No abstract

BRASH syndrome, which stands for Bradycardia, Renal failure, Atrioventricular (AV) Nodal blockade, and shock, is a relatively new clinical condition. Bradycardia develops because of the synergistic effect of AV-nodal blockers and hyperkalemia in a renal failure resulting in a vicious cycle of progressive bradycardia, renal hypoperfusion, and hyperkalemia. We present a case of an 88-year-old man with chronic systolic heart failure, atrial fibrillation, stage 3 chronic kidney disease, and dementia who presented to our emergency department with poor oral intake and weakness. He was found to have symptomatic bradycardia in the 30s secondary to hyperkalemia and beta-blockers in the setting of acute renal failure from dehydration, raising concern for BRASH syndrome. Treatment of each component conservatively resulted in complete resolution without the need for aggressive measures such as dialysis or pacing. This case report also discusses the pathophysiology, management, and the need for recognizing this underdiagnosed and novel clinical condition.

Current literature suggests an increased incidence of rhabdomyolysis in patients with chronic liver disease (CLD) compared to the general population. We present a case of a 60-year-old female with a history of non-alcoholic fatty liver disease and cirrhosis who developed rhabdomyolysis and acute kidney injury after starting high-intensity atorvastatin therapy. This case highlights the potential risks associated with high-intensity statin therapy in patients with CLD, particularly those with advanced liver dysfunction, emphasizing the need for cautious prescribing and thorough risk-benefit assessment in this vulnerable patient population.

Background: Despite previous studies exploring female reproductive factors, early menarche and its impact on stroke risk remains under-reported. This systematic review seeks to further explore this correlation. Methods: PubMed, SCOPUS and EMBASE databases were systematically reviewed for studies reporting long-term incidence and odds of stroke in patients who had menarche at an early age vs. menarche at a normal age. Random effects models were used for the meta-analysis and subgroup analysis. I2 statistics were used to identify substantial (>75%) heterogeneity. A sensitivity analysis was performed using the leave-one-out method. Results: Ten prospective studies with a total of 1,971,454 patients were included and the odds of stroke were evaluated for patients with early menarche vs controls. Overall unadjusted odds for stroke with early menarche was 1.14 (95%CI 1.08 -1.20, p<0.01, I2=0%). (Fig.1b) Adjusted odds ratio; [aOR 1.22 (95% CI 1.08 - 1.39), I2=86.85%, p<0.01]. (Fig. 1a) Leave-one-out sensitivity analysis confirmed equivalent results. (Fig.1c) On subgroup analysis, studies from the USA with early menarche had the highest stroke risk of countries reported (1.48, 95%CI 1.04-2.09) followed by China (1.26, 95% CI 1.09-1.45) and the UK (1.08, 95%CI 0.96-1.21). There was stronger stroke association with mean/median age cohort ≥ 60 yrs (1.43, 95% CI 1.08 - 1.89) vs <60 yrs (1.18, 95% CI 1.03 - 1.36). Conclusions: This meta-analysis revealed that early menarche is associated with a higher risk of stroke with the strongest association in women from the USA.

Although formic acid (FA) poisoning is rare, it is usually fatal. Many FA poisoning cases commonly involve rubber plantation workers in which these workers ingest FA accidentally or with suicidal intentions. This is a case presentation of FA poisoning by a 73-year-old man. Additionally, the patient's old age likely contributed to his severe prognosis.