% (97/123) reported having access to at least one ultrasound machine. There was at least one clinician that regularly used ultrasound in 81 responding hospitals (65.9%). There was significant geographic heterogeneity in the use of ultrasound and availability of accredited supervisors. At a regional level, ultrasound expertise is typically concentrated within a relatively small number of hospitals. Conclusion Geographic variation in the use of ultrasound and availability of registered supervisors represents a significant challenge to ultrasound training provision at the national level. Targeted interventions in areas with less developed training infrastructure, such as regional training hubs may be required to ensure more equitable access to training opportunities.

A middle-aged man with no previous cardiac history was admitted to the hospital being treated for thigh cellulitis, during his stay he developed palpitations and tachycardia which on initial ECG showed atrial flutter with a 2:1 AV block and evidence of an accessory pathway. He was subsequently given AV nodal blocking agents in the form of beta-blockers (bisoprolol) to slow his heart rate down; unfortunately, this led to hemodynamic instability due to 1:1 conduction of the atrial flutter down the accessory pathway. This case report demonstrates the importance of recognising pre-excitation on an ECG and the potential adverse effect of administering AV nodal blockade. [ABSTRACT FROM AUTHOR]

Key Clinical Message Pulmonary sarcoidosis can manifest in different radiologic patterns. Typical manifestations in high‐resolution computed tomography are bilateral perihilar lymphadenopathy, micronodules, and fibrotic changes. Atypical manifestations are mass‐like or alveolar opacities, honeycomb‐like cysts, miliary opacities, tracheobronchial involvement, and pleural disease. Cystic bronchiectasis in pulmonary sarcoidosis is rare, with only a few reported cases in the literature. We present another case of cystic bronchiectasis with a honeycomb‐like pattern in pulmonary sarcoidosis and with cardiac involvement. This case was presented as an abstract poster at the American Thoracic Society conference in 2022.

Copyright of Anaesthesiologie & Intensivmedizin is the property of DGAI e.V. - Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin e.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

• One out of four older adults at the ED presents with nonspecific complaints (NSC). • NSC occur more often in frail older females. • The risk of functional decline and institutionalization doubles in patients with NSC. • In half of the NSC-patients, a specific underlying complaint was found after additional analysis. • NSC should be considered as a red flag and needs appropriate evaluation. Older adults at the Emergency Department (ED) often present with nonspecific complaints (NSC) such as 'weakness' or 'feeling unwell'. Health care workers may underestimate illness in patients with NSC, leading to adverse health outcomes. This study compares characteristics and outcomes of NSC-patients versus specific complaints (SC) patients. Cohort study in patients ≥ 70 years in two Dutch EDs. NSC was classified according to the BANC-study-framework based on the medical history in the ED letter, before additional diagnostics took place. A second classification was performed at the end of the ED visit/hospital admission. Primary outcomes were functional decline, institutionalization, and mortality at 30 days. 26% (n = 228) of a total of 888 included patients presented with NSC. Compared with SC-patients, NSC-patients were older, more frail, and more frequently female. NSC-patients had a higher risk of functional decline and institutionalization at 30 days (adjusted ORs 1.84, 95% CI 1.27 – 2.72, and 2.46, 95% CI 1.51–4.00, respectively), but not mortality (adjusted OR 1.26, 95% CI 0.58 – 2.73). Reclassification to a specific complaint after the ED visit or hospital admission occurred in 54% of NSC-patients. NSC occur especially in older, frail female patients and are associated with an increased risk of functional decline and institutionalization, even after adjustment for worse baseline status. In half of the patients, a specific complaint revealed during ED or hospital stay. Physicians at the ED should consider NSC as a red flag needing appropriate observation and evaluation of underlying serious conditions and needs of this vulnerable patient group. [ABSTRACT FROM AUTHOR]

Key Clinical Massage: Abdominal aortic aneurysms (AAAs) are typically asymptomatic. When symptomatic, AAA may present as a chief concern of musculoskeletal hip and low back pain. Assessment in the orthopedic clinic should focus on a holistic examination of the patient. [ABSTRACT FROM AUTHOR]

