Segurança, Eficácia e Protocolo de Dose de Metoprolol para Redução de Frequência Cardíaca em Pacientes Pediátricos Externos que Passaram por Angiografia Cardíaca por TC / Safety, Efficacy, and Dose Protocol of Metoprolol for Heart Rate Reduction in Pediatric Outpatients Undergoing Cardiac CT Angiography

Resumo Fundamento Qualidade de imagem e dose de radiação são otimizadas com uma frequência cardíaca (FC) lenta e estável na realização de imagens de artérias coronárias durante a angiografia cardíaca por tomografia computadorizada (CCTA, do inglês cardiac computed tomography angiography) A segurança, a eficácia e o protocolo para a redução da FC com medicamento betabloqueador ainda não foi bem descrita em uma população de pacientes pediátricos. Objetivo Oferecer um protocolo de dose de metoprolol eficiente a ser usado em pacientes pediátricos externos durante a CCTA. Métodos Realizamos uma revisão retrospectiva de todos os pacientes pediátricos externos que receberam o metoprolol durante a CCTA. As características demográficas e clínicas foram resumidas e a redução média em FC foi estimada utilizando-se um modelo de regressão linear multivariada. As imagens foram avaliadas em uma escala de 1 a 4 (1= ideal). Resultados Um total de 78 pacientes externos passaram a uma CCTA com o uso de metoprolol. A média de idade foi de 13 anos, a média de peso foi de 46 kg, e 36 pacientes (46%) eram do sexo masculino. As doses médias de metoprolol foram 1,5 (IQR 1,1; 1,8) mg/kg, e 0,4 (IQR 0,2; 0,7) mg/kg para administrações orais e intravenosas, respectivamente. O produto dose-comprimento por exame foi de 57 (IQR 30, 119) mGy*cm. A redução média da FC foi 19 (IQR 12, 26) batimentos por minuto, ou 23%. Não foram relatadas complicações ou eventos adversos. Conclusão O uso de metoprolol num cenário de pacientes pediátricos externos para redução da FC antes de uma CCTA é seguro e eficiente. Pode-se reproduzir um protocolo de dose de metoprolol quando for necessário atingir uma FC mais lenta, garantindo tempos de aquisição mais rápidos, imagens mais claras e redução na exposição à radiação nessa população. (Arq Bras Cardiol. 2021; 116(1):100-105)

Abstract Background Image quality and radiation dose are optimized with a slow, steady heart rate (HR) when imaging the coronary arteries during cardiac computed tomography angiography (CCTA). The safety, efficacy, and protocol for HR reduction with beta blocker medication is not well described in a pediatric patient population. Objective Provide a safe and efficient metoprolol dose protocol to be used in pediatric outpatients undergoing CCTA. Methods We conducted a retrospective review of all pediatric outpatients who received metoprolol during CCTA. Demographic and clinical characteristics were summarized and the average reduction in HR was estimated using a multivariate linear regression model. Images were evaluated on a 1-4 scale (1= optimal). Results Seventy-eight pediatric outpatients underwent a CCTA scan with the use of metoprolol. The median age was 13 years, median weight of 46 kg, and 36 (46%) were male. The median doses of metoprolol were 1.5 (IQR 1.1, 1.8) mg/kg and 0.4 (IQR 0.2, 0.7) mg/kg for oral and intravenous administrations, respectively. Procedural dose-length product was 57 (IQR 30, 119) mGy*cm. The average reduction in HR was 19 (IQR 12, 26) beats per minute, or 23%. No complications or adverse events were reported. Conclusion Use of metoprolol in a pediatric outpatient setting for HR reduction prior to CCTA is safe and effective. A metoprolol dose protocol can be reproduced when a slower HR is needed, ensuring faster acquisition times, clear images, and associated reduction in radiation exposure in this population. (Arq Bras Cardiol. 2021; 116(1):100-105)

Bevacizumab and gefitinib enhanced whole-brain radiation therapy for brain metastases due to non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) patients who experience brain metastases are usually associated with poor prognostic outcomes. This retrospective study proposed to assess whether bevacizumab or gefitinib can be used to improve the effectiveness of whole brain radiotherapy (WBRT) in managing patients with brain metastases. A total of 218 NSCLC patients with multiple brain metastases were retrospectively included in this study and were randomly allocated to bevacizumab-gefitinib-WBRT group (n=76), gefitinib-WBRT group (n=77) and WBRT group (n=75). Then, tumor responses were evaluated every 2 months based on Response Evaluation Criteria in Solid Tumors version 1.0. Karnofsky performance status and neurologic examination were documented every 6 months after the treatment. Compared to the standard WBRT, bevacizumab and gefitinib could significantly enhance response rate (RR) and disease control rate (DCR) of WBRT (P<0.001). At the same time, RR and DCR of patients who received bevacizumab-gefitinib-WBRT were higher than those who received gefitinib-WBRT. The overall survival (OS) rates and progression-free survival (PFS) rates also differed significantly among the bevacizumab-gefitinib-WBRT (48.6 and 29.8%), gefitinib-WBRT (36.7 and 29.6%) and WBRT (9.8 and 14.6%) groups (P<0.05). Although bevacizumab-gefitinib-WBRT was slightly more toxic than gefitinib-WBRT, the toxicity was tolerable. As suggested by prolonged PFS and OS status, bevacizumab substantially improved the overall efficacy of WBRT in the management of patients with NSCLC.

