Johnson City Medical Center

Abstract Introduction: • BRASH syndrome—Bradycardia, Renal failure, AV nodal blocker use, Shock, and Hyperkalemia—is an emerging clinical entity characterized by a synergistic interaction between bradycardia, acute renal failure, hyperkalemia, and the use of AV nodal blocking agents like beta-blockers or calcium channel blockers.• We present the case of a 54-year-old male with chronic kidney disease and hypertension who developed BRASH syndrome, resulting in multi-organ dysfunction and necessitating emergent intervention. Case: • A 54-year-old male with chronic alcoholism, cirrhosis, atrial fibrillation, coronary artery disease, hypertension, hyperlipidemia, uncontrolled diabetes, anemia, and smoking presented with acute shortness of breath. • He arrived lethargic, hypoxic on 2L oxygen, bradycardic (HR in 30s), and hypotensive. Initial labs showed sodium 118 mmol/L, potassium 6.5 mmol/L, and creatinine 3.47 mg/dL. Multiple prescription bottles of diltiazem and metoprolol were found, raising suspicion of overdose.• He was started on dopamine and treated with calcium gluconate, insulin, dextrose, and albuterol for hyperkalemia. Glucagon was trialed with limited response, followed by an insulin drip for suspected calcium channel blocker toxicity.• Unfortunately, the patient's condition deteriorated with worsening hypoxia and poor GCS, requiring intubation. Repeat labs showed severe metabolic acidosis (pH 7.00, HCO39.4), potassium 6.6 mmol/L, creatinine 3.86 mg/dL, and lactate >12 mmol/L. • Bedside echocardiogram indicated poor cardiac contractility. A diagnosis of cardiogenic shock was made and patient was started on multiple pressors with insulin gradually increased to 4.5 U/kg/hr.• A trialysis catheter was then placed, and CRRT was initiated. Within the next few hours, patient made remarkable recovery with resolution of lactic acidosis. He was extubated and transferred out of ICU on the same day. Discussion:• BRASH syndrome is increasingly recognized in emergency and critical care settings. • The syndrome arises from an interplay between hyperkalemia and AV-nodal-blockers, leading to severe bradycardia. The bradycardia reduces cardiac output, worsening renal perfusion and exacerbating renal failure and hyperkalemia in a dangerous cycle.• It is most common in elderly patients with heart disease and renal dysfunction on antihypertensives, especially those managing atrial fibrillation with multiple AV-nodal blockers.• Management typically involves medical therapy, with renal replacement therapy required in 20% of cases, and pacing in 33%. Mortality is estimated at 5.7%.• This case highlights the importance of recognizing and interrupting the BRASH cycle early to prevent progression to multi-organ failure. Conclusion:BRASH syndrome is a potentially fatal interaction of bradycardia, renal failure, hyperkalemia, and AV-nodal blocker use, requiring timely intervention.

Background An overwhelming majority of matriculating medical students in the USA are keen to deliver quality health care to all people, including the socioeconomically disadvantaged populations in remote, resource-scarce regions nationally and worldwide. Here, we describe a protocol developed to evaluate the interest of our medical students in global health activities. We also examined the relationship between students' interest in global health and readiness to pursue a future career in the primary care specialty. Materials and methods We designed a survey in Qualtrics online software and reached all first-year and third-year medical students between 2019 and 2022 enrolled at the Alabama College of Osteopathic Medicine (ACOM).The survey utilized ordinal scale items to explore the medical students' interest in primary care residency programs, their interest in global health and international travel, and their perceptions of how a range of factors might motivate their desire to participate in global health activities. The study was approved by ACOM's Institutional Review Board (IRB). In order to compare findings from this study withdata from other medical schools, we developed constructs using the national aggregate data, in percentages, from matriculants and graduates of Doctor of Osteopathic Medicine (DO) degree-granting medical schools according to gender, published by the American Association of Colleges of Osteopathic Medicine (AACOM). Statistical analysis of national aggregate data was performed using the unpaired t-test. Results Both female and maleparticipants had lived or traveled abroad before starting medical school.Female (98%, n=249) and male (95%, n=140) participants in the first-year cohorts considered helping the underserved population as important or very important as it is related to a career in medicine. Females in the third-year cohorts (97%, n=71) also ranked this statement as important or very important compared to male cohorts (89%, n=31). Ahigher proportion of females (43%, n=108) compared to males (35%, n=52) in first-year cohorts agreed or strongly agreed that they would likely pursue a residency in primary care.More females (59%, n=43)than males (46%, n=16)in the third-year cohorts agreed or strongly agreed with the same statement. Analysis of the aggregatenational data (2009-2022) revealed that the percentage (actual count not available) of female students who plannedto practice in underserved/shortage areawas higher both at the time of matriculation (M=51%, SD=4%) and before graduation (M=40%, SD=4%) compared to males (matriculation: M=40%, SD=5%; graduation: M=33%, SD=4%) presenting a significant difference (matriculation t(24)=6.7, p<0.0001; graduation t(24)=5.4, p<0.0001). Furthermore, a higher percentage of females at the time of matriculation (M=25%, SD=5%) and graduation (M=40%, SD=6%) plannedto practice in the primary care specialtiescompared to males (matriculation: M=17%, SD=4%; graduation: M=29%, SD=6%) presenting a significant difference (matriculation: t(24)=4.6, p = 0.0001; graduation: t(24)=4.8, p<0.0001). Conclusions Interest in global health activities may be associated with interest in pursuing a future career in the primary care specialty. In this study, more female medical students expressed interestin participating in global healthexperiences, serving the underserved population domesticallyand abroad, andexpressing interest in primary care than males.

