Increased expression of six-large extracellular vesicle-derived miRNAs signature for nonvalvular atrial fibrillation.

BACKGROUNDS: Non-valvular atrial fibrillation (AF) is the most common type of cardiac arrhythmia. AF is caused by electrophysiological abnormalities and alteration of atrial tissues, which leads to the generation of abnormal electrical impulses. Extracellular vesicles (EVs) are membrane-bound vesicles released by all cell types. Large EVs (lEVs) are secreted by the outward budding of the plasma membrane during cell activation or cell stress. lEVs are thought to act as vehicles for miRNAs to modulate cardiovascular function, and to be involved in the pathophysiology of cardiovascular diseases (CVDs), including AF. This study identified lEV-miRNAs that were differentially expressed between AF patients and non-AF controls. METHODS: lEVs were isolated by differential centrifugation and characterized by Nanoparticle Tracking Analysis (NTA), Transmission Electron Microscopy (TEM), flow cytometry and Western blot analysis. For the discovery phase, 12 AF patients and 12 non-AF controls were enrolled to determine lEV-miRNA profile using quantitative reverse transcription polymerase chain reaction array. The candidate miRNAs were confirmed their expression in a validation cohort using droplet digital PCR (30 AF, 30 controls). Bioinformatics analysis was used to predict their target genes and functional pathways. RESULTS: TEM, NTA and flow cytometry demonstrated that lEVs presented as cup shape vesicles with a size ranging from 100 to 1000 nm. AF patients had significantly higher levels of lEVs at the size of 101-200 nm than non-AF controls. Western blot analysis was used to confirm EV markers and showed the high level of cardiomyocyte expression (Caveolin-3) in lEVs from AF patients. Nineteen miRNAs were significantly higher (> twofold, p < 0.05) in AF patients compared to non-AF controls. Six highly expressed miRNAs (miR-106b-3p, miR-590-5p, miR-339-3p, miR-378-3p, miR-328-3p, and miR-532-3p) were selected to confirm their expression. Logistic regression analysis showed that increases in the levels of these 6 highly expressed miRNAs associated with AF. The possible functional roles of these lEV-miRNAs may involve in arrhythmogenesis, cell apoptosis, cell proliferation, oxygen hemostasis, and structural remodeling in AF. CONCLUSION: Increased expression of six lEV-miRNAs reflects the pathophysiology of AF that may provide fundamental knowledge to develop the novel biomarkers for diagnosis or monitoring the patients with the high risk of AF.

The benefits of a novel chicken-based oral nutritional supplement for older adults: A double-blind randomized controlled trial.

BACKGROUND AND OBJECTIVES: A considerable proportion of older adults are lactose intolerant. The aim of this study was to investigate the clinical safety, efficacy, and tolerability of a chicken-based oral nutritional supplement (ONS). METHODS AND STUDY DESIGN: Double-blind randomized controlled trial. Subjects in the intervention group received chicken-based ONS, and those in the control group received a similarly flavored oral fluid placebo. All subjects were followed-up every two months for a total of 6 months. RESULTS: Thirty-eight older adults aged ≥70 years were recruited. The mean age and BMI were 81.5±5.6 years and 19.6±2.5 kg/m2. At the end of this trial, there was no statistically significant change in sarcopenia-related variables in the intervention group. However, the higher-level physical activity (PA) group within the intervention group had a significantly improved usual gait speed (UGS) compared to the lower-level PA group (p=0.04). The adjusted mean differences in UGS between the high and low level PA groups in the intervention and placebo groups were 0.149 m/sec and 0.083 m/sec, respectively. Significant difference was observed for changes in two bone markers between the intervention and placebo groups. CONCLUSIONS: The chicken-based ONS evaluated in this study was well-tolerated. No improvement of sarcopenia-related components was shown by the study ONS. Up to nearly an 80% increase in adjusted mean difference in UGS between the high and low level PA groups was observed in the nutritional intervention group compared to the zero-protein calorie placebo group. Significant improvement in age-related bone resorption was the earliest advantage of taking our ONS.

Differentiation of Takotsubo Cardiomyopathy from ST Elevation Myocardial Infarction in Patients Activated for Fast-Track Coronary Angiography.

