Volume 9 (2015): Issue 5 (October 2015)

Cardiopulmonary bypass (CPB) can contribute to the development of an inflammatory response and postsurgical morbidity. Conventional ultrafiltration and modified ultrafiltration (MUF) can mitigate the adverse effects of CPB by removing free water and inflammatory mediators, at least in part.

To evaluate evidence for the effects of MUF on clinical outcomes of cardiac surgery in pediatric and adult patients.

A literature review of MEDLINE-indexed articles published between 1990 and June 2014 was conducted on PubMed. A search on the CTS.net website and the Cochrane Central Register of Controlled Trials was also performed with relevant keywords. The search was limited to English language articles and human studies.

Our primary search identified 84 potential articles, of which 55 articles were relevant to conventional ultrafiltration, modified ultrafiltration, ultrafiltration, cardiopulmonary bypass, extracorporeal circulation, pediatric and adult cardiac surgery. There were 3 meta-analyses, 7 review literatures, 21 randomized controlled trials. The remainder consisted of 18 controlled and 6 observational studies. MUF has been beneficial effects on postoperative bleeding, chest drainage, transfusion requirement, and improvement cardiac function, but effects in adult cardiac surgery inconclusive because data was relatively limited.

MUF may improve post-CPB hemodynamic activity and cardiac function in pediatric cardiac surgery. By contrast, the clinical trials in adults are limited mostly by small sample sizes that preclude an adequately powered assessment of clinically relevant outcomes. The available data are conflicting and several studies show no differential outcomes. Further studies are required to identify patients who will most likely benefit from ultrafiltration and to establish standard protocols.

Hyperlipidemia can induce the endogenous production of reactive oxygen species (ROS), which may cause carcinogenesis. Cytochrome P450 (CYP) 2E1 activity, induced by various factors including polyunsaturated fatty acids, effects the incidence of cancers, whereas NQO1, a flavoprotein, may protect against ROS.

To investigate the effect of CYP2E1 and NQO1 polymorphism on oxidative stress status in Thais with and without dyslipidemia.

We included 1380 apparently healthy employees of the Electricity Generating Authority of Thailand in this study. We determined their CYP2E1 and NQO1 genotypes and related these to blood lipid profiles, and circulating levels of antioxidant enzymes, malondialdehyde (MDA), and reduced glutathione (GSH). Lifestyle-related factors were determined from questionnaires.

All tested genotype frequencies were in Hardy-Weinberg equilibrium. The heterozygous and variant genotype distribution and allele frequency of CYP2E1 *5B were less common than CYP2E1 *6. Heterozygous NQO1 was the most prevalent form. The frequency of the mutated allele CYP2E1 *5B was 0.16, CYP2E1 *6 was 0.22, and NQO1 *2 was 0.43. Significant differences were observed for blood cholesterol, triglyceride, low-density lipoprotein-cholesterol, and high-density lipoprotein-cholesterol between normolipidemic participants, and those with hypercholesterolemia, hypertriglyceridemia, and combined hyperlipidemia. Participants in the hyperlipidemic subgroup who bore any variant alleles of genes had higher plasma MDA and GSH levels, and superoxide dismutase and glutathione peroxidase activity, but lower catalase activity when compared with normolipidemic participants bearing wild-type alleles.

Variations in genetic disposition and dyslipidemia can modify oxidative stress status. Relatively more free radicals may be generated in individuals in subgroups with hyperlipidemia bearing any variant alleles.

The increase in prevalence of diabetes is a serious public health issue. It is well-documented that use of blood glucose screening can help to reduce the risk of developing diabetes.

To examine the socioeconomic and lifestyle factors associated with use of blood glucose screening among Malaysian adults.

Nationally representative data from 2,415 survey respondents was used. The survey was a cross-sectional population-based study previously conducted by the Ministry of Health Malaysia. A logistic regression model was developed to estimate the likelihood of using blood glucose screening.

Age, marital status, ethnicity, income, smoking, and body mass index were significantly associated with use of blood glucose screening. In particular, older individuals, married individuals, Malays, higher income earners, non-smokers, and being obese, overweight or of normal weight were correlated with a higher likelihood of using blood glucose screening.

It is important to acquire a better knowledge of the factors that can influence the decision of people to adopt preventive measures. Having better information regarding which groups of individuals use or do not use blood glucose screening can assist governments in developing appropriate intervention programs.

Serum levels of soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) reflect increases in LOX-1 receptor expression associated with inflammation and metabolic disorders.

To examine sLOX-1 levels in metabolic syndrome and association of sLOX-1 with classical risk factors, and with metabolic syndrome, a clustering of metabolic disorders associated with cardiovascular risk factors.

