Platelet count and platelet parameters in hemoglobin E carriers.

Hemoglobinopathies are an important inherited disorder with a high prevalence in Thailand. Of several hemoglobinopathies, hemoglobin E (Hb) disorder (beta 26, GAG-AAG, Glu-Lys) is the most common. Coagulation disorders in these patients have also been proposed. Even though thrombotic risks in the patients with hemoglobin disorders from standpoints of platelet dysfunction and coagulation factors are controversial, they are in favor of thrombosis due to thrombocytosis. A study was performed in 57 healthy subjects to evaluate platelet count and platelet parameters in hemoglobin E carriers compared to values in healthy subjects. Classified by standard hemoglobin electrophoresis, there were 46 healthy subjects and 11 hemoglobin E carriers. There are no significant differences in platelet count and platelet parameters between the two groups (p > 0.05). Although there are reports that indicate the change in the quality of platelet in hemoglobin E disorders, no quantitative disorder was detected. There was no trend toward increased platelet count in the HbE carriers.     

MR-Guided Vertebroplasty With Augmented Reality Image Overlay Navigation

Purpose

To evaluate the feasibility of magnetic resonance imaging (MRI)-guided vertebroplasty at 1.5 Tesla using augmented reality image overlay navigation.

Materials and Methods

Twenty-five unilateral vertebroplasties [5 of 25 (20 %) thoracic, 20 of 25 (80 %) lumbar] were prospectively planned in 5 human cadavers. A clinical 1.5-Teslan MRI system was used. An augmented reality image overlay navigation system and 3D Slicer visualization software were used for MRI display, planning, and needle navigation. Intermittent MRI was used to monitor placement of the MRI-compatible vertebroplasty needle. Cement injections (3 ml of polymethylmethacrylate) were performed outside the bore. The cement deposits were assessed on intermediate-weighted MR images. Outcome variables included type of vertebral body access, number of required intermittent MRI control steps, location of final needle tip position, cement deposit location, and vertebroplasty time.

Results

All planned procedures (25 of 25, 100 %) were performed. Sixteen of 25 (64 %) transpedicular and 9 of 25 (36 %) parapedicular access routes were used. Six (range 3–9) MRI control steps were required for needle placement. No inadvertent punctures were visualized. Final needle tip position and cement location were adequate in all cases (25 of 25, 100 %) with a target error of the final needle tip position of 6.1 ± 1.9 mm (range 0.3–8.7 mm) and a distance between the planned needle tip position and the center of the cement deposit of 4.3 mm (range 0.8–6.8 mm). Time requirement for one level was 16 (range 11–21) min.

Conclusion

MRI-guided vertebroplasty using image overlay navigation is feasible allowing for accurate vertebral body access and cement deposition in cadaveric thoracic and lumbar vertebral bodies.     

Antioxidant in plasma of hemoglobin-E trait

A study of antioxidant levels among Thai subjects with a hemoglobin E trait was undertaken. The objective of this study was to determine whether the antioxidant level would be disturbed in the HbE condition. All 185 volunteer subjects, 171 normal healthy subjects and 14 HbE carriers were recruited. For each case, an antioxidant determination was performed using the Trolox equivalent antioxidant capacity (TEAC) method. According to this study, the average antioxidant level in the healthy group was 3.439 +/- 0.220 mM Trolox equivalent, and in HbE trait group was 3.276 +/- 0.209 mM Trolox equivalent. There was a significant decrease of the antioxidant level in the HbE trait group (p = 0.008).     

Cervical Cancer Detection between Conventional and Liquid Based Cervical Cytology: a 6-Year Experience in Northern Bangkok Thailand

