Search

Background:Sepsis is a common life threatening medical problem and first leading cause of death in Myanmar. This study was aimed to determine the predictive values of initial mSOFA score, point-of-care lactate, neutrophil-lymphocyte ratio and platelet count for mortality in patients with sepsis and septic shock. Method:A hospital based prospective observational study done in No.(1) Defence Services General Hospital, Yangon, from January 2021 to October 2022. All patients above 18 years old admitted with sepsis and qSOFA ≥ 2 were enrolled and sample size was 121 patients. The predictors were mSOFA score, point-of-care lactate, neutrophil-lymphocyte ratio and platelet count, which were assessed within 24 hour of admission and the mortality was observed for 28 days. Logistic regression was used to find out the predictive value and the predictors were compared by receiver operating characteristic curve analysis. Results:The initial mSOFA score, point-of-care lactate and neutrophil-lymphocyte ratio of non survivors were significantly higher than survivors (mSOFA score 9 vs 4), (blood lactate 3.3 mmol/L vs 2 mmol/L), (neutrophil-lymphocyte ratio 13.4 vs 8.3). Platelet count was significantly lower in non-survivors than survivors (175 x 10^9/L vs 290 x 10^9/L). The mortality was 33.1%. The mSOFA score and lactate were strongly correlated (rho= 0.650,p< 0.001). The adjusted odds ratio of mSOFA score was 1.350 (1.135 – 1.606) with adjusted R20.478 and accuracy 80.2%. The adjusted odds ratio of lactate was 1.819 (1.168 – 2.834); NLR, 1.108 (1.023 – 1.200); platelet 0.992 (0.987 – 0.998) with adjusted R20.616 and accuracy 86.8%. Each predictor had moderate prognostic value (AUC > 0.7) and the combinations of mSOFA score and/or lactate with NLR and platelet count, good prognostic value (AUC > 0.8). Conclusion:The mSOFA score, lactate, NLR and platelet count had predictive value for mortality assessment in patients with sepsis or septic shock. Lactate level was strongly correlated with disease clinical severity of the sepsis, mSOFA score. The combination of mSOFA score and/or lactate with NLR and platelet count had better predictive value.

Additional file 1: Supplementary Table 1. Correlation between plasma vaspin level and baseline clinical and biochemical parameters according to diabetic status. PDE, peritoneal dialysis effluent; LDL, low-density lipoprotein; HDL, high-density lipoprotein; PTH, parathyroid hormone; SGA, subjective global assessment overall score; MIS, malnutrition inflammation score; E: I ratio, extra-cellular to intracellular volume ratio; D/P4, dialysate-to-plasma creatinine concentration at 4 hours; MTAC, mass transfer areas coefficient of creatinine; GFR, glomerular filtration rate; FEBM, fat-free edema-free body mass, NAPA for normalized protein nitrogen appearance; PWV, pulse wave velocity. Data are compared by Spearman’s rank correlation coefficient. Supplementary Table 2. Correlation between plasma vaspin level and insulin resistance. HbA1C, Hemoglobin A1C; HOMA, Homeostatic Model Assessment; IR, Insulin resistance; 2B, beta 2 cell function. Data are compared by Spearman’s rank correlation coefficient. Supplementary Table 3. Cox regression analysis for patient survival (all patients). HR, hazards ratio; AHR, adjusted hazards ratio; CI, confidence interval; GFR, glomerular filtration rate; CCI, Charlson’s comorbidity index; SGA, subjective global assessment overall score; MIS, malnutrition inflammation score; CR_PWV, carotid to radial pulse wave velocity; CF_PWV, carotid to femoral pulse wave velocity, BMI, body mass index; hsCRP, high sensitivity C-reactive protein; MTAC, mass transfer areas coefficient of creatinine; NPNA, normalized protein nitrogen appearance; E: I ratio, extra-cellular to intracellular volume ratio; HDL, high-density lipoprotein; LDL, Low-density lipoprotein; PTH, parathyroid hormone. *interaction between plasma vaspin level quartile and diabetic status. **male as compared to female

