Factors related to in-hospital heart failure are very different for unstable angina and non-ST elevation myocardial infarction

Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) resulted in different degrees of damage to the heart muscle, and yet, when factors related to in-hospital outcomes were examined, these two subsets were often lumped together as non-STelevation acute coronary syndrome. Therefore, we investigated predictors of in-hospital heart failure (HF) in UA and NSTEMI separately. Factors related to HF (Killip ≥ 2) were analyzed for NSTEMI and UA in a Thai Acute Coronary Syndrome (ACS) registry conducted in 17 institutions between 2002 and 2005. The registry comprised of 9373 single admissions age 65.1 ± 12.3 years, 40.2% women, and 45.1% with HF. There were 3548 NSTEMI and 1989 UA with HF prevalence of 56.2% and 27.4%, respectively. Heart failure patients were older, more were women, sicker (as shown by more of those with shock, postcardiac arrest, and breathless on admission), more with diabetes mellitus (DM), received less intervention and medication, and showed higher total death (19.3% vs 5.3% for NSTEMI with and without HF; and correspondingly, 5.9% and 1.9% for UA). Independent predictors (at presentation) for the development of HF following NSTEMI or UA were age (not sex), breathlessness, and less prevalence of chest pain. However, shock and DM were risks only for NSTEMI but not UA. Heart failure was found to be a factor for in-hospital death for NSTEMI only, with odds ratio of 2.84 (confidence interval 2.11–3.82) and 3.23 (2.25–4.64) for total and cardiac deaths, respectively. Non-ST-elevation myocardial infarction and UA showed substantial differences in factors related to predictors for in-hospital outcome such that these should be examined separately.     

Oral lesions and dental caries status in perinatally HIV-infected children in Northern Thailand

Summary. Objective. To describe the prevalence of oral lesions and dental caries status in perinatally HIV-infected children.
Design. A cross-sectional study.
Setting. Paediatric HIV outpatient department at the Nakornping Provincial Hospital, Chiang Mai, Thailand.
Patients and methods. Forty children with perinatal HIV infection, from early infancy to 12 years of age, were included in the study. These children were examined for oral lesions and dental caries. A number of children receiving antifungal and antiretroviral (ART) therapy were recorded.
Results. The mean DMFT and DMFS scores were both 2·1 (SD = 2·3). The dft and dfs scores were 4·1 (SD = 5·0) and 10·9 (SD = 14·8), respectively. A total of 57·5% of the children had one or more oral lesions. Oral candidiasis and hairy leukoplakia were the most common oral lesions. Only 12·5% of children had received ART. A total of 22·5% of the children had a history of receiving antifungal therapy.
Conclusions. Oral lesions and dental caries were relatively high in this study. Consequently, treatment and prevention for oral lesions and dental caries are inevitably required for children with HIV infection in Northern Thailand. Furthermore, ART should be made available for all HIV-infected children to decrease the prevalence of HIV-associated oral lesions.     

Acute aortic valvulitis as an initial presentation of systemic lupus erythematosus.

Valvular involvement in patients with systemic lupus erythematosus (SLE) is not uncommon but patients rarely present with it. The mitral valve is most commonly involved. We report a 36-year-old man who had an episode of acute fever, arthritis, and acute aortic insufficiency with a small vegetation at the tip of the aortic valve mimicking infective endocarditis, proven later to be due to SLE. SLE should be considered as one of the uncommon causes of acute aortic insufficiency.     

