Cases of levamisole overdose without coingestants in human subjects are rare. Existing knowledge of human toxicity depends in part on records of adverse events of therapeutic use such as nausea, vomiting, headache, and rarer central nervous system effects. Much of our knowledge also comes from levamisole's role as an adulterant in cocaine, where it is known to have immune modulatory properties and is associated with vasculitis. The few cases of levamisole-only toxicity are either non-fatal or lack clinical details. We present the first case of a fatal, oral ingestion of levamisole in a patient who presented alive with clinical symptoms and had treatment documented. The patient's early symptoms included nausea, vomiting, tremors, and visual changes. Following this, the patient experienced bradycardia followed by pulseless electrical activity cardiac arrest. This presentation was consistent with what would be expected of the pharmacodynamic effects of levamisole as a nicotinic agonist. Levamisole's presence was confirmed by post-mortem confirmatory testing, with a recorded femoral blood concentration of 19,000 ng/mL. The clinical picture and post-mortem testing were consistent with the cause of death as levamisole overdose.

Background Subarachnoid block (SAB) is a widely practiced regional anesthetic for lower limb surgeries. The patient position for subarachnoid block induction, either sitting or lateral decubitus, may affect hemodynamic stability and block quality. Objective To compare the incidence of hypotension and the onset times of block in these two positions. Method In this prospective single-center observational comparative study, 108 patients, who were scheduled to undergo elective lower limb surgery, were equally assigned to subarachnoid block in sitting position (SP) and Lateral decubitus position (LP) groups. An intrathecal dose of hyperbaric Bupivacaine 0.5% (15 mg) was given. Hemodynamic variables, onset of sensory and motor block, maximum level of sensory and motor block and any complications including hypotension and bradycardia were recorded and compared. Categorical variables were analyzed using the Chi-square test, and continuous variables were compared using the unpaired Student's t-test. Result The incidence of hypotension was greater in sitting position group (20.41%) than in LP group (16.67%), but the difference was not statistically significant. Out of these, bradycardia was more frequent in sitting position (9.2%) as compared to lateral decubitus position (7.4%). The onset times of sensory and motor blocks in the lateral decubitus position group were significantly shorter (p < 0.05). Conclusion Lateral decubitus position results in superior early hemodynamic stability and shorter time to sensory and motor block onset as compared to sitting in subarachnoid block for elective lower limb surgeries.

Background Atrial fibrillation (AF) is associated with high early rehospitalization rates following index hospitalization. While beta-blockers remain the cornerstone of rate control, amiodarone is frequently used for rhythm control in selected patients. The clinical impact of concurrent amiodarone and beta-blocker therapy at discharge on short-term rehospitalization remains incompletely defined. Methods  A retrospective cohort study using the TriNetX platform was conducted. Adult patients hospitalized with AF were identified and stratified based on discharge prescription of amiodarone plus a beta-blocker versus comparator therapy. Strict exclusion criteria were applied to minimize confounding, including exclusion of patients with recent cardiac surgery, implantable device placement, advanced conduction disease, or incomplete follow-up. Propensity score matching in a 1:1 ratio was performed using demographic and clinical variables. The primary outcome was 30-day all-cause rehospitalization. Secondary outcomes included AF-related rehospitalization, rhythm-related interventions, and safety endpoints. Results  A total of 2,647 patients met the inclusion criteria. After propensity score matching, 1,323 patients per group were successfully matched, yielding a final analytic sample of 2,646 patients; one patient could not be matched and was excluded. Baseline characteristics were well balanced, with standardized mean differences below 0.10. At 30 days, all-cause rehospitalization occurred in 13.6% of patients receiving combination therapy compared with 16.9% in the comparator group, yielding an odds ratio of 0.77, with a 95% CI of 0.62 to 0.95 and p = 0.014. Atrial fibrillation-related rehospitalization was significantly lower in the combination group, at 5.1% versus 7.4%, with an odds ratio of 0.67 and p = 0.008. Rhythm-related urgent visits occurred in 3.6% versus 5.4%, with an odds ratio of 0.65 and p = 0.019. No significant difference in 30-day mortality was observed, at 0.9% versus 1.2%, with p = 0.40. Safety analysis demonstrated a higher rate of bradycardia- or hypotension-related encounters in the combination group, at 2.7% versus 1.5%, with an odds ratio of 1.83 and p = 0.038, without differences in pacemaker implantation. Conclusion  Among patients hospitalized with AF, discharge on amiodarone plus beta-blocker therapy was associated with a modest reduction in 30-day rehospitalization, driven primarily by fewer rhythm-related events, with a small increase in bradycardia-related complications. These findings support a selective rhythm-control strategy in appropriately chosen patients.

Functional bradycardia, characterized by a heart rate below the normal range due to dysregulation of the autonomic nervous system (ANS), poses a clinical challenge with limited treatment options. Symptomatic sinus bradycardia is an uncommon but potentially significant complication following bariatric surgery. Cardioneuroablation (CNA) has emerged as a novel therapeutic intervention targeting the cardiac ANS to modulate heart rate. This case series describes two patients, with the aim of providing a simplified but successful approach with targeted partial CNA for sinus bradycardia complicating bariatric surgery.