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Background Ultra‐low contrast administration during coronary angiography has been previously shown to be feasible and safe among patients with stable chronic kidney disease. In the present study, we investigate the safety of ultra‐low contrast coronary angiography in patients with pre‐existing acute kidney injury (AKI). Methods The study was a retrospective single‐center evaluation of hospitalized patients who had AKI and required coronary angiography. Ultra‐low contrast use was defined as ≤18 mL of contrast media. Results The cohort consisted of a case series of eight inpatients with AKI who required coronary angiography. The mean age was 57 (±16) years and half were females. All patients had chronic kidney disease with a mean baseline estimated glomerular filtration rate of 34 (±17) mL/min/1.73 m2. The mean creatinine before angiography was 3 (±1) mg/dL and volume of contrast administered was 14 (±4) mL. One patient had a 0.1 mg/dL increase in creatinine during admission, and no patients had further AKI up to 1‐week postprocedure. Conclusions The current data suggest that ultra‐low contrast coronary angiography can be safely performed in patients with pre‐existing AKI The study should be viewed as hypothesis‐generating due to its small sample size. A larger cohort is required to validate the results. Eight patients who had acute kidney injury (AKI) and an indication for coronary angiography were included. After 24 h of stabile serum creatinine, patients underwent ultra‐low contrast angiography. None of the participants had further AKI postprocedure. This hypothesis‐generating small sample study suggests that ultra‐low contrast coronary angiography can be safely performed in patients with pre‐existing AKI.

Lateral medullary syndrome (LMS) is an ischemic disease of the medulla oblongata, which involves the territory of the posterior inferior cerebellar artery. Lateral medullary syndrome is often missed as the cause of autonomic dysregulation in patients with recent brain stem stroke. Due to the location of the baroreceptor regulatory center in the lateral medulla oblongata, patients with LMS occasionally have autonomic dysregulation-associated clinical manifestations. We report a case of LMS-associated autonomic dysregulation. The case presented as sinus arrest and syncope, requiring permanent pacemaker placement. A dual-chamber pacemaker was placed, after failure of conservative measures to alleviate the patient’s symptoms. Our case shows the importance of recognizing LMS as a potential cause for life-threatening arrhythmias, heart block, and symptomatic bradycardia. Placement of permanent pacemaker may be necessary in some patients with LMS presenting with syncope, secondary to sinus arrest.

Infiltrative cardiomyopathies include a variety of disorders that lead to myocardial thickening resulting in a constellation of clinical manifestations and eventually heart failure that could be the first clue to reach the diagnosis. Among the more described infiltrative diseases of the heart is amyloid cardiomyopathy. The disease usually presents with subtle, nonspecific symptoms. Herein, we illustrate a case of recurrent syncope as the initial presenting symptom for systemic amyloid with polyneuropathy and cardiomyopathy as a cause of syncope. The article illustrates the role of advanced cardiac imaging in the diagnosis of the disease with a focused literature review. We also highlight the role of early, shared decision-making between patient, family, and medical team in the management of cardiac amyloidosis.

A 42-year-old woman presented to the emergency department (ED) with acute-onset crushing substernal chest pain that occurred while working in the hospital as a sign language interpreter. At 8:15 am, she developed bilateral arm tightness and heaviness that subsequently radiated to her chest. The symptoms were associated with shortness of breath and nausea. She was urgently transported to the ED. The patient disclosed a history of intermittent episodes of substernal chest pain dating back 9 years. Over the preceding 15 months she had increasing bouts of chest pain predominantly occurring in the early morning and lasting for up to 5 minutes with accompanied nausea and arm heaviness. She correlated her symptoms to the level of stress associated with current family and financial matters.

Studies have shown the importance of simulation-based training on the outcomes of central venous catheter (CVC) insertion by trainees. To compare the performance of internal medicine trainees who underwent standardized simulation training of CVC insertion with that of internal medicine trainees who had traditional CVC training and were already deemed competent to perform the procedure during a proficiency evaluation using a training mannequin. Trainees who perform CVC insertion were enrolled in the institutional Central Line Workshop, which includes both an online and an experiential simulation component. The training is followed by a certification station proficiency assessment. Residents and fellows previously certified competent to perform CVC placement without supervision completed the online module, but they could opt out of the experiential component and proceed directly to the evaluation. Forty-eight trainees participated in the study. Twenty-one (44%), 15 (31%), 6 (13%), 1 (2%), 2 (4%), and 3 (6%) were in postgraduate year 1 (PGY1), PGY2, PGY3, PGY4, PGY5, and PGY6, respectively. Twenty-nine completed the hands-on instruction, 28 (97%) of whom successfully passed the simulation-based assessment on their first attempt. Nineteen trainees previously credentialed to perform CVC placement without supervision opted out of the simulation-based experiential training. Of these, five (26%) failed in their first attempt (P = 0.02 vs. trainees who completed the simulation training). Standardized simulation-based training can improve CVC insertion proficiency, even among trainees with previous experience sufficient to have been deemed competent in the procedure. Improved performance at simulation-based testing may translate to improved outcomes of CVC placement by trainees.

