Ten-year survival and factors associated with increased mortality in patients admitted for acute decompensated heart failure in Thailand

INTRODUCTIONData on the long-term outcomes of Asian patients admitted for acute decompensated heart failure is scarce. The objectives of this study were to determine short-term, intermediate-term and long-term survival among patients admitted for acute decompensated heart failure in Thailand, and to identify factors independently associated with increased mortality.METHODSPatients who were admitted with a primary diagnosis of heart failure were enrolled in the Thai Acute Decompensated Heart Failure Registry (ADHERE) from 18 hospitals located across Thailand during 2006. Medical record data was collected according to ADHERE protocol. Mortality data was collected from death certificates on file at the Thailand Bureau of Registration Administration.RESULTSA total of 1,451 patients were included. The mean age of the patients was 63.7 ± 14.4 years, and 49.7% were male. One-year, five-year and ten-year mortality rates in Thai patients admitted for acute decompensated heart failure were 28.0%, 58.2% and 73.3%, respectively. Independent predictors of increased mortality were identified. There were more cardiovascular-related deaths than non-cardiovascular-related deaths (54.6% vs. 45.4%, respectively).CONCLUSIONSThe ten-year mortality rate in Thai patients admitted for acute decompensated heart failure was 73.3%. Many factors were found to be independently associated with increased mortality, including left ventricular ejection fraction.     

An economic evaluation of bupivacaine plus fentanyl versus ropivacaine alone for patient-controlled epidural analgesia after total-knee replacement procedure: a double-blinded randomized study

BACKGROUND AND OBJECTIVES: Total-knee replacement (TKR) surgery is one of the most painful orthopedic procedures after surgery. Opioid has been commonly combined with a local anesthetic to improve the quality of pain relief, but the treatment has opioid-related side effects. This study compared the cost effectiveness of patient-controlled epidural analgesia (PCEA) with 0.0625% bupivacaine plus fentanyl (BF) 3 microg/mL versus 0.15% ropivacaine alone (R) during the first 48 hours after TKR procedure. METHODS: This prospective randomized double-blinded study was performed on 70 patients who underwent unilateral TKR procedure and received either BF or R after surgery. Visual analog scale (VAS) pain score at rest and upon movement, side effects, and cost of treatment were compared. RESULTS: Overall pain at rest and upon movement between groups was not significantly different (P = 0.58, 95% CI = 4.4 to -7.8 and P = 0.8, 95% CI = 6.4 to -8.2, respectively). Patients in the BF group experienced more pruritus and had more vomiting episodes than those in the R group (P = .015), whereas no difference occurred in other side effects. Nevertheless, patient satisfaction with pain management was higher in the BF group compared with that in the R group. In addition, pain treatment with bupivacaine and fentanyl was 18% less costly compared with ropivacaine alone. CONCLUSIONS: Considering the economic evaluation, we conclude that PCEA with 0.0625% bupivacaine plus fentanyl 3 microg/mL is more cost effective and provides more patient satisfaction than PCEA with ropivacaine alone. However, use of epidural ropivacaine alone causes fewer opioid-related side effects, particularly pruritus and vomiting.     

Derived 12-lead electrocardiogram in the assessment of ST-segment deviation and cardiac rhythm

BACKGROUND: There are little data on the validation of 12-lead electrocardiogram (ECG) derived by the EASI lead system used for continuous monitoring in critical care settings. OBJECTIVE: The objectives of this study were to determine the accuracy of 12-lead ECG derived by the EASI lead system in the detection of ST-segment deviation and cardiac rhythm compared with the standard 12-lead ECG. METHODS: All patients admitted to the coronary care unit were studied. Kappa statistics was used to calculate the agreement between both ECG systems in the determination of cardiac rhythm and premature ventricular complex morphology. ST-segment analysis was performed in patients with acute coronary syndromes. Pearson correlation was used to correlate the ST-segment deviation between both techniques. The sensitivity and specificity of the determination of significant ST-segment deviation by the EASI lead system were calculated. RESULTS: There were a total of 282 patients enrolled in this study. There was a complete agreement in the interpretation of cardiac rhythm between the 2 methods (kappa = 1). Analysis of ST-segment deviation of 12-lead ECG also showed a significant correlation (correlation coefficient varied from 0.62 in lead I to 0.823 in lead aVF with a P value of <.001 in all leads) between the 2 methods with very high sensitivity and specificity in the detection of significant ST-segment elevation and depression. CONCLUSION: The 12-lead ECG derived by the EASI lead system is an accurate and reliable information for the assessment of ST-segment deviation and cardiac rhythm in critically ill patients.     

