Reconocimiento y manejo de la anafilaxia en pediatría / Detection and management of anaphylaxis in children

INTRODUCCIÓN: La anafilaxia es una emergencia. De acuerdo con las últimas recomendaciones internacionales el reconocimiento de los criterios clínicos y el tratamiento temprano con adrenalina intramuscular se asocian a mayor sobrevida. OBJETIVO: Determinar el conocimiento de los médicos pediatras de un Hospital Pediátrico de tercer nivel sobre los criterios diagnósticos y el tratamiento de la anafilaxia. MATERIAL Y MÉTODO: Estudio descriptivo transversal que considera diseño, aplicación y validación de una encuesta anónima a médicos con residencia completa en pediatría que realizan guardias en un hospital de tercer nivel. Los ítems de la Encuesta comprendieron tres dimensiones, experiencia del operador (2 ítems), manejo farmacológico (3 ítems) e identificación del cuadro (4 ítems). El análisis estadístico utilizó el programa SPSS v.21, presentando medidas de tendencia central (mediana, rango y tabla de frecuencias) y para su comparación prueba de Chi cuadrado. Se consideró significativo un valor de p < 0,05. RESULTADOS: Se encuestaron 71 médicos con una mediana de 3 años transcurridos desde el fin de la residencia. 35% identificó todos los criterios clínicos; 99% (70) indicó adrenalina, 73% por vía intramuscular y 55% a dosis correcta (solo el 48% contestó la dosis y vía correctamente). En forma global la adecuación para identificación más manejo correcto fue del 21%. Los médicos con menos de 5 años de experiencia tuvieron mejor desempeño en la administración de adrenalina intramuscular (83% vs 52% p = 0,005) y en la detección de síntomas gastrointestinales (60%vs35% p = 0,043). CONCLUSIONES: Existen dificultades para la identificación y el manejo apropiado de la anafilaxia por pediatras de un Hospital de tercer nivel en un escenario teórico. Aunque la mayoría eligió la adrenalina como droga de primera línea, la mitad no la indicó de forma correcta y solo un tercio reconoció el cuadro en todos sus escenarios.

INTRODUCTION: Anaphylaxis is an emergency condition. According to the latest international guide lines, early recognition and treatment with intramuscular epinephrine are associated with increased survival. OBJECTIVE: To determine the level of knowledge of pediatricians in a tertiary Pediatric Hos pital about the diagnostic criteria and treatment of anaphylaxis. MATERIAL AND METHOD: A cross-sec tional descriptive study was conducted, designing, applying, and validating an anonymous survey to physicians with complete residency in pediatrics who are on call at a third level hospital. The statisti cal analysis was made using the SPSS v.21 software, presenting measures of central tendency (median, range, and frequency table) and Chi-square test for comparison. A value of p < 0.05 was considered significant. RESULTS: 71 physicians completed the survey with a median of three years after the end of residency.35% of them identified all clinical criteria, 99% (70) indicated epinephrine, 73% chose the intramuscular route, and 55% indicated the correct dose. Only 48% of responders chose the dose and administration route correctly. In general, 21% recognized anaphylaxis and used epinephrine correctly. Physicians with less than five years of experience performed better in the intramuscular administration of epinephrine (83% vs 52% p = 0.005) and in the detection of gastrointestinal symp toms (60% vs 35% p = 0.043). CONCLUSIONS: There are difficulties in the identification and proper management of anaphylaxis by pediatricians of a tertiary Pediatric Hospital in a theoretical clinical setting. Although most of pediatricians chose epinephrine as a first-line drug, half of them did not indicate it correctly, and only one-third recognized anaphylaxis in all scenarios.

