Nattachai Anantasit

Tumour necrosis factor gene polymorphism in dengue infection: association with risk of bleeding

Abstract Background: A single nucleotide polymorphism located at the promoter -308A of tumour necrosis factor-alpha (TNF-α) gene may affect transcription and increase cytokine production, leading to the severe manifestation of dengue virus infection. Aim: To study the association of the TNF-α -308A allele and the severity of patients with dengue infection. Methods: 112 patients suspected of having dengue infection and 106 normal controls were enrolled in the study. Mean (SD) age was 10·4 (3·6) years. In all, 19 and 82 patients were diagnosed with dengue fever (DF) and dengue haemorrhagic fever (DHF), respectively, while 11 were diagnosed with other febrile illnesses (OFIs). They were tested for the polymorphisms at the promoter -308 position of the TNF-α gene and their TNF-α levels were measured. Results: In the patients with dengue infection (14/202, 6·9%) with OFIs (1/22, 4·5%) and in normal controls (17/212, 8·0%), the frequency of the TNF-α -308A allele was not significantly different. Moreover, no statistically significant difference was found in patients with various clinical manifestations of dengue infection involving DF (5·3%, 2/38), DHF grade I (5·0%, 2/40), DHF grade II (9·5%, 4/42), DHF grade III (2·5%, 1/40) and DHF grade IV (11·9%, 5/42). However, patients with dengue infection and significant bleeding manifestations, apart from petechiae and ecchymosis, tended to have a higher frequency of the TNF-α -308A allele (11·8%, 9/76) than those without significant bleeding manifestations (5/126, 4·0%) (P = 0·056). The levels of TNF-α were additionally measured in 67 patients but the results failed to demonstrate a functional effect in the transcriptional rate of the TNF-α -308A allele. Conclusion: In patients with dengue infection there is an association between the TNF-α -308A allele and the risk of bleeding. The test may be used as one of the predictors of the severity of dengue infection.

Nebulized Fluticasone for Preventing Postextubation Stridor in Intubated Children: A Randomized, Double-Blind Placebo-Controlled Trial*

Objectives: To evaluate the efficacy of nebulized fluticasone propionate in the prevention of postextubation stridor in children. Design: Double-blind, placebo-controlled randomized clinical trial. Setting: PICU in a tertiary referral center. Patients: Children 1 month to 15 years old who underwent mechanical ventilation. Interventions: Patients were randomly assigned into two groups after stratification based on age group receiving nebulized fluticasone 1,000 µg or normal saline solution, immediately after extubation. Vital signs and modified Westley score were evaluated for 6 hours after extubation. The primary outcome was the prevalence of postextubation stridor. Measurements and Main Results: One hundred forty-seven intubated children were enrolled into this study. Baseline characteristics between two groups were not different. There was no significant difference in the incidence of postextubation stridor (12/74 [16%] vs 13/73 [18%]; p = 0.797). However, when analyzing the subgroup of emergently intubated children, the fluticasone group had a longer delay median time for the initiation of noninvasive ventilation than the control group (380 [90–585] vs 60 [42–116] min; p = 0.044). The modified Westley scores at 30 and 60 minutes in the control group were significantly higher than the fluticasone group (4 vs 2, p = 0.04; 4.5 vs 0.5, p = 0.02, respectively). Conclusions: The single dose of 1,000-µg nebulized fluticasone did not decrease the prevalence of postextubation stridor. However, it might be beneficial in emergently intubated children.

Low plasma FVII:C and activated FVII as predictive markers for overt disseminated intravascular coagulation

In sepsis, binding of factor VII (FVII:C) and activated factor VII (FVIIa) with tissue factor is the key step of coagulation resulting in disseminated intravascular coagulation (DIC). We conducted a prospective cohort study among 47 septic patients, aged 8 months to 18.8 years. They were initially divided into three groups of no DIC (n=27), non-overt DIC (n=14) and overt DIC (n=6). Blood samples were collected at 0, 24 and 48 hours (h) after the onset of sepsis. At the onset of sepsis, FVII:C tended to be lower in the non-overt DIC [median 57 % (interquartile range [IQR] 41-80)] and overt DIC groups [33 % (23-52)] than that in the no DIC group [65 % (44-87)]. Whereas FVIIa tended to be lower in the overt DIC group [1.29 % (0.50-4.19)] than those in the non-overt DIC [3.01 % (1.01-5.24)] and no DIC groups [2.49 % (1.14-3.13)]. At 24 h, FVII:C was significantly lower in the non-overt DIC [57 % (41-101)] and overt DIC groups [31 % (28-49)] than that in the no DIC group [83 % (70-102)]. While FVIIa was significantly lower in the overt DIC group [2.15 % (0.86-3.96)] than that in the no DIC group [3.83 % (2.90-5.46)]. Using FVII:C <65 % or FVIIa <3 % at 24 h among patients without hepatic dysfunction to determine overt DIC at 24 h, the sensitivity was 83.9 % and 77.4 %, respectively, and the specificity was both 83.3 %. Patients with low FVII:C and low FVIIa at 24 h after the onset of sepsis had a 20.8-fold (95 % confidence interval [CI], 2.0-213.0, p=0.010) and 14.4-fold (95 %CI, 1.5-142.4, p=0.023) chance of overt DIC.