A 58 year old man was brought to hospital in state of deep coma following severe headache for one day. His GCS was 3/15 and had flaccid all 4 limbs with equivocal planter response on both sides on arrival. NECT head showed acute subdural haemorrhage with surrounding cerebral oedema, mid-line shift and corning of brain stem. After giving mannitol and dexamethasone, four hours later, he became fully conscious and orientated; his motor power returned to normal. He was on warfarin 3mg daily for rheumatic mitral valvular heart disease with atrial fibrillation and his INR on arrival was 3.5. He had intractable hiccups once he regained consciousness. Both pharmacological and non-pharmacological measures were tried for distressing hiccups; there was no therapeutic success. His hiccups disappeared completely only after removing the haematoma by burr hole surgery.

A young man presented with abdominal pain and vomiting after eating Naphthalene Mothball. He had dyspnea, central cyanosis (SaO2 on air was 67% on air), marked pallor, deep jaundice and dehydration. His urine color was black; and, his plasma in clotted blood sample was brownish. He was treated as methemoglobinemia due to suicidal Naphthalene Mothball poisoning with fluid and electrolyte replacement, ascorbic acid, N-acetylcystine and exchange transfusion twice with four units of whole blood. Dramatic improvement in central cyanosis immediately following exchange transfusion. Psychiatric consultation and counselling were done; he admitted the main reason for committing suicide was socioeconomic stress due to COVID-19.

Background:Sepsis is the first leading cause of death in Myanmar and complications are also difficult to solve. This study aimed to detect the effect of thiamine on lactate clearance and mortality in patients with sepsis. Method:A randomized controlled trial done in No.(1) Defence Services General Hospital, Yangon from October 2020 to June 2022. All patients > 18 years old admitted with suspected or documented infection and qSOFA score 2 or 3 were included but alcohol related cases were excluded. Total 80 patients were assigned 1:1 by block randomization. Intervention group was given IV thiamine 100 mg 6 hourly for 3 days. Primary outcome was lactate clearance and secondary outcomes, mSOFA score (both were assessed in day 1, day 3 and day 7), and mortality within 7 days. Intention to treat analysis with worst data imputation in missing value for expired cases. Results:Significant lactate clearance was seen in intervention group compared with control group, in day 3, [23.53% (34.37) vs 16.67% (43.30), z = -2.353,p= 0.019] and day 7, [53.85% (28.90) vs 30.22% (38.61), z = -3.186,p= 0.001]. Lactate clearance over time was well observed in the intervention group, [X2(2) = 29.356,p< 0.001] but not in the control group, [X2(2) = 3.152,p= 0.207]. Significant mSOFA score reduction over time was also observed in the intervention group, [X2(3) = 39.330,p< 0.001]. All-cause mortality within 7 days was not different, [X2(1) = 0.949, p = 0.330, OR 0.949, 95% CI (0.51 – 7.12)]. Conclusion:Thiamine supplementation in sepsis patient was benefit in lactate clearance starting from day 3 and reduction of mSOFA score starting from day 7. But it did not show the mortality benefit within 7 days period.