Hemodynamic parameters of adult patients undergoing pharmacologic mydriasis using tropicamide+phenylephrine versus tropicamide alone: Randomized controlled trial

Background@#Systemic absorption of topical phenylephrine administered during mydriasis may potentially cause hemodynamic changes in patients. @*Objective@#To compare the hemodynamic outcomes between patients given tropicamide+phenylephrine and those given tropicamide alone for mydriasis. @*Design@#Randomized controlled trial. @*Setting@#Ophthalmology Outpatient Clinic, Southern Philippines Medical Center, Davao City, from April to June 2017. @*Participants@#56 male and female patients aged ≥ 19 years and scheduled for mydriasis. @*Interventions@#Random allocation to either one drop of 0.5% tropicamide plus 0.5% phenylephrine or one drop of 0.5% tropicamide for mydriasis of the examined eye. @*Main outcome measures@#Mean systolic BP, mean diastolic BP, mean arterial pressure, mean heart rate, and at least one episode of tachycardia or bradycardia. @*Main results@#Thirty (53.57%) patients received tropicamide drops, and the rest received tropicamide+phenylephrine drops. The demographic and clinical characteristics of the two intervention groups were comparable at baseline. The mean blood pressures and heart rates at 15, 30, 45, and 60 minutes postmydriasis did not significantly differ between the two groups. Four patients from the tropicamide group, and none from the phenylephrine+tropicamide group had tachycardia (p=0.1153). On the other hand, five patients from the tropicamide group, and four from the phenylephrine+tropicamide group had bradycardia (p=1.0000). @*Conclusion@#Hemodynamic outcomes did not significantly differ up to 60 minutes after mydriasis between patients who received tropicamide+phenylephrine drops and those who received tropicamide drops.

Proper administration of psychostimulants

Psychostimulants are a broad class of sympathomimetic drugs that include drugs of abuse, such as illegal substances, as well as therapeutic drugs, such as methylphenidate and modafinil. The common effect of psychostimulants is to improve motivation, mood, movement, energy, wakefulness, arousal, anorexia and attention. Methylphenidate and modafinil are psychostimulants used in the treatment of attention deficit hyperactivity disorder and narcolepsy. They have also been found to be effective for treating certain cognitive disorders that result in secondary depression or profound apathy, obesity, cancer-related fatigue as well as in specific treatment-resistant depressions as an augmentation therapy with antidepressants. Psychostimulants are also used in an non-medical manner, such as cognitive and/or performance enhancers in healthy population. However, the most limiting adverse effect of psychostimulants is their vulnerability to psychological and physical dependence. Therefore, the abuse and misuse of stimulants, including methylphenidate and modafinil, for the purpose of neuroenhancement is an issue of concern throughout the world including Korea. Although several recent studies have reported on the cognitive and performance enhancement effects of methylphenidate and modafinil in healthy population, psychostimulants should be administered with discretion in the light of their potential adverse effects and the lacks of long-standing efficacy.

Elucidation of the profound antagonism of contractile action of phenylephrine in rat aorta effected by an atypical sympathomimetic decongestant

Vasoconstrictive properties of sympathomimetic drugs are the basis of their widespread use as decongestants and possible source of adverse responses. Insufficiently substantiated practice of combining decongestants in some marketed preparations, such are those containing phenylephrine and lerimazoline, may affect the overall contractile activity, and thus their therapeutic utility. This study aimed to examine the interaction between lerimazoline and phenylephrine in isolated rat aortic rings, and also to assess the substrate of the obtained lerimazoline-induced attenuation of phenylephrine contraction. Namely, while lower concentrations of lerimazoline (10⁻⁶ M and especially 10⁻⁷ M) expectedly tended to potentiate the phenylephrine-induced contractions, lerimazoline in higher concentrations (10⁻⁴ M and above) unexpectedly and profoundly depleted the phenylephrine concentration-response curve. Suppression of NO with NO synthase (NOS) inhibitor N(w)-nitro-L-arginine methyl ester (L-NAME; 10⁻⁴ M) or NO scavanger OHB₁₂ (10⁻³ M), as well as non-specific inhibition of K⁺-channels with tetraethylammonium (TEA; 10⁻³ M), have reversed lerimazoline-induced relaxation of phenylephrine contractions, while cyclooxygenase inhibitor indomethacin (10⁻⁵ M) did not affect the interaction between two vasoconstrictors. At the receptor level, non-selective 5-HT receptor antagonist methiothepin reversed the attenuating effect of lerimazoline on phenylephrine contraction when applied at 3×10⁻⁷ and 10⁻⁶ M, but not at the highest concentration (10⁻⁴ M). Neither the 5-HT1D-receptor selective antagonist BRL 15572 (10⁻⁶ M) nor 5-HT₇ receptor selective antagonist SB 269970 (10⁻⁶ M) affected the lerimazoline-induced attenuation of phenylephrine activity. The mechanism of lerimazoline-induced suppression of phenylephrine contractions may involve potentiation of activity of NO and K⁺-channels and activation of some methiothepin-sensitive receptors, possibly of the 5-HT(2B) subtype.