Objectives: To determine the prevalence of abnormal Papanicolaou (Pap) smear, cervical intraepithelial neoplasia(CIN) 2 or higher and cancer between conventional Pap smear (CPP) and liquid based Pap smear (LBP). Methods: Thisretrospective study was conducted at Bhumibol Adulyadej Hospital, Bangkok, Thailand between January 2011 andDecember 2016. Data was collected from medical records of participants who attended for cervical cancer screening test.Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for detectingCIN 2 or higher were evaluated by using the most severity of histopathology reports. Results: A total of 28,564 caseswere recruited. Prevalence of abnormal Pap smear from CPP and LBP were 4.8 % (1,092/22,552) and 5.7 % (345/6,012),respectively. Percentage of unsatisfactory smears in CPP (52.3%) was higher than LBP (40.5%). From CPP and LBP,cervical cancer percentages were 0.2 and 0.1, respectively. Sensitivity, specificity, PPV, NPV and accuracy of CPP andLBP for detection cancer were 42.5 vs 26.1%, 99.9 vs 100.0%, 69.8vs 75.0%, 99.7 vs 100.0 % and 99.7 vs 99.7%,respectively. Conclusion: Prevalence of abnormal cervical cytology and cancer from CPP and LBP were 4.8/0.2and 5.7/0.1 percent, respectively. Unsatisfactory smear of LBP was less than CPP. Sensitivity, specificity, PPV, NPVand accuracy of CPP and LBP for detection CIN 2 or higher and cancer were comparable.     

Sodium Thiosulfate as a Treatment for Calciphylaxis

The use of sodium thiosulfate has emerged as a promising treatment for calciphylaxis, albeit inconclusively in terms of efficacy and variable outcomes. Research in this field has been limited by a paucity of samples due to the rarity of the disease. We herein discuss eight calciphylaxis patients'' responses to STS, the potential predictive factors affecting outcomes and compare our results with previously published literature. We are able to show that lesion severity, concomitant drugs, and dialysis duration may be predictive factors of outcomes. Further, improvement of the wound site may be a clinically relevant prognostic determinant.     

Beneficial effects of transcatheter closure of atrial septal defects not only in young adults

Objectives: To compare cardiac events and remodeling effects after transcatheter closure of atrial septal defects (ASD) in pediatric, adult, and older adult patients. Methods: A retrospective review was conducted of 353 patients who underwent transcatheter ASD closure between February 1999 and December 2007 at Siriraj Hospital. The patients were divided into 3 groups according to age: children (<18 years; n = 99); adults (18–50 years; n = 169); and older adults (>50 years; n = 85). Cardiac events at 1 year, and changes in left and right ventricular dimensions between preprocedure and 6 months and 1 year postprocedure were compared between groups. Results: Of the 353 patients, the average size of ASD was 22.1 ± 6.6 mm. Device: ASD diameter was 1.25 ± 0.28 mm. At 1 year postprocedure, the prevalence of chest discomfort and atrial fibrillation (AF) was higher in older adult patients, compared to the other age groups. Device embolization, cardiac erosion, pericardial effusion, syncope, migraine, thrombus formation, and residual shunt did not differ between groups. Within the first 6 months, the right ventricular (RV) dimension tended to dramatically decrease, while the left ventricular (LV) dimension increased in all age groups. These changes leveled off in children and in older adults, but in the adult group (18–50 years), RV shrinkage and LV expansion continued for 1 year. A low rate of early and late complications was noted. Conclusion: Transcather closure of ASD can cause cardiac remodeling, regardless of the patient's age at the time of the procedure. For older adult patients, the long‐term risk of AF continuation and chest discomfort is likely. (J Interven Cardiol 2012;25:382–390)     

Potential Role of Neutrophil Gelatinase‐Associated Lipocalin in Identifying Critically Ill Patients With Acute Kidney Injury Stage 2–3 Who Subsequently Require Renal Replacement Therapy

