Safety and immunogenicity of booster vaccination and fractional dosing with Ad26.COV2.S or BNT162b2 in Ad26.COV2.S-vaccinated participants

We report the safety and immunogenicity of fractional and full dose Ad26.COV2.S and BNT162b2 in an open label phase 2 trial of participants previously vaccinated with a single dose of Ad26.COV2.S, with 91.4% showing evidence of previous SARS-CoV-2 infection. A total of 286 adults (with or without HIV) were enrolled >4 months after an Ad26.COV2.S prime and randomized 1:1:1:1 to receive either a full or half-dose booster of Ad26.COV2.S or BNT162b2 vaccine. B cell responses (binding, neutralization and antibody dependent cellular cytotoxicity-ADCC), and spike-specific T-cell responses were evaluated at baseline, 2, 12 and 24 weeks post-boost. Antibody and T-cell immunity targeting the Ad26 vector was also evaluated. No vaccine-associated serious adverse events were recorded. The full- and half-dose BNT162b2 boosted anti-SARS-CoV-2 binding antibody levels (3.9- and 4.5-fold, respectively) and neutralizing antibody levels (4.4- and 10-fold). Binding and neutralizing antibodies following half-dose Ad26.COV2.S were not significantly boosted. Full-dose Ad26.COV2.S did not boost binding antibodies but slightly enhanced neutralizing antibodies (2.1-fold). ADCC was marginally increased only after a full-dose BNT162b2. T-cell responses followed a similar pattern to neutralizing antibodies. Six months post-boost, antibody and T-cell responses had waned to baseline levels. While we detected strong anti-vector immunity, there was no correlation between anti-vector immunity in Ad26.COV2.S recipients and spike-specific neutralizing antibody or T-cell responses post-Ad26.COV2.S boosting. Overall, in the context of hybrid immunity, boosting with heterologous full- or half-dose BNT162b2 mRNA vaccine demonstrated superior immunogenicity 2 weeks post-vaccination compared to homologous Ad26.COV2.S, though rapid waning occurred by 12 weeks post-boost. Trial Registration: The study has been registered to the South African National Clinical Trial Registry (SANCTR): DOH-27-012022-7841. The approval letter from SANCTR has been provided in the up-loaded documents.

Safety and immunogenicity of booster vaccination and fractional dosing with Ad26.COV2.S or BNT162b2 in Ad26.COV2.S-vaccinated participants

Background

We report the safety and immunogenicity of fractional and full dose Ad26.COV2.S and BNT162b2 in an open label phase 2 trial of participants previously vaccinated with a single dose of Ad26.COV2.S, with 91.4% showing evidence of previous SARS-CoV-2 infection.

Methods

A total of 286 adults (with or without HIV) were enrolled >4 months after an Ad26.COV2.S prime and randomized 1:1:1:1 to receive either a full or half-dose booster of Ad26.COV2.S or BNT162b2 vaccine. B cell responses (binding, neutralization and antibody dependent cellular cytotoxicity-ADCC), and spike-specific T-cell responses were evaluated at baseline, 2, 12 and 24 weeks post-boost. Antibody and T-cell immunity targeting the Ad26 vector was also evaluated.

Results

No vaccine-associated serious adverse events were recorded. The full- and half-dose BNT162b2 boosted anti-SARS-CoV-2 binding antibody levels (3.9- and 4.5-fold, respectively) and neutralizing antibody levels (4.4- and 10-fold). Binding and neutralizing antibodies following half-dose Ad26.COV2.S were not significantly boosted. Full-dose Ad26.COV2.S did not boost binding antibodies but slightly enhanced neutralizing antibodies (2.1-fold). ADCC was marginally increased only after a full-dose BNT162b2. T-cell responses followed a similar pattern to neutralizing antibodies. Six months post-boost, antibody and T-cell responses had waned to baseline levels. While we detected strong anti-vector immunity, there was no correlation between anti-vector immunity in Ad26.COV2.S recipients and spike-specific neutralizing antibody or T-cell responses post-Ad26.COV2.S boosting.

Conclusion

In the context of hybrid immunity, boosting with heterologous full- or half-dose BNT162b2 mRNA vaccine demonstrated superior immunogenicity 2 weeks post-vaccination compared to homologous Ad26.COV2.S, though rapid waning occurred by 12 weeks post-boost.

Trial Registration

South African National Clinical Trial Registry (SANCR): DOH-27-012022-7841.

Funding

South African Medical Research Council (SAMRC) and South African Department of Health (SA DoH).

Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations

Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI).

METHODS

Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence.

CONCLUSIONS

Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine: a pooled analysis of four randomised trials

BACKGROUND

The ChAdOx1 nCoV-19 (AZD1222) vaccine has been approved for emergency use by the UK regulatory authority, Medicines and Healthcare products Regulatory Agency, with a regimen of two standard doses given with an interval of 4-12 weeks. The planned roll-out in the UK will involve vaccinating people in high-risk categories with their first dose immediately, and delivering the second dose 12 weeks later. Here, we provide both a further prespecified pooled analysis of trials of ChAdOx1 nCoV-19 and exploratory analyses of the impact on immunogenicity and efficacy of extending the interval between priming and booster doses. In addition, we show the immunogenicity and protection afforded by the first dose, before a booster dose has been offered.

METHODS

We present data from three single-blind randomised controlled trials-one phase 1/2 study in the UK (COV001), one phase 2/3 study in the UK (COV002), and a phase 3 study in Brazil (COV003)-and one double-blind phase 1/2 study in South Africa (COV005). As previously described, individuals 18 years and older were randomly assigned 1:1 to receive two standard doses of ChAdOx1 nCoV-19 (5 × 10¹⁰ viral particles) or a control vaccine or saline placebo. In the UK trial, a subset of participants received a lower dose (2·2 × 10¹⁰ viral particles) of the ChAdOx1 nCoV-19 for the first dose. The primary outcome was virologically confirmed symptomatic COVID-19 disease, defined as a nucleic acid amplification test (NAAT)-positive swab combined with at least one qualifying symptom (fever ≥37·8°C, cough, shortness of breath, or anosmia or ageusia) more than 14 days after the second dose. Secondary efficacy analyses included cases occuring at least 22 days after the first dose. Antibody responses measured by immunoassay and by pseudovirus neutralisation were exploratory outcomes. All cases of COVID-19 with a NAAT-positive swab were adjudicated for inclusion in the analysis by a masked independent endpoint review committee. The primary analysis included all participants who were SARS-CoV-2 N protein seronegative at baseline, had had at least 14 days of follow-up after the second dose, and had no evidence of previous SARS-CoV-2 infection from NAAT swabs. Safety was assessed in all participants who received at least one dose. The four trials are registered at ISRCTN89951424 (COV003) and ClinicalTrials.gov, NCT04324606 (COV001), NCT04400838 (COV002), and NCT04444674 (COV005).

