BRASH Syndrome: A Case Report

BackgroundBRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym.Case ReportAn elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome.Why Should an Emergency Physician Be Aware of This?Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity.     

Prevalence and determinants of hypertension in a rural community

Background: There are few epidemiological studies on prevalence of hypertension and its determinants in rural population. This cross sectional study was done to determine the same in a rural community.     

Food Poisoning Outbreak in a Military Establishment

Background

An outbreak of food poisoning involving 121 persons of a military establishment was investigated.

Methods

On investigation, a total of 94 persons became ill, with an attack rate of 77.7%. The symptoms included nausea, vomiting, abdominal pain, diarrhoea, weakness and fever. The mean incubation period was 2.3 hours while the median was 1.7 hours. Retrospective cohort study incriminated raita as the food item responsible for the outbreak, with a risk ratio of 21.35. Left over food was not available for laboratory analysis. There were no deaths and all affected persons recovered within 24 hours.

Result

Coagulase positive staphylococci were cultured from the vomitus and stool samples of cases. Nasal and fingernail swabs collected from food handlers also showed staphylococcal growth. The most likely cause of contamination of raita with the enterotoxin could be the staphylococci which had colonised the bodies of food handlers.

Conclusion

The aggravating factor was the storage of raita at room temperature before its consumption, which provided ideal conditions for enterotoxin formation.Key Words: Food poisoning, Staphylococci, Food handlers     

Elevated basal intestinal mucosal cytokine levels in asymptomatic first-degree relatives of patients with Crohn's disease

AIM To determine levels of cytokines in colonic mucosa of asymptomatic first degree relatives of Crohn's disease patients.METHODS Cytokines (Interleukin (IL) 1-Beta,IL-2, IL-6 and IL-8) were measured using ELISA in biopsy samples of normal looking colonic mucosa of first degree relatives of Crohn's disease patients (n = 9) and from normal controls (n=10) with no family history of Crohn's disease.RESULTS Asymptomatic first degree relatives of patients with Crohn's disease had significantly higher levels of basal intestinal mucosal cytokines (IL-2, IL-6 and IL-8) than normal controls. Whether these increased cytokine levels serve as phenotypic markers for a genetic predisposition to developing Crohn's disease later on, or whether they indicate early (preclinical) damage has yet to be further defined.CONCLUSION Asymptomatic first degree relatives of Crohn's disease patients have higher levels of cytokines in their normal-looking intestinal mucosa compared to normal controls.This supports the hypothesis that increased cytokines may be a cause or an early event in the inflammatory cascade of Crohn's disease and are not merely a result of the inflammatory process.     

Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: a meta-analysis

BACKGROUND & AIMS: The aim of this study was to compare the diagnostic yield of capsule endoscopy (CE) with double-balloon enteroscopy (DBE) in small-bowel (SB) disease using meta-analysis. METHODS: We performed a search of studies comparing CE with DBE in SB disease. Data on diagnostic yield of CE and DBE were extracted, pooled, and analyzed. The weighted incremental yield (IY(W)) (yield of CE--yield of DBE) of CE over DBE and 95% confidence intervals (95% CIs) for pooled data were calculated using a fixed-effect model (FEM) for analyses without, and a random-effect model (REM) for analyses with, significant heterogeneity. RESULTS: Eleven studies compared CE and DBE; the pooled overall yield for CE and DBE was 60% (n = 397) and 57% (n = 360), respectively (IY(W), 3%; 95% CI, -4% to 10%; P = .42; FEM). Ten studies reported vascular findings; the pooled yield for CE and DBE was 24% (n = 371) and 24% (n = 364), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .88; REM). Nine studies reported inflammatory findings; the pooled yield for CE and DBE was 18% (n = 343) and 16% (n = 336), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .89; FEM). Nine studies reported polyps/tumors; the pooled yield for CE and DBE was 11% (n = 343) and 11% (n = 336), respectively (IY(W), -1%; 95% CI, -5% to 4%; P = .76; FEM). CONCLUSIONS: CE and DBE have comparable diagnostic yield in SB disease, including obscure gastrointestinal bleeding. CE should be the initial diagnostic test because of its noninvasive quality, tolerance, ability to view the entire SB, and for determining the initial route of DBE. Because of its therapeutic capabilities, DBE may be indicated in patients with a positive finding on CE requiring a biopsy or therapeutic intervention, if suspicion for a SB lesion is high despite a negative CE, and in patients with active bleeding.