Background:Patients on maintenance hemodialysis (MHD) are at high risk of contracting SARS-CoV-2 and developing severe COVID-19 infection because they have low innate immunity as well as poor antibody response to COVID-19 vaccine. This study aimed to assess the effectiveness of 4 doses of COVID-19 vaccine in preventing 5thwave of COVID-19 infections in patients on maintenance hemodialysis in Myanmar. Methods:A hospital-based descriptive study was conducted in July 2022 to November 2022 among patients on MHD who received COVID-19 vaccine 4 doses; last dose was 2 weeks ago. Data were collected by using standardized forms and analysis was done. Results:A total of 61 patients on maintenance hemodialysis ( MHD) who had 4 doses of COVID-19 vaccination more than 2 weeks were included. Nasopharyngeal swab PCR was taken twice a week to all patients (if they did not have symptoms) and it was repeated if they had symptoms suggestive of COVID-19 infection or they had history of contact with patients having COVID-19 infection. Their signs and symptoms were analyzed; chest radiograph and blood tests were taken if indicated. Then, the severity of COVID-19 infection was determined according to WHO criteria and they were given treatment according to hospital guideline. They were followed up till 28 days. The base line characteristics were as follows: mean age was 51.15 ± 12.85 years; male to female ratio was 4:6; mean BMI was 19.93 ± 2.83 kg/m2; 16.4%(10/61) had diabetic nephropathy; 9.8%(6/61) had cerebrovascular accident; 24.6%(15/61) had coronary heart disease; and one fifth of them were current smokers. Sixty six percent had past history of COVID-19 infection; duration from last infection was 404 days. Thirty three percent of cases had shortest duration of hemodialysis (6 months) and 23% were over 3 years. Mean duration from last vaccination was 39 days. Thirty six percent (22/61) had confirmed COVID-19 infection and 64% (39/61) of them were not infected till the end of 5thwave. All infected cases were mild form according to WHO criteria; none of them required oxygen therapy. One case having multiple comorbidities (lymphoma, coronary heart disease, hypertension and malignant cachexia) had sudden death due to pulmonary embolism. Conclusions:The protection rate of four doses of COVID-19 vaccine in patients on MHD was not good as 36% of them were infected in the 5thwave of epidemic in Myanmar. However, all the infected cases were mild form and they did not need oxygen therapy showing that booster vaccination prevented morbidity and mortality. Therefore, the protection rate of four doses of COVID-19 vaccine in patients on MHD was nearly 65%; it reduced the severe form of infection and death. Fifth dose of COVID-19 vaccine is necessary along with personnel protective measures.

Mitochondrial DNA (mtDNA) resembles bacterial DNA and potentially triggers local and systemic inflammation. We evaluate the prognostic implications of PD effluent mtDNA level in peritoneal dialysis (PD) patients.We measured mtDNA in the PD effluent (PDE) sediment and supernatant of 168 incident PD patients. All patients were followed for hospitalization, technique and overall survival.The median PD effluent supernatant and sediment mtDNA levels were 255.4 unit (interquartile range [IQR] 157.5-451.3) and 201.6 unit (IQR 147.8-267.3), respectively. Serum C-reactive protein level closely with PDE sediment mtDNA level (r = 0.471, p 0.001) and less with supernatant mtDNA level (r = 0.156, p = 0.044). PDE supernatant mtDNA level correlates with dialysate-to-plasma creatinine ratio at 4 h (D/P4) (r = 0.361, p 0.001) but not with any clinical outcome. PDE sediment mtDNA was an independent predictor of technique survival (p = 0.011) and the duration of hospitalization (p = 0.044) after adjusting for clinical confounding factors.PDE sediment mtDNA level significantly correlated with systemic inflammation, while PDE supernatant mtDNA level correlated with peritoneal transport. PDE sediment mtDNA level also independently predicted technique survival and duration of hospitalization. The mechanism of the different implications between PDE sediment and supernatant mtDNA levels deserves further investigations.

Background The global prevalence of both obesity and end-stage kidney diseases (ESKDs) has increased in recent decades. Given the complicated interaction between obesity and ESKD, we examined the change in the prevalence of obesity in incident Chinese peritoneal dialysis (PD) patients over the past 25 years. Methods We reviewed the anthropometric measures of incident PD patients in a single Hong Kong center from 1995 to 2019. The results are reported in five 5-year periods. Patients with and without diabetes were analyzed separately, and the incidence of new-onset diabetes after PD was explored. Results We reviewed 1681 patients. Their mean age was 58.4 ± 12.5 years; 931 patients (55.4%) had pre-existing diabetes. From 1995–99 to 2015–19, the prevalence of obesity or overweight at the initiation of PD increased progressively for every 5-year period (from 21.9% to 26.2, 37.9, 42.7 and 47.3%, P < 0.001 for linearity). The increase in the prevalence of obesity or overweight was more pronounced in diabetic patients (from 33.7% to 59.6%) than non-diabetic ones (from 13.2% to 32.3%). Among nondiabetics patients, the incidence of new-onset diabetes after started on PD showed an insignificant rising trend during that period (from 18.0, 19.7, 17.8 and 22.4% to 23.3%, P = 0.106). The incidence of new-onset impaired fasting glucose or diabetes was significantly higher in obese or overweight patients than the others (56.9% versus 51.4%, P < 0.001). Conclusions The prevalence of obesity has increased substantially in both diabetic and nondiabetic new PD patients in Hong Kong over the past 25 years. The incidence of new-onset diabetes was significantly higher in new PD patients with pre-existing obesity or overweight than those without obesity. The prognostic implication and impacts on the healthcare system deserve further studies., GRAPHICAL ABSTRACT Graphical Abstract