FINDINGS

Between April 23 and Dec 6, 2020, 24 422 participants were recruited and vaccinated across the four studies, of whom 17 178 were included in the primary analysis (8597 receiving ChAdOx1 nCoV-19 and 8581 receiving control vaccine). The data cutoff for these analyses was Dec 7, 2020. 332 NAAT-positive infections met the primary endpoint of symptomatic infection more than 14 days after the second dose. Overall vaccine efficacy more than 14 days after the second dose was 66·7% (95% CI 57·4-74·0), with 84 (1·0%) cases in the 8597 participants in the ChAdOx1 nCoV-19 group and 248 (2·9%) in the 8581 participants in the control group. There were no hospital admissions for COVID-19 in the ChAdOx1 nCoV-19 group after the initial 21-day exclusion period, and 15 in the control group. 108 (0·9%) of 12 282 participants in the ChAdOx1 nCoV-19 group and 127 (1·1%) of 11 962 participants in the control group had serious adverse events. There were seven deaths considered unrelated to vaccination (two in the ChAdOx1 nCov-19 group and five in the control group), including one COVID-19-related death in one participant in the control group. Exploratory analyses showed that vaccine efficacy after a single standard dose of vaccine from day 22 to day 90 after vaccination was 76·0% (59·3-85·9). Our modelling analysis indicated that protection did not wane during this initial 3-month period. Similarly, antibody levels were maintained during this period with minimal waning by day 90 (geometric mean ratio [GMR] 0·66 [95% CI 0·59-0·74]). In the participants who received two standard doses, after the second dose, efficacy was higher in those with a longer prime-boost interval (vaccine efficacy 81·3% [95% CI 60·3-91·2] at ≥12 weeks) than in those with a short interval (vaccine efficacy 55·1% [33·0-69·9] at <6 weeks). These observations are supported by immunogenicity data that showed binding antibody responses more than two-fold higher after an interval of 12 or more weeks compared with an interval of less than 6 weeks in those who were aged 18-55 years (GMR 2·32 [2·01-2·68]).

INTERPRETATION

The results of this primary analysis of two doses of ChAdOx1 nCoV-19 were consistent with those seen in the interim analysis of the trials and confirm that the vaccine is efficacious, with results varying by dose interval in exploratory analyses. A 3-month dose interval might have advantages over a programme with a short dose interval for roll-out of a pandemic vaccine to protect the largest number of individuals in the population as early as possible when supplies are scarce, while also improving protection after receiving a second dose.

FUNDING

UK Research and Innovation, National Institutes of Health Research (NIHR), The Coalition for Epidemic Preparedness Innovations, the Bill & Melinda Gates Foundation, the Lemann Foundation, Rede D'Or, the Brava and Telles Foundation, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and AstraZeneca.

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK

BACKGROUND

A safe and efficacious vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), if deployed with high coverage, could contribute to the control of the COVID-19 pandemic. We evaluated the safety and efficacy of the ChAdOx1 nCoV-19 vaccine in a pooled interim analysis of four trials.

METHODS

This analysis includes data from four ongoing blinded, randomised, controlled trials done across the UK, Brazil, and South Africa. Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control (meningococcal group A, C, W, and Y conjugate vaccine or saline). Participants in the ChAdOx1 nCoV-19 group received two doses containing 5 × 1010 viral particles (standard dose; SD/SD cohort); a subset in the UK trial received a half dose as their first dose (low dose) and a standard dose as their second dose (LD/SD cohort). The primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid amplification test-positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020. Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age. Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674.

FINDINGS

Between April 23 and Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 in the UK, 4088 in Brazil) were included in the interim primary efficacy analysis. In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0-75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4-97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010). Overall vaccine efficacy across both groups was 70·4% (95·8% CI 54·8-80·6; 30 [0·5%] of 5807 vs 101 [1·7%] of 5829). From 21 days after the first dose, there were ten cases hospitalised for COVID-19, all in the control arm; two were classified as severe COVID-19, including one death. There were 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3-4·8): 175 severe adverse events occurred in 168 participants, 84 events in the ChAdOx1 nCoV-19 group and 91 in the control group. Three events were classified as possibly related to a vaccine: one in the ChAdOx1 nCoV-19 group, one in the control group, and one in a participant who remains masked to group allocation.

INTERPRETATION

ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19 in this interim analysis of ongoing clinical trials.

FUNDING

UK Research and Innovation, National Institutes for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, Bill & Melinda Gates Foundation, Lemann Foundation, Rede D'Or, Brava and Telles Foundation, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and AstraZeneca.

Product qualities and sensory evaluation of high protein snack bar incorporated with pea protein isolate

Snack bars are convenient and nutritious food composed of several ingredients. It also can be supplemented by some health-promoting substances such as pea protein isolate (PPI). The aim of this study was to formulate a high-protein snack bar using pea protein isolate using INMUCAL-Nutrients V.4.0. Moreover, the product qualities of PPI snack bars in term of physical and sensory qualities and nutritive values were also determined. Protein content of the PPI snack bars (20-25 g per 100 g sample) was criteria for the formulation. As the result the physical qualities of PPI snack bars showed that water activity was below 0.65, therefore snack bars should be stable against microbial growth. No significant difference was found in color values between the PPI snack bar and the control formula, but PPI snack bars had higher hardness than the control formula. The energy, carbohydrate, protein, fat and dietary fiber of PPI snack bar was 439.40 kcal, 46.88 g, 22.20 g 18.12 g and 7.17 g per 100 g, respectively. Moreover, it had balanced energy distribution of carbohydrate: protein: fat at 54:25:21. The results from the sensory evaluation indicated that the liking score of appearance, color, odor, taste texture and overall liking of PPI snack bars were higher than 7 (like moderately). Therefore, PPI appears to be an alternative ingredient used to improve the nutritional quality of the high protein diet bar

A global call to action to improve the care of people with fragility fractures

The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. Disrupting the status quo has therefore become an obligation and a necessity. Initiated by the Fragility Fracture Network (FFN) at a "Presidents' Roundtable" during the 5th FFN Global Congress in 2016 several leading organisations agreed that a global multidisciplinary and multiprofessional collaboration, resulting in a Global Call to Action (CtA), would be the right step forward to improve the care of people presenting with fragility fractures. So far global and regional organisations in geriatrics/internal medicine, orthopaedics, osteoporosis/metabolic bone disease, rehabilitation and rheumatology were contacted as well as national organisations in five highly populated countries (Brazil, China, India, Japan and the United States), resulting in 81societies endorsing the CtA. We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay. There is an urgent need to improve: To address this fragility fracture crisis, the undersigned organisations pledge to intensify their efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life.

