Case report
Magnesium sulphate and 123I-MIBG in pheochromocytoma: Two useful techniques for a complicated disease
Utilidad de la gammagrafia con 123 I-MIBG y del Sulfato de Magnesio en el diagnóstico y tratamiento del feocromocitoma
Read
719
Timeswas read the article
513
Total PDF
206
Total HTML
Share statistics
array:23 [ "pii" => "S003493561500105X" "issn" => "00349356" "doi" => "10.1016/j.redar.2015.04.001" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "597" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2014" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:48-53" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 551 "formatos" => array:3 [ "EPUB" => 8 "HTML" => 189 "PDF" => 354 ] ] "itemSiguiente" => array:18 [ "pii" => "S0034935615001061" "issn" => "00349356" "doi" => "10.1016/j.redar.2015.04.002" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "598" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:54-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 827 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 252 "PDF" => 572 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CASO CLÍNICO</span>" "titulo" => "Derrame pleural unilateral tras perforación vascular por catéter venoso central de inserción periférica: utilidad del verde de indocianina en el diagnóstico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "54" "paginaFinal" => "57" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Unilateral pleural effusion caused by vessel perforation due to peripherally inserted central catheter: Indocyanine green as a diagnostic tool" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 950 "Tamanyo" => 72548 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Corte coronal de la TC toracoabdominal con contraste, donde se observa el trayecto del catéter central por la vena subclavia izquierda. Perforación vascular de la vena innominada por el catéter, con extravasación del contraste al espacio pleural derecho, originando un derrame pleural masivo ipsilateral.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Álvarez-Baena, P. Duque, R. Ramos, L. Zarain Obrador, L. Fernández-Quero" "autores" => array:5 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Álvarez-Baena" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Duque" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Ramos" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Zarain Obrador" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Fernández-Quero" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935615001061?idApp=UINPBA00004N" "url" => "/00349356/0000006300000001/v1_201512230015/S0034935615001061/v1_201512230015/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0034935615002406" "issn" => "00349356" "doi" => "10.1016/j.redar.2015.11.002" "estado" => "S300" "fechaPublicacion" => "2016-01-01" "aid" => "663" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "pgl" "cita" => "Rev Esp Anestesiol Reanim. 2016;63:e1-e22" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2280 "formatos" => array:3 [ "EPUB" => 5 "HTML" => 1185 "PDF" => 1090 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Documento de consenso</span>" "titulo" => "Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e1" "paginaFinal" => "e22" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.V. Llau, F.J. Acosta, G. Escolar, E. Fernández-Mondéjar, E. Guasch, P. Marco, P. Paniagua, J.A. Páramo, M. Quintana, P. Torrabadella" "autores" => array:10 [ 0 => array:2 [ "nombre" => "J.V." "apellidos" => "Llau" ] 1 => array:2 [ "nombre" => "F.J." "apellidos" => "Acosta" ] 2 => array:2 [ "nombre" => "G." "apellidos" => "Escolar" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Fernández-Mondéjar" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Guasch" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Marco" ] 6 => array:2 [ "nombre" => "P." "apellidos" => "Paniagua" ] 7 => array:2 [ "nombre" => "J.A." "apellidos" => "Páramo" ] 8 => array:2 [ "nombre" => "M." "apellidos" => "Quintana" ] 9 => array:2 [ "nombre" => "P." "apellidos" => "Torrabadella" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935615002406?idApp=UINPBA00004N" "url" => "/00349356/0000006300000001/v1_201512230015/S0034935615002406/v1_201512230015/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Magnesium sulphate and <span class="elsevierStyleSup">123</span>I-MIBG in pheochromocytoma: Two useful techniques for a complicated disease" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "48" "paginaFinal" => "53" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Vendrell, N. Martín, A. Tejedor, J.T. Ortiz, À. Muxí, P. Taurà" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Vendrell" "email" => array:1 [ 0 => "marina_vendrell@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Tejedor" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.T." "apellidos" => "Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "À." "apellidos" => "Muxí" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "P." "apellidos" => "Taurà" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínic Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Clínic Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínic Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de la gammagrafia con 123 I-MIBG y del Sulfato de Magnesio en el diagnóstico y tratamiento del feocromocitoma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1528 "Ancho" => 1432 "Tamanyo" => 280419 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(a) Transmitral flow Doppler shows the early ventricular filling (E) and atrial contraction (A). Basal E/A relationship shows an E/A ratio of 2.154. (b) M mode echocardiography in the left ventricle reveals the improvement of heart contractility.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pheochromocytoma is a tumour of the chromaffin tissue which affects around 1 in every 2500–6500 individuals. It produces systemic effects via release of catecholamines. Its main symptoms are headaches and sustained hypertension, but paroxysmal hypertension and arrhythmias may happen. Pheochromocytoma crisis, with severe myocardial damage such as life-threatening cardiomyopathies, has a reported incidence of up to 26%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> These are probably caused by autonomic imbalance when there is an elevated secretion of catecholamines coming from the pheochromocytoma.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Paroxysmal episodes are unpredictable.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In such a setting, two particularities must be recalled. Firstly, and regarding therapeutic approach, magnesium sulphate (MgSO<span class="elsevierStyleInf">4</span>) is a well-known, safe agent, which helps in improving cardiovascular stability, as it inhibits catecholamine release, blocks catecholamine receptors, and has antiarrhythmic properties, both atrial and ventricular, related to calcium channel antagonism.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Secondly, the use of <span class="elsevierStyleSup">123</span>I-metaiodobenzylguanidine (<span class="elsevierStyleSup">123</span>I-MIBG) scintigraphy technique is not only useful to functionally confirm tumour tissue, but it can also assess severity and prognosis of cardiac failure. Also, it can be a helpful tool in establishing a differential diagnosis in case heart function fails to improve after pheochromocytoma removal.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 48-year-old woman with hypertension and type 2 diabetes mellitus consulted at her community hospital complaining of abdominal pain, nausea and vomiting. Initial exploration revealed marked hypertension (180/130<span class="elsevierStyleHsp" style=""></span>mmHg) and acute-onset dyspnoea with pulse oximeter saturation of 88% (despite rebreathing mask at 40% oxygen). During general screening, supra-ventricular paroxysmal tachycardia with haemodynamic instability occurred (60/40<span class="elsevierStyleHsp" style=""></span>mmHg), requiring cardioversion with adenosine (18<span class="elsevierStyleHsp" style=""></span>mg administered in two boluses) and amiodarone (bolus of 150<span class="elsevierStyleHsp" style=""></span>mg), as well as treatment with 1.5<span class="elsevierStyleHsp" style=""></span>μg/kg/min norepinephrine and 10<span class="elsevierStyleHsp" style=""></span>μg/kg/min dopamine.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Chest X-ray compatible with pulmonary oedema, electrocardiogram with sinus tachycardia of 130<span class="elsevierStyleHsp" style=""></span>bpm and ST-segment elevation in the anterolateral side, and elevated troponin levels suggested acute myocardial infarction Killip IV. However, emergency coronary angiography showed normal coronary arteries with normal coronary flow. Echocardiogram demonstrated a global hypokinesia of the heart with normal chamber size. Ejection fraction (EF), calculated using a biplane Simpson formula, was 20%, with an E/A ratio<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.154 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Cardiac index, measured by thermodilution method with a pulmonary arterial catheter, was 0.9<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">−2</span>. Despite vasoactive therapy with norepinephrine and dopamine, she remained hemodynamically unstable and an intra-aortic balloon pump (IABP) was placed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In this condition, she was remitted to our hospital and into the cardiology intensive care unit. Due to important blood pressure swings (varying from 170/120<span class="elsevierStyleHsp" style=""></span>mmHg to 60/35<span class="elsevierStyleHsp" style=""></span>mmHg), fluctuating from need of vasoactive (1.8<span class="elsevierStyleHsp" style=""></span>μg/kg/min norepinephrine, 25<span class="elsevierStyleHsp" style=""></span>μg/kg/min dobutamine) to hypotensive drugs (8<span