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Transesophageal echocardiography (TEE) is essential to perioperative cardiac care, providing enhanced cardiac visualization compared to transthoracic echocardiography (TTE), especially in complex cases. While TEE is standard in high-income countries, its utilization in resource-limited settings is not as well-defined. This study aimed to quantify the impact of intraoperative TEE on surgical management at a major tertiary care center in Thailand and to investigate the effects of combining preoperative TTE and TEE on surgical planning. This prospective observational study enrolled 624 adult patients undergoing cardiac surgery from January 2023 to January 2024. All patients received intraoperative TEE, with preoperative assessment conducted via either TTE alone or TTE combined with TEE. The primary outcome was the rate of change in surgical management prompted by new intraoperative TEE findings. Intraoperative TEE findings led to a change in surgical management in 10.58% of all cases (95% CI: 8.28–13.26). The rate of change was higher in patients undergoing preoperative TTE combined with TEE (16.13%) compared to those receiving TTE alone (9.60%); however, after multivariable adjustment, this difference was not statistically significant (adjusted RR 1.18, 95% CI: 0.67–2.09, p = 0.567). The type of surgery was the only independent predictor of management changes, with isolated valve surgery (adjusted RR 2.32, 95% CI: 1.05–5.16) and combined valve with CABG procedures (adjusted RR 3.03, 95% CI: 1.30–7.05) showing the highest likelihood of alteration. Postoperative outcomes, including 30-day mortality and complication rates, were comparable between patients with and without surgical management changes. In this study, intraoperative TEE was associated with changes in surgical decision-making in approximately 10% of cardiac surgeries, suggesting a potential clinical impact, particularly in complex valve-related procedures. The addition of a preoperative TEE, while associated with longer surgical wait times, did not independently associate with the likelihood of intraoperative changes. These findings underscore the crucial role of intraoperative TEE for real-time assessment and support its selective use in high-complexity cases, while also highlighting logistical challenges within resource-limited healthcare systems.

Background: Ventilator-induced lung injury (VILI) presents a grave risk to acute respiratory failure patients undergoing mechanical ventilation. Low tidal volume (LTV) ventilation has been advocated as a protective strategy against VILI. However, the effectiveness of limited driving pressure (plateau pressure minus positive end-expiratory pressure) remains unclear. Objectives: This study evaluated the efficacy of LTV against limited driving pressure in preventing VILI in adults with respiratory failure. Design: A single-centre, prospective, open-labelled, randomized controlled trial. Methods: This study was executed in medical intensive care units at Siriraj Hospital, Mahidol University, Bangkok, Thailand. We enrolled acute respiratory failure patients undergoing intubation and mechanical ventilation. They were randomized in a 1:1 allocation to limited driving pressure (LDP; ⩽15 cmH2O) or LTV (⩽8 mL/kg of predicted body weight). The primary outcome was the acute lung injury (ALI) score 7 days post-enrolment. Results: From July 2019 to December 2020, 126 patients participated, with 63 each in the LDP and LTV groups. The cohorts had the mean (standard deviation) ages of 60.5 (17.6) and 60.9 (17.9) years, respectively, and they exhibited comparable baseline characteristics. The primary reasons for intubation were acute hypoxic respiratory failure (LDP 49.2%, LTV 63.5%) and shock-related respiratory failure (LDP 39.7%, LTV 30.2%). No significant difference emerged in the primary outcome: the median (interquartile range) ALI scores for LDP and LTV were 1.75 (1.00–2.67) and 1.75 (1.25–2.25), respectively (p = 0.713). Twenty-eight-day mortality rates were comparable: LDP 34.9% (22/63), LTV 31.7% (20/63), relative risk (RR) 1.08, 95% confidence interval (CI) 0.74–1.57, p = 0.705. Incidences of newly developed acute respiratory distress syndrome also aligned: LDP 14.3% (9/63), LTV 20.6% (13/63), RR 0.81, 95% CI 0.55–1.22, p = 0.348. Conclusions: In adults with acute respiratory failure, the efficacy of LDP and LTV in averting lung injury 7 days post-mechanical ventilation was indistinguishable. Clinical trial registration: The study was registered with the ClinicalTrials.gov database (identification number NCT04035915). Plain language summary Limited breathing pressure or low amount of air given to the lung; which one is better for adults who need breathing help by ventilator machine We conducted this research at Siriraj Hospital in Bangkok, Thailand, aiming to compare two ways of helping patients with breathing problems. We studied 126 patients who were randomly put into two groups. One group received a method where the pressure during breathing was limited (limited driving pressure: LDP), and the other group got a method where the amount of air given to the lungs was kept low (low tidal volume: LTV). We checked how bad the lung injury was at seven days later. The results showed that there was no difference between the two methods. Both ways of helping patients breathe had similar outcomes, and neither was significantly better than the other in preventing lung problems. The study suggests that both approaches work about the same for patients who need help with breathing using a machine.