[Contribution of magnetic resonance imaging in diagnosis of pericardial mesothelioma: a case report]

Pericardial mesothelioma is a rare form of pericardial tumor. The invasive investigations such as biopsy make the diagnosis. Non-invasive imaging techniques provide valuable information about its diagnosis and its clinical impact. We report here the results of magnetic resonance imaging of pericardial mesothelioma in a 65-year-old woman. The originality and purpose of this case is to illustrate the additional value of magnetic resonance imaging that should be systematically performed when assessing this pathology.

[Cardiac surgery in Cameroon. Results at one year of the pilot phase]

In the framework of implementation of his national program for control and prevention of cardiovascular diseases, Cameroonian government has set up a cardiac surgery project. We report in this manuscript results of one year follow up of the patients operated during the pilot phase. From September 22 till 26, 2008, 11 patients have been operated in Cameroun. Surgical procedures were 5 mitral mechanic valve replacement, 2 aortic mechanic valve replacement, 1 atrial septal defect closure, 2 pace maker implantation. No intrahospital death was observed. One patient died at 11th month after the operation due to mitral valve thrombosis and attributed to lack of compliance. One patient presented low cardiac output, pneumonia and a pleural effusion. 2 patients presented 2 minor complications consisting of pericarditis and superficial wound infection. The results of the pilot phase of cardiac surgery in Cameroon are effective. However, the sustainability of the program require human, material capacity building, and funding mechanism as well.

The effect of coenzyme Q10 on idiopathic chronic dilated cardiomyopathy in children

The objective of this study was to assess the effect of coenzyme Q10 (CoQ10) as supplementation to conventional antifailure drugs on quality of life and cardiac function in children with chronic heart failure due to dilated cardiomyopathy (DCM). The study was an open-label prospective study performed in two of the largest pediatric centers in Thailand from August 2000 to June 2003. A total of 15 patients with idiopathic chronic DCM were included, with the median age of 4.4 years (range, 0.6-16.3). Presenting symptoms were congestive heart failure in 12 cases (80%), cardiogenic shock in 2 cases (13.3%), and cardiac arrhythmia in 1 case (6.7%). Sixty-one percent of patients were in the New York Heart Association functional class 2 (NYHA 2), 31% in NYHA 3, and 8% in NYHA 4. Cardiothoracic ratio from chest x-ray, left ventricular ejection fraction, and left ventricular end diastolic dimension in echocardiogram were 0.62 (range, 0.55-0.78), 30% (range, 20-40), and 5.2 cm (range, 3.8-6.5), respectively. CoQ10 was given at a dosage of 3.1 ? 0.6 mg/kg/day for 9 months as a supplementation to a fixed amount of conventional antifailure drugs throughout the study. At follow-up periods of 1, 3, 6, and 9 months, NYHA functional class was significantly improved, as was CT ratio and QRS duration at 3 and 9 months follow-up with CoQ10 when compared to the baseline and post-discontinuation of CoQ10 at 9 months (range, 4.8-10.8). However, when multiple comparisons were taken into consideration, there was no statistical significant improvement. In addition to the conventional antifailure drugs, CoQ10 may improve NYHA class and CT ratio and shorten ventricular depolarization in children with chronic idiopathic DCM.

Cardiac troponin T: a marker in the diagnosis of acute myocarditis in children

This study was conducted to assess the use of serum cardiac troponin T (cTnT) level as a noninvasive indicator to diagnose acute myocarditis in children. Noninvasive conventional methods often fail to diagnose myocarditis, A median cTnT level of 0.088 ng/ml (0.04-3.11) was reported in pediatric patients with acute myocarditis in our previous study. Hence, we attempted to determine the cutfoff level of cTnT to diagnose acute myocarditis in children. Pediatric patients with clinically suspected myocarditis or dilated cardiomyopathy (DCM) and a control group were recruited. History, physical examination, elctrocardiogram, chest roentgenogram, echocardiogram, cTnT level, and/or endomyocardial biopsy and clinical course were studied. The gold standard to diagnose acute myocarditis was endomyocardial biopsy proved according to the Dallas criteria and/or recovery from cardiovascular problems within 6 months of follow-up. Forty-three patients were admitted due to cardiovascular problems from primary myocardial dysfunction. Twenty-four patients were diagnosed as acute myocarditis (group 1), 19 were idiopathic chronic DCM (group 2), and 21 patients had moderate to large ventricular septal defect and congestive heart failure (group 3). Median cTnT level was statistically higher in (group 1) compared to groups 2 and 3. Ejection fraction (EF) and left ventricular end diastolic dimension (LVEDd) z score of acute myocarditis were 38.5% (range, 21-67) and 1.3 (range, -0.8-3.0), respectively, which were significantly better than DCM [28.0% (range, 17-45) and 6.0 (range, 2.0-10.0)]. The cutoff point of cTnT level to diagnose acute myocarditis was 0.052 ng/ml (sensitivity, 71%; specificity, 86%). cTnT level, EF, and LVEDd z score did not predict short-term outcomes of patients. In acute myocarditis, cTnT level and EF were significantly higher and LVEDd z score was significantly lower than in DCM. However, the three parameters had no significant effect on outcomes of the patients. Our data show that cardiac a cTnT level of 0.052 ng/ml is an appropriate cutoff point for the diagnosis of acute myocarditis.

Immunoglobulin failure and retreatment in Kawasaki disease

Several cases of Kawasaki disease (KD) were unresponsive to the initial treatment with intravenous immunoglobulin (IVIG). We retrospectively analyzed all children admitted with KD to determine the occurrence and variables associated with the initial IVIG treatment failure. All patients who fulfilled the criteria for KD and were treated with a single dose (2 g/kg) of IVIG between January 1995 and August 2001 were enrolled. An analysis of the patients who had initially failed to respond to IVIG was performed. A total of 120 patients were enrolled during the study period. There were 68 boys (56.7%). Fourteen patients (11.6%) were found to be unresponsive to initial IVIG treatment. Patients who were anemic (Hb<10 G/DL), had a high neutrophil count (> 75%), a high band count, and low albumin were at risk of failure to respond to a single dose of IVIG. We found no correlation among age, gender, days since starting IVIG treatment, and erythrocyte sedimentation rate (ESR) with failure of the initial IVIG treatment. There were 12 patients (10%) who developed coronary artery aneurysms. The failure of a single dose of IVIG treatment occured in up to 11.6% of our Kawasaki patients. We found that low hemoglobin (<10 G/DL), high neutrophil count (> 75%), high band count, and a low albumin were associated with the requirement for retreatment with a second dose of IVIG.