Delayed initiation of renal replacement therapy (RRT) in critically ill acute kidney injury (AKI) patients results in high mortality while too early RRT causes unnecessary risks of the treatment. Current traditional indications cannot clearly identify the appropriate time for initiating RRT. This prospective cohort study was conducted to determine the accuracy of using plasma neutrophil gelatinase‐associated lipocalin (pNGAL) and urine NGAL (uNGAL) in early identifying of the AKI patients who subsequently required RRT. Forty‐seven critically ill patients with AKI stage 2–3 who did not reach the traditional indications for RRT were enrolled in this study. The pNGAL, uNGAL, and other parameters were determined in each patient. The primary end point was RRT initiation according to the traditional indications within 3 days. The mean age of the patients was 63.0 ± 18.1 years. pNGAL could predict subsequent RRT requirements with area under ROC 0.813 (P < 0.001, 95%CI 0.66–0.90). The cut‐off point of 960 ng/mL provided sensitivity and specificity of 72.2 and 89.6%, respectively, and positive and negative predictive values of 81.25% and 83.8%, respectively. The uNGAL provided slightly lower significance of statistical parameters. The combination of pNGAL level of 960 ng/mL and APACHE II score of 20 improved statistical values. In conclusion, pNGAL is an excellent early biomarker for RRT initiation in critically ill patients with AKI stage 2–3. The pNGAL value of 960 ng/mL, alone or in combination with APACHE II score might be used as the early new indicator for early initiation of RRT in AKI stage 2–3 and this might improve patient survival.     

The benefits of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers combined with calcium channel blockers on metabolic,renal, and cardiovascular outcomes in hypertensive patients: a meta-analysis

Background

The prevalence of hypertension and its associated complications are markedly growing. Most patients need more than one drug to achieve blood pressure (BP) target. However, most guidelines only focus on the first-line treatment. We conducted a meta-analysis to explore the benefits of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) combined with calcium channel blockers (CCBs) on metabolic, renal, and cardiovascular outcomes in hypertensive patients.

Methods

A systematic literature search was conducted in MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov (until April 7, 2016) to identify randomized controlled trials (RCTs) comparing the benefits of ACEIs/ARBs combined with CCBs versus other dual or triple combinations on clinical outcomes in hypertensive patients. Random effects models were used to compute the weighted mean difference (WMD) for continuous variables.

Results

Sixty RCTs (48,913 patients) were identified. When compared with other combinations, the combination of ACEIs/ARBs and CCBs had comparable WMD of systolic as well as diastolic BP (73 study arms) but provided better benefits on metabolic parameters, such as HDL, FBS, HbA1C, and serum uric acid; renal functions, including serum creatinine and estimated glomerular filtration rate; and cardiovascular diseases, including reduction of all cardiovascular events, myocardial infarction, and syncope/hypotension. A significant increase of serum potassium was observed.

Conclusion

The combination of ACEIs/ARBs with CCBs has superior benefits on metabolic, renal, and cardiovascular outcomes in hypertensive patients. Therefore, this combination should be considered whenever monotherapy does not achieve the guideline target.

     

Neutralizing antibody response after intradermal rabies vaccination in hemodialysis patients

Abnormal immune function in chronic hemodialysis (HD) patients could impair immunologic responsiveness to various vaccinations. Such inadequate response makes the HD patients to be at risk of certain fatal but preventable diseases including rabies. Although the effectiveness of rabies vaccination has been established in healthy subjects, the responsiveness of the current rabies vaccination has never been examined in HD patients. The effectiveness of post-exposure rabies vaccine was assessed in 20 stable thrice-a-week chronic HD patients who received adequate dialysis and did not have history of rabies vaccination during the last 20 years. All participants received the standard intradermal Thai Red Cross post-exposure rabies vaccination. Blood samples were obtained for determination of rabies neutralizing antibody (Nab) before the first dose (day 0) and on days 14 and 90 after vaccination. Prior to simulated vaccination, six of twenty patients already had Nab titers above the protective levels of 0.5 IU/mL while the remaining fourteen patients showed undetectable Nab. All subjects reached Nab titers above 0.5 IU/mL(acceptable level for rabies protection) by days 14 after vaccination. The geometric mean titers (GMTs) on days 14 after vaccination were 3.2 + 3.1 IU/mL (range 0.81–9.17 IU/mL). At day 90 after vaccination, 13 of 14 patients had Nab titers above the protective levels, resulting in the response rate of 92.8%. The GMTs of Nab on day 90 after vaccination were 5.09 + 1.79 IU/mL (0.42–25.0 IU/mL). There were no correlations between Nab titers and patient characteristics. No serious adverse reactions were detected. In conclusion, chronic HD patients receiving adequate dialysis have excellent protective immunological response after intradermal post-exposure rabies vaccination as WHO recommendation.