Vascular leakage in severe dengue virus infections: a potential role for the nonstructural viral protein NS1 and complement

BACKGROUND: Vascular leakage and shock are the major causes of death in patients with dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Thirty years ago, complement activation was proposed to be a key underlying event, but the cause of complement activation has remained unknown. METHODS: The major nonstructural dengue virus (DV) protein NS1 was tested for its capacity to activate human complement in its membrane-associated and soluble forms. Plasma samples from 163 patients with DV infection and from 19 patients with other febrile illnesses were prospectively analyzed for viral load and for levels of NS1 and complement-activation products. Blood and pleural fluids from 9 patients with DSS were also analyzed. RESULTS: Soluble NS1 activated complement to completion, and activation was enhanced by polyclonal and monoclonal antibodies against NS1. Complement was also activated by cell-associated NS1 in the presence of specific antibodies. Plasma levels of NS1 and terminal SC5b-9 complexes correlated with disease severity. Large amounts of NS1, complement anaphylatoxin C5a, and the terminal complement complex SC5b-9 were present in pleural fluids from patients with DSS. CONCLUSIONS: Complement activation mediated by NS1 leads to local and systemic generation of anaphylatoxins and SC5b-9, which may contribute to the pathogenesis of the vascular leakage that occurs in patients with DHF/DSS.     

Placebo-controlled double-blind cross-over study of botulinum A toxin in hemifacial spasm

The evaluation of the efficacy of botulinum A toxin injection for hemifacial spasm has never previously been done in a double-blind study in spite of its use as a treatment. We thus conducted a double-blind cross-over study of botulinum A toxin use in hemifacial spasm in 55 patients at Siriraj Hospital, Mahidol University, Bangkok, Thailand. Thirteen patients decided to withdraw from the study due to a lack of efficacy, all of them were subsequently found to be in the saline injection group. The remaining 42 patients, in the botulinum A toxin injection (30 mouse units) group, reported the responses as: excellent (34 patients; 80.95%), moderate patients; 2.38%). In contrast, when given the saline injection they reported no excellent outcome, 1 patient (2.38%) with moderate improvement, 5 patients (11.90%) with mild improvement and, 36 patients (85.71%) with no response. Side effects of botulinum toxin injections were found in 14.29% of patients compared with 9.5% of the saline injection group. The side effects of botulinum toxin injection were mild transient facial weakness (7.14%), local pain (4.76%) and excessive lacrimation (2.38%).

We concluded that botulinum A toxin injection was a simple and effective out-patient treatment for the management of hemifacial spasm.     

Echocardiography as a Simple Initial Tool to Assess Right Ventricular Dimensions in Patients with Repaired Tetralogy of Fallot before Undergoing Pulmonary Valve Replacement: Comparison with Cardiovascular Magnetic Resonance Imaging

Objective: Accurate assessment of the right ventricle (RV) is essential in patients with repaired tetralogy of Fallot (TOF). We proposed a simple echocardiographic method to assess the RV dimensions and evaluated the relationship between linear echocardiographic measures of the RV and RV volumes obtained by cardiovascular magnetic resonance imaging (CMR). Methods: A total of 45 patients (27.4 ± 11.2 years; 40% male) with repaired TOF underwent CMR and echocardiography. Using echocardiography, RV dimensions were assessed from the parasternal short‐axis view using the longest RV internal diameter perpendicular to the mid‐interventricular septum. Significant RV dilatation was defined as an RV end‐diastolic volume index >160 mL/m² on CMR. Results: There were significant correlations between RV dimensions determined by echocardiography and the pulmonary regurgitation fraction, RV size, and function determined by CMR. The cutoff values of echocardiographic RV outflow tract (RVOT), end‐systolic and end‐diastolic dimension indices, and the combination of RVOT and end‐diastolic dimension indices to determine significant RV dilatation were 19.0, 19.4, 24.5, and 45.2 mm/m², respectively. The positive and negative predictive values for significant RV dilatation were 89.7% and 68.8% with RVOT diameter index ≥19.0 mm/m², 85.0% and 52.4% with RV end‐systolic dimension index ≥19.4 mm/m², 87.5% and 64.7% with RV end‐diastolic dimension index ≥24.5 mm/m², and 92.3% and 80.0% with the combination of RVOT and end‐diastolic dimension indices ≥45.2 mm/m², respectively. Conclusion: Echocardiography can be used to assess RV size in patients with repaired TOF with acceptable correlations with CMR as the reference standard.     