Cardiac troponin T: its role in the diagnosis of clinically suspected acute myocarditis and chronic dilated cardiomyopathy in children

This study was conducted to assess the use of the serum cardiac troponin T (cTnT) level as a noninvasive indicator to differentiate acute myocarditis and chronic dilated cardiomyopathy in pediatric patients. Myocarditis and dilated cardiomyopathy are clinically difficult to differentiate. Endomyocardial biopsy proved to be quite useful. However, the nature of the procedure--invasiveness, time-consuming, and limited sensitivity--caused some concerns, especially in pediatric patients. Hence, we attempted to find an alternative method that could give a prompt diagnosis of acute myocarditis. Twenty cases with clinically suspected myocarditis or dilated cardiomyopathy and a control group of 21 cases with moderate left-to-right shunt and congestive heart failure were recruited. History, physical examination, electrocardiogram, chest roentgenogram, echocardiogram, cTnT, creatine kinase MB isoenzyme (CK-MB mass), and/or endomyocardial biopsy were compared. The gold standard used to diagnose myocarditis is endomyocardial biopsy (Dallas criteria) and/or recovery from cardiovascular problems within 6 months of follow-up. Ten patients were diagnosed as having myocarditis (group 1) and 10 with chronic dilated cardiomyopathy (group 2). The control group of 21 cases was designated as group 3. The median serum cTnT levels were 0.088 (0.04-3.11), 0.010 (0.010-0.990), and 0.010 (0.010-0.550) ng/ml in groups 1, 2, and 3, respectively. The mean CK-MB mass level for groups, 1, 2, and 3 were 18.35 (7.14-70.00), 4.80 (0.54-108.00), and 2.26 (0.95-7.06) ng/ml. The study showed that both the cTnT and CK-MB mass levels were significantly higher in group 1 than either group 2 or group 3. Histopathology was studied in 9 cases. In 2 of 5 cases and in all 4 cases in group 1 and group 2 histopathology was pathologically proved. Levels of cTnT and CK-MB were significantly higher for myocarditis than for dilated cardiomyopathy and left-to-right shunt with CHF. Further study is needed to assess the optimum cTnT level for differentiating both conditions.

Comparison of atrial septal defect closure using amplatzer septal occluder with surgery

Our study reports the results of a comparison of closure of atrial septal defect (ASD) surgically with transcatheter closure using the Amplatzer septal occluder. Patients having an ASD and a surgical closure or transcatheter closure between January 1999 and July 2000 were selected. There were 103 patients who had ASD. All 64 patients in group 1 (surgery) had a successful operation, with only 2 patients with a mild residual shunt. There were 39 patients enrolled for transcatheter closure of the ASD (group 2). Four patients were excluded initially. The median age for group 1 was 25 years (range 2.3-64 years) compared to 11.7 years (range 2-69 years) in group 2 (p = 0.035). In group 1, the mean ASD diameter measured was 28.4 +/- 10.2 mm compared to 23.4 +/- 5.7 mm in group 2 (p = 0.003). In 29 patients, devices were deployed with sizes from 10 mm to 30 mm (median 24 mm). Three patients were excluded because a larger device (>30 mm) was not available and devices were not successfully deployed in another 3 patients. One patient had a device embolized into the right ventricle (surgical removal and closure of the ASD). Complications occurred in 13 patients in group 1 and 4 patients in group 2. Complete occlusion occurred in 27 of 28 group 2 patients (96.4%) during the follow-up period (10.2 +/- 5.4 months). The Amplatzer septal occluder is a new device for closure of different-sized ASDs. The intermediate-term follow-up demonstrated excellent closure results. The benefit for each patient was demonstrated in less morbidity and less time spent in the hospital.

Tibial intramedullary nail distal interlocking screw placement: comparison of the free-hand versus distally-based targeting device techniques

Intramedullary nailing is the standard treatment for closed and some open unstable diaphyseal tibia fractures. Fluoroscopy, while essential for proper nail placement can subject the surgical team and patient to substantial radiation. A new targeting system for tibia nail distal interlocking was developed by Orthofix to limit fluoroscopy. This prospective clinical study compares the Orthofix targeting system versus a free-hand technique for the tibial nail distal interlocking. Fifty eight consecutive patients with sixty tibial fractures amenable for nail fixation were randomly assigned into two equal groups: Group 1: Orthofix distally based distal targeting device and Group 2: a free-hand technique. In all the cases stabilization was achieved with a reamed statically locked tibial nail. Recorded data included accuracy of screw placement, duration of surgery prior to and during distal interlocking, and the fluoroscopy time prior to and during distal interlocking. Both groups revealed comparable fracture patterns. In all fractures the technical aspects of the surgical treatment were performed without complications. There was no statistically significant difference between the groups in the mean time of surgery prior to (62.02 vs. 61.01 min, P=0.92) and during distal interlocking (17.06 vs. 19.08 min, P=0.55), or in the total surgical time (81 vs. 85 min), respectively. Neither was there a statistically significant difference in the mean fluoroscopy time prior to distal interlocking (69 vs. 81 s, p=0.22) nor in the total fluoroscopy time (84 vs. 117 s). There was however, a statistically significant difference between the Orthofix and free-hand groups with regards to the mean fluoroscopy time during distal interlocking (15 vs. 36 s, P=0.01, respectively). This study demonstrates that the distally based distal targeting device by Orthofix for tibial nailing can significantly decrease the mean fluoroscopy time necessary to complete distal interlocking versus free-hand technique.

Chronic obstructive pulmonary diseases in Thailand: incidence, prevalence, present status and future trends

MATERIAL AND METHOD

Data on cases of COPD in 1999 were collected.

RESULTS

[table in text] The mortality rate was 0.6-3.4 per cent in OPD cases and 11-17 per cent in IPD cases. The hospital stay was 2-90 days (mean 14 days). The cost per day in the ICU of government hospitals was Bht 7,000 and in private hospitals Bht 10,000.

Limitation of transthoracic echocardiography in the diagnosis of congenital heart diseases

Nowadays, it has been widely accepted that echocardiography is the most efficient, non invasive diagnostic tool to diagnose congenital heart diseases. However, cardiac catheterization remains the gold standard to diagnose and obtain hemodynamic data prior to cardiovascular surgery. In order to find out the accuracy of transthoracic echocardiography in relation to the anatomical diagnosis of congenital heart diseases, 175 consecutive patients who underwent diagnostic cardiac catheterization during January 1999 to December 1999 were reviewed. All of them had complete echocardiographic studies prior to the procedure. The male to female ratio was 1.06:1. The median age at the time of echocardiography was 3.36 (0.01-28.8) years old. The indications of the cardiac catheterization were to demonstrate cardiovascular anatomy 64 per cent, to obtain pulmonary artery pressure and pulmonary vascular resistance 13.7 per cent, and to get both information 22.3 per cent. Tetralogy of Fallot (23.4%) was the most frequent cardiac malformation, followed by complex congenital heart diseases (22.3%), simple left to right shunt (12%), pulmonary atresia with ventricular septal defect (8.6%), tricuspid atresia (5.7%), simple d-transposition of great arteries (4%), etc. From cardiac catheterization; 49 cases (28%) revealed additional data which were surgically important, 3 cases (1.7%) resulted in different diagnoses, and 3 cases (1.7%) revealed additional information which was not surgically important. Inadequate imaging technique (36 cases, 65.5%) and limitation of technique (19 cases, 34.5%) were the reasons for missing anatomical findings of transthoracic echocardiography. Age at the time of echocardiography was not a significant factor affecting the accuracy. Persistent left superior vena cava, multiple aorto-pulmonary collateral arteries, pulmonary artery anatomy, and coronary artery anatomy were the most frequent cardiac lesions misdiagnosed by transthoracic echocardiography that were somewhat surgically important. The incorrect echocardiographic diagnoses were aorto-pulmonary window, patent ductus arteriosus, and vascular ring. Thorough and extensive echocardiographic scanning coupled with cooperative or adequately sedated patients by an experienced operator using an efficient echocardiographic machine might improve the accuracy of transthoracic echocardiography in the diagnosis of congenital heart diseases.