Characteristics and Risk Factors for Mortality in Paediatric In-Hospital Cardiac Events in Singapore: Retrospective Single Centre Experience

: There is limited data on paediatric resuscitation outcomes in Asia. We aimed to describe outcomes of paediatric in-hospital cardiac arrests (IHCA) and peri-resuscitation factors associated with mortality in our institution.: Using data from our hospital's code registry from 2009 to 2014, we analysed all patients younger than 18 years of age with IHCA who required cardiopulmonary resuscitation (CPR). Exposure variables were obtained from clinical demographics, CPR and post-resuscitation data. Outcomes measured were: survival after initial CPR event and survival to hospital discharge. We analysed categorical and continuous variables with Fisher's exact and Wilcoxon rank- sum tests respectively. Statistical significance was taken as<0.05.: We identified 51 patients in the study period. Median age of patients was 1.9 (interquartile range [IQR]: 0.3, 5.5) years. Twenty-six (51%) patients had bradycardia as the first-recorded rhythm. The most common pre-existing medical condition was respiratory-related (n = 25, 48%). Thirty-eight (75%) achieved sustained return of spontaneous circulation, 24 (47%) survived to paediatric intensive care unit (PICU) discharge and 23 (45%) survived to hospital discharge. Risk factors for hospital mortality included: age, duration of CPR, adrenaline, calcium or bicarbonate administration during CPR, Paediatric Index of Mortality (PIM)- II scores, first recorded post-resuscitation pH and hyperglycaemia within 24 hours of resuscitation.: We demonstrated an association between clinical demographics (age, PIM-II scores), CPR variables (duration of CPR and administration of adrenaline, calcium or bicarbonate) and post-resuscitation laboratory results (first recorded pH and hyperglycaemia within 24 hours) with PICU survival. The availability and quality of post- resuscitation care may have implications on survival after paediatric IHCA.

Anaphylaxis in Children: Experience of 485 Episodes in 1,272,482 Patient Attendances at a Tertiary Paediatric Emergency Department from 2007 to 2014

: Anaphylaxis is a predominantly childhood disease. Most of the literature on anaphylaxis has emerged from Western countries. This study aimed to describe the incidence, triggers and clinical presentation of anaphylaxis among children in Singapore, look for predictors for anaphylaxis with severe outcomes, and study the incidence of biphasic reactions.: We retrospectively reviewed records of children presenting with anaphylaxis to our paediatric emergency department from 1 January 2007 to 31 December 2014.: We identified 485 cases of anaphylaxis in 445 patients. Cutaneous symptoms (urticarial/angio-oedema) were the most common across all age groups (481 cases, 99%), followed by respiratory (412, 85%), gastrointestinal (118, 24%) and cardiovascular (35, 7.2%) symptoms. Central nervous system symptoms (drowsiness/ irritability) were rare across all age groups (11, 2.2%). Food was identified as the most common trigger across all age groups (45% to 63%). Seafood was the most common food trigger (57, 25%). A total of 420 (86.6%) children were treated with adrenaline, 451 (93%) received steroids and 411 (85%) received antihistamines. Sixty-three (13%) children fulfilled the criteria of severe anaphylaxis. There was no statistically significant association between severe anaphylaxis and the type of trigger (= 0.851), nor an overall past history of atopy (= 0.428). The only independent predictor for severe anaphylaxis was a previous drug allergy (= 0.016). A very low prevalence of biphasic reactions (0.6% of study population) was noted in our study.: We described the presentation and management of anaphylaxis in the Singapore population. A history of drug allergy is associated with severe presentation. Biphasic reactions are rare in our population.