Background: Major adverse cardiac and cerebrovascular events (MACCE) are critical clinical outcomes in patients undergoing percutaneous coronary intervention (PCI); however, evidence regarding the impact of fine particulate matter (PM2.5) on these outcomes remains limited. Methods: This retrospective cohort study included 22,188 Thai adults who underwent PCI to investigate the association between PM2.5 exposure and the incidence of MACCE. Baseline demographic, clinical characteristics, and comorbidities, with angiographic and procedural data, were collected. Cumulative PM2.5 exposure was estimated using satellite-derived data based on patients’ residential locations over a 12-month follow-up period. The primary outcome was a composite MACCE endpoint. A multilevel survival model was employed to assess the association between PM2.5 exposure and MACCE, adjusting for potential confounding variables. Results: During the median follow-up of 11.97 months (ranging from 0.03 to 12 months), 6,382 patients (28.8%) experienced at least one MACCE. PM2.5 levels in Thailand exhibit a distinct seasonal pattern, peaking around February (Quarter 1; Q1) and reaching their lowest levels in Q3. In the final multivariable model, a 1 µg/m3 increase in PM2.5 exposure was associated with MACCE (adjusted hazard ratio (HR) 1.45 (95% CI: 1.37, 1.54)). The adjusted HR for PM2.5 comprising quarterly seasonal variations was as follows: 1.015 (95% CI: 1.005, 1.024) in Q4, 1.222 (95% CI: 1.132, 1.319) in Q1, 1.177 (95% CI: 1.096, 1.265) in Q2, and 1.500 (95% CI: 1.381, 1.629) in Q3. Conclusion: The study’s findings suggested that higher seasonal PM2.5 exposure is associated with MACCE in patients who underwent PCI. These results underscore the urgent need for public health policies that focus on reducing PM2.5 to improve health outcomes and reduce the burden of the disease.

Background: Osteoporosis is commonly evaluated using dual-energy X-ray absorptiometry (DXA) for bone mineral density (BMD). Non-contrast computed tomography (CT) scans provide an alternative for opportunistic osteoporosis assessment. This study aimed to evaluate screening thresholds for osteoporosis based on CT attenuation values in Hounsfield units (HU) of L1–L4 vertebrae from CT scans of the abdominal region, compared to DXA assessments of the lumbar spine and hips. Methods: Conducted retrospectively over approximately two years, the analysis included 109 patients who had both CT and DXA scans within 12 months, excluding those with metal artifacts affecting the vertebrae. CT attenuation values in the trabecular region of the vertebrae were measured and compared among three groups based on the lowest T-score from DXA. Results: In a predominantly female cohort (mean age 66.3 years), the lowest CT attenuation values for L1–L4 vertebrae showed a moderate correlation with the lowest T-score, with a Pearson correlation coefficient of 0.542 (95% CI: 0.388, 0.667). A HU threshold of ≤142 at the L1 vertebra showed 91.9% sensitivity and 48.4% specificity, while a threshold of ≤160 HU showed 97.3% sensitivity and 31.3% specificity for screening osteoporosis. Conclusions: This study supports the use of non-contrast CT with these HU thresholds as an opportunistic tool for osteoporosis assessment.

Purpose. Osteoporotic VF is frequently asymptomatic and affects not only women but also men. Identifying patients at risk is essential for early management and prevention. BMD and the TBS are measurements of bone strength and trabecular microarchitecture, respectively. Their role in VF prediction in men is less well-studied. We determined the BMD and TBS predictive ability for osteoporotic VF in men. Methods. A total of 115 male participants of the Electricity Generating Authority of Thailand (EGAT) cohorts without a history of VF who completed the baseline BMD and TBS measurements in 2012 and a thoracolumbar spine radiograph in 2017 were recruited. The VF was assessed using the Genant semiquantitative method. Logistic regression analysis was performed to identify factors associated with the fracture. The area under the receiving operator curve (AUC) was analyzed to define VF predictive ability. Results. Forty subjects (34.78%) had VFs. The unadjusted relative risks (95% confidence interval) for VF for one standard deviation decrease in the TBS and low TBS were 1.319 (1.157–1.506) and 2.347 (1.496–3.682), respectively, and remained significant after BMD and age adjustment. For VF prediction, combined models had a greater AUC than models predicted from a single variable. The use of low TBS, femoral neck BMD, and age provided the best AUC (0.693). Conclusion. BMD and the TBS could predict osteoporotic VF in male EGAT employees. The use of both BMD and the TBS in the VF prediction process improved predictive ability.