Coarctation of the aorta in children at Siriraj Hospital

A retrospective analysis of 33 children who were diagnosed to have coarctation of aorta at Siriraj Hospital between January 1989 and December 1998 was undertaken. There were 21 males (64%) and 12 females (36%). Their ages ranged from one day to 11 years (median 2 months). The majority of the patients (78.8%) were presented early within the first year of life. The predominant clinical manifestations were congestive heart failure (69.6%), systemic hypertension of the upper extremities (36.3%) and decreased femoral pulses. Chest roentgenogram revealed cardiomegaly (70%) and increased pulmonary blood flow (84%), reflecting congestive heart failure and associated left-to-right shunting. Electrocardiogram showed normal pattern (33.3%), right ventricular hypertrophy (33.3%), left ventricular hypertrophy (22.2%) and biventricular hypertrophy (11.2%). The younger the patient is, the more right ventricular predominance is demonstrated. According to the echocardiogram and/or aortogram, juxtaductal type was found in 51.5 per cent, postductal type in 27.3 per cent and preductal type in 21.2 per cent. Medical management included prostaglandin E1 infusion in a newborn baby presented with low-cardiac output state, anticongestion and antihypertension, if indicated, followed by surgical correction. The result of coarctectomy with end-to-end anastomosis with or without arch augmentation was good. The operative mortality rate was 5 per cent. The overall mortality in the present study was 9 per cent. The most common causes of death were multiorgan failure and pulmonary infection. Residual coarctation was found in 5 per cent.

The Fontan operation: experience at Siriraj Hospital

Seventy five patients underwent modified Fontan operation at Siriraj Hospital from October 1987 to December 1998. Cardiology data was analyzed retrospectively. Four patients' data was unavailable. Median age at operation was 9.7 (1.8-34) years old. Tricuspid atresia accounted for 38 per cent of the patients. Ten patients (14.1%) died in the acute post operative period due to consequence of low cardiac output. Another 3 patients (4.2%) expired in the intermediate and late post operative period. Age at operation, pulmonary artery size, pre-operative oxygen saturation, and mean pre-operative pulmonary artery pressure were not different between those who survived and those who died. Abnormal pulmonary vein, atrioventricular valve regurgitation, and underlying ventricular morphology statistically affected the acute survival of modified Fontan operation. Intraoperative aortic cross clamp time, and post operative mean pulmonary artery pressure on day 0, 1 and 2 post operation were found statistically shorter and lower in the survival group. Survival rate at 5 years was 83 per cent. Modified Fontan operation is the final palliative operation of choice for low risk single ventricle physiology in our institution with acceptable outcome. Thorough pre-operative hemodynamic and anatomic studies and staging modified Fontan procedure may include a higher number of candidates and improve the outcome of the operation.

Intermediate term follow-up on transcatheter closure of atrial septal defects by Amplatzer septal occluder

BACKGROUND

Surgical repair of secundum atrial septal defect (ASD) is a safe, widely accepted procedure with negligible mortality. However, it is associated with morbidity, discomfort and a thoracotomy scar. As an alternative to surgery, a variety of devices for transcatheter closure of ASD have been developed.

OBJECTIVES

We report our clinical experience with transcatheter closure of ASD using the Amplatzer Septal Occluder, a new occlusion device with intermediate term follow-up.

PATIENTS & METHOD

Patients having ASD met established two-dimensional echocardiographic criteria for transcatheter closure were selected. ASD size was measured by transesophageal echocardiogram (TEE) and balloon occlusion catheter (stretched diameter). The Amplatzer's size was chosen to be equal to or 1 mm less than the stretched diameter. The device was advanced transvenously into a guiding sheath and deployed under fluoroscopic and TEE guidance. Once its position was optimal, it was released. TEE was undertaken to demonstrate the residual shunt.

RESULTS

There were 26 patients with a mean age of 17.2 +/- 15.9 years old (2 to 60) and a mean weight of 22 +/- 37.5 kg. (10.7 to 62.5). The mean ASD diameter measured by TEE was 18.3 +/- 5.2 mm. and by stretched diameter was 22 +/- 7.5 mm. Four patients who had ASD stretched diameter over 32 mm were excluded because a larger device was not available. Devices were deployed in 22 patients with sizes from 9 to 30 mm (median = 22mm). Immediately after closure a tiny residual shunt was observed at the core of the device in each case. At 24 hours only two patients had a small (< 2 mm) shunt. One patient with fenestrated ASD had a device embolized into the right ventricle with successful removal and surgical closure. Patients were followed-up for a mean duration of 8 +/- 3.5 months (from 3 to 12 months). Complete occlusion was found in 20 out of 21 patients (95%).

CONCLUSION

The Amplatzer Septal Occluder is a new device designed for closure of different sizes of ASD and can be easily and safely deployed. Our experience showed that this device could be used to close an ASD as large as 30 mm. The intermediate term follow-up also demonstrated an excellent closure result. Caution should be undertaken with patients who have a fenestrated atrial septal defect particularly at the septal rim.

Reference spirometric values for healthy lifetime nonsmokers in Thailand

The normal spirometric reference values for Thai people are still not yet available. The aim of this study was to establish standard spirometric equations for Thai people. Subjects 10 years of age and over were selected and their demographic distributions represented that of the population of the whole country. Inclusion criteria were strictly lifetime nonsmokers, no history of chronic cardiopulmonary disease (using a modified ATS--DLD 78 respiratory adult questionnaire), normal standard chest radiograph and unremarkable physical examination. They had to be without respiratory symptoms at the time of the study. Spirometric values were obtained by 5 turbine system 'Pony graphic' (Cosmed, Italy) spirometers which met ATS recommendations. A normal group of 2299 women and 1655 men were selected. Regression analyses using sex, height and age as independent variables were used to provide equations for predicted values. The results were: [table: see text] FVC and FEV1 from this study are close to the Chinese but are 8-20 per cent lower than the Caucasians. These predicted equations are recommended to be used for future reference values in the Thai population.

Bending of the Cotrel-Dubousset instrumentation after direct trauma: a case report

STUDY DESIGN

Case report.