Ultrasound Versus Traditional Palpation to Guide Radial Artery Cannulation in Critically Ill Children: A Randomized Trial

To identify success rates for radial artery cannulation in a pediatric critical care unit using either palpation or ultrasound guidance to cannulate the radial artery.

Spontaneous Pneumomediastinum in Non-Asthmatic Children with Exercise-Induced Bronchoconstriction.

Case series Patient: Male, 11 • Male, 15 Final Diagnosis: Spontaneous pneumomediastinum Symptoms: — Medication: — Clinical Procedure: None Specialty: Pediatrics and Neonatology Objective: Unusual clinical course Background: Subcutaneous emphysema can result from rupture of the respiratory or gastrointestinal systems, commonly occurring after trauma or surgery, as well as from rupture of alveoli as pneumothorax or pneumomediastinum. Spontaneous pneumomediastinum with subcutaneous emphysema is rare in children without chest or neck trauma. Here, we report 2 cases of spontaneous pneumomediastinum with exercise-induced bronchoconstriction. Case Report: The first case is an 11-year-old boy who presented with neck pain after vigorous exercise. Radiography showed pneumomediastinum. The second case is a 15-year-old boy who presented with pleuritic chest pain and respiratory failure requiring intubation. We extensively investigated the possible causes of pneumomediastinum. Both patients had no history of trauma or asthma, and were diagnosed with exercise-induced bronchoconstriction. They were discharged after conservative treatment, without complication. Conclusions: Early recognition and investigation of serious conditions should be promptly done in spontaneous pneumomediastinum patients. Conservative treatment, extensive investigations of predisposing factors, and treatment are important.

Comparison of three non-invasive hemodynamic monitoring methods in critically ill children

Introduction Hemodynamic parameters measurements were widely conducted using pulmonary artery catheter (PAC) with thermodilution as a reference standard. Due to its technical difficulties in children, transthoracic echocardiography (TTE) has been widely employed instead. Nonetheless, TTE requires expertise and is time-consuming. Noninvasive cardiac output monitoring such as ultrasonic cardiac output monitor (USCOM) and electrical velocimetry (EV) can be performed rapidly with less expertise requirement. Presently, there are inconsistent evidences, variable precision, and reproducibility of EV, USCOM and TTE measurements. Our objective was to compare USCOM, EV and TTE in hemodynamic measurements in critically ill children. Materials and methods This was a single center, prospective observational study in critically ill children. Children with congenital heart diseases and unstable hemodynamics were excluded. Simultaneous measurements of hemodynamic parameters were conducted using USCOM, EV, and TTE. Inter-rater reliability was determined. Bland-Altman plots were used to analyse agreement of assessed parameters. Results Analysis was performed in 121 patients with mean age of 4.9 years old and 56.2% of male population. Interrater reliability showed acceptable agreement in all measured parameters (stroke volume (SV), cardiac output (CO), velocity time integral (VTI), inotropy (INO), flow time corrected (FTC), aortic valve diameter (AV), systemic vascular resistance (SVR), and stroke volume variation (SVV); (Cronbach’s alpha 0.76–0.98). Percentages of error in all parameters were acceptable by Bland-Altman analysis (9.2–28.8%) except SVR (30.8%) and SVV (257.1%). Conclusion Three noninvasive methods might be used interchangeably in pediatric critical care settings with stable hemodynamics. Interpretation of SVV and SVR measurements must be done with prudence.

Clinical and Pathological Correlation in Pediatric Invasive Pulmonary Aspergillosis

Introduction Invasive’ pulmonary aspergillosis (IPA) has been one of the major causes of mortality in immunocompromised patients. The gold standard method for a diagnosis of IPA is histopathological examination of the lung tissue; however, post-procedural bleeding limits the feasibility of lung biopsy. The European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and The National Institute of Allergy and Infectious Disease Mycoses Study Group (EORTC/MSG) defined IPA. The objective of this study was to validate the EORTC/MSG 2008 definition of IPA, compared with histopathology in the pediatric population. Methods Histopathological examinations of lung tissues of children aged 1 month–18 years with respiratory tract infection at the time of obtaining biopsy were retrieved. Retrospective chart reviews for clinical characteristics were performed. IPA diagnosis was classified according to the EORTC/MSG 2008 definition. Results During the 10-year period, there were 256 lung tissues, of which 58 specimens were suspected to have pulmonary infection. Fourteen patients (24%) were noted to have IPA. Seven patients (50%) with proven IPA were classified as probable, while the remaining 50% were classified as possible, and none were classified as no IPA, by using EORTC/MSG 2008 definition. Other 44 specimens demonstrated 14 (32%), 14 (32%), and 16 (36%) were classified as probable, possible, and no IPA, respectively. When comparing probable or possible IPA with no IPA, we found that the EORTC/MSG 2008 definition had 100% sensitivity, 36% specificity, 33% positive predictive value, and 100% negative predictive value in diagnosis of IPA. Conclusion Our study illustrated that the EORTC/MSG 2008 definition provided an excellent sensitivity but low specificity for diagnosing IPA.