We selected 148 serum samples from patient participants with metabolic syndrome and 206 samples from patients with non-metabolic syndrome as controls, using the modified National Cholesterol Educational Program Adult Treatment Panel III (NCEP-ATP III) criteria.

Levels of sLOX-1 were increased significantly in participants with metabolic syndrome (P < 0.001). Serum sLOX-1 was positively associated with body mass index (BMI), blood pressure, fasting plasma glucose, triglyceride, and total cholesterol, but negatively associated with high-density lipoprotein cholesterol. Analysis of serum sLOX-1 for metabolic syndrome showed 99.03% specificity and 100% sensitivity. The area under the receiver operating characteristic curve was 0.998 (95%CI 0.996-1.001, P < 0.001). A univariate analysis showed sLOX-1 was significantly correlated with metabolic syndrome, but was not after adjustment for sex, age, blood pressure, and BMI. Multivariate regression analysis found that being overweight (82.3; 95%CI 10.7–631.9), hyperglycemia (1.1; 95%CI 1.1–1.2), and hypertriglyceridemia (1.1; 95%CI 1.0–1.1) were significantly correlated with metabolic syndrome. HDL cholesterol was a protective factor (0.96; 95%CI: 0.93–0.99).

Serum sLOX-1 is a suitable biomarker for diagnosis of metabolic syndrome. However, univariate and multivariate analysis suggested that sLOX-1 may be a modulating factor, and not an independent risk factor.

Prompt diagnosis and treatment of retinopathy of prematurity (ROP) is crucial to prevent blindness. Telemedicine for ROP diagnosis can be applied in regions that lack an expert ophthalmologist.

To assess the value-for-money of telemedicine in screening for ROP in high-risk infants.

A cost-utility analysis of screening and diagnosis of ROP using telemedicine was compared with the current process for ROP screening (Thai Clinical Trials Registry Identification No. TCTR20130911001). We used decision analytical models to compare costs and outcomes in terms of quality-adjusted life years (QALY) to the health provider and society. We used one-way sensitivity analysis and probabilistic sensitivity analysis to consider parameter uncertainty.

The total capital cost for telemedicine to the health provider was 951,000 THB per year. With the base case analysis of 400 children screened per year per RetCam, the performance of screening and diagnosis of ROP using telemedicine (100% sensitivity and 97.8% specificity) was higher compared with the current method (88.9% sensitivity and 93.4% specificity). We therefore expect that blindness can be prevented in 3 children per 400 screening cases. The incremental cost to society of telemedicine compared with the current practice was 837 THB. Preventing just one child from becoming blind can save around 146,000 THB throughout their lifetime based on savings to welfare costs for disabled people. The incremental cost-effectiveness ratio of this telemedicine was 259 THB per case of prevented blindness and 17,397 THB per QALY saved.

Store and forward telemedicine for ROP screening is cost-effective.

Trichomoniasis is a sexually transmitted vaginal infection caused by a protozoan called Trichomonas vaginalis. Its prevalence ranges between 3–40% among randomly tested women.

To investigate the presence of T. vaginalis in infertile women presenting to a Turkish gynecology outpatient clinic using parasitological methods.

The study population comprised 51 patient participants who attended the gynecology clinic of Mustafa Kemal University Hospital between March and August 2013. The women were divided into those presenting with infertility (n = 22) and a patient control group (n = 29). Women in the control group had complaints other than infertility. Microscopic examination, Giemsa staining, and cysteine-peptone-liver-maltose culture were performed on samples taken from posterior fornix tested for T. vaginalis.

T. vaginalis was observed in 18% (n = 4) of infertile patients and in none of the control group (P = 0.03).

Asymptomatic infertile women should be examined for T. vaginalis infection, which may play a role as a cause or contributing factor in infertility.

Pediatric sedation for diagnostic radiological procedures remains the mainstay for adequate imaging quality.

To clarify the risk of adverse events during anesthesiologist-led sedation or anesthesia for diagnostic radiological procedures in children in order to improve quality of care.

We enrolled children aged <15 years given sedation or anesthesia by an anesthesiologist and scheduled for computed tomography, magnetic resonance imaging, or nuclear medicine imaging November 2010-September 2014. We recorded adverse events occurring in the first 24 h.