Hydrogen sulfide in posthemorrhagic shock mesenteric lymph drainage alleviates kidney injury in rats

Posthemorrhagic shock mesenteric lymph (PHSML) is a key factor in multiple organ injury following hemorrhagic shock. We investigated the role of hydrogen sulfide (H2S) in PHSML drainage in alleviating acute kidney injury (AKI) by administering D,L-propargylglycine (PPG) and sodium hydrosulfide hydrate (NaHS) to 12 specific pathogen-free male Wistar rats with PHSML drainage. A hemorrhagic shock model was established in 4 experimental groups: shock, shock+drainage, shock+drainage+PPG (45 mg/kg, 0.5 h prehemorrhage), and shock+drainage+NaHS (28 µmol/kg, 0.5 h prehemorrhage). Fluid resuscitation was performed after 1 h of hypotension, and PHMSL was drained in the last three groups for 3 h after resuscitation. Renal function and histomorphology were assessed along with levels of H2S, cystathionine-γ-lyase (CSE), Toll-like receptor 4 (TLR4), interleukin (IL)-10, IL-12, and tumor necrosis factor (TNF)-α in renal tissue. Hemorrhagic shock induced AKI with increased urea and creatinine levels in plasma and higher H2S, CSE, TLR4, IL-10, IL-12, and TNF-α levels in renal tissue. PHSML drainage significantly reduced urea, creatinine, H2S, CSE, and TNF-α but not TLR4, IL-10, or IL-12. PPG decreased creatinine, H2S, IL-10, and TNF-α levels, but this effect was reversed by NaHS administration. In conclusion, PHSML drainage alleviated AKI following hemorrhagic shock by preventing increases in H2S and H2S-mediated inflammation.

Identification and Characterization of German Cockroach Allergen / 소아알레르기및호흡기학회지

PURPOSE: Cockroaches have been reported one of the major causes of allergic disease such as bronchial asthma and allergic rhinitis. About 10% of children and 20% of adult respiratory allergy patients have positive results of allergy skin tests to cockroach allergen. This finding suggests that cockroach is also important allergen in Korea. Among 4,000 species, German cockroach seems predominant species in the Korean peninsula. Identification and charactrerization of the major allergen is the first step in German cockroach allergen research. But, there have been controversies. It may depends upon different identifying methods. The aim of our study was to identify the major allergen in German cockroach using Westernblot. METHODS: Crude German cockroach allergen extracts with or without protease inhibitor cocktail mixture were prepared, and protein patterns of these two extracts were compared using SDS-PAGE and Coommssie stain. Sera from 32 atopic asthmatic patients with positive allergy skin test against cockroach allergen were used for IgE immunoblot. RESULTS: Coomassie stain after SDS-PAGE demonstrated some discordance between the differently prepared crude allergen extracts. In comparison with the allergen extract which abolished endogenous protease activity, the untreated extract revealed new 32, 55 and 78 kD protein bands and 41 kD protein band was disappeared. About 60% of sera with positive allergy skin test revealed IgE binding bands in Westernblot. Among them, 10, 21, 25, 36 and 52 kD protein band might seemed important German cockroach allergen. CONCLUSION: Finding above may suggest that endogenous protease could denature allergenic proteins in the process of crude cockroach allergen extract. The 10, 21, 25, 36, and 52 kD might be the important allergens in German cockroach.

Persistent hypoglycemic hemiplegia: A case report

Hypoglycemia sometimes manifests as focal neurologic deficits simulating cerebrovascular disease. Symptoms are usually resolved by glucose infusion, but persistent hemiplegia is rarely reported. A 68-year-old diabetic woman on oral hypoglycemic agent(OHA) was admitted with right hemiplegia and global aphasia. Blood glucose level was 29 mg/dl on admission. No evidence of cerebral infarct or underlying brain disease could be found on initial brain CT and follow up MRI. Focal stenosis or occlusion was also absent on MR angiography. Hemiplegia and aphasia were not improved despite adequate therapy. Hypoglycemic hemiplegia should be suspected in all diabetic patients using insulin or OHA with stroke-like episode, and we suggest that prolonged hypoglycemia may be related to persistence of neurologic deficits.

MRI FINDINGS OF WERNICKE ENCEPHALOPATHY IN THE ACUTE PHASE AND FOLLOW-UP

OBJECTIVE: To correlate the MRI findings in acute and chronic stage of Wemicke encephalopathy with the well-known clinical and pathologic findings. Background. Wemicke encephalopathy is an acute phase of Wemicke-Korsakoff syndrome. Pathologic findings change between acute and chronic phases. Only a few MRI studies have been done in this disease to date. METHODS: Ten consecutive patients with Wemicke encephalopathy were evaluated with MRI; seven within 24 hours of thiamine treatment, and three between 2 and 4 days. They presented with confusion, ophthalmoplegia and gait ataxia which improved with intravenous thiamine. Korsakoff psychosis became evident on followup. Tl-, proton- and T2-weighted axial images were obtained with additional 5 mmthick Tl-weighted sagittal and coronal images to evaluate the morphology and size of the mammillary body. RESULTS: Increased T2 signal was seen in the periaqueductal area in seven(sometimes involving superior colliculus); medial thalamus in five; and splenium of the corpus callosum in two. Among the seven patients with T2 signal abnormalities, five had follow-up MRI in 2 to 70 days, which showed complete resolution of the abnormalities. Seven patients showed atrophy of mammillary body on the initial MRI. In the three patients who had normal mammillary body in size on initial scan, follow up MRI revealed atrophic change of mammillary body. Tlweighted sagittal image showed superior cerebellar vermis atrophy in seven. Four patients revealed dilatation of the third ventricle. CONCLUSION: MRI findings of Wernicke encephalopathy appear diagnostic in acute stage and may reflect the pathological evolution in acute and chronic phases of Wernicke-Korsakoff syndrome.