class="elsevierStyleHsp" style=""></span>μg/kg/min nitroprusside), as well as persistent abdominal pain, pheochromocytoma was suspected. A bedside abdominal echography revealed a right suprarenal tumour of 60<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>52<span class="elsevierStyleHsp" style=""></span>mm, confirmed by abdominal computed tomography. In order to establish the definitive diagnosis, a <span class="elsevierStyleSup">123</span>I-MIBG scintigraphy showed a low-uptaking infrahepatic image, suggestive of pheochromocytoma necrosis. Levels of plasma metanephrines of 352<span class="elsevierStyleHsp" style=""></span>pg/mL (normal <90) and normetanephrines 7249<span class="elsevierStyleHsp" style=""></span>pg/mL (normal <200) corroborated the diagnosis. Cardiac sympathetic denervation was also assessed, by measuring the heart-to-mediastinum activity ratio at 4<span class="elsevierStyleHsp" style=""></span>h post <span class="elsevierStyleSup">123</span>I-MIBG injection in the anterior view. The ratio of 1.5 (normal >1.8) demonstrated low myocardial uptake (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At this point, the anaesthesiology team was contacted in order to optimize the patient prior to surgery since, despite aggressive pharmacological treatment with vasoactive drugs and IABP support, persistent haemodynamic instability did not allow for introduction of α blocker therapy. MgSO<span class="elsevierStyleInf">4</span> infusion was considered valuable as a bridge for α-blocker treatment. Thus, on day 3, MgSO<span class="elsevierStyleInf">4</span> infused at 1<span class="elsevierStyleHsp" style=""></span>g/h after priming dose of 2<span class="elsevierStyleHsp" style=""></span>g was added. Twenty-four hours later, the patient showed gradual stabilization (blood pressure around 100/70<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 80<span class="elsevierStyleHsp" style=""></span>bpm), with no further hypertensive crisis weaning off of vasoactive drugs, removal of IABP, and volume overload in order to refill the depleted vascular space. A bedside echocardiogram demonstrated a non-dilated left ventricle (LV), with normal motility and no segmentary alterations. Calculated EF was 45%.</p><p id="par0040" class="elsevierStylePara elsevierViewall">This favourable evolution allowed for removal of the IABP and initiation of alpha blockade on day 9, with phenoxybenzamine 10<span class="elsevierStyleHsp" style=""></span>mg thrice a day, scheduling the patient for resection of the right adrenal mass. Laparoscopic surgery was performed on day 18 after admission. Prior to surgery, echocardiogram showed a slightly hypertrophic LV, with no dilation and normal global motility. Heart valves and right side of the heart were normal. Estimated EF had increased up to 60% with complete restoration of left ventricular systolic function with light diastolic dysfunction (Doppler transmitral flow velocity E/A ratio<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.8) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Prior to anaesthesia induction, which was performed with midazolam and etomidate, to avoid severe blood pressure drops and reflex tachycardia, as well as fentanyl and cisatracurium, invasive arterial monitorisation via left radial artery was obtained. As established in our hospital's protocol, a bolus (4<span class="elsevierStyleHsp" style=""></span>g) plus infusion (1<span class="elsevierStyleHsp" style=""></span>g/h) of MgSO<span class="elsevierStyleInf">4</span> was initiated before anaesthesia induction and maintained throughout surgery, which lasted 85<span class="elsevierStyleHsp" style=""></span>min. Suprarenal gland was removed without incidences. Anaesthesia was maintained with desflorane, fentanyl and cisatracurium. Intra-operatively, a modified pulmonary arterial catheter (Swan-Ganz thermodilution ejection fraction/volumetric catheter, continuous cardiac output/continuous end diastolic volume/EF and SvO<span class="elsevierStyleInf">2</span>, model 777F8, Baxter, American Edwards L, Irvine, CA), and invasive arterial monitorisation were used.</p><p id="par0050" class="elsevierStylePara elsevierViewall">No inotropes or vasoconstrictors were needed intraoperatively, and the patient remained stable, with blood pressure around 110/70 and heart rate around 80<span class="elsevierStyleHsp" style=""></span>bpm. At this time, haemodynamic profile showed a significant CI increase (2.4–3.64<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">−1</span><span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">−2</span>) with normal right ventricular function (end-dyastolic ventricular index: 156<span class="elsevierStyleHsp" style=""></span>mL<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">−2</span>; ejection fraction index: 51%). The patient was extubed in the operating room and transferred to the reanimation ward for 24<span class="elsevierStyleHsp" style=""></span>h-control where she made an uneventful recovery. Tramadol and dexketoprophen were used for postoperative analgesia. She was discharged home 4 days after surgery with no drug therapy. The histopathological study confirmed the diagnosis of pheochromocytoma, 85% of which was necrosed. At nine months follow-up, the patient was clinically asymptomatic, hemodynamically stable, with an echocardiogram that showed normal contractility with an estimated EF of 65%.