Background: The outcomes of acute medical admissions have been shown to be influenced by a variety of factors including system, patient, societal, and physician-specific differences. Aim: To evaluate the influence of on-call specialty on outcomes in acute medical admissions. Methods: All acute medical admissions to our institution from 2015 to 2020 were evaluated. Admissions were grouped based on admitting specialty. Thirty-day in-hospital mortality and length of stay (LOS) were evaluated. Data was analysed using multivariable logistic regression and truncated Poisson regression modelling. Results: There were 50,347 admissions in 30,228 patients. The majority of admissions were under Acute Medicine (47.0%), and major medical subspecialties (36.1%); Elderly Care admitted 12.1%. Acute Medicine admissions were older at 72.9 years (IQR 57.0, 82.9) vs. 67.2 years (IQR 50.1, 80.2), had higher Acute Illness Severity (grades 4–6: 85.9% vs. 81.3%; p < 0.001), Charlson Index (> group 0; 61.5% vs. 54.6%; p < 0.001), and Comorbidity Score (40.7% vs. 36.7%; p < 0.001). Over time, there was a small (+ 8%) but significant increase in 30-day in-hospital mortality. Mortality rates for Acute Medicine, major medical specialties, and Elderly Care were not different at 5.1% (95% CI: 4.7, 5.5), 4.7% (95% CI: 4.3, 5.1), and 4.7% (95% CI: 3.9, 5.4), respectively. Elderly Care admissions had shorter LOS (7.8 days (95% CI: 7.6, 8.0)) compared with either Acute Medicine (8.7 days (95% CI: 8.6, 8.8)) or major medical specialties (8.7 days (95% CI: 8.6, 8.9)). Conclusion: No difference in mortality and minor differences in LOS were observed. The prior pattern of improved outcomes year on year for emergency medical admissions appears ended. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Visceral leishmaniasis and hemophagocytic lymphohistiocytosis share many features in common and may coincide in the same patient. Timely diagnosis and management of visceral leishmaniasis could save patients from unnecessary toxic treatment. Visceral leishmaniasis and hemophagocytic lymphohistiocytosis share many clinical features in common and may coexist in the same patient. Visceral leishmaniasis should be promptly ruled out in patients coming from endemic areas before starting immunosuppressive therapy for hemophagocytic lymphohistiocytosis. The mainstay treatment, in this case, is anti‐leishmania medications preferably liposomal amphotericin‐B. [ABSTRACT FROM AUTHOR]

Background: There is an emerging consensus that point-of-care ultrasound is an essential skill in acute care. This is reflected in recent changes to the Acute Internal Medicine curriculum in the UK. The need to develop and maintain specific ultrasound competencies is now a mandatory component of training. There is a degree of uncertainty as to how existing training infrastructure can best accommodate these changes. Methods: Data were obtained from the latest annual Society for Acute Medicine Benchmarking Audit 2021. All Acute Medical Units in the UK are eligible to participate. Data pertaining to the number of ultrasound machines and number of clinicians that regularly use point of care ultrasound were collected. This was used to develop a series of maps demonstrating variation in provision at the national level. Results: In total, 123 AMUs responded to the questions related to ultrasound prevalence and numbers of trained clinicians. Of these, 78.9% (97/123) reported having access to at least one ultrasound machine. There was at least one clinician that regularly used ultrasound in 81 responding hospitals (65.9%). There was significant geographic heterogeneity in the use of ultrasound and availability of accredited supervisors. At a regional level, ultrasound expertise is typically concentrated within a relatively small number of hospitals. Conclusion: Geographic variation in the use of ultrasound and availability of registered supervisors represents a significant challenge to ultrasound training provision at the national level. Targeted interventions in areas with less developed training infrastructure, such as regional training hubs may be required to ensure more equitable access to training opportunities. [ABSTRACT FROM AUTHOR]

Herpes simplex encephalitis (HSE) is the most common cause of infectious encephalitis. Our case is of a 75‐year‐old woman who presented with dysuria and altered mental status. Our case addresses the difficulties in diagnosis and highlights the importance of early recognition of HSE and its associated neurological sequelae. [ABSTRACT FROM AUTHOR]

Sepsis is a common presentation to the emergency department (ED) with the main aim of treatment being prompt antibiotics, source identification and control, all preferably within the initial golden hour. In the majority of patients, a good history and examination is adequate to elicit the most likely source of infection and thus target therapy appropriately. However it is well known that this can be difficult in some patient groups. In this report we present two patients with sepsis with spinal cord injury (SCI) where both the history and examination were unhelpful in identifying the source of infection and demonstrate why the unique physiology and risk factors in SCI patients must be considered early in their work up. Both patients were admitted with vague, nonspecific constitutional symptoms. Both had no evidence of abdominal or flank pain or any objective tenderness. One of the patients had a long-term suprapubic catheter and one intermittently self catheterised meaning that urine dip stick results were unreliable. In both instances, the patients were found to have obstructed renal stones with associated infection and both had good outcomes after surgical intervention. [ABSTRACT FROM AUTHOR]

Key Clinical Massage Abdominal aortic aneurysms (AAAs) are typically asymptomatic. When symptomatic, AAA may present as a chief concern of musculoskeletal hip and low back pain. Assessment in the orthopedic clinic should focus on a holistic examination of the patient.

Abstract The Rumpel‐Leede sign, characterized by a non‐blanching petechial rash distal to venous occlusion, has historically been associated with thrombocytopenia and capillary fragility. This phenomenon has been observed in various situations involving pressure application, such as tourniquet tests and continuous non‐invasive pressure monitoring. Here, we present a case of Rumpel‐Leede sign occurring after transulnar percutaneous coronary angiography in a 55‐year‐old female patient with a history of myocardial infarction. The patient had an uneventful recovery, highlighting the benign nature of the rash and the lack of intervention required. This underscores the importance of recognizing this sign and its association with specific procedures.

