Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation?

Sepsis can lead to cardiac arrhythmias, of which the most common is atrial fibrillation (AF). Sepsis is associated with up to a six-fold higher risk of developing AF, where it occurs most commonly in the first 3 days of hospital admission. In many patients, AF detected during sepsis is the first documented episode of AF, either as an unmasking of sub-clinical AF or as a newly developed arrhythmia. In the short term, sepsis that is complicated by AF leads to longer hospital stays and an increased risk of inpatient mortality. Sepsis-driven AF can also increase an individual's risk of inpatient stroke by nearly 3-fold, compared to sepsis patients without AF. In the long-term, it is estimated that up to 50% of patients have recurrent episodes of AF within 1-year of their episode of sepsis. The common perception that once the precipitating illness is treated or sinus rhythm is restored the risk of stroke is removed is incorrect. For clinicians, there is a paucity of evidence on how to reduce an individual's risk of stroke after developing AF during sepsis, including whether to start anticoagulation. This is pertinent when considering that more patients are surviving episodes of sepsis and are left with post-sepsis sequalae such as AF. This review provides a summary on the literature available surrounding sepsis-driven AF, focusing on AF recurrence and ischaemic stroke risk. Using this, pragmatic advice to clinicians on how to better detect and reduce an individual's stroke risk after developing AF during sepsis is discussed.

Incidental non-complicated posterior rectus sheath hernia.

Posterior rectus sheath hernia is a truly rare finding, with only 11 documented cases since the first report in 1937. A posterior rectus sheath hernia is herniation of bowel and/or omentum through the posterior portion of the rectus sheath, but not through any other structure. This can only occur medial to the spigelian fascia, differentiating it from a spigelian hernia. Previous missed cases have led to complications such as bowel incarceration, obstruction or even strangulation and have required surgical intervention. In this case report, we describe an incidental finding of a non-complicated posterior rectus sheath hernia in an 83-year-old male. Annotated cross-sectional imaging provides anatomical context that is not widely available in the existing literature. Due to its rarity and potential complications, it is also important to report this case in order to enhance the evidence base for posterior rectus sheath hernia and to familiarize this uncommon condition to radiologists, clinicians and surgeons.

The critical role of logarithmic transformation in Nernstian equilibrium potential calculations.

The membrane potential, arising from uneven distribution of ions across cell membranes containing selectively permeable ion channels, is of fundamental importance to cell signaling. The necessity of maintaining the membrane potential may be appreciated by expressing Ohm's law as current = voltage/resistance and recognizing that no current flows when voltage = 0, i.e., transmembrane voltage gradients, created by uneven transmembrane ion concentrations, are an absolute requirement for the generation of currents that precipitate the action and synaptic potentials that consume >80% of the brain's energy budget and underlie the electrical activity that defines brain function. The concept of the equilibrium potential is vital to understanding the origins of the membrane potential. The equilibrium potential defines a potential at which there is no net transmembrane ion flux, where the work created by the concentration gradient is balanced by the transmembrane voltage difference, and derives from a relationship describing the work done by the diffusion of ions down a concentration gradient. The Nernst equation predicts the equilibrium potential and, as such, is fundamental to understanding the interplay between transmembrane ion concentrations and equilibrium potentials. Logarithmic transformation of the ratio of internal and external ion concentrations lies at the heart of the Nernst equation, but most undergraduate neuroscience students have little understanding of the logarithmic function. To compound this, no current undergraduate neuroscience textbooks describe the effect of logarithmic transformation in appreciable detail, leaving the majority of students with little insight into how ion concentrations determine, or how ion perturbations alter, the membrane potential.