Mana Rochanawutanon

Cryopreserved, irradiated tracheal homograft transplantation for laryngotracheal reconstruction in human beings.

Subglottic tracheal stenosis is a common clinical entity. Management in severe cases is often problematic. Various techniques for tracheal replacement have been used with varying degrees of success. In this study we used cryopreserved, irradiated tracheal homografts, the use of which in human beings has not been reported previously. In a sterile setup, the tracheas were harvested from donor cadavers within 24 hours of death. The grafts were initially kept at 57 degrees C for 20 minutes; they were then placed in a -70 degrees C chamber for another 2 to 3 days or more and were irradiated to 25 kGy (2.5 million rad). Finally, the grafts were stored at -70 degrees C until usage. Seven patients underwent the surgery, but only 4 are presented here. In the remaining 3 patients, the follow-up time was too short to be evaluated. Four patients, 2 male and 2 female (aged 2-40 years, mean 16 years), with severe subglottic tracheal stenosis underwent segmental tracheal graft reconstruction. Immunosuppressant medications were not given to any patient. Follow-up ranged from 18 to 20 months. Three patients successfully underwent decannulation, and 1 patient had local infection and dislodgment of the intraluminal stent with subsequent restenosis. The postoperative tracheal lumen appeared to be near normal, with histologic evidence of normal respiratory epithelium at the grafted site. In conclusion, cryopreserved, irradiated tracheal homograft transplantation is a valuable alternative for subglottic tracheal reconstruction.

Pulmonary arterial hypertension after childhood cancer therapy and bone marrow transplantation.

According to the Third World Symposium on Pulmonary Arterial Hypertension (PAH), chemotherapy is considered to be one of the possible risk factors for patients developing PAH. However, to date, no literature has sufficiently addressed the risk, natural history, and effective treatment of this condition. We report our experience on how early diagnosis, detailed monitoring of disease course, and appropriate treatment application have led to a successful outcome of PAH management in childhood after cancer therapy. Our report reaffirmed the fact that PAH is now a recognized complication of chemotherapy and bone marrow transplantation for leukemia. Combined pulmonary vasodilator treatment has a beneficial effect in improving the patient’s condition and functional status as suggested by initial acute pulmonary vasodilator testing.

Prevalence and clinical predictors of endometrial hyperplasiain anovulatory women presenting with amenorrhea.

The aim of the present study was to determine the prevalence and clinical predictors of endometrial hyperplasia (EH) in amenorrheic women with anovulation. Fifty-seven women were enrolled in the study. Of these, 43 were diagnosed to have polycystic ovary syndrome (PCOS) and 14 to have idiopathic anovulation. All women received transvaginal sonography to assess endometrial thickness (ET), patterns and abnormalities. At the same time, an endometrial biopsy was taken using a Pipelle instrument. The womens age, body mass index (BMI) and waist-to-hip ratio (WHR) were 32.0±6.0 years, 27.3±6.5 kg/m2 and 0.82±0.06 (mean±standard deviation), respectively. Twenty (35.1%) and 19 (33.3%) women were classified as obese by BMI and WHR, respectively. Hypertension was found in 17 (29.8%) women. The prevalence of EH was 45.6%. Most cases were simple EH, and only one (1.75%) was simple EH with atypia. EH prevalence was 48.8% and 35.7% in PCOS and idiopathic anovulatory women, respectively. Age, BMI, WHR and ET did not predict EH, whereas the endometrial hyperechogenic pattern was a clinical predictor of EH with borderline significance. In conclusion, this study demonstrated that almost half of the anovulatory women with amenorrhea had EH and no significant predictor was found. In view of these findings, an endometrial biopsy should be performed in all women with this disorder.

Primary polymorphous low-grade adenocarcinoma of the bronchus: Complete tumor removal with bronchoscopic resection

Primary polymorphous low-grade adenocarcinoma (PLGA) is an uncommon malignant tumor arising from the minor salivary glands, but its occurrence as a primary tumor of the tracheobronchial tree is very rare. Herein, we have reported a rare case of endobronchial PLGA in a 56-year-old woman presenting with chronic cough and progressive exertional dyspnea. Chest CT clearly demonstrated an endobronchial tumor obstructing the distal part and bifurcation of the left main bronchus and causing distal atelectasis. She underwent rigid bronchoscope with electrocautery and bronchoscopic resection of the tumor. PLGA was diagnosed histologically. Subsequent left pneumonectomy was performed and showed no evidence of residual tumor.