Key Clinical Message Visceral leishmaniasis and hemophagocytic lymphohistiocytosis share many features in common and may coincide in the same patient. Timely diagnosis and management of visceral leishmaniasis could save patients from unnecessary toxic treatment. Abstract Visceral leishmaniasis and hemophagocytic lymphohistiocytosis share many clinical features in common and may coexist in the same patient. Visceral leishmaniasis should be promptly ruled out in patients coming from endemic areas before starting immunosuppressive therapy for hemophagocytic lymphohistiocytosis. The mainstay treatment, in this case, is anti‐leishmania medications preferably liposomal amphotericin‐B.

BackgroundHip fractures in older people are a common health problem often associated with malnutrition that might affect outcomes. Screening for malnutrition is not a routine examination in emergency departments (ED). This analysis of the EMAAge study, a prospective, multicenter cohort study, aimed to evaluate the nutritional status of older patients (≥ 50 years) with hip fracture, factors associated with malnutrition risk, and the association between malnutrition and the six-months mortality.MethodsRisk of malnutrition was evaluated using the Short Nutritional Assessment Questionnaire. Clinical data as well as data on depression and physical activity were determined. Mortality was captured for the first six months after the event. To assess factors associated with malnutrition risk we used a binary logistic regression. A Cox proportional hazards model was used to assess the association of malnutrition risk with six-month survival adjusted for other relevant risk factors.ResultsThe sample consisted of N = 318 hip fracture patients aged 50 to 98 (68% women). The prevalence of malnutrition risk was 25.3% (n = 76) at the time of injury. There were no differences in triage categories or routine parameters measured in the ED that could point to malnutrition. 89% of the patients (n = 267) survived for six months. The mean survival time was longer in those without malnutrition risk (171.9 (167.1–176.9) days vs. 153.1 (140.0–166.2) days). The Kaplan Meier curves and the unadjusted Cox regression (Hazard Ratio (HR) 3.08 (1.61–5.91)) showed differences between patients with and patients without malnutrition risk. In the adjusted Cox regression model, risk of death was associated with malnutrition risk (HR 2.61, 1.34–5.06), older age (70–76 years: HR 2.5 (0.52–11.99); 77–82 years: HR 4.25 (1.15–15.62); 83–99 years: HR 3.82 (1.05–13.88)) and a high burden of comorbidities (Charlson Comorbidity Index ≥3: HR 5.4 (1.53–19.12)).ConclusionRisk of malnutrition was associated with higher mortality after hip fracture. ED parameters did not differentiate between patients with nutritional deficiencies and those without. Therefore, it is particularly important to pay attention to malnutrition in EDs to detect patients at risk of adverse outcomes and to initiate early interventions.

Abstract Herpes simplex encephalitis (HSE) is the most common cause of infectious encephalitis. Our case is of a 75‐year‐old woman who presented with dysuria and altered mental status. Our case addresses the difficulties in diagnosis and highlights the importance of early recognition of HSE and its associated neurological sequelae.

We report long‐term follow‐up of a patient who underwent a tailored laparoscopic procedure for symptomatic cholelithiasis, massive splenomegaly, and a planned pregnancy. There were no complications, and the patient remained symptom‐free at the 5‐year follow‐up. We supplemented our case report with national surgical data demonstrating the safety of laparoscopic splenectomy. Laparoscopic splenectomy is a safe and effective approach for patients with immune thrombocytopenic purpura, even those with massive splenomegaly. We highlight the benefits of tailoring the surgical approach to address the patient's surgical needs. [ABSTRACT FROM AUTHOR]

Abstract Background There is increased demand for urgent and acute services during the winter months, placing pressure on acute medicine services caring for emergency medical admissions. Hospital services adopt measures aiming to compensate for the effects of this increased pressure. This study aimed to describe the measures adopted by acute medicine services to address service pressures during winter. Methods A survey of acute hospitals was conducted during the Society for Acute Medicine Benchmarking Audit, a national day-of-care audit, on 30th January 2020. Survey questions were derived from national guidance. Acute medicine services at 93 hospitals in the United Kingdom completed the survey, evaluating service measures implemented to mitigate increased demand, as well as markers of increased pressure on services. Results All acute internal medicine services had undertaken measures to prepare for increased demand, however there was marked variation in the combination of measures adopted. 81.7% of hospitals had expanded the number of medical inpatient beds available. 80.4% had added extra clinical staff. The specialty of the physicians assigned to provide care for extra inpatient beds varied. A quarter of units had reduced beds available for providing Same Day Emergency Care on the day of the survey. Patients had been waiting in corridors within the emergency medicine department in 56.3% of units. Conclusion Winter pressure places considerable demand on acute services, and impacts the delivery of care. Although increased pressure on acute hospital services during winter is widely recognised, there is considerable variation in the approach to planning for these periods of increased demand.

Abstract An accurate medication history prevents medication errors during transitions of care, whereas an inaccurate medication history may lead to unnecessary tests or prolonged hospitalization. We describe the case of a patient with chronic hypothyroidism who presented to the hospital with severe hypothyroidism and reported strict adherence to her home levothyroxine.