Andrew Lee @ AGT & BGT

I'm proud to share that our M'sian celebrity magician - Andrew Lee, has made it all the way to BGT! The knife throwing act was performed so well and it has captivated the whole audience.


Here's his act in the recent AGT at semi-final. It was done so charmingly, hilarious at the same time and with a perfect twist in the end.

Follow him for more impressive magic to come! A very well done to him, and all the best in his BGT!

Extracardiac Compression of Right Atrium by Hepatic Cysts in ADPKD

What is the impact of growing hepatic cysts in patient with polycystic kidney disease? We reported a rare complication - the cysts have caused extracardiac compression of right atrium resulting in impaired filling. Patient is at risk of refractory hypotension in the presence of significantly impaired right ventricular filling. Beside this, hepatic cysts burden has been reported to cause inferior vena cava compression, hepatic venous outflow obstruction and portal hypertension. Therapeutic options for symptomatic patients include cyst aspiration and sclerotherapy, cyst fenestration, transcatheter arterial embolization, or surgical intervention including cyst resection and liver transplantation.

Full Text:
KG Lee, SH Teo, H John, KWQ Guo, JL Kwek. Extracardiac compression of right atrium by hepatic cysts in a patient with polycystic kidney disease. Kidney International 2016; 90:230.

If you're interested in updates in ADPKD, a position statement by European ADPKD Forum can be read here.

Outcome of AVF Creation, Effects of Preop Vein Mapping and Predictors of Fistula Success in Incident Hemodialysis Patients

This single-centre study reported arteriovenous (AVF) outcomes of incident hemodialysis patients with 19,450 patient-month follow-up, successful AVF maturation was achieved in 78% with 1-year cumulative patency rate of 74%. Routine pre-operative vein mapping was not necessary if veins are suitable on physical examination for AVF creation.

Full text:

KG Lee, TT Chong, N Goh et al. Outcomes of arteriovenous fistula creation, effect of preoperative vein mapping and predictors of fistula success in incident hemodialysis patients: A single-centre experience. Nephrology (Carlton) 2017; 22:382-7.

 

SCE Nephrology Exam Questions Writing

I am glad to be invited for authoring questions for SCE Nephrology Prep Course and all the questions were accepted. The guidance provided in authoring MCQs and replies from Editors are enlightening. Overall a good learning process!

Read more about the SCE Nephrology exam:

http://darrenmagic.blogspot.my/2012/04/sce-in-nephrology.html

Hyperkalemia - Principles of Management

Nice animation of ECG changes during hyperkalemia - this shows clearly that time is life when dealing with severe hyperkalemia.

5 essential principles of management, in simple terms:

1. Protect the heart - IV Ca Gluconate/ Ca Chloride (note contains 3x more calcium) to antagonise the cardiac membrane excitability thereby protect the heart against arrhythmias;

2. Shift K into cells - Insulin/ glucose infusion, nebulised Salbutamol (unlikely to work for patients on non-selective beta-blockers), Sodium Bicarbonate (not for routine use, comes with risk of Na and fluid overload);

3. Remove K from the body - Cation exchange resins (Resonium/ Kalimate, new agents: Patiromer, Zirconium), hemodialysis;

4. Monitor K level - do monitor for rebound hyperkalemia which is common;

5. Prevent recurrence - Do not walk away without knowing the cause of hyperkalemia and to stop further K accumulation, stop ALL potential offending drugs immediately.

Read more at:

CPG of Treatment of Acute Hyperkalemia

Rivaroxaban and Topical Miconazole - Do Not Mix

1. Direct oral anticoagulants (DOAC) are being increasingly use. Rivaroxaban is metabolized via CYP3A4, with in vitro studies supporting the involvement of P-glycoprotein as the responsible active transporter in renal secretion of rivaroxaban.

2. Antifungal imidazole derivatives have been shown to demonstrate significant inhibition of CYP450. Miconazole, a combined p-glycoprotein and strong CYP3A4-inhibitor, can potentially cause significant drug interaction and increased rivaroxaban concentration.

3. Interference of topical miconazole with warfarin has been reported, but not with DOAC. Systemic absorption appears to be enhanced when miconazole is applied under occlusion on large surface, close to mucous membranes or in cases of intertrigo skin lesions.

4. In summary, the use of topical miconazole may have significant drug interaction with rivaroxaban resulting in adverse event from over-anticoagulation.

The prescribing clinician should be aware of this possible interaction and exercise close monitoring if simultaneous use is indicated.

The interaction has been highlighted previously as a short communication (http://journals.sagepub.com/doi/pdf/10.1177/201010581502400209), and it was cited in Reactions journal as the first report of such interaction (https://link.springer.com/article/10.1007/s40278-015-4084-y).

Full text:
KG Lee, DL Jennifer. Increased bleeding tendency from interaction between rivaroxaban and topical miconazole: Case report. Proceedings of Singapore Healthcare 2015; 24:121-2.