Obesity is a global epidemic that has a complicated pathogenesis as well as impact on the outcome of peritoneal dialysis (PD) patients. In this review, the prevalence of obesity in incident PD patients as well as the phenomenon of new-onset glucose intolerance after PD will be reviewed. Published literature on the effect of obesity on the survival and incidence of cardiovascular disease in PD patients will be discussed. Particular emphasis would be put on literature that compared the impact of obesity on the outcome of hemodialysis and PD, and the confounding effect of dialysis adequacy. Next, the complex concept of obesity and its relevance for PD will be explored. The focus would be put on the methods of assessment and clinical relevance of central versus general obesity, as well as visceral versus subcutaneous adipose tissue. The relation between obesity and systemic inflammation, as well as the biological role of several selected adipokines will be reviewed. The confounding effects of metabolic syndrome and insulin resistance will be discussed, followed by the prevalence and prognostic impact of weight gain during the first few years of PD. The differences between weight gain due to fluid overload and accumulation of adipose tissue will be discussed, followed by the current literature on the change in body composition after patients are put on chronic PD. The methods of body composition will be reviewed, and the clinical relevance of individual body component (fluid, fat, muscle, and bone) will be discussed. The review will conclude by highlighting current gaps of knowledge and further research directions in this area.

A 22-year-old unmarried Myanmar girl presented with symptoms of anemia: fatigue, exertional dyspnea and fainting attack. There was no abdominal pain or amenorrhea. The hemodynamic status was stable except sinus tachycardia. Anemia was refractory to blood transfusion; thus, the differential diagnosis were autoimmune hemolytic anemia and occult blood loss. Blood film, bone marrow examination, Comb tests, Anti-nuclear antibody profile and PNH screen tests excluded autoimmune hemolytic anemia. Presence of fibrous strands in free fluids of abdominal cavity with normal uterus and ovary mislead the diagnosis of tuberculosis. Blood tap in ascitic fluid aspiration made all the answer- rupture ectopic pregnancy. The symptoms resolved after right salpingectomy and blood transfusion. The clerking on sexual exposure to Myanmar single is not acceptable in our culture; it is regarded as “social insult”. Atypical presentation and not asking sexual history caused delay in diagnosis; diagnosed 10 days after hospital stay. She recovered uneventfully.

Though coronary artery disease primarily occurs in those over the age of 40 years, younger individuals who use recreational drugs may be afflicted with coronary events. Cannabis is one such perilous agent that can cause myocardial infarction (MI) and is one of the most common psychoactive drugs used worldwide. Cannabis (also known as marijuana, weed, pot, dope or grass) is the most widely used illegal drug in the UK. The desired euphoric effects are immediate, as are life-threatening hazardous ones. In this article, we briefly describe a case series of two unique but similar cases of cannabis-induced ST-elevation MI witnessed at our hospital in quick succession. We will analyse the composite pathophysiology in acute coronary syndromes provoked by cannabis and discuss the evolving legality around the use of the drug.

Supervisor:金子 峰雄, 先端科学技術研究科, 修士（情報科学）

A-91-year old man had severe Covid-19 infection (bilateral pneumonia, SaO2 85% on air). He was treated with antibiotics, oxygen, dexamethasone and convalescent plasma therapy.