Pharmacotherapy for Obesity

Obesity is an important risk factor for metabolic disease and various cancers. Treatments of obesity include lifestyle intervention, pharmacotherapy, and bariatric surgery. If weight loss with lifestyle intervention is only modest, pharmacotherapy might be needed. Pharmacotherapy agents can be grouped by treatment period as short term or long term use agent. Several sympathomimetic drugs such as benzphetamine, diethylpropion, phendimetrazine and phentermine, are approved for short term treatment due to their safety issues. For long term treatment, orlistat, lorcaserin, and combination of phentermine/topiramate are approved by U.S. Food and Drug Administration (FDA). Orlistat partially blocks intestinal digestion of fat, therefore producing weight loss. Lorcaserin is a serotonin 2C receptor agonist. The combination of phentermine/topiramate produces a mean weight loss of 8-10 kg. Side effects of each drug are quite different. For obesity patient, side effects are important factor when choosing drugs. The goal of this article is to review currently available anti-obesity drugs.

Priapism: Current Updates in Clinical Management

Priapism is a persistent penile erection that continues for hours beyond, or is unrelated to, sexual stimulation. Priapism requires a prompt evaluation and usually requires an emergency management. There are two types of priapism: 1) ischemic (veno-occlusive or low-flow), which is found in 95% of cases, and 2) nonischemic (arterial or high-flow). Stuttering (intermittent or recurrent) priapism is a recurrent form of ischemic priapism. To initiate appropriate management, the physician must decide whether the priapism is ischemic or nonischemic. In the management of an ischemic priapism, resolution should be achieved as promptly as possible. Initial treatment is therapeutic aspiration with or without irrigation of the corpora. If this fails, intracavernous injection of sympathomimetic agents is the next step. Surgical shunts should be performed in cases involving failure of nonsurgical treatment. The first management of a nonischemic priapism should be observation. Selective arterial embolization is recommended for the management of nonischemic priapism in cases that request treatment. The goal of management for stuttering priapism is prevention of future episodes. This article provides a review of recent clinical developments in the medical and surgical management of priapism and an investigation of scientific research activity in this rapidly developing field of study.

Protective effect of Ginkgo biloba against experimental cardiotoxicity induced by isoproterenol in adult male albino rats a histological and biochemical study

The present study was designed to investigate whether Ginkgo biloba [GB] might protect the heart against myocardial injury induced by isoproterenol [ISO] on the basis of its effects on biochemical and histological parameters. Twenty four adult male albino rats [180-200 g] were used in this study. They were divided into 4 equal groups of six rats each. Group I was the control group and group II received ISO [85 mg/kg body weight [bw], subcutaneously [S.C.] for two consecutive days to induce myocardial injury. Group III received GB [200 mg/kg bw] orally by gastric gavage daily for 21 days while group IV received GB [200 mg/kg bw] orally daily for 21 days in addition to ISO [85 mg/kg bw], S.C. on the 20th and 21st day from starting GB. After 24 hours, rats were sacrificed and the levels of cardiac marker enzymes [creatine kinase-CK] and its myocardial isoenzyme [CK-MB]] were assessed in serum. Heart specimens were processed for light and electron microscopic examination. Administration of GB before ISO significantly prevented ISO-induced elevation of serum cardiac marker enzymes. Light and electron microscopic findings of the heart pretreated with GB revealed a well preserved normal morphology of cardiac muscle with minimal evidence of myocardial injury when compared to ISO-treated hearts. This study demonstrated that GB had a significant effect in the protection of heart against myocardial injury induced by ISO. This beneficial effect was mostly related to its antioxidant property. The results of the present investigation may trigger an interest towards the use of GB in myocardial infarction

Hypotension in preterm infants.