Of 1,042 patients enrolled, adverse events were recorded in 254 (24.4%, 95% confidence interval [CI] 21.9 to 27.1). Adverse respiratory events occurred in 31 (3.0%), cardiovascular events in 7 (0.7%), sedation was prolonged in 165 (15.8%), there was one case of contrast allergy (0.01%), and there were 50 other minor complications (4.9%). Of the respiratory complications, there were 14 of airway obstruction (1.3%), 2 of apnea (0.2%), 14 of oxygen desaturation (1.3%), and one of laryngospasm (0.01%). There were no life threatening complications or consequences. Age <1 year (adjusted odds ratio [adjusted OR] 2.5, 95% CI 1.2 to 5.3) and American Society of Anesthesiologists (ASA) physical status classification 2 and 3 (adjusted OR 4.6, 95% CI 1.1 to 19.8, and adjusted OR 6.3, 95% CI 1.3 to 30.9, respectively) were risk factors for respiratory complications.

Adverse events were common during sedation or anesthesia, but no life threatening or sentinel events occurred under experienced supervision. Caution should be exercised in children <1 year or with an ASA classification >1.

Blunt eye trauma is an important emergency in ophthalmology practice, and may alter the structure of the macula.

To evaluate the optic coherence tomography (OCT) measurements of central macular thickness (CMT) among patients admitted to the hospital within 48 hours of blunt eye trauma.

Prospective cross-sectional study to evaluate patients who were admitted to hospital with blunt eye trauma within 48 hours trauma. Spectral domain OCT was used to measure macular thickness. CMT measurements of 24 healthy and 26 traumatized eyes of same patients were analyzed as control and case groups, respectively.

The mean CMT measurements were 230.04 ± 18.64 μm in control and 226.50 ± 18.89 μm in traumatized groups. The difference between two groups was not statistically significant (P = 0.412). However, when the patients were classified according to the severity of trauma, CMT measurements of severely injured patients were found significantly lower than both healthy and mildly traumatized eyes (P = 0.008, P = 0.004, respectively).

Early stage macular OCT findings at blunt eye trauma may change with the severity of trauma. We have determined an insignificant increase in the mildly traumatized group in CMT compared with the healthy group within the first 48 hours of blunt trauma as a sign of macular trauma. However, in the severely traumatized group in CMT values significantly decreased, which may be a sign of cellular loss. Further prospective studies with long follow-up periods are warranted to elucidate the effects of this decrease in thickness.

Infants with an inappropriate birth weight for their gestational age are more likely to develop complications during pregnancy and postpartum, and have increased long-term health risks.

To determine the prevalence and risk factors for infants with inappropriate birth weight for their gestational age.

We enrolled 820 women with uncomplicated, singleton pregnancies who gave birth to a live born infant at term. Prepregnancy baseline and obstetric information were extracted from medical records, including body mass index (BMI), gestational weight gain, and infant birth weight. Prevalence of small-for-gestational age (SGA) and large-for-gestational age (LGA) infants was determined. We compared variables between groups to identify associated factors.

Prevalence of SGA was 2.6% and LGA was 10.5%. Prepregnancy BMI and gestational weight gain were significantly higher in the LGA than in the SGA group (P = 0.041 and < 0.001, respectively). The birth weight and gestational weight gain, but not the prepregnancy BMI, were significantly different (P < 0.001). Logistic regression analysis determined that inadequate gestational weight gain significantly increased the risk of SGA (adjusted OR 3.20, 95%CI 1.06 to 9.64, P = 0.039), and significantly reduced the risk of LGA (adjusted OR 0.43, 95% CI 0.20 to 0.91, P = 0.028). Excessive gestational weight gain significantly increased the risk of LGA (adjusted OR 2.00, 95% CI 1.21 to 3.30, P = 0.006). There was no significant association with prepregnancy BMI.

Controlling gestational weight gain may improve maternal and neonatal outcomes.

The Q angle is a relevant clinical diagnostic measurement to detect various disorders of the knee. The common method used to measure the Q angle in the routine clinical practice is by radiography. An alternative to radiographic measurement is goniometry, by which exposure to x-rays can be avoided.

To compare and correlate the goniometric measurement of Q angle with radiographic measurement of the Q angle in patients with acute knee pain.

We selected 45 patient participants with a mean age of 32.5 years who satisfied the inclusion criteria for this study. All the patients underwent goniometric measurement of the Q angle followed by x-ray imaging of the entire lower limb. Later the bony prominences were marked on the x-ray image and the Q angle formed was measured using a protractor. The Pearson correlation coefficient between the goniometric and radiographic measurements was determined.

We found a significant relationship between Q angles obtained using a goniometer and x-ray imaging in the supine position (r = 0.91, P = 0.001). The mean difference between the goniometric measurement of Q angle and the radiographic measurement was 0.1°, which is not significant.

Goniometry can be used to measure Q angle as accurately as radiography, and can be used as an inexpensive and radiation free alternative.