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This case report was performed in a university hospital setting, based on patient data acquired during care-as-usual. The data were analyzed retrospectively, and all requirements for patient anonymity are in agreement with the regulations of the ethical committee of our hospital for publication of patient data.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">We report the case of a patient presenting with spontaneous haemorrhagic necrosis of pheochromocytoma, with sudden release of catecholamines. This caused what is known as a catecholamine storm or “attack”, with myocardial stunning, pulmonary oedema and heart failure.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The patient had to undergo surgery for tumour removal. Prior to surgery, it is essential to block α-adrenergic receptors, since emergency surgery in absence of preparation is associated to poor survival rates. However, the patient's unstable haemodynamic condition did not allow for introduction of alpha-blockade. After ensuring there were no other treatable causes of acute-onset heart failure, such as coronary artery lesions, magnesium sulphate was used as bridge therapy for weaning off vasoactive drugs and initiation of alpha-blockade treatment.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The successful use of magnesium sulphate for prevention of catecholamine storms during surgical removal of pheochromocytoma has been known for quite a long time.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> However, MgSO<span class="elsevierStyleInf">4</span> is also useful for treating pheochromocytoma crisis, and it has been recognized as such since James et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> presented three cases of life-threatening crisis in which MgSO<span class="elsevierStyleInf">4</span> was particularly beneficial.</p><p id="par0075" class="elsevierStylePara elsevierViewall">MgSO<span class="elsevierStyleInf">4</span> has a generally marked anti-adrenergic effect, inhibiting catecholamine release and storage and mainly blocking extra-cellular and intra-cellular sites of calcium action. It is mostly well known for treatment of ventricular arrhythmias such as Torsades de Pointes because of its aforementioned action on calcium channels, but it may also be used for auricular arrhythmias, since it acts on sodium and potassium currents that affect membrane potentials in the heart's conductive system.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4,8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The haemodynamic behaviour observed in our patient suggested the protective cardiac effects of MgSO<span class="elsevierStyleInf">4</span>, improving the contractile response of stunned myocardium with a decrease of systemic vascular resistance and an increase in cardiac index without changes in heart rate or arterial pressure.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Another interesting consideration derived from this case is the use of <span class="elsevierStyleSup">123</span>I-MIBG scintigraphy. Being a norepinephrine analogue, MIBG demonstrates a high uptake in sympathetically innervated tissues, and it has been in use for diagnostic assessment of tumours that arise from neural crest cells since the 1980s. Its main goal is to functionally confirm tumour tissue that has been localized via computerized tomography scan or magnetic resonance imaging, and to diagnose extra-adrenal pheochromocytomas and remaining tumour tissue after surgery, being a useful tool for follow-up.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">However, and as in our case, once this was performed, cardiac sympathetic denervation was also assessed.</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">123</span>I-MIBG scintigraphy can also be used for the assessment of cardiac sympathetic function in heart failure. In chronic heart failure, there is a reduction in NE uptake, with an accelerated spillover in the myocardial adrenergic nerve terminals (increase in pre-synaptic activity). MIBG, with the same uptake and storage methods as NE, allows for autonomic cardiac function characterization.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> This technique can also be used in acute heart failure syndromes. As a direct effect of excessive catecholamines, myocardial injury and myocardiocyte degeneration have been reported.