PURPOSE: Hypotension is a frequent occurrence in sick preterm neonates. It is important to appropriately recognise and treat hypotension in preterm infants due to the possible association with short and long term adverse outcomes. SEARCH STRATEGY: An extensive search for relevant articles was carried out on PubMed, Embase and Cochrane database of systematic reviews. Cross references were hand searched. CONCLUSIONS: The pathophysiology hypotension in preterm infants is multifactorial. Hypovolemia plays only a minor role in the absence of overt fluid losses. Cardiac dysfunction seems to be a factor in some neonates. Assessment of hypotension should be based on an overall clinical condition. Overzealous fluid administration seems to be associated with adverse outcomes and should be avoided in the absence of obvious fluid losses. Inotropes should be used if fluid boluses fail to correct hypotension. Dopamine is the most effective inotrope. Dobutamine can be used as add on therapy or as first line if cardiac dysfunction is an obvious cause. Evidence points to hypocortisolism in at least some hypotensive infants. Steroids have been used successfully in inotrope-resistant hypotension in some infants. Steroids should be used judiciously since there have been concerns about adverse neurological outcome in preterm infants who received steroids in the neonatal period.

A Case of Anaphylaxis to Chlorhexidine during Digital Rectal Examination

Chlorhexidine is widely used as an antiseptic and disinfectant in medical and nonmedical environments. Although the sensitization rate seems to be low, its ubiquitous use raises the possibility of sensitization in many patients and medical care workers. We describe a patient with anaphylaxis during digital rectal examination with chlorhexidine jelly. Urticaria, angioedema, dyspnea, and hypotension developed within a few minutes of the rectal examination. The patient fully recovered after treatment with epinephrine and corticosteroids. Skin tests for chlorhexidine were undertaken 5 weeks later, showing positive prick and intradermal skin tests. Within 30 min of the skin test, the patient complained of febrile sensation, chest tightness, angioedema, and urticaria on the face and trunk. An enzyme allergosorbent test for latex was negative. We present this case to alert clinicians about hypersensitivity to chlorhexidine that could potentially be life-threatening. We suggest that chlorhexidine should be recognized as a causative agent of anaphylaxis during procedural interventions.

Effect of Intracoronary Shunt on Right Ventricular Function During Off-pump Grafting of Dominant Right Coronary Artery with Poor Collateral

Although numerous studies have validated the efficacy of intracoronary shunt on reducing left ventricular dysfunction during off-pump coronary artery bypass surgery (OPCAB), there is lack of evidence supporting its role on right ventricular (RV) function during right coronary artery (RCA) revascularization. Therefore, we studied the effect of intracoronary shunt during grafting of dominant RCA without visible collateral supply on global RV function using thermodilution method. Forty patients scheduled for multivessel OPCAB with right dominant coronary circulation without collateral supply confirmed by angiography were randomized to RCA revascularization either with a shunt (n=20) or soft snare occlusion (n=20). RV ejection fraction (RVEF) was recorded at baseline, during RCA grafting, and 15 min after reperfusion. Corresponding RV stroke work index (RVSWI) was calculated. RVEF and RVSWI decreased significantly during RCA grafting and returned to baseline values after reperfusion in both groups without any significant differences between the groups. Intracoronary shunt did not exert any beneficial effect on global RV function during RCA grafting, even in the absence of visible collateral supply. Regarding the possibility of graft failure by intracoronary shunt-induced endothelial damage, routine use of intracoronary shunt during RCA grafting is not recommended in patients with preserved biventricular function.

Lead acetate induced contraction in rat tracheal smooth muscle is independent of epithelium.

Airways are the primary target of lead exposure from atmospheric pollution, its effect on airway smooth muscle and their responsiveness to bronchoactive agents is not clearly understood. In the present investigation the effect of lead on the isolated airway smooth muscle activity was studied in organ bath set-up. Further the involvement of airway epithelium was examined and the responsiveness of airway smooth muscle to adenosine, acetylcholine (bronchoconstrictors) and isoproterenol (bronchodilator) was also investigated. Lead in concentration of 10(-12) M to 10(-4) M produced concentration-dependant contractile response in rat tracheal rings. Acetylcholine and adenosine induced concentration-dependent contractile response was slightly inhibited after lead exposure. The relaxant response to isoproterenol was also inhibited in lead exposed tissues. Epithelium removal did not significantly change the contractile response to lead suggesting that the lead induced contraction of airway smooth muscle is epithelium independent.

