Few will deny that the past 6 months have been particularly challenging for all clinicians working in hospital medicine. The pressures of ward closures, which many acute hospitals have faced recently, have undoubtedly increased the ‘bottle-neck’ effect at the front door. Any ‘slack’ which might have existed in the past has now disappeared – 82% occupancy, which was once touted as the Holy Grail of bed-crisis prevention now seems a forlorn hope. One of the Government’s solutions is that chronic disease will be managed without admission to hospital. In reality, this will require dramatic changes in the attitudes of patients, carers and general practitioners and will not happen quickly. The impact of any pre-emptive reduction in capacity will be felt long before any such changes take effect. In the meantime it will up to those of us working in the AMU to ‘sort-out’ and ‘turf-out’, where appropriate. Looking on the bright side, at least when the next round of consultant redundancies is announced we should have little difficulty in justifying our existence…. The request to ‘rule-out serious pathology’ is a frequent justification for hospital referral. When the problem is that of a sudden onset of headache the need to rule-out subarachnoid haemorrhage becomes paramount. Most readers will not make the mistake I made once as an SHO, in assuming that negative CT brain scanning is adequate in this context. However, CSF analysis is not always straightforward. Stephen Hill and Ashwin Pinto’s excellent review of this subject will help unravel some of the complexities in this area. Hopefully the reviews of the acute management of chronic liver disease, psoas abscess and sickle cell disease will also be helpful in your day-to-day working practices. I would also draw your attention to the postcard, which Dr Snape has kindly submitted from a collection donated to him by a patient. Referring to the 1918 Avian Inf luenza outbreak the postcard’s author provides a chilling reminder of the impact of this pandemic. If ‘rule-out avian ‘f lu’ becomes a reason for referral to hospital in the future, we will hopefully be well prepared. Finally in a slight change to the previous format there is now a special section of the journal relating to the Society for Acute Medicine. I am aware that a large proportion of readers are members of the society and this needs to be ref lected in the journal’s content. The ‘Society Pages’ will become a regular feature in the journal, hopefully providing readers with useful information and updates on developments within Acute Medicine. In this edition I have included the abstracts from the Free Paper session at the recent meeting in Hull, along with a summary of the meeting and programme for the next meeting in the Royal College of Physicians. Submissions for this section could include summaries of working practices within different acute medicine units around the country, as well as experiences of trainees undertaking the new acute medicine training programmes. All would be gratefully received.
Cumulative Dis/Advantege, Structure, and Change: Three New Directions for CDA Research