Objective: To compare clinical and electrocardiographic (ECG) features between Takotsubo cardiomyopathy (TC) and ST-elevation myocardial infarction (STEMI). Material and Method: We retrospectively reviewed clinical, electrocardiographic, and laboratory features of 20 consecutive TC patients and 155 consecutive STEMI patients who were activated for fast-track coronary angiography and were ultimately diagnosed with either TC or STEMI and compared these data between the two groups. Results: Patients with TC were older (p = 0.001), more often female (p = 0.001), had more often been triggered by intense emotional or physical stress (p = 0.001) or illness (p = 0.001), and had a lower rate of smoking (p = 0.005) than STEMI patients. Compared with patients who presented with anterior wall STEMI, those with TC less commonly had Q waves (30.0% vs. 62.9%, p = 0.007) and reciprocal change (0.0% vs. 37.1%, p = 0.001), and had a lower rate of ST-segment elevation in lead V1 (5.0% vs. 59.8%, p = 0.001). ST-segment depression was also more common in TC in lead aVR (20.0% vs. 2.1%, p = 0.008). Previously proposed ECG criteria had low sensitivity, but high specificity in our patients. Our proposed point scoring model includes the use of both clinical and ECG findings. According to our proposed model, a score ≥4 had 90% sensitivity and 98% specificity in differentiating TC from acute anterior STEMI (AUC = 0.976, p<0.001). Conclusion: In patients activated for fast-track coronary angiography because of acute coronary ST-segment elevation syndrome, a number of clinical and ECG features differ between TC patients and patients with true STEMI. Our proposed point scoring model that uses clinical and ECG findings demonstrated improved diagnostic accuracy in differentiating TC from acute anterior STEMI.

Comparative outcomes of different endovenous thermal ablation systems on great and small saphenous vein insufficiency: Long-term results.

BACKGROUND AND OBJECTIVE: This study examined the outcomes of over a decade of endovenous thermal ablation (EVTA) treatments for great and small saphenous vein (GSV and SSV) insufficiency, utilizing three different endovenous thermal ablation systems. MATERIALS AND METHODS: This retrospective study reviewed EVTA treatments performed at an outpatient clinic (MDLSVI) from April 1999 to February 2013. Systems included 810 nm diode (hemoglobin targeting), 1,320 nm laser (water targeting) and a radiofrequency (direct thermal transfer) (RF) device. Clinical and ultrasonographic evaluation were performed before treatment and at each follow-up visit. Patients were examined yearly by Duplex ultrasonography. Success was defined as complete absence of reflux. RESULTS: Analysis of 934 treatments demonstrated that although recanalization could occur over time, endovenous ablation has a very high success rate. Ablation rates were 92.5%, 85.9%, and 71.9% at 6-months, 1-year, and 5-years after procedures. Recanalization occurred in 156 out of 934 treatments (16.7%) during the follow-up period. Among three difference systems, the total ablation success rate was significantly different (P < 0.001). The 1,320 nm Nd:YAG laser (n = 502) provided the highest ablation rate compared to the radiofrequency (n = 398) and 810 nm diode (n = 34) throughout their follow-up period, which were 8, 13, and 9 years, respectively. At 1-year follow-up, successful ablation rates of RF, 810 nm, and 1,320 nm were 78.2%, 80.8%, and 93.7%, respectively. At 5-year follow-up, successful ablation rates of RF, 810 nm, and 1,320 nm were 61.7%, 65.7%, and 84.7%, respectively. CONCLUSION: EVTA is very effective for ablation of the GSV and SSV. Complete ablation varied significantly among different systems with water targeting 1,320 nm providing the highest incidence saphenous vein ablation. This remained durable at 8-year follow-up by Duplex ultrasound.

Comparison between the effects of generic and original salmeterol/fluticasone combination (SFC) treatment on airway inflammation in stable asthmatic patients.