Terapéutica en el glaucoma crónico de ángulo abierto / Therapeutic in the open angle chronic glaucoma

El objetivo fundamental del tratamiento en el glaucoma es evitar la progresión de la neuropatía óptica glaucomatosa. El tratamiento farmacológico está dirigido básicamente a disminuir la producción de humor acuoso en el epitelio ciliar, aumentar su evacuaciòn por la vía uveo escleral o por la vía trabecular. El glaucoma se encuentra entre las primeras causas de ceguera en el mundo. En este trabajo presentamos los medicamentos más recomendados en el glaucoma primario de ángulo abierto...

Determinação de efedrinas em urina por cromatografia em fase gasosa (CG/DNP) para o controle da dopagem no esporte / Gas chromatographic mehod for the determination of ephedrines in urine for doping control purposes

Efedrinas sao aminas simpatomiméticas componentes de diversas especialidades farmacêuticas, utilizadas no tratamento de doenças respiratórias devido à sua ação descongestionante e broncodilatora. Atualmente, diversos produtos comercializados como suplementos nutricionais contêm efedrinas e são amplamente utilizados no meio esportivo, com o objetivo de facilitar a queima de gorduras e melhorar o desempenho. Entretanto, o uso indiscriminado destas substâncias pode acarretar série de efeitos tóxicos como hipertensão, taquicardia, cefaléia e tremores. Devido à sua ação psicoestimulante, foram incluídas na lista de substâncias proibidas nas atividades esportivas pelo Comitê Olímpico Internacional (COI) e estabelecidas...

Recent trends in management of noctural enuresis

There are many different treatment modalities for nocturnal enuresis options of treatment include behavior modification and Pharmacotherapy. The latter include a scope of drugs like 1-deamino-8-D arginine vasopressin [DDAVP], tricyclic antidepressants anticholinergics and other drugs. Is to study the efficacy of sympathomimetics [e.g. ephedrine] in the treatment of nocturnal enuresis. Two hundred patients selected after complete history, examination, laboratory, radiological and urodynamic study, those patients were given ephedrine HCL according to their age for 2 months and followed for 6 months. Complete dry bed: 172 patients [86%] within the first 2 weeks of treatment and the number increased to reach 189 patients [92%] after 2 months of treatment. Eight patients [4%] complained of relapse after 3 months of stoppage of treatment and the number increased after 6 months of stoppage of treatment to 13 patients [6.5%]. Alpha sympathomimetics [ephedrine HCL] is a cheap, simple, easy, effective and safe method for nocturnal enuresis treatment

Effects of isoproterenol on weight and cell structure of parotid and submandibular salivary glands in stray dogs

Isoproterenol is a sympathomimetic agent that has been used for treatment of cardiac and respiratory diseases such as atrio-ventricular block, cardiac arrest and asthma in human and animals. Isoproterenol stimulates Beta adrenergic receptors in secretory units of salivary glands and causes increasing of salivation and histomorphological changes in short and long terms, respectively. Twenty adult female stray dogs were used as control and treatment groups. Chronic treatment ofisoproterenol with dosage of 0.3 mg per kg [19.9 +/- 1.4 kg bw] for 20 days revealed remarkable changes on weight of the parotid and submandibular salivary glands. In treatment group, histomorphological changes in submandibular gland were more clear than parotid and its mean weight from 8086 +/- 172 mg increased to 18587 +/- 379 mg. Hyperplasia and hypertrophy of secretory units in the submandibular gland were also detectable. As a result, the histomorphological differences that have been seen in this research between parotid and submandibular salivary glands can be related to type of receptors of secretory units