Small-dense LDL/large-buoyant LDL ratio associates with the metabolic syndrome

OBJECTIVE Heterogeneous particles of intermediate-density lipoprotein (IDL) and low-density lipoprotein (LDL) vary in atherogenesis. We investigated the association between the metabolic syndrome (MetS) score and lipoprotein subclasses. DESIGN AND METHODS A total of 260 outpatients were scored into six groups, based on their number of MetS components. Lipoprotein subclass determined by polyacrylamide tube gel electrophoresis separates IDL particles into three midbands (MID-A to C) and LDL into larger-buoyant (LDL1 and LDL2) and small-dense LDL (LDL3 to LDL6). RESULTS Mean concentrations of VLDL, MIDC, LDL2, and LDL3 to LDL6 positively correlated with increasing MetS score, but those of MIDA, LDL1 and HDL-C inversely correlated. LDL2 and LDL3 to LDL6 increased while MIDA and LDL1 decreased with increasing visceral fat, HOMA-IR, and triglycerides, with a reverse pattern for HDL-C. MIDB and MIDC were unchanged. By logistic regression, LDL1 and LDL3 to LDL6 significantly associates with the MetS score (odds ratio=0.957 and 1.077, respectively). The ratio of (LDL3 to LDL6)/LDL1 in the presence of HDL-C, showed the strongest association with MetS. CONCLUSIONS Respective subpopulations of IDL and LDL particles can vary in their ability to identify MetS. Because of the most strongly associated with MetS, (LDL3 to LDL6)/LDL1 ratio is proposed as an excellent marker for evaluating lipid metabolic status in patient with MetS.

Heterogeneous properties of intermediate- and low-density lipoprotein subpopulations.

OBJECTIVE Intermediate-density lipoprotein (IDL) and low-density lipoprotein (LDL) consist of heterogeneous particles whose subpopulations may have different atherogenic characteristics. This study investigated the associations between these subpopulations and other lipids, lipoproteins and atherosclerosis-related markers. DESIGN AND METHODS A total of 416 subjects (124 males and 292 females, mean age: 50.8 years) were enrolled in this study. Using polyacrylamide gel electrophoresis, serum lipoproteins were separated according to their specific electrophoretic mobility based on particle size. The IDL particles were separated into three midbands (MID-A to C), and the LDL particles were separated into seven subfractions (LDL1 to 7). RESULTS MID-B, MID-C, LDL2 and LDL3 to 6 (as a small LDL fraction) were significantly and positively correlated with very LDL (VLDL), while MID-A and LDL1 were significantly and inversely correlated with VLDL. MID-A and LDL1 were significantly and positively correlated with high-density lipoprotein (HDL). The correlation patterns between MID-A or LDL1 and triglycerides, apolipoprotein A-I, glucose, the insulin resistance index, creatinine and the mean LDL particle size had similar trends to those between HDL and these parameters. CONCLUSIONS The respective subpopulations of IDL and LDL particles can vary in their ability to predict cardiovascular disease risks. These variations may partially explain why quantitative assessments using LDL-cholesterol concentrations, as typically performed in conventional practice, are not perfect predictors of cardiovascular disease. Further studies are required to determine the clinical relevance of analyzing the IDL and LDL subpopulations.

Case report: Increased viral receptor expression associated with high viral load and severe pneumonia in a young patient infected with 2009 H1N1 influenza a with no pre‐existing conditions

A case of unusually high severity of influenza pneumonia leading to acute respiratory distress syndrome and death was investigated. This was a previously a healthy 28‐year‐old man with no underlying conditions, admitted to a hospital during the first wave of influenza pandemic in Thailand in July 2009. He had experienced high fever and influenza‐like illness for 5 days before coming to the hospital. He developed acute respiratory distress syndrome and expired on day 7 after admission. In comparison to three other cases of influenza pneumonia in the same outbreak with known risk factors for severe influenza, such as pregnancy and diabetes mellitus, a much higher viral load was detected in the lungs of this patient despite antiviral treatment. In agreement with the high viral load, the lung specimens from this patient, but not the other three patients, showed a high expression of α‐2,6‐linked sialic acid by lectin staining. The gene responsible for the synthesis of this sialic acid was also found to be upregulated. The data indicated overexpression of the viral receptor as a potential mechanism for severe disease in some patients. J. Med. Virol. 84:380–385, 2012.

