Early/Subtle Electrocardiography Features of Acute Coronary Syndrome and ST-Segment Elevation Myocardial Infarction.

Chest pain is one of the most common presenting complaints in the emergency department. Interpreting a 12-lead electrocardiography (ECG) for evidence of ischemia is always challenging. Frank ECG changes such as ST-segment elevation and ST-segment depression can be easily identified by emergency physicians. However, identifying subtle or early features of ACS in the 12-lead ECG is essential in preventing significant mortality and morbidity from ACS. In the following case series, we describe five of the subtle/early ECG changes of ACS, namely (1) T-wave inversion in lead aVL; (2) terminal QRS distortion; (3) hyperacute T-waves; (4) negative U-waves in precordial leads; and (5) loss of precordial T-wave balance. In all these cases, the initial 12-lead ECG showed only subtle/early ECG changes which were followed up with serial ECGs which progressed to STEMI.

The Alpha-bent and Tunneling: A Novel Technique for Fixing the Transvenous Pacer Lead during Temporary Transvenous Pacing in the Emergency Department.

The last step in the management of symptomatic bradycardia according to the advanced cardiac life support algorithm is temporary transvenous pacemaker insertion (TPI). TPI done by an emergency physician in the emergency department (ED) is on the rise particularly in South India owing to the increased incidence of yellow oleander poisoning. As in ED, we use passive fixation leads, fixation of a transvenous pacer lead is very important. In the following case series, we describe two novel techniques namely, "the alpha-bent" and "tunneling" for fixing the transvenous pacer lead. This technique of fixing the lead reduces lead displacement thus minimizing the potential complications.

Brugada phenocopy induced by consumption of yellow oleander seeds - A case report.

Brugada phenocopy is a brugada-like pattern in ECG seen in some diseases without an inherited channelopathy. The causes of brugada phenocopy are usually reversible. Once the reversible condition resolves, the ECG pattern disappears. There are many conditions that cause brugada phenocopy like myocardial infarction, hyperkalemia etc. Here we report a case of brugada phenocopy induced by consumption of yellow oleander seeds (T. Peruviana).

Memory T-Waves, a Rare Cause of T-Wave Inversion in the Emergency Department.

One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.

Wild tuber poisoning: Arum maculatum - A rare case report.

Arum maculatum, commonly known as wild Arum, is a woodland plant species of the Araceae family. All parts of this plant are considered toxic. We report a case of a young man who allegedly consumed poisonous wild tuber with suicidal intention. He presented to our emergency department 3 h later with features of angioedema. He was managed successfully with adrenaline and hydrocortisone. He was discharged after 4 days of observation. Later, the wild tuber plant was identified to be A. maculatum. We recommend that all patients who present with unknown substance poisoning should be managed according to the principles of intensive care, irrespective of the diagnosis.

The value of specialist care-infectious disease specialist referrals-why and for whom? A retrospective cohort study in a French tertiary hospital.

This study evaluated the impact of infectious disease (ID) specialist referrals on outcomes in a tertiary hospital in France. This study tackled methodological constraints (selection bias, endogeneity) using instrumental variables (IV) methods in order to obtain a quasi-experimental design. In addition, we investigated whether certain characteristics of patients have a bearing on the impact of the intervention. We used the payments database and ID department files to obtain data for adults admitted with an ID diagnosis in the North Hospital, Marseille from 2012 to 2014. Comparable cohorts were obtained using coarsened exact matching and analysed using IV models. Mortality, readmissions, cost (payer perspective) and length of stay (LoS) were analysed. We recorded 15,393 (85.97%) stays, of which 2,159 (14.03%) benefited from IDP consultations. The intervention was seen to significantly lower the risk of inpatient mortality (marginal effect (M.E) = -19.06%) and cost of stay (average treatment effect (ATE) = - €5,573.39). The intervention group was seen to have a longer LoS (ATE = +4.95 days). The intervention conferred a higher reduction in mortality and cost for stays that experienced ICU care (mortality: odds ratio (OR) =0.09, M.E cost = -8,328.84 €) or had a higher severity of illness (mortality: OR=0.35, M.E cost = -1,331.92 €) and for patients aged between 50 and 65 years (mortality: OR=0.28, M.E cost = -874.78 €). This study shows that ID referrals are associated with lower risk of inpatient mortality and cost of stay, especially when targeted to certain subgroups.

In vitro activities of 28 antimicrobial agents against methicillin-resistant Staphylococcus aureus (MRSA) from a clinical setting in Malaysia.

Methicillin-resistant Staphylococcus aureus (MRSA), an established nosocomial and emerging community pathogen associated with many fatalities due to its hyper-virulence and multiple drug resistant properties, is on the continuous rise. To update the current status on the susceptibility of local MRSA isolates to various classes of antibiotics and to identify the most potent antibiotics, thirty-two clinical isolates comprised of hospital acquired (HA) and community acquired (CA) infections were investigated by disk diffusion test. Of the 32 MRSA isolates, 14 (43.75%) and 18 (56.25%) were community and hospital acquired MRSA, respectively. All isolates were multiple drug resistant to more than 3 classes of antibiotics despite the source or specimen from which it was isolated. The oxacillin MICs for all isolates ranged from 2 to > or = 256 microg/ml. Twenty-five of 26 erythromycin-resistant MRSA isolates exhibited an inducible MLS(B) resistance phenotype while one showed an MS phenotype. More than half the isolates (68.75%) were resistant to at least one of the six aminoglycosides tested, with netilmicin as the most susceptible. The most effective antistaphylococcal agents were linezolid, vancomycin, teicoplanin and quinupristin/dalfopristin exhibited 100% susceptibility. Since MRSA is under continuous pressure of acquiring multiple drug resistance, it is imperative to focus routine surveillance on HA and CA-MRSA strains to monitor and limit the spread of this organism.

Complications in 1000 consecutive treadmill tests.

Complication in 1000 consecutive Tread Mill Tests (TMT) done at the Cardiology Centre of Command Hospital (SC) Pune are reported. The tests were done following Bruce Protocol and analysed based on Selzer's criteria. Complications were noted in 18 cases (1.8%) which included ventricular fibrillation, ventricular tachycardia, atrial fibrillation, malignant VPBs, conduction disturbances, asystole following hyperventilation (HV), complete SA block following HV, atrial flutter following HV, hypotension and severe angina requiring ICCU care. No acute myocardial infarctions or deaths were noted. Coronary arteriography (CART) was done in 50 (5.0%) selected cases including 10 with complications. It is concluded that TMT is a safe procedure if carried out after proper patient selection and under supervision of an experienced and efficient team.