BACKGROUND: Little is known about the effect of inhaled corticosteroids (ICS)/long-acting beta2 agonists (LABA) in combination on inflammatory markers in asthma. In addition, therapeutic equivalence of generic salmeterol/fluticasone combination (SFC) and original SFC is as yet unknown. OBJECTIVE: To determine the effects of SFC and the effects of generic and original SFC on airway inflammation in patients with mild-to moderate stable asthma. MATERIAL AND METHOD: A randomized double-blinded, crossover non-inferiority study was conducted to compare the antiinflammatory effects of generic SFC and original SFC on sputum eosinophils as a primary outcome and fractional exhaled nitric oxide (FENO) as a secondary outcome. PATIENTS: The authors studied 51 mild-to-moderate asthmatic patients who ranged from 18 to 80 years of age and were treated with ICS or ICS/LABA of any dose, and whose asthma was stable without an exacerbation episode for at least 3 months prior to study entry. RESULTS: Both sputum eosinophils percentage and absolute eosinophil counts well correlated with FENO levels at baseline prior to the initiation of study medications. Significant reduction in sputum eosinophil percentage was observed following generic SFC and original SFC treatment. The degree of sputum eosinophil suppression by generic SFC was not inferior to original SFC, and this was not affected by treatments with the sequence of generic SFC first vs. original SFC second or original SFC first vs. generic SFC. In addition, there was no significant difference between treatments in terms of normalized gain in asthma control scores, including the number of patients found to have improved asthma control, irrespective of sequence, as change from baseline. However, this was not the case for the magnitude of FENO reduction that occurred after generic SFC treatment to a significantly larger extent than original SFC treatment. CONCLUSION: This short-term study demonstrated that there was no significant difference between generic SFC and original SFC in terms of anti-inflammatory activity and the control of asthma symptoms. However, it is completely unknown whether generic SFC could effectively prevent the development of asthma exacerbations on a long-term basis. Therefore, longer-term studies are indicated to evaluate generic SFC's relative efficacy on asthma exacerbations.

Accuracy of ECG criteria for the diagnosis of left ventricular hypertrophy: a comparison with magnetic resonance imaging.

BACKGROUND: There are many ECG criteria for the diagnosis of left ventricular hypertrophy (LVH). There are, however limited data on the accuracy of these criteria in comparison with cardiac magnetic resonance (CMR). OBJECTIVE: To determine the accuracy of ECG criteria for the diagnosis of LVH using CMR as the gold standard and to assess gender-specific data. MATERIAL AND METHOD: Patients who were referred for CMR for clinical purposes were studied. ECG and CMR were performed on the same day. Functional CMR protocol was performed for the assessment of cardiac volume, function and mass. CMR variables were indexed by the adjustment of body surface area. The following ECG criteria were used: Romhilt-Estes criteria (score at least 4 or 5 points were used in the present study), Sokolow-Lyon and Sokolow-Lyon-Rappaport, Cornell voltage and Cornell product, and sum of QRS voltage of all 12 leads. CMR of 184 subjects (120females, 64 males) free of cardiovascular disease was used as controls. Patients with left ventricular mass index above 95 percentile of gender specific left ventricular mass in control group were considered LVH. Diagnostic yield of ECG criteria for LVH was calculated for the whole group and each gender RESULTS: There were a total of 1,882 patients, 994 males and 888 females. Average age was 64.6 +/- 11.3 years. LVH was diagnosed by CMR in 23.3% in female and 25.4% in male. ECG criteria for the diagnosis of LVH had a relatively low sensitivity (0.25-0.61), and high specificity (0.75-0.95). Female had a lower sensitivity, higher specificity, higher PPV similar NPV and higher overall accuracy than male. Cornell product, Romhilt-Estes (at least 4 points) and Sokolow-Lyon were the ECG criteria with the best accuracy, sensitivity and specificity, respectively. CONCLUSION: ECG criteria for the diagnosis of LVH had a relatively low sensitivity, and high specificity. The accuracy was in the range of 0.71-0.80. Cornell product had the highest accuracy.

Increased small extracellular vesicle levels and decreased miR-126 levels associated with atrial fibrillation and coexisting diabetes mellitus.

BACKGROUND: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Diabetes mellitus (DM) is one of the risk factors for the development of stroke and thromboembolism in patients with AF. Early identification may reduce the incidence of complications and mortality in AF patients. HYPOTHESIS: AF patients with DM have different pattern of small extracellular vesicle (sEV) levels and sEV-derived microRNA (miRNA) expression compared with those without DM. METHODS: We compared sEV levels and sEV-miRNA expression in plasma from AF patients with and without DM using nanoparticle tracking analysis and droplet digital polymerase chain reaction, respectively. RESULTS: We observed a significant increase in total sEV levels (p = .004) and a significant decrease in sEV-miR-126 level (p = .004) in AF patients with DM. Multivariate logistic regression analysis revealed a positive association between total sEV levels and AF with DM (p = .019), and a negative association between sEV-miR-126 level and AF with DM (p = .031). The combination of clinical data, total sEVs, and sEV-miR-126 level had an area under the curve of 0.968 (p < .0001) for discriminating AF with DM, which was shown to be significantly better than clinical data analysis alone (p = .0368). CONCLUSIONS: These results suggest that an increased level of total sEV and a decreased sEV-miR-126 level may play a potential role in the pathophysiology and complications of AF with DM, especially endothelial dysfunction, and can be considered as an applied biomarker for distinguishing between AF with and without DM.