OBJECTIVES

To describe a fracture through the fusion mass of a spine that had been corrected previously with Cotrel-Dubousset rods. These rods had failed in bending after direct trauma.

SUMMARY OF BACKGROUND DATA

Nine years after successful treatment of scoliosis with Cotrel-Dubousset instrumentation, the patient was in a motor vehicle accident and sustained a hyperextension spine injury with complete L1-L2 paraplegia and disruption of the fusion mass. The Cotrel-Dubousset instrumentation rods, which failed in bending, could not be corrected in situ, and the angulated segments had to be resected. The spine then became extremely unstable, and the patient consulted the authors for definitive stabilization.

RESULTS

The spine was stabilized by attaching the proximal and distal retained Cotrel-Dubousset instrumentation to supplemental rods in a "domino" fashion. Crosslinks were added to improve the torsional stability. Intraoperatively, the fracture was well reduced, and the fixation was stable. A posterolateral fusion was performed with allogenic bone graft.

CONCLUSION

Bent Cotrel-Dubousset instrumentation rods are still very strong and may not correct in situ.- If resection is required, the retained portions of Cotrel-Dubousset instrumentation can serve as attachments to restore stable fixation a "domino"technique.

Respiratory symptoms and pulmonary function of traffic policemen in Thonburi

A cross-sectional study was conducted to assess whether traffic policemen working in Thonburi district of Bangkok had poorer respiratory health than the normal Thai population. The benefits of wearing masks as a preventative measure against the respiratory hazards of air pollution were assessed. Traffic policemen (n = 629) who had worked in Thonburi and male subjects (n = 303, the control group) were evaluated for respiratory symptoms using the British Medical Research Council questionnaire. Their pulmonary function was measured by spirometry. Only non-smokers were included in the final analysis and it was found that traffic policemen (n = 242) suffered significantly more cough or phlegm (18.6% vs 7.8%, P = 0.005) and more rhinitis symptoms (17.8% vs 7.8%, P = 0.009) than the control subjects (n = 129). The traffic policemen also had a significantly higher prevalence of abnormal air flow (FEV1 < 80% predicted) than the control group (21.1% vs 12.4%, P = 0.04). The mean values of FEV1 and FVC of the traffic policemen were significantly lower than the control group (3.29 +/- 0.5 L vs 3.43 +/- 0.5 L, P = 0.01 for FEV1 and 3.86 +/- 0.5 L vs 3.98 +/- 0.6 L, P = 0.047 for FVC). Traffic policemen who did not use protective masks had not only a significantly higher prevalence of abnormal FEV1 but also a significantly higher prevalence of abnormal FVC than the control group (35% vs 14%, P = 0.046). They also had higher relative risks of abnormal FEV1 (2.76 vs 1.63) and FVC (2.51 vs 1.23) than those who used protective masks. Multivariate analyses with controlling for age, height, and pack-years of cigarette smoking, revealed that the traffic policemen were significantly and independently associated with lower FEV1 and FVC. In conclusion, the traffic policemen who work in Thonburi have more cough and rhinitis symptoms and lower FEV1 and FVC than the normal Thai population. Traffic policemen who do not use protective masks have higher relative risks of abnormal FEV1 and FVC than those who use them.

High-dose inhaled budesonide may substitute for oral therapy after an acute asthma attack

Patients attending the emergency room with acute asthma, participating in a study comparing salbutamol (albuterol in the United States) via a dry powder inhaler (Turbuhaler) with pressurized metered-dose inhaler (pMDI), were included in this 1-week follow-up study with the aim of assessing whether inhaled budesonide via Turbuhaler may be an alternative to prednisolone tablets after an acute asthma attack. Eighty-one patients with a mean age of 38 years and forced expiratory volume in 1 sec (FEV1) of 64% predicted normal value after treatment with salbutamol were randomized in this double-blind, double-dummy, parallel-group study. The doses given were budesonide 1600 microg b.i.d. or prednisolone in daily doses from 40 mg (day 1) decreased to 5 mg (day 7). FEV1 was recorded before and after the 7-day treatments and peak expiratory flow (PEF) morning and evening, clinical symptoms (visual analogue scale 0-100), and doses of rescue medication (terbutaline Turbuhaler 0.25 mg/dose) were recorded daily. The mean increase in FEV1 from baseline to day 7 was 17.3% in the budesonide Turbuhaler group and 17.6% in the prednisolone group. Mean values of morning PEF increased from day 1 to day 7 by 67 L/min in the budesonide Turbuhaler group and by 57 L/min in the prednisolone group (not significant). There were no statistically significant differences between the groups in clinical symptoms and in the number of doses of rescue medication. Because of disease deterioration, five patients in the Turbuhaler group and three in the prednisolone group needed additional symptomatic as well as corticosteroid treatment. Inhaled budesonide in high doses may be a substitute for oral therapy as follow-up treatment after an acute asthma attack.

Transcatheter laser-assisted balloon valvulotomy as primary treatment in newborn with pulmonary atresia and intact ventricular septum

We report our initial experience and the first case in Thailand in successfully performing transcatheter laser perforation of membranous pulmonary valve and subsequent balloon dilations of the valve in a 14-day-old baby with pulmonary atresia and intact ventricular septum. After the procedure, right ventricular angiograms revealed anterograde flow across the pulmonary valve. There was no major complication. Doppler echocardiography one week later demonstrated a pressure gradient across the pulmonary valve of 30 mmHg and right ventricular systolic pressure of 60 mmHg. Her peripheral oxygen saturation improved from 70's immediately after the procedure to 92-97 per cent at one-month after the procedure.

Results of rapid two-stage arterial switch operation in patients with transposition of the great arteries: one-year postoperation

The rapid two-stage arterial switch operation is an alternative therapy for patients with simple transposition of the great arteries who present beyond the neonatal period and have low left ventricular pressure. It provides normal ventricular function compared to the atrial switch operation. Between July 1994 and February 1997, there were 13 such infants who had rapid two-stage arterial switch operation performed at Siriraj Hospital. There was 1 late death (11 months after the operation). All 12 survivors (mean age 22.4 +/- 5.7 months) were clinically evaluated and had echocardiography performed at 14.8 +/- 4.9 months after the operation. All were asymptomatic. Echocardiogram revealed a residual small atrial septal defect (1 case), small ventricular septal defect (1 case), mild supravalvar neopulmonary stenosis (2 cases), bicuspid neoaortic valve without stenosis (2 cases), dilated neoaortic sinus of Valsalva (6 cases, 50%) and mild neoaortic insufficiency (11 cases, 91.7%). The left ventricular function was hyperdynamic after pulmonary artery banding and significantly decreased to normal level at the time of study (shortening fraction of 43.8 +/- 10.7 vs 29.2 +/- 3.8%, respectively, p = 0.0005). The wall thickness was significantly increased after pulmonary artery banding and decreased overtime (0.48 +/- 0.08 vs 0.32 +/- 0.05 cm, respectively, p < 0.0005). The left ventricular dimension was significantly increased both after pulmonary artery banding and at the time of study (2.06 +/- 0.42 vs 3.32 +/- 0.30 cm, respectively, p < 0.0005). The left ventricular mass was significantly increased after pulmonary artery banding and at the time of study (21.79 +/- 7.79 vs 33.08 +/- 7.40 g/m2, respectively, p = 0.0005). The mortality and morbidity of rapid two-stage arterial switch operation are low. However, long-term follow-up should be monitored.

