Paradoxical eosinophilic and cytokine responses to oral corticosteroid treatment in patients with asthma exacerbations.

Background: Thymic stromal lymphopoietin (TSLP) orchestrates eosinophilic inflammation, which may increase during asthma exacerbations. In contrast, microRNA-1 (miR-1) inhibits TSLP-mediated eosinophil trafficking in lung endothelium. Whether the balance of TSLP and miR-1 levels determines the response to oral corticosteroids (OCSs) during the treatment of asthma exacerbations remains unknown. Objective: Our aim was to investigate the involvement of TSLP/miR-1 axis in inflammatory response to OCS treatment for asthma exacerbations. Methods: We measured the concentrations of TSLP and other inflammatory cytokines and miR-1 expression during acute asthma exacerbations treated with standard OCSs in a real-life setting. A total of 28 consecutive patients with acute asthma exacerbations treated with OCS (prednisolone 30 mg/d) for 1 week at the emergency department were studied prospectively. Steroid responders were identified by a significant reduction in blood eosinophil counts, whereas paradoxical responders (PRs) showed no markedly decreased or even increased absolute blood eosinophil counts after OCS treatment. Differential white blood cell counts, blood cytokine levels, and miR-1 expression within and between groups were compared before and after OCS treatment. The baseline cytokine concentrations in both groups were compared with those of patients with stable asthma. Results: OCS treatment significantly reduced TSLP levels in steroid responders, whereas this effect did not occur in PRs (P = .006 and P = .742, respectively). In contrast, miR-1 expression was unchanged in steroid responders in response to OCS, whereas it was markedly reduced in the PRs, despite higher expression at baseline than in patients with stable asthma, which may account for slower resolution of the exacerbation. Conclusions: In some asthmatic patients with acute exacerbations who do not suppress eosinophils after a course of OCS, there is a paradoxical decrease in plasma miR-1 level and increase in TSLP level versus in steroid responders, which may result in slower clinical recovery.

The Incidence of Diaphragmatic Dysfunction in Patients Presenting With Dyspnea in the Emergency Department.

OBJECTIVES: Diaphragmatic dysfunction has been reported as a cause of dyspnea, and its diagnosis can be made using ultrasound. Diaphragmatic ultrasound is mainly used to predict respiratory failure in chronic conditions. The use of diaphragmatic ultrasound has also risen in acute settings, such as emergency departments (EDs). However, the number of studies on its use still needs to be increased. The present study aimed to find the incidence of diaphragmatic dysfunction in the ED. METHODS: This prospective cohort study was conducted in an ED. We enrolled patients aged greater than 18 years who presented with dyspnea. Diaphragmatic excursion and diaphragmatic thickness techniques were performed. The primary outcome was the incidence of diaphragmatic dysfunction. The secondary outcomes were the associations between diaphragmatic dysfunction and the composition of respiratory therapies within 24 hours, intubation within 24 hours, and 7-day mortality. RESULTS: A total of 237 patients were analyzed. The incidences of diaphragmatic dysfunction assessed by diaphragmatic excursion and diaphragm thickness were 22.4 and 32.1%, respectively. Patients with sepsis and cancer had the highest incidences. Diaphragmatic dysfunction assessed by both techniques was not associated with the composition of respiratory support therapies within 24 hours, intubation within 24 hours, or 7-day mortality. CONCLUSIONS: The incidence of diaphragmatic dysfunction in dyspneic patients in the ED ranged from 22.4 to 32.1%, depending on the ultrasound technique. Diaphragmatic dysfunction was not associated with the composition of respiratory support therapies, intubation, or mortality.

Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand.

BACKGROUND: The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality. METHODS: A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included. RESULTS: A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was 'cannot control symptoms' (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality. CONCLUSION: The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.

Number of attempts required by emergency physicians to achieve competency in diaphragmatic ultrasound imaging.