Are two sputum samples enough for diagnosing pulmonary tuberculosis.

OBJECTIVE: To determine the optimum number of sputum specimens for smear and culture in the diagnosis of pulmonary tuberculosis. MATERIAL AND METHOD: A retrospective study was conducted in culture-positive pulmonary tuberculosis patients at Siriraj Hospital during April 2009 to October 2010. Number of sputum specimens and microbiological results were retrieved from the microbiologic laboratory. Positive yield and incremental yield of each sputum specimen were calculated. RESULTS: There were 401 patients during the study period, 153 (38.2%) had positive smear for acid-fast bacilli. Overall diagnostic yields of solid culture media and liquid culture media, were 72.1% and 95.3% respectively. Incremental of overall diagnostic yield from 1 to 2 and 2 to 3 sputum specimens were 8% and 6% respectively. CONCLUSION: In place where a routinely combined smear and culture for every sputum sample submitted to the microbiologic laboratory, two specimens are sufficient for the diagnosis in nearly all pulmonary tuberculosis patients.

A comparison of outcomes between percutaneous coronary intervention versus coronary artery bypass surgery in octogenarian patients.

BACKGROUND: Percutaneous Coronary Intervention (PCI) is emerging as new revascularization procedure for coronary artery disease patients. The octogenarians are the most fragile and vulnerable age group for any type of revascularization therapy and usually discarded from any randomized trials. There is no consensus in the choice of treatment among octogenarians including PCI and coronary artery bypass grafting (CABG). OBJECTIVE: To compare PCI and CABG among Thai octogenarians (> or = 80 years old) with coronary artery disease for immediate and 24-month clinical outcomes. MATERIAL AND METHOD: Retrospective cohort study was conducted at Siriraj Hospital from January 2005 to December 2007 to obtain a complete 24-month follow-up period after revascularization. From CALYSTO database, a list of all octogenarians was retrieved (n = 333); after cleaning of the data, 265 patients (PCIn = 202, CABG n = 63) were enrolled for the present study. The primary endpoint is defined as a 30-day major adverse cardiac and cerebral event (MACCE). Secondary endpoint is a 24-month major adverse event (MACE). RESULTS: The 30-day MACCE were 11.4% in PCI group vs. 44.4% in CABG group (p < 0.001), all cause-mortality was 2.5% in PCI group vs. 8.3% in CABG group (p = 0.05), cardiovascular mortality was 1% vs. 5% (p = 0.046), mortality from sepsis was 1.5% vs. 1.5% (p = 1.0). Recurrent MI was 5.4% vs. 4.8% (p = 0.74). Cerebrovascular event occurred in 0.5% vs. 1.6% (p = 0.10). There was a crossover treatment as 0.5% vs. 0% (p = 1.0). There was no repeat target revascularization at 30-day in both groups. Major vascular complication due to bleeding requiring > or = 5 of pack-red cell transfusion was more common in CABG group (1.5% vs. 31.8%, p < 0.001). At 24-month follow-up, MACE were 35.2% in PCI group vs. 27.9% in CABG group (p = 0.36), all cause-mortality was 11.3% vs. 27.9% (p = 0.002), cardiovascular mortality was 1.5% vs. 11.5% (p < 0.001). Sepsis mortality was 2.5% vs. 11.1% (p = 0.05). MI occurred in 7.4% vs. 6.3% (p = 1.0). Repeat target revascularization was higher in PCI group (20.3% vs. 0%, p < 0.001). However, hospital stay was longer in CABG group (4.7 +/- 9 vs. 16.8 +/- 17.4 days, p = 0.01). CONCLUSION: The current revascularization strategy was evaluated. These results reflect our physician selection, patient willingness to undergo the treatment option. Lesser 30-day and 24-month all-caused mortality, cardiovascular mortality, hospital stay was observed in PCI treated octogenarians with a trade off of more frequent repeat target revascularization.

Predictive factors associated with resistance to initial methotrexate treatment in women with low-risk gestational trophoblastic neoplasia.