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In our patient, <span class="elsevierStyleSup">123</span>I-MIBG scintigraphy showed a low myocardial uptake, as demonstrated by a low heart-to-mediastinum ratio (1.5, normal >1.8) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This ratio correlates with the severity of heart failure and outcome.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> When <span class="elsevierStyleSup">123</span>I-MIBG scintigraphy for pheochromocytoma is performed, it is useful to have myocardial uptake measured by an experienced radiologist, in order to assess the influence of catecholamines on the heart.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">After pheochromoytoma removal, catecholamine over-stimulation is discontinued. Accordingly, tumour removal prompts a reversal of cardiomyopathy and associated symptoms. Heart function should improve, with the myocardium returning to normal within months.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">If heart function fails to improve, again <span class="elsevierStyleSup">123</span>I-MIBG scintigraphy proves useful. A continued heart-to-mediastinum ratio alteration may be due to a permanent remaining lesion on the heart after the insult; but it may also be because of persistent adrenergic influence on the heart, due to incomplete tumour removal, contra-lateral pheochromocytoma, or extra-adrenal paragangliomas.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion, we believe that the use of these two well-known ‘devices’ – magnesium as a therapeutic one and <span class="elsevierStyleSup">123</span>I-MIBG scintigraphy as a diagnostic and prognostic one – is a relatively simple and extremely useful approach to keep in mind when facing pheochromocytomas, helping us to better manage cardiovascular alterations caused by this tumour.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">None of the authors have declared conflict of interest related to the case.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical responsibilities</span><p id="par0125" class="elsevierStylePara elsevierViewall">The information in this case was collected during the usual process of diagnosis and treatment of a patient. The authors have followed the protocols established by the Hospital Clinic of Barcelona to access data from medical records. The patient gave permission by informed consent for the usage of such data.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres591425" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec607014" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres591426" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec607015" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethical responsibilities" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-30" "fechaAceptado" => "2015-04-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec607014" "palabras" => array:3 [ 0 => "Pheochromocytoma" 1 => "Magnesium sulphate" 2 => "Scintigraphy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec607015" "palabras" => array:3 [ 0 => "Feocromocitoma" 1 => "Sulfato de magnesio" 2 => "Gammagrafía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pheochromocytoma is a tumour of the chromaffin tissue. It may, through catecholamine release, have deleterious effects on myocardial structure.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 48-year-old woman with a history of hypertension and type II diabetes mellitus (ASA II) was diagnosed of pheochromocytoma-induced myocarditis, which caused severe cardiogenic shock, with an ejection fraction of 20%. Extreme blood pressure swings required aggressive therapy with vasoactive drugs (norepinephrine and dopamine) and an intra-aortic balloon pump, despite which severe haemodynamic instability persisted. Finally, the use of magnesium sulphate allowed for cardiovascular stabilization and weaning off vasoactive drugs prior to surgery.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">123</span>I-metaiodobenzylguanidine scintigraphy helps not only to functionally confirm tumour tissue, but also to assess severity and prognosis of cardiac failure.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Prognosis of pheochromocytoma-induced heart failure can be very poor. The use of these two well-known and relatively simple ‘tools’ for treatment and prognosis is a helpful option to keep in mind.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los feocromocitomas son tumores del tejido cromafín. Pueden, a través de la secreción de catecolaminas, causar efectos deletéreos sobre el miocardio.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Una mujer de 48 años, con antecedentes de hipertensión arterial y diabetes mellitus tipo II (ASA II) fue diagnosticada de feocromocitoma, con miocardiopatía, y shock cardiogénico con fracción de eyección del 20%. Las extremas oscilaciones hemodinámicas requirieron tratamiento con fármacos vasoactivos (noradrenalina y dopamina) así como el uso de un balón de contrapulsación intra-aórtico, a pesar de lo cual persistía la inestabilidad. Finalmente, el uso de sulfato de magnesio permitió la estabilización de la paciente, pudiéndose retirar las drogas vasoactivas previo a la cirugía.