Pulmonary thrombosis in Covid-19: before, during and after hospital admission.

Disordered coagulation, endothelial dysfunction, dehydration and immobility contribute to a substantially elevated risk of deep venous thrombosis, pulmonary embolism (PE) and systemic thrombosis in coronavirus disease 2019 (Covid-19). We evaluated the prevalence of pulmonary thrombosis and reported RV (right ventricular) dilatation/dysfunction associated with Covid-19 in a tertiary referral Covid-19 centre. Of 370 patients, positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 39 patients (mean age 62.3 ± 15 years, 56% male) underwent computed tomography pulmonary angiography (CTPA), due to increasing oxygen requirements or refractory hypoxia, not improving on oxygen, very elevated D-dimer or tachycardia disproportionate to clinical condition. Thrombosis in the pulmonary vasculature was found in 18 (46.2%) patients. However, pulmonary thrombosis did not predict survival (46.2% survivors vs 41.7% non-survivors, p = 0.796), but RV dilatation was less frequent among survivors (11.5% survivors vs 58.3% non-survivors, p = 0.002). Over the following month, we observed four Covid-19 patients, who were admitted with high and intermediate-high risk PE, and we treated them with UACTD (ultrasound-assisted catheter-directed thrombolysis), and four further patients, who were admitted with PE up to 4 weeks after recovery from Covid-19. Finally, we observed a case of RV dysfunction and pre-capillary pulmonary hypertension, associated with Covid-19 extensive lung disease. We demonstrated that pulmonary thrombosis is common in association with Covid-19. Also, the thrombotic risk in the pulmonary vasculature is present before and during hospital admission, and continues at least up to four weeks after discharge, and we present UACTD for high and intermediate-high risk PE management in Covid-19 patients.

Letters to Editor.

Huntington and Pennington's recent article1 on a case of Fatal Methaeglobinaemia Due To Intentional Sodium Nitrate Poisoning was very interesting, is a useful overview of initial diagnosis and management, and has helped remind the readers of this potentially life-threatening condition.

Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era.

Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.

A structured tool for delivering feedback on medical student clinical clerkings.

This article was migrated. The article was marked as recommended. Introduction: The initial history and examination is a fundamental aspect of clinical practice. Most medical students cultivate this skill through regular undertaking of 'clerkings' during their clinical placements. We designed a written, structured, proforma-based approach to delivery of feedback on student clerkings which also promoted the undertaking of a 'complete clerking' encouraging students to maintain a whole-system holistic approach. Within this paper, we present our findings following its introduction at a London teaching hospital. Methods: Sixty-one medical students on their first clinical attachment within acute medicine were asked to submit at least one full medical clerking for objective appraisal using the structured clerking feedback proforma by a clinical teaching fellow. Students completed a 'pre' and 'post' assessment using Likert Scales at the time of receiving their clerking feedback. Structured interviews of randomly selected students and senior medical educators were also undertaken. Results: Following introduction of the structured feedback proforma, there was a significant increase across all indices of student-perceived utility and satisfaction compared to previously received feedback (which was mostly ad-hoc verbal). Using Likert Scales (1 to 10: 1 representing least effect and 10 representing greatest effect) student assessment of usefulness was 9.0 (versus 6.34 for previous feedback); likelihood of influencing future practice was 8.8 (versus 6.47); extent to which it reinforced the message of a complete clerking was 9.5 (versus 6.13) and extent to which the feedback would encourage them to undertake complete clerkings was 9.0. Free text comments and subsequent interviews of randomly selected students and senior medical educators reinforced the positive perception of this approach. Conclusions: The introduction of a structured clerking feedback proforma can improve the quality and utility of the feedback delivered to medical students on their acute medical clerkings and can promote and reinforce the value of maintaining a whole-system holistic approach.

Simulation training for acute medical specialist trainees: a pilot.

Simulation training is a method of interactive teaching and training for healthcare professionals. Medical education research demonstrates that high fidelity simulation leads to effective learning. Acute Medical Specialist Year Three-plus Trainee (ST3+) doctors are often required to manage high-pressure situations, requiring a combination of clinical and non-clinical abilities. We therefore hypothesised that simulation training could be an ideal training tool for this cohort. We designed a simulation training day for ST3+trainees which exposed them to ethically challenging scenarios. The learning objectives were mapped to the acute medical curriculum, focusing on areas trainees may traditionally describe as either difficult to achieve, or for those for which providing evidence may be challenging. Simulation scenarios and debriefing sessions enabled trainees to explore different views in a protected environment, and feedback was strongly positive. We strongly recommend simulation training as a teaching tool for Acute Medical ST3+ doctors.

Severe sepsis, social media and the #Sepsis 6: 'Tweeting' national innovations.

The Surviving Sepsis Campaign (SSC) was launched in 2002 with guidelines created to help manage severe sepsis and septic shock. In response to poor compliance with the SSC guidelines in the UK, the 'Sepsis 6' model of delivery was created. We report some of the innovative methods hospitals from around the UK are using to help deliver the 'Sepsis 6' care bundle. The use of social media, such as Twitter, for disseminating these innovations is also explored.

Problem based review: alcohol-use disorders on the Acute Medical Unit.

Alcohol-use disorders including acute intoxication and withdrawal are common in the acute medical setting. Acute physicians should be aware of the indications for inpatient detoxification, and be able to liase with specialist alcohol services in the hospital and in the community to determine those patients for whom community-based detoxification may be beneficial. Additionally, it is important to recognise the benefit of Brief Interventions for higher-risk drinkers who are not yet dependent. For patients with confusion and a possible history of high alcohol intake and malnutrition, acute physicians should maintain a high index of suspicion for Wernicke's Encephalopathy and treat appropriately with parenteral thiamine.

Acquired methemoglobinaemia.

Acquired methemoglobinaemia is a relatively rare condition and, therefore infrequently encountered in acute medical practice. Suspicion of the condition may be triggered when the measured PaO2 is 'out of keeping' with the oxygen saturations that are discovered with pulse oximetry. We describe two separate cases of acquired methemoglobinaemia secondary to the recreational use of alkyl nitrites ('poppers'). The patients presented at separate times to two different teaching hospitals in London, UK. The similarity of these cases has led the authors to conclude that a raised awareness of this potentially fatal condition, and its association with a widely-available recreational drug, is necessary to ensure a correct and timely diagnosis.