AIM: To compare clinical characteristics and identify factors predictive of resistance to initial treatment with methotrexate-folinic acid (MTX-FA) in women with low-risk gestational trophoblastic neoplasia (GTN). METHODS: Retrospective chart reviews were conducted in patients diagnosed with low-risk GTN who were treated with MTX-FA at Siriraj Hospital between 2002 and 2018. Demographic data, disease characteristics, treatment response, toxicity, and data of the subsequent pregnancy were collected and analyzed. Groups of patients who were responsive or resistant to treatment were compared. Stepwise logistic regression analysis was used to identify factors predictive of resistance to methotrexate chemotherapy. RESULTS: Totally, 113 patients were eligible for analysis. The primary remission rate was 55.8% with first-line MTX-FA. All other patients achieved remission by subsequent treatment with actinomycin D or multiple-agent chemotherapy. Relapse of disease occurred in 4.4% and the overall survival rate was 99.1%. Univariate analysis showed that pretreatment serum hCG, neutrophil-to-lymphocyte ratio at baseline, and serum hCG ratio of the first three consecutive cycles (C) were significantly associated with resistance to MTX-FA. Independent factors that predict failure to respond to first-line MTX-FA were pretreatment serum hCG ≥15,000 IU/L, a less than 4.8-fold reduction of serum hCG between cycle 1 and cycle 2 (C1/C2), and a less than seven-fold reduction of serum hCG from cycle 2 to cycle 3 (C2/C3). CONCLUSIONS: First-line MTX-FA treatment is effective in 55.8% of patients. Pretreatment serum hCG, and serum hCG ratio between consecutive treatment cycles can predict initial treatment failure.

Prevalence and prognosis of myocardial scar in patients with known or suspected coronary artery disease and normal wall motion.

BACKGROUND: Some patients may have normal wall motion after myocardial infarction. The aim of this study was to determine the prevalence and prognosis of patients with myocardial scar in the absence of abnormal wall motion. We studied patients with suspected or known coronary artery disease (CAD) who were referred for cardiovascular magnetic resonance (CMR) for the assessment of global and regional cardiac function and late gadolinium enhancement (LGE) and had normal left ventricular wall motion. Prognostic value was determined by the occurrence of hard endpoints (cardiac death and nonfatal myocardial infarction) and major adverse cardiac events (MACE) which also included hospitalization due to unstable angina or heart failure or life threatening ventricular arrhythmia. RESULTS: A total 1148 patients (70.3%) were studied. LGE was detected in 104 patients (9.1%). Prevalence of LGE increased in patients with increased left ventricular mass. Average follow-up time was 955 ± 542 days. LGE was the strongest predictor for hard endpoints and MACE. CONCLUSION: LGE was detected in 9.1% of patients with suspected or known CAD and normal wall motion. LGE was the strongest predictor of significant cardiac events.

Late gadolinium enhancement from cardiac magnetic resonance in ischemic and non-ischemic cardiomyopathy.

BACKGROUND: Diagnosis of coronary artery disease in patients with heart failure with systolic dysfunction usually requires coronary angiography. Cardiac magnetic resonance (CMR) is an accurate tool for the assessment of myocardial scar which may be the major cause of left ventricular systolic dysfunction. OBJECTIVE: This study was to determine the prevalence and the difference in pattern of late gadolinium enhancement (LGE) between patients with ischemic (ICM) and non-ischemic cardiomyopathy (NICM). MATERIAL AND METHOD: We enrolled 98 patients with heart failure and left ventricular systolic dysfunction with left ventricular ejection fraction less than 50%. Allpatients underwent CMR. CMR protocol included functional study and assessment of LGE. Left ventricular volume and ejection fraction was measured. The presence and extent of LGE including its pattern were assessed. RESULTS: There were 58 patients with ICM and 40 patients with NICM. Patients with NICM had a lower left ventricular ejection fraction than those with ICM with a similar left ventricular wall thickness. LGE was detected in 53 patients with ICM (91.5%) and 10 patients with NICM (25%). LGE pattern was transmural or subendocardial pattern in patients with ICM and midwall scar in those with NICM. CONCLUSION: The presence and pattern ofLGE can differentiate systolic heart failure from ICM and NICM.

Genetic polymorphism of low-density lipoprotein receptor did not affect treatment outcome of chronic hepatitis C genotype 3.

