ABSTRACT
Background: Bradycardia can have a number of different aetiologies, including as a side effect of medications. Brimonidine is a rare, but recognized, cause of bradycardia. Brimonidine is indicated in the treatment of facial erythema in rosacea when given as topical brimonidine gel (Mirvaso). It may also be administered as eye drops for raised intraocular pressure in open-angle glaucoma and ocular hypertension. Brimonidine is an alpha-2 agonist, which if systemically absorbed can present with bradycardia, hypotension, and dizziness. The authors are unaware of any other case reports regarding topical administration of Mirvaso in an adult and symptomatic bradycardia. Case summary: We present the case of a 78-year-old man with a background of rosacea, benign prostatic hyperplasia, and hypertension who had two separate admissions with symptomatic bradycardia. Electrocardiograms showed sinus bradycardia with AV block first degree, with rate recorded as low as 31 b.p.m. during a syncopal episode. These episodes of symptomatic bradycardia were intermittent and had a temporal association with topical administration of Mirvaso. He had no further episodes of bradycardia on discontinuation of Mirvaso and has remained symptom free for over 6 months. Discussion: The topical administration of Mirvaso should be avoided to broken or inflamed skin. This is owing to the increased risk of systemic absorption, which as in this case report, may present with bradycardia. This case reiterates the importance of completing a full medication history including all topical and parenteral medications in patients with arrhythmia.
ABSTRACT
PURPOSE: Spondylodiscitis represents a condition with significant heterogeneity. A significant proportion of patients are managed without surgical intervention, but there remains a group where surgery is mandated. The aim of our study was to create a scoring system to guide clinicians as to which patients with spondylodiscitis may require surgery. METHODS: A retrospective analysis of patients presenting to our institution with a diagnosis of spondylodiscitis between 2005 and 2014 was performed. Data for 35 variables, characterised as potential risk factors for requiring surgical treatment of spondylodiscitis, were collected. Logistic regression analysis was performed to evaluate the predictability of each. A prediction model was constructed, and the model was externally validated using a second series of patients from 2014 to 2015 meeting the same standards as the first population. The predicted odds were calculated for every patient in the data set. Receiver operating characteristic (ROC) curves were created, and the area under curve (AUC) was determined. RESULTS: Sixty-five patients were identified. Surgery was deemed necessary in 21 patients. Six predictors: distant site infection, medical comorbidities, the immunocompromised patient, MRI findings, anatomical location and neurology, were found to be the most consistent risk factors for surgical intervention. An internally validated scoring system with an AUC of 0.83 and an Akaike information criterion (AIC) of 115.2 was developed. External validation using a further 20 patients showed an AUC of 0.71 at 95% confidence interval of 0.50-0.88. CONCLUSIONS: A new scoring system has been developed which can help guide clinicians as to when surgical intervention may be required. Further prospective analyses are required to validate this proposed scoring system. These slides can be retrieved under Electronic Supplementary Material.
