Three cases of corticosteroid therapy triggering ventricular fibrillation in J-wave syndromes

Bradycardia after pulse methylprednisolone therapy in a child-Uncommon side effect of a frequently used drug: A case report

Corticosteroids are potent anti-inflammatory agents used as a mainstay of therapy in most of the rheumatologic disorders. Common side effects of pulse steroid therapy include hypertension, hyperglycemia, seizure, hypokalemia, and infection. We report a case of an 11-year-old girl with polyarticular Juvenile idiopathic arthritis who developed bradycardia following pulse methylprednisolone therapy. On day 2 of methylprednisolone infusion, she developed bradycardia with a heart rate between 50 and 60/min. ECG was suggestive of sinus bradycardia. There was no evidence of dyselectrolytemia (Na-141 mmol/l, K-3.54 mmol/l, Ca-8.72 mg/l) or sepsis. The patient did not receive methylprednisolone on day 3 and vitals continued to be monitored. Her heart rate improved after 12 hours. In the mid of infusion on day 4, again the patient had bradycardia with a heart rate of 50-60/minute. Since she was hemodynamically stable, we continued the infusion, and bradycardia resolved in the next 8 hours. On follow-up after 2 weeks, she had some improvement in joint symptoms and normal heart rate. As per Naranjo adverse drug reaction probability scale, the adverse reaction in our case was probable with a score of 8. Although bradycardia associated with pulse steroid therapy is benign and is usually reversible following cessation of therapy, a baseline heart rate, ECG, and electrolyte level are suggested before infusion as a cautionary measure to minimize serious adverse events.

Polypharmacy and Malnutrition Management of Elderly Perioperative Patients with Cancer: A Systematic Review

Malnutrition, which commonly occurs in perioperative patients with cancer, leads to decreased muscle mass, hypoalbuminemia, and edema, thereby increasing the patient's risk of various complications. Thus, the nutritional management of perioperative patients with cancer should be focused on to ensure that surgical treatment is safe and effective, postoperative complications are prevented, and mortality is reduced. Pathophysiological and drug-induced factors in elderly patients with cancer are associated with the risk of developing malnutrition. Pathophysiological factors include the effects of tumors, cachexia, and anorexia of aging. Metabolic changes, such as inflammation, excess catabolism, and anabolic resistance in patients with tumor-induced cancer alter the body's ability to use essential nutrients. Drug-induced factors include the side effects of anticancer drugs and polypharmacy. Drug-drug, drug-disease, drug-nutrient, and drug-food interactions can significantly affect the patient's nutritional status. Furthermore, malnutrition may affect pharmacokinetics and pharmacodynamics, potentiate drug effects, and cause side effects. This review outlines polypharmacy and malnutrition, the impact of malnutrition on drug efficacy, drug-nutrient and drug-food interactions, and intervention effects on polypharmacy or cancer cachexia in elderly perioperative patients with cancer.

Noncontact Wearable Wireless ECG Systems for Long-Term Monitoring

Electrocardiography (ECG) is the most common and extensively used vital sign monitoring method in modern healthcare systems. Different designs of ambulatory ECG systems were developed as alternatives to the commonly used 12-lead clinical ECG systems. These designs primarily focus on portability and user convenience, while maintaining signal integrity and lowering power consumption. Here, a wireless ECG monitoring system is developed using flexible and dry capacitive electrodes for long-term monitoring of cardiovascular health. Our capacitive-coupled dry electrodes can measure ECG signals over a textile-based interface material between the skin and electrodes. The electrodes are connected to a data acquisition system that receives the raw ECG signals from the electrodes and transmits the data using Bluetooth to a computer. A software application was developed to process, store, and display the ECG signal in real time. ECG measurements were obtained over different types of textile materials and in the presence of body movements. Our experimental results show that the performance of our ECG system is comparable to other reported ECG monitoring systems. In addition, to put this research into perspective, recent ambulatory ECG monitoring systems, ECG systems-on-chip, commercial ECG monitoring systems, and different state-of-the-art ECG systems are reviewed, compared, and critically discussed.

Ventricular repolarization disturbances after high dose intravenous methylprednisolone Theraphy

OBJECTIVE

There are no randomized trials evaluating the effects of pulse steroid treatment on cardiac electrophysiologic functions. The data are limited only to case series. In this study, we sought to evaluate the effects of high dose intravenous methylprednisolone therapy on indices of ventricular repolarization.

METHODS

Fifty patients with various autoimmune and inflammatory disorders were enrolled to the study. Electrocardiography (ECG) was obtained 4h before and 12h after the pulse steroid treatment. All ECGs were thoroughly evaluated by an experienced electrophysiologist. Indices of ventricular repolarization including QTc, JT, Tp-Te, Tp-Te/QTc were measured and compared with before and after-treatment ECGs.

RESULTS

There were 36 female and 14 male patients. Mean age was 36±13years. Heart rate was significantly reduced after the therapy (87,16±17,45bpm vs 73,86±17,45 p:0,001). QT interval (361,0±29,91 vs 388,20±42,84 p:0,001) and corrected QT interval (QTc) was significantly prolonged (401,60±19,79 vs 413,72±26,38 p:0,01) after pulse steroid therapy. Also, JT interval (273,0±28,73 vs. 299,60±45,66 p:0,001) and JT interval index (JTI%) was significantly prolonged (118,18±17,54 vs. 110,56±13,92 p:0,01). Tp-e interval was significantly prolonged after high-dose steroid treatment (74,60±13,12 vs. 83,80±13,68 p:0.001). The ratio of Tp-Te to QTc was also significantly increased after pulse steroid therapy (0,18±0,03 vs 0,20±0,03 p:0,009).

CONCLUSION

Our study shows that indices of ventricular repolarization are significantly prolonged after pulse steroid treatment. These findings indicate an increased risk of arrhythmias related to high dose intravenous methylprednisolone therapy.

Insight into specific pro-arrhythmic triggers in Brugada and early repolarization syndromes: results of long-term follow-up

The pro-arrhythmic triggers in Brugada and early repolarization syndromes (BrS, ERS) have not been analyzed systematically except for case reports. We clinically investigated the circumstances which precede/predispose to arrhythmic events in these syndromes during long-term follow-up. A detailed history from the patients/witnesses was taken to investigate the antecedent events in the last few hours that preceded syncope/ventricular fibrillation (VF); medical records, ECG and blood test from the emergency room (ER) were reviewed. 19 patients that fulfilled the investigation criteria were followed up for 71 ± 49 months (34-190 months). Prior to the event (syncope/VF), the patients were partaking different activities in the following decreasing order; drinking alcoholic beverage, having meal, and getting up from sleep, exercise. 3 patients reported mental/physical stress prior to the event and 2 patients developed VF several days after starting oral steroid for treatment of bronchial asthma. In the ER, elevated J-wave amplitude (0.27 ± 0.15 mV) was found with 58 % of the patients having hypokalemia. After electrolyte correction and cessation of steroids, the following day plasma K⁺ (4.2 ± 0.3 mEq/L, P < 0.001) was significantly increased and J-wave amplitude (0.13 ± 0.1 mV, P < 0.001) was remarkably reduced. Three patients were kept on oral spironolactone/potassium supplements. During follow-up for 71 ± 49 (34-190) months, among 4 patients with VF recurrence, one patient developed VF after taking oral steroid. In ERS and BrS, hypokalemia and corticosteroid therapy add substantial pro-arrhythmic effects, but potentially treatable. Stopping steroid therapy and avoiding hypokalemia had excellent long-term outcome.