Introduction: This study aims to explore the burden of cardiovascular disease (CVD) and associated risk factors in Sub-Saharan Africa (SSA) using data from the Global Burden of Disease (GBD). Hypothesis: That the burden of CVD has increased in SSA over time, and there are associated risk factors contributing to this burden. Methods: We analyzed CVD prevalence, mortality, and incidence in 46 SSA countries using Bayesian regression, demographic methodologies, and mortality-to-incidence ratios. Disability-adjusted life years (DALYs) were calculated, and risk factors were assessed through the comparative risk assessment framework of the GBD. Results: Between 1990 and 2019, CVD prevalence in SSA increased by 131.7%, with a modest rise of 2.1% in age-standardized prevalence rates. Ischemic heart disease, stroke (CVA), and rheumatic heart disease were the most prevalent conditions. CVD deaths increased from 564,140 to 1,003,893, with a 14.4% decrease in death rates. Non-rheumatic valvular disease showed a significant increase. DALYs increased by 68.4%, but some CVDs saw decreases in DALY rates. Conclusions: Despite rising CVD prevalence in SSA, age-standardized rates only modestly increased. However, the persistently high burden, increasing non-rheumatic valvular disease, and rising DALYs highlight challenges in prevention and management. These findings highlight the persistent challenge of CVD in SSA and emphasize the need for continued efforts in prevention and management strategies to address the growing burden of CVD in this region.

Aspiration pneumonia is a clinically important infectious process that can result in increased morbidity and mortality. Empiric antimicrobial therapy with activity against anaerobes has been a standard practice based on previous studies, which isolated anaerobes from respiratory cultures. Recent studies have failed to identify anaerobes as causative pathogens, however, these studies did not assess patient outcomes based on the presence or absence of anaerobic coverage. This retrospective cohort study evaluated patients at least 18 years of age requiring mechanical ventilation diagnosed with aspiration pneumonia between 1 October 2020 and 31 July 2021. The primary outcome was the incidence of clinical failure. Secondary outcomes included the time to clinical failure, the incidence of Clostridioides difficile infections and development of multidrug-resistant infections, as well as time on mechanical ventilation and intensive care unit length of stay. A total of 141 patients were included with 83 patients initially receiving anaerobic coverage and 58 patients treated without anaerobic coverage. There was no difference in the incidence of clinical failure between cohorts (18.1% vs. 22.4%; p= 0.41). There was a statistically significant difference in anaerobic escalations with more escalations in the cohort without anaerobic coverage (0% vs. 20.7%; p< 0.0001). Patients initially treated with drugs with anaerobic activity had a higher incidence of multidrug resistant infections on current admission (7.2% vs. 0%; p= 0.04) and a longer length of intensive care unit stay. In critically ill adults with aspiration pneumonia, our study found no difference in clinical failure based on the presence or absence of empiric anaerobic coverage adding to evolving literature suggesting that anaerobic coverage is not routinely warranted in this patient population. Interpretation of the results needs to consider, however, that the retrospective design led to the inclusion of sicker patients in the anaerobic cohort. The frequency of empiric anaerobic coverage demonstrates the need for a prospective randomized control trial to confirm these findings.

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 784 doi: 10.1097/01.ccm.0000812564.96988.a4