Diagnostic value of bronchoalveolar lavage and postbronchoscopic sputum cytology in peripheral lung cancer

The objective of this study was to evaluate the value of bronchoalveolar lavage (BAL) and postbronchoscopic sputum cytology in diagnosing peripheral lung cancer. We performed a prospective study in 55 patients with lesions on chest radiographs who were suspected of having lung cancer and had non-endoscopically visible lesions on fiberoptic bronchoscopy. The sequence of procedures in all cases was BAL and transbronchial forceps biopsy. The final diagnosis of these patients were primary lung cancer in 30 patients, metatastic lung cancer in five and benign diseases in 20. In the primary lung cancer group, BAL was positive for malignant cells in 14 of the 30 patients (46.7%). In seven (50%) of these patients, the cell type diagnosed by BAL agreed with the final diagnosis. The diagnostic yield of BAL was influenced by the size and segmental location of the lesion. Bronchoalveolar lavage provided a higher diagnostic yield (46.7%) than transbronchial biopsy (16.7%). In five patients with metastatic lung cancer and 20 patients with benign disease, BAL gave negative results in all. Postbronchoscopic sputum cytology was positive in only two of the 26 patients (7.7%) from whom samples could be obtained. Bronchoalveolar lavage cytology proved to be a valuable diagnostic tool in detecting peripheral, primary lung cancer. Postbronchoscopic sputum cytology provided no significant additional information.

Beta 2-agonists administered by a dry powder inhaler can be used in acute asthma

Patients with acute asthma attending the emergency room were included in a double-blind, double-dummy and parallel group study to investigate whether a dry powder inhaler (Turbuhaler) can be used in acute asthma. If so, the aim was to establish the potency relationship between a beta 2-agonist (salbutamol) administered by the dry powder inhaler and the pressurized metered-dose inhaler (pMDI). Eighty-six patients with a mean age of 38 years and forced expiratory volume in 1 s (FEV1) of 37% of predicted normal value were randomized at Siriraj Hospital in Bangkok to either Turbuhaler (50 micrograms dose -1) or pMDI (100 micrograms dose -1) with spacer (Volumatic). Doses of 100 + 300 + 300 + 300 micrograms salbutamol were given at 0, 15, 30 and 45 min via Turbuhaler and repeated at 90, 105, 120 and 135 min (total dose 2000 micrograms). The same inhalation schedule with identical number of doses was used for the pMDI with spacer but in double doses (total 4000 micrograms), assuming a dose-potency ratio of salbutamol administered via Turbuhaler compared with the pMDI of 2:1. At 85 min after the first dose, 60 mg prednisolone was given orally. FEV1 was measured 10 min after each dosing. Peak inspiratory flow (PIF) through Turbuhaler was measured on each dosing occasion. Plasma (P)-salbutamol, serum (S)-potassium concentrations, pulse rate, blood pressure and adverse events were recorded. No statistically significant differences were observed in the increase in FEV1 between the groups: 55 min (165 min) after the first dose, the increase was 0.47 l and 47% (0.64 l and 63%) in the Turbuhaler group, and 0.46 l and 42% (0.68 l and 65%) in the pMDI group. Mean PIF though Turbuhaler was 49 l min -1 (range 26-68) at first inhalation and increased to 60 l min -1 (range 38-86). There was no correlation between the initial PIF through Turbuhaler and the initial FEV1 response. P-salbutamol and S-potassium values correlated well. A larger decrease in S-potassium was noticed after 75 min in the pMDI group (0.38 mmol l -1) compared with the Turbuhaler group (0.23 mmol l -1) (P = 0.02). In conclusion, the use of a dry powder inhaler, Turbuhaler, was investigated in the emergency room treatment of acute asthma, and was as effective as a pMDI with spacer. Half the dose of salbutamol administered via Turbuhaler was as effective as the full dose given via a pMDI with spacer.

Clonidine for smoking cessation

Clonidine was used to reduce withdrawal symptoms of nicotine and increase the success rate of smoking cessation in the smoking cessation clinic of Siriraj Hospital. One hundred and fourteen subjects enrolled in a double-blind, randomised, placebo-controlled trial. Subjects were divided as clonidine group (n = 58) with the mean age of 38 years and placebo group (n = 56) with the mean age of 33 years. Both groups received information about harmful effects of smoking as well as behavioral modification protocol. The dose of clonidine used in this study was 300 micrograms and the duration of the trial was 5 weeks. Both subject groups attended the clinic weekly and received identical counselling. Clonidine did not reduce withdrawal symptoms of nicotine when compared to the placebo and the success rate of smoking cessation at the end of the 5 weeks' period was identical between the two groups (clonidine 50%; placebo 48%, p > 0.05). No significant side effects of clonidine were found. There was no correlation between background educational level, income, amount of cigarettes smoked per day and the success rate in both groups. In conclusion, clonidine did not show any beneficial effect on smoking cessation.

Percutaneous balloon pulmonary valvuloplasty in children: experience at Siriraj Hospital

Twenty-seven children with pulmonary valvar stenosis with pressure gradient (PG) > or = 40 mmHg underwent percutaneous balloon pulmonary valvuloplasty (PBPV) at Siriraj Hospital between February 1993 and August 1996. There were 13 males and 14 females, with an age range from 2 months to 14 years, and body weight from 4.7 to 42.1 kg. The majority (92.6%) were asymptomatic. Before the PBPV, the pulmonary valve annulus (PVA) measured by echocardiography was significantly greater than that measured by cardiac catheterization (15.2 +/- 3.7 vs 14.5 +/- 3.9 mm, P = 0.006). However, there was linear association (r = 0.972) between the two methods. The PG obtained by the two methods showed no significant difference (90.8 +/- 35.3 by echocardiography vs 97.3 +/- 47.2 mmHg by catheterization, P = 0.266). Immediately after PBPV, the right ventricular systolic pressure (113.7 +/- 41.1 pre vs 62.3 +/- 28.1 mmHg post) and the PG 103.4 +/- 43.4 pre vs 49.0 +/- 31.1 mmHg post) were significantly reduced (p < or = 0.0005). At 6-mo follow-up echocardiography, the PG was 28.6 +/- 17.6 mmHg and was significantly reduced (P = 0.0005). The PVA significantly increased at the 12 mo follow-up (15.2 +/- 3.6 pre vs 17.6 +/- 3.8 mm post, P = 0.001). Only minor complications were reported in the present study; bleeding (3.7%), transient bradycardia (7.4%) and pulmonary regurgitation not more than moderate severity (79%). The immediate and intermediate results of PBPV are excellent with a success rate of 85 per cent.