Correlation of selenium and zinc levels to antiretroviral treatment outcomes in Thai HIV-infected children without severe HIV symptoms

Background/Objectives:Deficiencies in antioxidants contribute to immune dysregulation and viral replication. To evaluate the correlation of selenium (Se) and zinc (Zn) levels on the treatment outcomes in HIV-infected children.Subjects/Methods:HIV-infected Thai children 1-12 years old, CD4 15-24%, without severe HIV symptoms were included. Se and Zn levels were measured by graphite furnace atomic absorption spectrometry at baseline and 48 weeks. Deficiency cutoffs were Se <0.1?μmol/l and Zn <9.9?μmol/l. Serum ferritin and C-reactive protein (CRP) were measured every 24 weeks. No micronutrient supplement was prescribed.Results:In all, 141 children (38.3% male) with a median (interquartile range (IQR)) age of 7.3 (4.2-9.0) years were enrolled. Median baseline CD4% was 20%, HIV-RNA was 4.6?log(10)copies/ml. At baseline, median (IQR) Se and Zn levels were 0.9 (0.7-1.0) μmol/l and 5.9 (4.8-6.9) μmol/l, respectively. None had Se deficiency while all had Zn deficiency. Over 48 weeks, 97 initiated antiretroviral therapy (ART) and 81% achieved HIV-RNA <50 copies/ml with 11% median CD4 gain. The mean change of Se was 0.06?μmol/l (P=0.003) and Zn was 0.42?μmol/l (P=0.003), respectively. By multivariate analysis in children who received ART, predictors for greater increase of CD4% from baseline were lower baseline CD4% (P<0.01) and higher baseline Zn level (P=0.02). The predictors for greater decrease of HIV-RNA from baseline were higher baseline HIV-RNA and higher ferritin (both P<0.01). No association of CRP with the changes from baseline of CD4% or HIV-RNA was found.Conclusion:In HIV-infected Thai children without severe immune deficiency who commenced ART, no correlation between Se and ART treatment outcomes was found. Higher pre-ART Zn levels were associated with significant increases in CD4% at 48 weeks.     

Poor quality of life among untreated Thai and Cambodian children without severe HIV symptoms

There are limited data on quality of life (QOL) 1 in untreated HIV-infected children who do not have severe HIV symptoms. Moreover, such data do not exist for Asian children. Poor QOL could be a factor in deciding if antiretroviral therapy (ART) should be initiated. Thai and Cambodian children (n=294), aged 1-11 years, na?ve to ART, with mild to moderate HIV symptoms and CD4 15-24% were enrolled. Their caregivers completed the Pediatric AIDS Clinical Trials Group QOL questionnaire prior to ART commencement. Six QOL domains were assessed using transformed scores that ranged from 0 to 100. Higher QOL scores indicated better health. Mean age was 6.1 (SD 2.8) years, mean CD4 was 723 (SD 369) cells/mm(3), 57% was female, and%CDC N:A:B was 2:63:35%. One-third knew their HIV diagnosis. Mean (SD) scores were 69.9 (17.6) for health perception, 64.5 (16.2) for physical resilience, 84.2 (15.6) for physical functioning, 77.9 (16.3) for psychosocial well-being, 74.7 (28.7) for social and role functioning, 90.0 (12.1) for health care utilization, and 87.4 (11.3) for symptoms domains. Children with CD4 counts above the 2008 World Health Organization (WHO) ART-initiation criteria (n=53) had higher scores in health perception and health care utilization than those with lower CD4 values. Younger children had poorer QOL than older children despite having similar mean CD4%. In conclusion, untreated Asian children without severe HIV symptoms had relatively low QOL scores compared to published reports in Western countries. Therapy initiation criteria by the WHO identified children with lower QOL scores to start ART; however, children who did not fit ART-initiation criteria and those who were younger also displayed poor QOL. QOL assessment should be considered in untreated children to inform decisions about when to initiate ART.     

Sustained immunologic and virologic efficacy after four years of highly active antiretroviral therapy in human immunodeficiency virus infected children in Thailand

We report the long-term efficacy of highly active antiretroviral therapy (HAART) in 107 antiretroviral-naive human immunodeficiency virus (HIV)-infected Thai children. In an intention-to-treat analysis, 70% of the children had undetectable HIV RNA titers after 192 weeks of HAART. The mean CD4 cell percentage increased from 5.3% to 26.6%. HAART is effective for HIV-infected children in this resource-poor setting despite initiation of treatment in the advanced stage of disease.