PURPOSE: This research aimed to determine the number of attempts that emergency physicians need to become proficient in undertaking diaphragmatic ultrasound imaging. METHODS: A prospective observational study was conducted at the emergency department (ED) of a tertiary-care university hospital. Sixteen emergency physicians were each required to obtain a set of images of the right hemidiaphragm of five dyspneic patients using both diaphragmatic excursion and thickness techniques. The images were subsequently reviewed by a specialist using American College of Emergency Physician guidelines. If the evaluations of a physician did not reach the expected standard, the physician was to be given feedback and requested to collect images from another five patients. The process was to be repeated until such time as the images obtained by the physician were deemed to be up to standard. RESULTS: Eighty patients, twelve emergency medicine residents, and four attending physicians were enrolled. Following a didactic session on diaphragmatic ultrasound imaging and its interpretation, practicing on five patients proved sufficient to achieve an adequate level of competency in conducting diaphragmatic ultrasound examinations. CONCLUSION: Practicing on five patients is sufficient for emergency physicians to achieve an adequate level of competency in conducting right-sided diaphragmatic ultrasound examinations.

The feasibility of the 1-h high-sensitivity cardiac troponin T algorithm to rule-in and rule-out acute myocardial infarction in Thai emergency patients: an observational study.

BACKGROUND: The 3-h high-sensitivity cardiac troponin T (hs-cTnT) algorithm is the most commonly used scheme to diagnose acute myocardial infarction. The 1-h hs-cTnT algorithm has recently been approved by the European Society of Cardiology as an alternative algorithm for earlier diagnosis. If the hs-cTnT test cannot discriminate the diagnosis of the patient at 1 h, the patient is defined as observational group. Their test must be repeated at 3 h. A high prevalence of this group may indicate a low clinical utility of the 1-h hs-cTnT algorithm. This study was aimed to estimate the proportion of the observational group in Thai emergency department (ED) patients and also the time to rule-in/out between both the algorithms. METHODS: A historical control study was conducted in patients with chest pain for 1-12 h at the ED of Siriraj Hospital, Bangkok, Thailand. The study compared two groups: one prospective group of all patients evaluated with the 1-h hs-cTnT algorithm between June and September 2017 and one historical control group evaluated with the 3-h hs-cTnT algorithm between January and March 2017. RESULTS: A total of 130 patients were included (3-h hs-cTnT algorithm group n = 65 and 1-h hs-cTnT algorithm group n = 65). Twelve patients [18.5% (95% CI 10.0-30.1)] were categorized as observational group in the 1-h hs-cTnT algorithm group. The mean rule-in/out times in the 3-h hs-cTnT algorithm and 1-h hs-cTnT algorithm groups were 238 min (SD 63.3) and 134 min (SD 68.5), respectively (both p < 0.001). The time to disposition was also shortened in the 1-h hs-cTnT algorithm group (p <  0.001). Multivariable regression analysis performed to identify and adjust for confounders among patient characteristics revealed no significant confounders. CONCLUSIONS: The use of the 1-h hs-cTnT algorithm in the ED resulted in an acceptable proportion in the observational group and a decreased time to rule-in/out compared with the 3-h hs-cTnT algorithm.

Prevalence of emergency medical service utilisation in patients with out-of-hospital cardiac arrest in Thailand.

BACKGROUND: Most patients with out-of-hospital cardiac arrest (OHCA) have grave outcomes. The efficacy of emergency medical services (EMS) may affect outcomes. However, no data exists in Thailand. OBJECTIVES: To ascertain the prevalence of EMS utilisation in patients with OHCA transferred to Siriraj Hospital and also to elucidate the rates of return of spontaneous circulation (ROSC), hospital admission and survival to hospital discharge. METHODS: This prospective cohort study was conducted in patients with OHCA at a university hospital in Bangkok, Thailand from May 2011 to February 2013. The data was gathered by interviewing bystanders. Data about the mode of transportation, reasons for EMS usage, response time, ROSC and 30-day mortality were collected. Patients with rigour mortis or livor mortis were excluded. The factors affecting ROSC and survival rate were determined by univariate analysis. RESULTS: One hundred and fifty-two patients were included. The prevalence of EMS usage was 14.5% (95% CI 9.3 to 21.0). The most common cause of non-usage of EMS was not knowing or forgetting an EMS number (49.2%). The proportion of bystanders having known an EMS number and using EMS was 34%. The ROSC and 30-day survival rates were 53.3% and 10.5%, respectively. Non-cardiac causes and witnessed arrests were associated with ROSC (p<0.05). CONCLUSIONS: The prevalence of EMS utilisation in OHCA at Siriraj Hospital was very low. This may affect the outcomes of patients with OHCA. Improving the EMS system by publicity to increase public awareness and providing life-support education nationwide may improve outcomes of patients with OHCA in Thailand.