BACKGROUND: The low-density lipoprotein receptor (LDL-R) has been proposed to function as a receptor for the hepatitis C virus (HCV) entry. Polymorphism of LDL-R gene may influence the clearance of virus and response to treatment. This study was conducted to evaluate the association of LDL-R gene polymorphism and the response to antiviral treatment in patients with chronic HCV infection. MATERIAL AND METHOD: A total of 112 naïve patients with HCV genotype 3 were enrolled in the study. All patients were treated with a combination of pegylated interferon and ribavirin for 24 weeks. Polymerase chain reaction combined with restriction fragment length polymorphism was used to detect the polymorphism at the LDL-R gene intron 11 loci, including intron1, intron 3.1, intron 3.2, intron 4, intron 6, exon 8, intron 11, intron 13, intron 14 and 3'UTR-2 SNPs in intron 16 region. Comparisons of genotype and allele frequency between responders and nonresponders were analyzed. RESULTS: Patients had a mean age of 54 years and 43% were male. Mean HCVRNA viral load and alanine aminotransferase level were 6.3 log, IU/mL and 100 IU/L, respectively. Sustained virological response, relapse and no response were documented in 68.7%, 17.9% and 13.4%, respectively. Baseline characteristics including age, sex, body weight, aminotransferase levels and HCV RNA viral load were similar between responders and nonresponders. No statistical difference was found for either genotype distribution or allele frequency among responders and nonresponders. CONCLUSION: This study did not provide the evidence for a role of LDL-R polymorphism the response to antiviral treatment in patients with HCV genotype 3. This indicates that a genetic component via the LDL-R may not control HCV treatment outcome in HCV genotype 3

Diagnostic accuracy of quadriceps strength-based criteria compared to handgrip-based criteria for diagnosing sarcopenia and severe sarcopenia in older adults.

AIM: . Handgrip strength (HS) is an established parameter for sarcopenia diagnosis; however, a considerable proportion of older adults have some kind of hand abnormality or limitation that can prevent reliable hand muscle power testing. This study set forth to investigate the diagnostic accuracy of quadriceps strength (QS)-based criteria compared to handgrip strength (HS)-based criteria for diagnosing sarcopenia and severe sarcopenia in older adults. SETTING AND PARTICIPANTS: . A total of 381 subjects aged ≥60 years who attended the outpatient geriatric clinic at Siriraj Hospital (Bangkok, Thailand) during 2015-2017 were recruited via convenience sampling. Patients who were ambulatory, able to communicate, and without metallic prosthesis or pacemaker were eligible for inclusion. METHODS: . All consenting subjects underwent HS and QS testing, muscle mass measurement by bioelectrical impedance analysis, and gait speed analysis. The Asian Working Group for Sarcopenia (AWGS) 2019 consensus criteria were used as reference standard. RESULTS: . The prevalence of sarcopenia and severe sarcopenia by HS-based criteria was 13.9% and 6.8%, respectively. In comparison, the prevalence of sarcopenia and severe sarcopenia by QS-based criteria was 14.7% and 10.2%, respectively. The sensitivity and specificity of QS-based criteria for diagnosing sarcopenia was 100% (95% confidence interval [CI]: 93.3-100%) and 99.1% (95%CI: 97.4-99.8%), respectively. The sensitivity and specificity of QS-based criteria for diagnosing severe sarcopenia was 88.5% (95%CI: 69.9-97.6%) and 95.5% (95%CI: 92.8-97.4%), respectively. CONCLUSIONS: . With very high sensitivity and specificity, QS-based diagnostic criteria could be used to diagnose sarcopenia and severe sarcopenia in older adults whose HS measurements could not be reliably obtained. THAI CLINICAL TRIALS REGISTRY REGISTRATION NUMBER: . TCTR 20200717004.

Factors predicting outcome of cardiopulmonary resuscitation in a developing country: the Siriraj cardiopulmonary resuscitation registry.

BACKGROUND: Outcomes of cardiac arrest and cardiopulmonary resuscitation (CPR) are not usually evaluated or monitored extensively in developing countries. OBJECTIVE: To determine the outcome of CPR and the factors predicting its outcome. MATERIAL AND METHOD: Siriraj Hospital is a 2,400-bed, 17-building, university hospital. Data were analyzed from the Siriraj CPR registry which was modified from the Utstein template. Data entry consisted of demographic data, reason for cardiac arrest, rhythm causing cardiac arrest, type of ward, type of department, status of patients before the event as well as sequence of action including the use of medications and outcome of CPR. The primary outcomes were rated to return of spontaneous circulation (ROSC) and survival to discharge. Univariate and multivariable logistic regression analysis were performed. RESULTS: Approximately 95,000 patients were admitted to the hospital each year. There were a total of 2,747 CPR reports during the time frame from January 2003 to December 2006. Of these 57.9% were males. The average age was 53.3 +/- 25.2 years. Most cardiac arrests occurred in the medicine, surgery and pediatric wards. Basic life support (BLS) was started within 1 minute in 83.1% and advanced life support (ALS) was started within 4 minutes in 78.6%. Of 516 (18.8%) patients were terminal cases. Outcomes of CPR were as follows: 49.8% had ROSC, 21% survived at 24 hours, and 7.4% survived to discharge. From a logistic regression analysis, predicting factors for both ROSC and survival to discharge included non-terminal cases, witnessed arrest, non-cardiac, non-sepsis causes, and arrest during daytime. CONCLUSION: The rate of ROSC and survival to discharge from the Siriraj CPR registry were 49.8% and 7.4% respectively. Several factors can be used to predict the immediate outcome of CPR. The present analysis should help monitor the quality of CPR and post-resuscitation care and aid in the strategic planning to improve CPR outcomes.