Acute lymphoblastic leukemia (ALL) is the most prevalent cancer in the pediatric population. From 25% to 30% of patients with ALL will have a relapse that leads to death when they are teenagers. At Cipto Mangunkusumo Hospital, 40% of 126 pediatric patients with ALL relapsed from 2005 to 2011. A multiple variant of multidrug resistance gene 1 (MDR1) is C3435T, which can be used to understand the genetic basis of susceptibility to relapse.

To identify the profile of MDR1 polymorphism in pediatric Indonesian patients with ALL.

We collected data from 44 patients with ALL who attended Cipto Mangunkusumo Hospital between January and June 2014. We investigated a silent C3435T polymorphism in MDR1 exon 26 with polymerase chain reaction- restriction fragment length polymorphism using MboI.

There were 32 male and 12 female patient participants in this study. Eighteen patients were 1–3 years old and 26 were over 3 years. The mean age at 1–3 years was 2.4 ± 0.86, and over 3 years it was 6.3 ± 2.67 years. There were 27 patients with ALL in the standard risk group and 17 in the high risk group. We determined that the 25 samples from patients with ALL in the standard risk group were not digestible (allele T) and the 6 samples from patients with ALL in the high risk group were digestible (allele C).

The prevalence of the T allele was higher than that of the C allele in pediatric Indonesian patients with ALL.

Not all morphological lung changes in the elderly contribute to respiratory disease and may be a consequence of normal aging.

To describe the changes in asymptomatic elderly patients compared with those in younger patients in a Thai population.

The study cohort comprised 60 participants without respiratory symptoms in three groups of 20 by age: 20-40 years, 41-60 years, and >60 years. Participants were prospectively selected from patients referred for computed tomography (CT) of the abdomen, or head and neck, and underwent sequential CT during deep breathing at four lung levels. Two observers scored images by consensus. We compared groups using Pearson chi-square and Fisher exact tests, and used receiver operating characteristic curves to categorize bronchiectasis and bronchial wall thickening by age.

Air trapping was related to age (5/20 group 1, 7/20 group 2, and 18/20 group 3 (P <0.01)) and was most prevalent in lower lobes (78%, P < 0.01). Reticulation was found in only one middle aged patient (P = 0.36). Bronchiectasis was more common in patients <56 years (7/23) than <56 years (3/37), P = 0.035. Bronchial wall thickening (7/23 in patients >56 years and 2/37 in patients <56 years, P = 0.02) and extensive air trapping were related to age (0/6 group 1, 1/6 group 2, and 5/6 group 3, P = 0.02). Findings were independent of smoking history.

Asymptomatic older patients had higher prevalence of bronchiectasis, bronchial wall thickening, and air trapping, independent of smoking history.

A Janus kinase 2 (JAK2) mutation polycythemia vera (PV) is a common manifestation of stem cell disorder. However, available data on the clinical and treatment response of JAK2-negative PV patients are limited.

We report the case and clinical course of a patient with PV and left hemiparesis who was JAK2V617-negative.

We conducted a literature review and compared our patient with previously published reports of JAK2-negative patients with P V.

Our patient presented with hemiparesis without a previous history of hematological disease. He was diagnosed with PV based on the British Committee for Standards in Haematology guidelines 2007. He underwent only phlebotomy with subsequent improvement of his neurological condition. He was discharged with therapeutic phlebotomy for one and a half months.

Although this rare condition required complex diagnostic criteria, the patient achieved good clinical outcome with therapeutic phlebotomy alone.

Southeast Asian ovalocytosis (SAO) is a red blood cell membrane disorder caused by a 27 base pair (bp) deletion in the SLC4A1 that transcribes to a truncated variant of band-3 glycoprotein. β-Thalassemia is another red blood cell disorder, caused by mutant alleles in the β-globin gene that lead to globin chain impairment. Both conditions occur in Southeast Asian countries, including Malaysia.

This report describes hematological and molecular features of a patient with both SAO and β-thalassemia and her children.

A 58-year-old Malay woman presented to our clinic with dizziness, tiredness, and easy fatigability. She was mildly anaemic. Analysis of her complete blood counts and her peripheral blood smear revealed microcytic hypochromic anaemia with large numbers of macro-ovalocytes and stomatocytes.

Hemoglobin and globin gene studies revealed heterozygous β-thalassemia, and further analysis demonstrated a heterozygous 27 bp deletion on the SLC4A1 gene consistent with SAO. Analysis of the patient’s offspring showed co-inheritance of β-thalassemia and SAO in her elder daughter and son, and SAO alone in another daughter.

High frequencies of SAO and different β-thalassemia mutations are present in the Malaysian population, thus coinheritance of SAO and β-thalassemia is not uncommon. However, this coinheritance is rarely reported, possibly because the red blood cell indices are overlooked and peripheral smear examinations are not routine.