Lymphocyte activation after non-thermal trauma

BACKGROUND: Severe injury causes immunological changes that may contribute to a poor outcome. Longitudinal characterization of lymphocyte response patterns may provide further insight into the basis of these immunological alterations. METHODS: Venous blood obtained seven times over 2 weeks from 61 patients with injury severity scores above 20 was assessed for lymphocyte phenotypic and activation markers together with serum levels of interleukin (IL) 2, IL-4, soluble IL-2 receptor (sIL-2R), soluble CD4 (sCD4), soluble CD8 (sCD8) and interferon gamma. RESULTS: Severe injury was associated with profound changes in the phenotypic and activation profile of circulating lymphocytes. Activation was indicated by increased numbers of T cells expressing CD25, CD69 and CD71, and raised serum levels of IL-2, sIL-2R, sCD4 and sCD8. Relatively higher levels of sIL-2R and sCD4 were found in patients with sepsis syndrome. CONCLUSION: Polytrauma is associated with dramatic alterations in the phenotypic and activation profile of circulating lymphocytes which are generally independent of clinical course. In contrast, several lymphocyte soluble factors, including sCD4 and sIL-2R, paralleled the clinical course. These data provide new insight into lymphocyte responses after injury and suggest that further assessment of soluble factors as clinical correlates, including those related to lymphocyte activation or generalized inflammation, may be warranted.     

Predictor of core hypothermia and the surgical intensive care unit

Inadvertent postoperative core hypothermia is associated with multiple physiological effects, especially in patients admitted to the intensive care unit (ICU). Despite previous reports of the relationship between patient, surgical, and anesthetic factors and immediate postoperative core hypothermia, this information might need to be reconsidered in the light of progress in surgery, anesthetic, and warming techniques. We designed this prospective study of 194 postgeneral surgical patients to assess the incidence, predictive factors, and outcome of core hypothermia (tympanic membrane core temperature [Tc] <36.0 degrees C) at the time of admission to the general ICU in a large tertiary university medical center from December 2000 to March 2001. The following variables were studied: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency surgery, surgical subspecialty performing surgery, type of surgery, type of anesthesia (general, regional, or combined epidural and general), temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and the ambient operating room temperature. Other outcomes, i.e., length of ICU stay and mortality, were also assessed. The incidence of core hypothermia was 57.1%, 41.3%, and 28.3% according to the definition of Tc <36.0 degrees C, <35.5 degrees C, and <35.0 degrees C, respectively. Multiple logistic regression showed the following risk factors for core hypothermia: high ASA physical status (odds ratio, 2.87; 95% confidence interval [CI], 0.82-10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67-41.88 for ASA >II), magnitude of surgical procedure (odds ratio, 6.60; 95% CI, 1.66-26.19 for medium surgery; odds ratio, 22.23; 95% CI, 5.41-91.36 for major surgery), use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05-10.88), and duration of surgery >2 h (odds ratio, 4.50; 95% CI, 1.48-13.68). Not using temperature monitoring seems to be a risk factor as well (odds ratio, 3.00; 95% CI, 0.87-10.12). Significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89-0.98), higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15-0.65), and warmer ambient operating room temperature (odds ratio, 0.67; 95% CI, 0.51-0.88). In conclusion, the incidence of core hypothermia (Tc <36.0 degrees C) at the time of admission to the general ICU is still frequent. To reduce the incidence, more efforts and concern should be taken to prevent core hypothermia, especially in the patient with high ASA physical status, undergoing more intensive and lengthy surgery, and using combined epidural and general anesthesia. IMPLICATIONS: In an effort to decrease the frequent incidence of core hypothermia at the time of admission to the general surgical intensive care unit, this prospective study showed that high ASA physical status, the use of a combined epidural and general anesthesia, surgery lasting longer than 2 h, and extensive surgery were the important risk factors, whereas heavier body weight, higher preoperative body temperature, and warmer ambient operating room temperature were important protective factors.     

Patient and parental awareness of the importance of immediate management of traumatised teeth

Abstract— The purpose of this study was to assess patient and parental awareness of the importance of immediate management of traumatised teeth. A three-part questionnaire comprising questions on demographic data, attitude and knowledge was distributed to patients or accompanying parents who presented to the principal author for treatment in an 8-week period. One hundred and fifty-seven respondents with a mean age of 31.1 years participated in the study. Only 30% of the respondents recalled having had previous experience of dental trauma. The majority of the respondents, especially those with a higher educational background, had a positive attitude, expressing enthusiasm for public education on emergency management of dental trauma (85%). The availability of an emergency service during office. hours was known by 71% of the respondents while only 26% were aware of the after-office-hour emergency service. Participants generally had a better concept of management of avulsed teeth (63%) compared to that of fractured teeth (35%). Knowledge on some critical aspects of the handling of avulsed teeth was poor (6%). Using multiple logistic regression analysis, it was found that the respondents' attitude tended to be influenced by their educational background ( P =0.08). In addition, subjects with higher education were more knowdedgeable regarding the emergency service available during office hours ( P =0.05) and the concept of management of fractured teeth ( P =0.02). Educational background appeared to influence the level of awareness of the importance of immediate management of traumatised teeth.