Early defibrillation: a key for successful outcome of in-hospital cardiac arrest.

BACKGROUND: The objectives of this study were to determine 1) the rate of delayed defibrillation and 2) the importance of early defibrillation in patients with cardiac arrest who need defibrillation in a large tertiary care hospital. MATERIAL AND METHOD: We analyzed data from Siriraj cardiopulmonary resuscitation (CPR) registry from January 2005 to December 2007. The registry recorded setting and cause of cardiac arrest, timing of cardiac arrest and time initiation of each step of treatment such as basic life support (BLS), advanced life support (ALS), defibrillation, medication, time of defibrillation. Outcome was recorded as return of spontaneous circulation (ROSC) which lasted at least 20 minutes and discharge from hospital. RESULTS: A total of 2160 in-hospital cardiac arrest records were sent to CPR center and were evaluated. 612 patients (28.3%) needed defibrillation. Average age was 57.1 +/- 21.2 years. Among patients who needed defibrillation, 250 patients (40.8) had early defibrillation. Median time to defibrillation after the detection of cardiac arrest was 8 (3, 15) minutes. Factors associated with delayed defibrillation were the patients being in non-intensive care unit (non-ICU) wards, being in wards without standby defibrillator, and female gender. 283 patients (46.2%) had ROSC after CPR and 50 patients (8.2%) survived to discharge from hospital. Time to defibrillation was the most important predictor for ROSC and survival to discharge. CONCLUSION: Among in-hospital patients with cardiac arrest and who needed defibrillation, early defibrillation is the major key to a successful outcome.

N-terminal pro brain natriuretic peptide and cardiac function in doxorubicin administered pediatric patients.

OBJECTIVE: Assess the use of N terminal pro brain natriuretic peptide (NT-pro BNP) to early diagnose ventricular dysfunction in doxorubicin-administered children. MATERIAL AND METHOD: Fifty-five cancer patients who received accumulative dose of doxorubicin <300 mg/m2 (group 1), 49 cases with accumulative dose > or = 300 mg/m2 (group 2) and 52 cases as a control group (group 3) were included in the study. Electrocardiogram, chest roentgenogram, echocardiogram, and serum NT-pro BNP were studied. RESULTS: At age 1-10 years, there were significantly higher NT-pro BNP in group 2 than group 1 (384 +/- 291 vs. 92.2 +/- 89 pg/ml; p = 0.001), and than group 3 (79 +/- 92 pg/ml; p = 0.001). Patients with NT-pro BNP level > 1 SD of the control group were more likely to have abnormal > or = 2 echocardiographic parameters of left ventricular diastolic dysfunction than patients with NT-pro BNP < or = 1 SD (OR = 3.8, 95% CI 1.18-12.5). Patients in group 2 were more likely to have abnormal > or = 2 parameters of left ventricular diastolic dysfunction than patients in group 1 (OR = 2.8, 95% CI 1.07-7.7) and more likely to have NT-pro BNP >1 SD than group 1 (OR = 8, 95% CI 1.96-38.4). There were association of NT-pro BNP > 1 SD, accumulative dose of doxorubicin > or = 300 mg/m2, and early left ventricular diastolic dysfunction by echocardiogram. CONCLUSION: Serum NT-pro BNP > 1 SD has a high probability to diagnose early doxorubicin-induced cardiomyopathy in patient 1-10 years old.

Altered profile of circulating microparticles in nonvalvular atrial fibrillation.