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El uso de la gammagrafía con 123-metayodobenzilguanidina sirve no sólo para la clasificación funcional del tejido tumoral, sino también para evaluar la severidad y pronóstico del fallo cardíaco.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El pronóstico de la insuficiencia cardíaca inducida por feocromocitoma puede ser grave. El uso de estas conocidas y relativamente sencillas ‘herramientas’ para el tratamiento y el pronóstico son una opción útil a tener en cuenta.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1528 "Ancho" => 1432 "Tamanyo" => 280419 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(a) Transmitral flow Doppler shows the early ventricular filling (E) and atrial contraction (A). Basal E/A relationship shows an E/A ratio of 2.154. (b) M mode echocardiography in the left ventricle reveals the improvement of heart contractility.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1872 "Ancho" => 1583 "Tamanyo" => 490217 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Calculation of <span class="elsevierStyleSup">123</span>I-metaiodobenzylguanidine (mIBG) heart-to-mediastinum ratio. Regions of interest (ROI) are drawn over the heart and mediastinum. Decreased cardiac mIBG activity: 1.51.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1604 "Ancho" => 1482 "Tamanyo" => 280654 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(a) Transmitral flow Doppler shows the early ventricular filling (E) and atrial contraction (A). Before surgery, E/A ratio is of 0.8. (b) M mode echocardiography in the left ventricle reveals the improvement of heart contractility compared to <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catecholamine-induced cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T.A. Kassim" 1 => "D.D. Clarke" 2 => "V.Q. Mai" 3 => "P.W. Clyde" 4 => "K.M. Mohammed Shakir" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4158/EP.14.9.1137" "Revista" => array:6 [ "tituloSerie" => "Endocr Pract" "fecha" => "2008" "volumen" => "14" "paginaInicial" => "1137" "paginaFinal" => "1149" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19158054" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phaeochromocytoma crisis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.C. Whitelaw" 1 => "J.K. Prague" 2 => "O.G. Mustafa" 3 => "K.M. Schulte" 4 => "P.A. Hopkins" 5 => "J.A. Gilbert" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Endocrinol" "fecha" => "2013" "volumen" => "80" "paginaInicial" => "13" "paginaFinal" => "22" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Magnesium: physiology and pharmacology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "W.J. Fawcett" 1 => "E.J. Haxby" 2 => "D.A. Male" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "1999" "volumen" => "83" "paginaInicial" => "302" "paginaFinal" => "320" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10618948" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Magnesium—essentials for anesthesiologists" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Herroeder" 1 => "M.E. Schönherr" 2 => "S.G. De Hert" 3 => "M.W. Hollmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e318210483d" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2011" "volumen" => "114" "paginaInicial" => "971" "paginaFinal" => "993" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21364460" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of 123I-MIBG scintigraphy in the evaluation of patients with known or suspected primary or metastatic pheochromocytoma or paraganglioma: results from a prospective multicenter trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.A. Wiseman" 1 => "K. Pacak" 2 => "M.S. O’Dorisio" 3 => "D.R. Neumann" 4 => "A.D. Waxman" 5 => "D.A. Mankoff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2967/jnumed.108.058701" "Revista" => array:6 [ "tituloSerie" => "J Nucl Med" "fecha" => "2009" "volumen" => "50" "paginaInicial" => "1448" "paginaFinal" => "1454" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19690028" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of magnesium sulphate in the anaesthetic management of phaeochromocytoma: a review of 17 anaesthetics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.F. James" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Br J Anaesth" "fecha" => "1989" "volumen" => "62" "paginaInicial" => "616" "paginaFinal" => "623" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2751917" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0190962210002124" "estado" => "S300" "issn" => "01909622" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pheochromocytoma crisis: the use of magnesium sulphate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.F. James" 1 => "L. Cronjé" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/01.ANE.0000133136.01381.52" "Revista" => array:7 [ "tituloSerie" => "Anesth Analg" "fecha" => "2004" "volumen" => "99" "paginaInicial" => "680" "paginaFinal" => "686" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15333393" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0190962210021171" "estado" => "S300" "issn" => "01909622" ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of pheochromocytoma: focus on magnesium, clevidipine, and vasopressin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.S. Lord" 1 => "J.G.T. Augoustides" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2012.01.002" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2012" "volumen" => "26" "paginaInicial" => "526" "paginaFinal" => "531" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22361482" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic significance of cardiac <span class="elsevierStyleSup">123</span>I metaiodobenzylguanidine imaging for mortality and morbidity in patients with chronic heart failure: a prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Ogita" 1 => "T. Shimonagata" 2 => "M. Fukunami" 3 => "K. Kumagai" 4 => "T. Yamada" 5 => "Y. Asano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2001" "volumen" => "86" "paginaInicial" => "656" "paginaFinal" => "660" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11711461" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Iodine-123-MIBG imaging in pheochromocytoma with cardiomyopathy and pulmonary edema" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Suga" 1 => "K. Tsukamoto" 2 => "K. Nishigauchi" 3 => "N. Kume" 4 => "N. Matsunaga" 5 => "T. Hayano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "J Nucl Med" "fecha" => "1996" "volumen" => "37" "paginaInicial" => "1361" "paginaFinal" => "1364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8708774" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0190962211005925" "estado" => "S300" "issn" => "01909622" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00349356/0000006300000001/v1_201512230015/S003493561500105X/v1_201512230015/en/main.assets" "Apartado" => array:4 [ "identificador" => "7568" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00349356/0000006300000001/v1_201512230015/S003493561500105X/v1_201512230015/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S003493561500105X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 3 | 1 | 4 |
| 2024 September | 6 | 2 | 8 |
| 2024 August | 0 | 2 | 2 |
| 2024 July | 0 | 1 | 1 |
| 2024 June | 0 | 1 | 1 |
| 2024 May | 0 | 4 | 4 |
| 2024 March | 0 | 1 | 1 |
| 2024 January | 1 | 3 | 4 |
| 2023 December | 0 | 1 | 1 |
| 2023 October | 0 | 3 | 3 |
| 2023 August | 0 | 2 | 2 |
| 2023 July | 0 | 3 | 3 |
| 2023 June | 0 | 2 | 2 |
| 2023 May | 0 | 2 | 2 |
| 2023 February | 0 | 5 | 5 |
| 2023 January | 0 | 1 | 1 |
| 2022 December | 0 | 1 | 1 |
| 2022 November | 0 | 3 | 3 |
| 2022 October | 1 | 2 | 3 |
| 2022 September | 0 | 6 | 6 |
| 2022 August | 1 | 6 | 7 |
| 2022 July | 0 | 1 | 1 |
| 2022 June | 0 | 1 | 1 |
| 2022 May | 0 | 2 | 2 |
| 2022 April | 0 | 21 | 21 |
| 2022 March | 0 | 16 | 16 |
| 2022 February | 0 | 2 | 2 |
| 2022 January | 0 | 1 | 1 |
| 2021 December | 0 | 1 | 1 |
| 2021 November | 1 | 0 | 1 |
| 2021 October | 0 | 4 | 4 |
| 2021 August | 1 | 9 | 10 |
| 2021 July | 2 | 6 | 8 |
| 2021 June | 0 | 4 | 4 |
| 2021 March | 0 | 7 | 7 |
| 2021 February | 0 | 3 | 3 |
| 2021 January | 0 | 5 | 5 |
| 2020 December | 0 | 1 | 1 |
| 2020 November | 0 | 2 | 2 |
| 2020 September | 0 | 1 | 1 |
| 2020 August | 1 | 1 | 2 |
| 2020 July | 0 | 1 | 1 |
| 2020 May | 0 | 3 | 3 |
| 2020 April | 0 | 6 | 6 |
| 2020 March | 0 | 4 | 4 |
| 2020 February | 0 | 7 | 7 |
| 2020 January | 0 | 2 | 2 |
| 2019 December | 0 | 5 | 5 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 1 | 3 | 4 |
| 2019 August | 0 | 4 | 4 |
| 2019 July | 0 | 7 | 7 |
| 2019 June | 0 | 9 | 9 |
| 2019 May | 0 | 15 | 15 |
| 2019 April | 0 | 7 | 7 |
| 2019 February | 0 | 1 | 1 |
| 2019 January | 0 | 1 | 1 |
| 2018 December | 0 | 4 | 4 |
| 2018 November | 0 | 4 | 4 |
| 2018 October | 0 | 3 | 3 |
| 2018 August | 0 | 6 | 6 |
| 2018 July | 0 | 5 | 5 |
| 2018 June | 0 | 5 | 5 |
| 2018 May | 0 | 14 | 14 |
| 2018 April | 0 | 2 | 2 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 0 | 1 | 1 |
| 2018 January | 0 | 6 | 6 |
| 2017 December | 0 | 3 | 3 |
| 2017 November | 1 | 4 | 5 |
| 2017 October | 0 | 3 | 3 |
| 2017 September | 1 | 8 | 9 |
| 2017 August | 0 | 10 | 10 |
| 2017 July | 17 | 8 | 25 |
| 2017 June | 26 | 16 | 42 |
| 2017 May | 20 | 15 | 35 |
| 2017 April | 27 | 16 | 43 |
| 2017 March | 24 | 43 | 67 |
| 2017 February | 33 | 7 | 40 |
| 2017 January | 14 | 4 | 18 |
| 2016 December | 0 | 5 | 5 |
| 2016 November | 1 | 6 | 7 |
| 2016 October | 2 | 7 | 9 |
| 2016 September | 0 | 8 | 8 |
| 2016 August | 2 | 8 | 10 |
| 2016 July | 1 | 4 | 5 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 1 | 14 | 15 |
| 2016 April | 2 | 7 | 9 |
| 2016 March | 1 | 9 | 10 |
| 2016 February | 1 | 11 | 12 |
| 2016 January | 14 | 21 | 35 |
Show all
