The role of consultants in the referral process for acute medicine has been a subject of discussion for as long as I have been involved with the speciality. This journal has previously published data from individual sites which demonstrated benefits on a local level when consultants were directly involved in taking referral phone calls from general practitioners. This was further evaluated as part of the Society for Acute Medicine’s 2016 Benchmarking Audit, (SAMBA16), which generated some National data around outcomes according to the seniority of clinician receiving the referral. This is presented in the current edition. The authors acknowledge the limitations of the data, particularly the difficulty in comparing units with different facilities for assessment, treatment and follow-up, which may have influenced the options available for consultants when taking referrals. As with previous research in this area, the paper focuses on the quantitative benefits in terms of the admissions ‘avoided’ as a result of telephone advice given; the data collection does not allow any analysis of what subsequently happened to these patients, and it is possible that some were subsequently admitted to hospital. It is important also to remember the qualitative benefits of direct communication with GPs: the ability to glean important nuggets of information which may be omitted from a referral letter, as well as the value of regular conversations in building relationships between primary and secondary care. My own experiences over the past 2 decades suggest that these benefits are often at least as great, albeit more difficult to measure, than ‘admission avoidance’. Infections represent a large proportion of the acute medical intake, and this is reflected in many of the case reports we receive for consideration of publication. Three such cases are included in this edition. When the case history includes ‘visiting sewage-contaminated land’, many clinicians would be thinking along the lines of leptospirosis while awaiting serological testing. However in the case presented by Sarah Lawrence and colleagues from the Manchester area, it turned out to be the family pet which was responsible for their patient’s disseminated intravascular coagulation. Captocytophaga carnimorsis is not an organism with which I was previously familiar, but this case has reinforced my view that allowing your dog to lick your mucus membranes is something to be avoided. Lemierr’s syndrome is another condition which I have not previously encountered; however the authors of our third case report suggest this may be worth considering when a patient’s ‘simple sore throat’ fails to improve. In this case, it was the finding of another unusual bacterium – fusebacterium necrophorum – in the blood culture which led to the further investigation and diagnosis of this condition. Early recognition and initiation of appropriate antibiotic therapy is associated with an improved outcome, so this represents an important reminder of a condition which might otherwise be forgotten. Although this is technically the ‘autumn edition’, I suspect that Winter may already have arrived with a vengeance by the time it has been printed and mailed, so I hope that readers working in the NHS’ busy Acute Medical Units are managing to keep their spirits up, and have battened down the necessary hatches for whatever the months ahead choose to throw at us.
Genes and hormones of the hypothalamic–pituitary–adrenal axis in post-traumatic stress disorder. What is their role in symptom expression and treatment response?
