BRASH Syndrome: A Systematic Review of Reported Cases.

The pathophysiology of Bradycardia-Renal Failure-Atrioventricular Nodal Blockade-Shock-Hyperkalemia (BRASH) syndrome involves acute renal injury leading to ineffective clearance of AV nodal agents and potassium. Theoretically, the synergy between AV nodal blockade and hyperkalemic cardiac dysconduction results in circulatory collapse at less-than-expected doses of both. Our study aims to characterize the presentation of BRASH and provide clinical evidence of its risk factors. This systematic review comprises all reported cases of BRASH until February 2022. The average age and Charleston Comorbidity Index at presentation was 69 years and 3.8 respectively - hypertension (71%) was most prevalent followed by diabetes mellitus (48%) and chronic kidney disease (44%). The most frequent presenting complaint was fatigue or syncope (49%). More than half of all patients presented with nonsevere hyperkalemia (less than 6.5 mmol/L) and the mean serum creatinine was 3.6 mg/dL. Beta-blockers (75%) were the most commonly implicated nodal agents. Presenting mean arterial pressure was 62 mm Hg and heart rate averaged 36 bpm; junctional escape rhythm (50%), sinus bradycardia (17.1%), and complete heart block (12.9%) were generally observed on EKG. While most patients responded to medical management, 20% of patients required renal replacement therapy and 33% required transvenous or transcutaneous pacing. No patients underwent permanent pacemaker placement and the in-hospital mortality of BRASH was 5.7%. The diagnosis of BRASH requires a high index of suspicion; its synergistic pathology results in a dramatic clinical presentation that can be easily overlooked. As hypothesized, the degree of renal failure and hyperkalemia are not congruent with the presenting circulatory shock. The significant mortality of this syndrome presents an opportunity for intervention with timely recognition.

Gender Parity in High Impact Cardiology Journals.

Despite increased female representation in medical training, women physicians continue to be under-represented in academic cardiology, particularly in senior roles of authorship and leadership. We analyzed the top 20 most-cited cardiology journals (31,540 total articles) between January 1, 2018 and October 31, 2021 for gender distribution of editorial staff and authorship. Our data demonstrated that only 27% of articles had women as first authors and 20% as senior authors. Women constituted 23% of editorial staff. There is a statistically significant negative correlation (R = 0.67, P = 0.0011) between the percentage of women as first authors and the percentage of men on editorial boards. Overall, female authorship increased from 26% first and 19% senior authors in 2018, to 29% first and 22% senior authors in 2021. Women authors are significantly under-represented in academic cardiology publications, and additional work is needed to identify and address barriers to publishing and academic advancement for women in cardiology.

Middle Meningeal Artery Embolization: A Paradigm Shift in Approach of Chronic Subdural Hematoma.

Chronic subdural hematoma (SDH) is commonly seen in the aged population. It is hypothesized to occur due to damage to the dural border cells, resulting in an inflammation-proliferation reaction. Inadequate repair leads to the formation of an external layer of cells and fragile capillaries, which are vulnerable to damage, contributing to worsening of the condition. Conventionally, asymptomatic chronic SDH was managed by observation, while symptomatic cases by surgical evacuation. However, the recurrence rate of chronic SDH after surgical evacuation was high. The middle meningeal artery (MMA) provides blood supply to the dura mater and feeds the capillaries of the membranes covering the SDH. MMA embolization blocks blood flow to this system and promotes hematoma resolution. In this manuscript, we discuss the underlying pathophysiology and current management options for chronic SDH. We also discuss the existing literature on MMA embolization.

Sirolimus-Induced Rash in a Kidney Transplant Patient.

Sirolimus is an inhibitor of the mammalian target of rapamycin, which is used in kidney transplant immunosuppression. The clinical spectrum of cutaneous adverse events associated with sirolimus use varies, with maculopapular rash being an uncommon side effect very rarely reported in the literature. We present the case of a 78-year-old male renal transplant recipient who developed a diffuse maculopapular pruritic rash after starting sirolimus. This case report demonstrates that maculopapular rash is an uncommon sirolimus-related side effect that must be identified promptly so the medication can be discontinued and rash progression prevented. LEARNING POINTS: Acneiform dermatitis, folliculitis, onychopathy, oral ulcers, rash and stomatitis are all common dermatological side effects of sirolimus.The occurrence of a diffuse pruritic maculopapular rash associated with sirolimus use is rare, but an important differential to keep in mind.Sirolimus cessation is required in case of diffuse pruritic maculopapular rash.