BRASH SYNDROME – A RARE CAUSE OF BRADYCARDIA WITH RENAL FAILURE The BRASH syndrome is a rare clinical pentad characterised by bradycardia, renal failure, atrioventricular (AV) blockade, shock and hyperkalaemia. Patients with BRASH syndrome typically present with bradycardia and hypotension due to the synergistic effect of AV node blocker and hyperkalaemia, compounded by underlying renal failure. In this report, we present a young patient with a history of chronic kidney disease and hypertension, who was taking regular beta-blockers and calcium channel blockers, and presented with persistent dizziness, headache and lethargy, which progressed into bradycardia and shock. These symptoms were refractory to initial resuscitation, requiring inotropic support and urgent haemodialysis. The patient was discharged in good condition after initiating regular dialysis. A high index of suspicion and early recognition are key to managing BRASH syndrome. Standard advanced cardiac life support algorithms without calcium are generally impractical for BRASH syndrome. The prognosis for BRASH syndrome is excellent with timely recognition and management.

Ischaemic heart disorders are among the leading causes of mortality worldwide. There has been a growing occurrence of heart disease among young adults. Thus, acute myocardial infarction (MI) should be considered in all patients with central chest pain. Herein, we report the case of a young, fit, active smoker with underlying dyslipidaemia presenting with acute MI, characterised by dynamic changes in lead aVL wherein T wave flattening progressed to inversion, suggestive of early reciprocal changes. Soon after, electrocardiogram (ECG) revealed ST elevation in leads III and aVF, indicative of acute inferior wall MI. Subsequently, coronary angiogram showed right coronary artery occlusion. This case report highlights the importance of serial ECGs in patients who present with chest pain and have a high clinical suspicion for acute MI with normal or inconclusive ECG findings. Measurement of highly sensitive serum troponin based on a 1- or 3-h protocol is important in diagnosing acute MI but not ST-elevation MI. An early sign of inferior wall MI may be a new T wave inversion in lead aVL.
Myocardial Infarction ; Electrocardiography ; Coronary Artery Disease

Background: The PLASMIC score is a convenient tool for predicting ADAMTS13 activity of ＜10%.Lactate dehydrogenase (LDH) is widely used as a marker of haemolysis in thrombotic thrombocytopenic purpura (TTP) monitoring, and could be used as a replacement marker for lysis. We aimed to validate the PLASMIC score in a multi-centre Asia Pacific region, and to explore whether LDH could be used as a replacement marker for lysis. Methods: Records of patients with thrombotic microangiopathy (TMA) were reviewed. Patients’ ADAMTS13 activity levels were obtained, along with clinical/laboratory findings relevant to the PLASMIC score. Both PLASMIC scores and PLASMIC-LDH scores, in which LDH replaced traditional lysis markers, were calculated. We generated a receiver operator characteristics (ROC) curve and compared the area under the curve values (AUC) to determine the predictive ability of each score. Results: 46 patients fulfilled the inclusion criteria, of which 34 had ADAMTS13 activity levels of ＜10%. When the patients were divided into intermediate-to-high risk (scores 5‒7) and low risk (scores 0‒4), the PLASMIC score showed a sensitivity of 97.1% and specificity of 58.3%, with a positive predictive value (PPV) of 86.8% and negative predictive value (NPV) of 87.5%. The PLASMIC-LDH score had a sensitivity of 97.1% and specificity of 33.3%, with a PPV of 80.5% and NPV of 80.0%. Conclusion Our study validated the utility of the PLASMIC score, and demonstrated PLASMIC-LDH as a reasonable alternative in the absence of traditional lysis markers, to help identify high-risk patients for treatment via plasma exchange.

Ischaemic heart disorders are among the leading causes of mortality worldwide. ere has been a growing occurrence of heart disease among young adults. us, acute myocardial infarction (MI) should be considered in all patients with central chest pain. Herein, we report the case of a young, t, active smoker with underlying dyslipidaemia presenting with acute MI, characterised by dynamic changes in lead aVL wherein T wave attening progressed to inversion, suggestive of early reciprocal changes. Soon after, electrocardiogram (ECG) revealed ST elevation in leads III and aVF, indicative of acute inferior wall MI. Subsequently, coronary angiogram showed right coronary artery occlusion. is case report highlights the importance of serial ECGs in patients who present with chest pain and have a high clinical suspicion for acute MI with normal or inconclusive ECG ndings. Measurement of highly sensitive serum troponin based on a 1- or 3-h protocol is important in diagnosing acute MI but not ST-elevation MI. An early sign of inferior wall MI may be a new T wave inversion in lead aVL.

Background: The Emergency Department (ED) is the major entry point for patients admitted into the hospital. The continued use of urinary catheters from the ED is identified as a risk for patients to develop catheter associated urinary tract infection (CAUTI). Objective: This study aimed firstly to identify the prevalence of ED-related CAUTI in our centre, University Malaya Medical Centre and the appropriateness of catheter use among all the cases. Secondly, to assess the impact of a urinary catheter care bundle E-learning training module on the rates of CAUTI and appropriate use of urinary catheter. Method: A pre-post intervention study was conducted between June 2017 and April 2019. A retrospective analysis was conducted to assess the changes in infection rate before and after the training module. The urinary care bundle E learning tutorial module was developed, and all ED staff were trained using this module from September 2018 to November 2018. Outcome measures were the prevalence rate of ED-related CAUTI, the rate of appropriateness indication in urinary catheter insertion and the association between patient’s characteristic and the rate of appropriateness in urinary catheterization. Result: The CAUTI rates were significantly dropped from 17.04 per 1000 device days in pre-intervention period to 7.4 in post-intervention period (p=0.03). Conclusion An online training module on urinary catheter bundle effectively reduced CAUTIs but not improve the appropriate use of urinary catheter. Therefore, further study is needed to improve the rate of appropriateness in urinary catheter insertion.