BACKGROUND: Nonvalvular atrial fibrillation (AF) is the most common cardiac arrhythmia, and it is associated with the prothrombotic state. Circulating microparticles (cMPs) are membrane vesicles that are shed from many cell types in response to cell activation and cell apoptosis. Several studies reported that cMPs may play a role in the hypercoagulable state that can be observed in patients with AF. The aim of this study was to determine the levels of total cMPs and characterize their cellular origins in AF patients. METHODS: Atotal of 66 AF patients and 33 healthy controls were enrolled. This study investigated total cMP levels and their cellular origin in AF patients using polychromatic flow cytometry. RESULTS: AF patients had significantly higher levels of total cMPs (median 36.38, interquartile range [IQR] 21.16-68.50 × 105 counts/mL vs median 15.21, IQR 9.91-30.86 × 105 counts/mL; P = 0.004), platelet-derived MPs (PMPs) (median 10.61, IQR 6.55-18.04 × 105 counts/mL vs median 7.83, IQR 4.44-10.26 × 10/mL; P = 0.009), and endothelial-derived MPs (EMPs CD31+ CD41-) (median 2.94, IQR 1.78-0.60 × 105 counts/mL vs median 1.16, IQR 0.71-2.30 × 105 counts/mL; P = 0.001) than healthy controls after adjusting for potential confounders. Phosphatidylserine positive MP (PS + MP) levels were similar compared between AF patients and healthy controls. CONCLUSION: The results of this study revealed a marked increase in total cMP levels, and evidence of elevated endothelial damage and platelet activation, as demonstrated by increased PMP and EMP levels, in AF patients. Additional study is needed to further elucidate the role of cMPs (PMPs and EMPs) in the pathophysiology of and the complications associated with AF.

Correlation Between NT-pro BNP levels and left ventricular wall stress, sphericity index and extent of myocardial damage: a magnetic resonance imaging study.

BACKGROUND: To determine the relationship between N-terminal pro-brain natriuretic peptide (NT-pro BNP) levels and left ventricular wall stress, sphericity index, function, and extent of myocardial damage in patients with coronary artery disease and abnormal left ventricular wall motion. METHODS AND RESULTS: All patients underwent cardiac magnetic resonance imaging (CMR). Measurements of sphericity index and wall stress were performed. Percentages of myocardial scarring were calculated from delayed-enhancement images. Correlations between log NT-pro BNP levels and various parameters were evaluated. There were 125 patients with an average age of 62.6 +/- 9.6 years. Median levels of NT-proBNP were 1012 pg/mL. Average left ventricular ejection fraction (LVEF) was 37 +/- 14.4%. Log NT-proBNP levels had positive correlations with wall stress, sphericity index, left ventricular dimension, volume, mass, wall motion score, extent of myocardial scarring, and age, and had negative correlations with creatinine clearance, LVEF, stroke volume, and body size. Multiple linear regression analysis showed that diastolic and systolic wall stress and systolic sphericity index were independent predictors for log NT-proBNP levels. CONCLUSIONS: NT-proBNP levels strongly correlated with left ventricular wall stress and moderately correlated with sphericity index.

Comparison of cardiovascular magnetic resonance of late gadolinium enhancement and diastolic wall thickness to predict recovery of left ventricular function after coronary artery bypass surgery.

BACKGROUND: The objective was to compare the value of late gadolinium enhancement (LGE) and end-diastolic wall thickness (EDWT) assessed by cardiovascular magnetic resonance (CMR) in predicting recovery of left ventricular function after coronary artery bypass surgery (CABG). METHODS: We enrolled patients with coronary artery disease and left ventricular ejection fraction < 45% who were scheduled for CABG. Regional contractility was assessed by cine CMR at baseline and 4 months after CABG. EDWT and LGE were assessed at baseline. Predictors for improvement of regional contractility were analyzed. RESULTS: We studied 46 men and 4 women with an average age of 61 years. Baseline left ventricular ejection fraction was 37 +/- 13%. A total of 2,020 myocardial segments were analyzed. Abnormal wall motion and the LGE area were detected in 1,446 segments (71.6%) and 1,196 segments (59.2%) respectively. Wall motion improvement was demonstrated in 481 of 1,227 segments (39.2%) that initially had wall motion abnormalities at baseline. Logistic regression analysis showed that the LGE area, EDWT and resting wall motion grade predicted wall motion improvement. Comparison of Receiver-Operator-Characteristic (ROC) curves demonstrated that the LGE area was the most important predictor (p < 0.001). Adding information from LGE to the EDWT can decrease the number of false predictions by EDWT alone from 483 to 127 segments. CONCLUSION: LGE and EDWT are independent predictors for functional recovery after revascularization. However, LGE appears to be a more important factor and independent of EDWT.