Performance of body mass index and percentage of body fat in predicting cardiometabolic risk factors in Thai adults

Background Body mass index (BMI) and percentage of body fat (PBF) are used to measure obesity; however, their performance in identifying cardiometabolic risk in Southeast Asians is unclear. Generally, Asian women have higher PBF and lower BMI than do men and other ethnic populations. This study was conducted to address whether a discord exists between these measures in predicting obesity-related cardiometabolic risk in a Thai population and to test whether associations between the measures and risk factors for cardiovascular disease have a sex-specific inclination. Methods A total of 234 (76 men and 158 women) outpatients were recruited. BMI obesity cutoff points were ≥25.0 and ≥27.0 kg/m2 and PBF cutoff points were ≥35.0% and ≥25.0% for women and men, respectively. Blood samples were analyzed for total cholesterol, triglycerides, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, lipoprotein subclasses, apolipoprotein A-I, apolipoprotein B, glucose, hemoglobin A1c, insulin, high-sensitive C-reactive protein (hsCRP), adiponectin, leptin, and 25-hydroxyvitamin D. Results Twenty-five percent of participants classified as normal-BMI had excessive fat, whereas 9% classified as normal-PBF had excessive BMI. Good relationships were found between BMI and PBF using sex stratification (R2 >0.5). The prevalence of metabolic syndrome was markedly increased in overweight and/or excess body fat groups compared with lean group. Logistic regression analyses showed that BMI was the best predictor of hypertension. BMI was an independent predictor of insulin resistance, hyperglycemia, hypertriglyceridemia, and hyperleptinemia in women, whereas PBF was for men. However, PBF proved to be a good indicator for atherogenic lipoprotein particles in both sexes. Notably, neither index predicted increased hsCRP or 25-hydroxyvitamin D insufficiency. Conclusion Considerable sex-specific variations were observed between BMI and PBF in their associations with and predictability of numerous cardiometabolic biomarkers. No single measure provides a comprehensive risk predication as shown herein with the Thai population, and therefore both should be applied in screening activities.

Comparison of a direct enzymatic assay and polyacrylamide tube gel electrophoresis for measurement of small, dense low-density lipoprotein cholesterol

Abstract Background: Small, dense low-density lipoprotein cholesterol (sdLDL-C) has been linked to the progression of cardiovascular disease. We compared two methods for determination of sdLDL-C, a direct enzymatic (ENZ) method and a polyacrylamide tube gel electrophoresis (PGE) assay, and investigated the associations of both sdLDL-C measurements with metabolic syndrome. Methods: We analyzed 242 patient sera for sdLDL and atherosclerosis-related markers. The PGE method separates the intermediate-density lipoprotein particles into three midbands (MID-A to MID-C) and the LDL particles into seven subfractions (LDL1 to LDL7); the sdLDL-PGE result is calculated as the sum of cholesterol concentrations from LDL3 to LDL7. Results: The regression equation for sdLDL-C was [ENZmmol/L]=0.779[PGE]+0.67, r=0.713. ENZ showed higher sdLDL-C concentrations than PGE (0.86±0.33 vs. 0.24±0.32 mmol/L); however, the difference was not associated with sdLDL-C concentration (p=0.290). sdLDL-C, as measured with the enzymatic assay, exhibited significant positive correlations with very-low-density lipoprotein, MID-C, MID-B, and LDL2 (all p<0.001), considered atherogenic lipoproteins, but did not correlate with the less atherogenic lipoproteins MID-A and LDL1 (all p>0.600). The ENZ and PGE methods yielded similar patterns of correlation between sdLDL-C, and atherosclerosis-related markers. Using logistic regression, sdLDL-ENZ and apolipoprotein B were identified as significant predictors of metabolic syndrome (p<0.03). Conclusions: The ENZ assay for sdLDL-C correlated well with the PGE method. The ENZ method measures a broader range of atherogenic lipoprotein particles than PGE and has the potential to identify subjects with vascular risk, thus contributing in directing specific interventions for cardiovascular prevention.

Fate of mucosal healing in transplanted deep frozen irradiated tracheal homograft

Objective Deep-frozen irradiated tracheal homograft has been successfully employed for subglottic-tracheal reconstruction, as in our previous report. Morphologically, though the transplanted site appeared to have good mucosal healing, the fate of the donor mucosa is not known. The objective of this study was to determine the survival of the mucosa of donor trachea. Study Design and Setting University hospital-based, prospective study. Methods Thirty samples from six sets of specimens, each set consisting of five samples of the tracheal mucosa, were studied. Of five samples in each set, 2 were taken from donors, one from a recipient, and another two from the transplanted sites, eight months postoperatively. The samples in each set of specimens were genetically matched by the process of DNA fingerprinting. Histological studies were done on the mucosa of donor and transplanted sites. Results The study demonstrated incompatibility between samples from recipient and transplanted site, and incompatibility between preoperative donor and recipient samples in all sets of specimens. Conclusion The mucosa of donor trachea did not survive at the transplanted site. The apparently normal postoperative mucosal lining actually represents migration of the recipient mucosa. Significance The fate of transplanted donor tracheal mucosa is elucidated, and may substantially explain the mechanism of rejection resistance.