Successful transcatheter coil embolizations of complex pulmonary arteriovenous fistulas: the first case in Thailand

Successful transcatheter coil embolizations of the left lower lobe pulmonary arteriovenous fistulas, the first case in Thailand, in a 6-year-old boy presenting with increased cyanosis was reported. Transcatheter management of unusual sites of right-to-left intrapulmonary shunting can provide gratifying clinical improvement in some children.

Percutaneous coil embolization and balloon-expandable stenting; new treatments in intractable cardiac failure after Fontan procedure: a case report

Successful percutaneous coil embolization of aortopulmonary collaterals and balloon-expandable stent implantation of left pulmonary artery stenosis in a child with hypoplastic right heart syndrome were reported, Presently, interventional cardiac catheterization is a very useful treatment strategy in congenital heart diseases unamenable to or inaccessible for surgery.

The efficacy of doxycycline as a pleural sclerosing agent in malignant pleural effusion: a prospective study

To determine the efficacy of doxycycline in producing pleuroedesis in patients with malignant pleural effusion (MPE), 31 documented cases of MPE, aged 19-82 years were prospectively studied. Pleural sclerosis was done with 500 mg of doxycycline. Response regarding respiratory symptoms and pleural fluid accumulation were evaluated monthly. At one month, 27 patients were evaluable (4 dropped out). All responded and required no therapeutic thoracentesis. At 3 months, 13 patients dropped out, only 14 patients were evaluable. It revealed that 13 out of 14 patients (92%) responded. Only one patient failed and required therapeutic thoracentesis. Five and two patients came for assessment at 6 and 12 months, respectively. They still benefited from doxycycline pleurodesis. Side effects including low grade fever in 30% of patients, moderate to severe pain in 60% and troublesome cough with hemoptysis in one patient (3%) were noted. Doxycycline is an effective agent in controlling MPE. It was successful in every patient at 1 month and in 92% at 3 months. At 6 and 12 months quite a few patients survived for evaluation. However, they still benefited from doxycycline pleurodesis. Side effects were tolerable.

Chronic lung diseases and the perception of breathlessness: a clinical perspective

Breathlessness is an extremely common symptom. Its genesis is incompletely understood but is known to be largely determined by many of the mechanical factors associated with the act of breathing. As with all subjective sensations various other factors including volition, behavioural style and other cortical and subcortical factors play a part in its genesis. The relief of breathlessness is primarily directed at the underlying disorder. In those conditions and situations where specific therapy has little to offer or little impact it is reasonable to consider ways of reducing the perception of breathlessness by pharmacological means. However, to date there is no convincing evidence that use of drugs in the pursuit of the relief of breathlessness has any specific effect in modifying the perception of this often distressing symptom. Any reduction in breathlessness achieved in this way can be adequately explained in terms of a reduction in ventilation and other indices of respiratory mechanics.

Treatment of community-acquired pneumonia with ofloxacin

Our study of 28 carefully selected patients proved that ofloxacin is a safe and effective drug for mild to moderately severe community-acquired pneumonia. An effective oral antimicrobial drug such as ofloxacin can be used as an alternative to conventional therapy in community-acquired pneumonia.

Intravenous enprofylline in the treatment of patients with acute asthma

The safety and efficacy of enprofylline were studied in 55 moderately severe asthmatic patients [forced expiratory volume in 1 s (FEV1) and peak expiratory flow rate (PEFR) no more than 50% of predicted values] presenting with an acute attack. A bolus injection of 1.5 mg/kg enprofylline was given over 20 min and then maintenance infusion of 0.4 mg/kg.h enprofylline for up to 24 h. On admission, 200 mg hydrocortisone was administered intravenously and additional oxygen and/or inhaled beta 2-agonist therapy was permitted after 1 h; this additional therapy was given to 39 patients. The bolus injection increased the PEFR from 121 +/- 44 l/min to 164 +/- 49 l/min at 20 min, with a further improvement during the maintenance infusion to 200 +/- 79 l/min at 24 h. Heart rate and blood pressure decreased towards normal in parallel with the improvement in lung function. The mean steady-state enprofylline plasma concentration was slightly higher than predicted. The mean renal clearance and recovery of enprofylline from urine were in good agreement with results previously obtained from healthy Caucasian subjects.

Clinico-physiological status of Thai COPD patients

We examined the relationships between certain clinical and physiological data from 56 patients with chronic obstructive pulmonary disease, and have formulated 15 relevant equations from which various respiratory indices can be estimated. Multiple linear regressions thus obtained evidently suggest that airway resistance and ventilatory drive are the main factors in the control of breathing among Thai COPD subjects; the exercise tolerance test showed some correlation with airflow obstruction and with respiratory muscle strength. Clinical implementation of certain findings has been outlined.

Patient comfort and plasma lignocaine concentrations during fibreoptic bronchoscopy

In a preliminary prospective study, eleven outpatients undergoing fibreoptic bronchoscopy using a titrated dose of topical lignocaine anaesthesia were studied. Patient comfort, lignocaine dosage and resultant plasma concentrations were measured at four stages during the procedure. Large total doses, mean 512 (SD 55) mg lignocaine, were frequent and systemic absorption was unpredictable with two patients having plasma concentrations in the toxic range (greater than 5 micrograms/ml). Peak plasma concentrations, mean 2.3 (SD 1.4) micrograms/ml, occurred 30 to 40 minutes after commencement of topical application and coincided with completion of the procedure. No correlation was found between the individual dose of lignocaine administered and either the resultant plasma concentration or patient comfort scores. In an effort to minimise potential lignocaine toxicity, a fixed total dose technique (lignocaine 370 mg) was studied in a further twenty-one patients. No change in patient comfort scores and no toxic plasma concentrations were observed. Mean completion plasma concentration was 2.0 (SD 1.0) micrograms/ml. No clinical toxicity was observed in either group. Fibreoptic bronchoscopy in both groups using topical lignocaine anaesthesia without premedication or intravenous supplementation was well tolerated.

[Involvement of the thyroid gland in clinical shock (anti-shock action of propylthiouracil)]

Propylthyouracil, a synthetic anti-thyroid drug, was given intravenously in ten patients in a severe shock condition and its action was followed on the blood cathecholamines. This was assessed in venous blood according to a modified colorimetric method by Manuhin, before and 30 minutes after the substance was perfused. Although statistically non-significantly the two amines show a tendency to fall after the administration of the drug. In line with a series of previous studies carried out in various institutes of chemical and pharmaceutical research the drug was given for the first time in humans in shock conditions. Discussing the results obtained the administration of propylthyouracil is recommended, as an adjuvant therapy in severe shock.