[...]the package insert for Biocor Epic tricuspid prosthesis specifically advises against this practice. 1-3 Instead, our patient underwent a subxiphoid surgical approach to place an epicardial right ventricular pacing lead. Since the TdP was precipitated by bradycardia and dofetilide (proarrhythmic agent) in the setting of AV dysfunction and loss of pacemaker capture, removing the offending agent (dofetilide) and addressing the lead dysfunction were sufficient to avoid further episodes of TdP. Dofetilide is known to prolong QT interval causing TdP.

BackgroundAlarm fatigue (AF) is a distressing factor for staff and patients in the hospital. Using cardiac telemetry (CT) without clinical indications can create unnecessary alarms, and increase AF and cost of healthcare. We sought to reduce AF and cost associated with CT monitoring.MethodsAfter implementing a new protocol for CT placement, data were collected on telemetry orders, alarms and bed cost for 13 weeks from 1 January 2015 through 31 March 2015. We also retrospectively collected data on the same variables for the 13 weeks prior to the intervention. A survey was administered to nurses to assess past and present perceptions of AF. Interventions included protocol creation and education for participants.ResultsAt baseline, 77% of patients were monitored with CT. A total of 145 (31%) order discrepancies were discovered during data collection, of which 72% had no indication for CT, so CT was discontinued. The other 28% had indications, so orders were placed. A total of 8336 alarms were recorded during 4 weeks of data collection, of which 333 (4%) were classified as true actionable alarms. Postintervention data showed 67% CT assignment with 10% reduction in CT usage, with no increase in mortality (p<0.001 and >0.05, respectively). A 42% cost reduction was achieved after adjusting the patient status. Nurses reported 27% perceived reduction in AF. One-year follow-up revealed that 69% of patients were being monitored by CT, and the rate of order discrepancies due to lack of indication was 9%.ConclusionAll hospital units may benefit from the protocols created during this study. If applied appropriately, these protocols can lead to reduced AF and cost per episode of care.

Propafenone is a Vaughan Williams class 1c antiarrhythmic medication widely used for treatment of arrhythmias. Although the long-term safety of propafenone use has not been established, it is commonly used for treatment of atrial fibrillation in patients with no structural heart disease. Propafenone is well known as pill-in-the-pocket treatment for its effect in terminating paroxysmal episodes of atrial fibrillation. Herein, we discuss an unusual adverse reaction to propafenone in a patient who presented with symptomatic bradycardia and hypotension. The aim of this article is to increase physician awareness for propafenone toxicity and its management, with a focused literature review on propafenone pharmacotherapy.

Abdominal radiographs revealed dilated bowel with increased intramural radiolucency (figure 1), and subsequent CT scan was confirmatory for extensive pneumatosis intestinalis (PI) (figure 2). PI is an imaging finding representative of gaseous infiltration within the submucosa or subserosa of the bowel wall.1 2 Causal conditions include a variety of benign conditions as well as life-threatening aetiologies such as bowel ischaemia, necrosis, perforation, abdominal abscess and volvulus.1 Two-thirds of abdominal radiographs demonstrate characteristic findings such as radiolucency within the bowel wall, pneumoperitoneum and the presence of portal venous gas.1 2 CT may demonstrate intramural gaseous infiltration, which may become evident within the mesenteric and portal veins, a finding more common with mesenteric ischaemia and which may correlate with higher mortality.1 CT is the best imaging modality, demonstrating higher sensitivity than radiographs or ultrasound and often delineating the causal pathology.1 2 Learning points Pneumatosis intestinalis has a variety of benign and life-threatening causes. Pneumatosis intestinalis is defined by gaseous infiltration into the submucosa or subserosa of the bowel wall and may be identified with X-ray, ultrasound or CT scan.