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Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous autonomic disorder. All patients have exaggerated tachycardia upon standing, but the pathophysiology may be diverse. We present a young adult Thai male with a chief complaint of palpitations while in an upright posture since childhood. The patient underwent a modified Ewing test battery which included standing test, deep breathing, and Valsalva maneuver. His heart rate increased more than 30 beats per minute (bpm) during repeated active stand tests (65 to 110 bpm and 77 to 108 bpm), while upright diastolic blood pressure increased more than 10 mmHg. Normal Valsalva ratio (2.01 and 1.86) and baseline heart rate variability (HFRRI = 4030.24 ms2 and 643.92 ms2) indicated intact vagal function. High low-frequency systolic blood pressure variability (LFSBP = 20.93 mmHg2), increased systolic blood pressure overshoot in phase IV of Valsalva (42 mmHg), and increased upright diastolic blood pressure indicated a hyperadrenergic state. In conclusion, the overall autonomic profile was compatible with hyperadrenergic POTS. Thus, we confirmed the first male POTS case reported in Thailand. We demonstrated the importance of autonomic function testing with continuous measurements to confirm POTS. There is a need for further research in POTS in Thailand.

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BACKGROUND: High-flow oxygen therapy via tracheostomy (HFT) can be used in tracheostomized patients during ventilator disconnection. The physiologic effects of this technique are unknown. We hypothesized that HFT would reduce inspiratory effort and improve breathing pattern compared to conventional oxygen therapy via T-tube. This study aimed to evaluate the physiologic effects of HFT compared to conventional O2 in patients with prolonged mechanical ventilation. METHODS: A randomized crossover physiologic study was conducted in adult tracheostomized patients who experienced temporary periods of ventilator disconnection. Subjects were ventilated with pressure support ventilation (PSV) for 15 min and were then randomly assigned to HFT or conventional O2 via T-tube for 30 min. After a washout period, subjects were switched to the other system. Esophageal pressure (Pes), breathing frequency, blood pressure, heart rate, [Formula: see text], and transcutaneously measured pressure of carbon dioxide ([Formula: see text]) were recorded. The primary outcome was inspiratory effort as determined by the simplified esophageal pressure-time product (sPTPes). Secondary outcomes were Pes swing, breathing frequency, heart rate, mean arterial pressure, [Formula: see text], and [Formula: see text] between groups. RESULTS: Twenty-two subjects were enrolled: sPTPes per minute was significantly higher with HFT and conventional O2 compared to PSV (153.5 ± 97.9, 163.5 ± 111.3, and 86.8 ± 51.1 cm H2O × s/min, respectively, P = .001), but it was not different between HFT and conventional O2 (P = .72). Breathing frequency increased significantly after switching from PSV to HFT and conventional O2 (23 ± 4 vs 26 ± 6 and 23 ± 4 vs 27 ± 5 breaths/min, respectively, P = .001). [Formula: see text] was higher with conventional O2 compared to HFT (P = .02). No differences in [Formula: see text], mean arterial pressure, or heart rate were observed between HFT and conventional O2. CONCLUSIONS: Inspiratory effort and breathing frequency increased significantly during unassisted breathing compared to PSV in tracheostomized subjects, but HFT via tracheostomy provided no measurable additional physiologic benefit compared to O2 therapy via T-tube.

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INTRODUCTION: Better treatment outcome of early-stage hepatocellular carcinoma (HCC) warrants employment of screening programs, in which ultrasonography (US) and serum alfa-fetoprotein (AFP) have been recommended. Considering cost-effectiveness, serum AFP has recently been withdrawn from several guidelines for HCC surveillance. However, there were limited studies on benefits of AFP for HCC surveillance in Thailand. MATERIALS AND METHODS: This is a retrospective study of a proportion of HCC cases in which a diagnostic study was triggered by high serum AFP levels, but US failed to detect the lesion. Patients who received diagnostic imaging for HCC at Siriraj Hospital between January 1, 2012 and December 31, 2014 were included. All the patients must fulfill criteria for HCC surveillance according to American Association for the Study of Liver Diseases (AASLD) practice guidelines on the management of HCC 2010 or European Association for the Study of the Liver-European Organisation for Research and Treatment of Cancer (EASL-EORTC) Clinical Practice Guidelines: Management of HCC 2012. Previous diagnosis of any liver malignancy was excluded. Demographic data, underlying liver diseases, screening of AFP and US results, and definite diagnosis of HCC were recorded. RESULTS: Of the 452 cases who fulfilled inclusion and exclusion criteria, chronic hepatitis B, C, and alcoholic cirrhosis were accountable for 53.8, 25.9, and 7.3% respectively. Totally, 150 cases were diagnosed with HCC. Additional HCC detection rate by high serum AFP but failed US of 15.3% was demonstrated. Subgroup analysis revealed significant benefit of AFP in cirrhotic patients with chronic hepatitis B and C (p-value 0.004 and 0.002). No significant benefit was observed in cirrhosis of other causes and in noncirrhotic chronic hepatitis B. CONCLUSION: We reported a 15.3% additional benefit of serum AFP for HCC surveillance in conjunction with US of liver. Chronic hepatitis B and C with cirrhosis significantly derived the benefit from serum AFP screening.How to cite this article: Lersritwimanmaen P, Nimanong S. Hepatocellular Carcinoma Surveillance: Benefit of Serum Alfa-fetoprotein in Real-world Practice. Euroasian J Hepato-Gastroenterol 2018;8(1):83-87.

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The highly pathogenic avian influenza (HPAI) H5N1 virus causes severe systemic infection in avian and mammalian species, including humans by first targeting immune cells. This subsequently renders the innate and adaptive immune responses less active, thus allowing dissemination of the virus to systemic organs. To gain insight into the pathogenesis of H5N1, this study aims to determine the susceptibility of human PBMCs to the H5N1 virus and explore the factors which influence this susceptibility. We found that PBMCs were a target of H5N1 infection, and that monocytes and B cells were populations which were clearly the most susceptible. Analysis of PBMC subpopulations showed that isolated monocytes and monocytes residing in whole PBMCs had comparable percentages of infection (28.97 ± 5.54% vs 22.23 ± 5.14%). In contrast, isolated B cells were infected to a much lower degree than B cells residing in a mixture of whole PBMCs (0.88 ± 0.34% vs 34.87 ± 4.63%). Different susceptibility levels of B cells for these tested conditions spurred us to explore the B cell-H5N1 interaction mechanisms. Here, we first demonstrated that monocytes play a crucial role in the enhancement of B cell susceptibility to H5N1 infection. Although the actual mechanism by which this enhancement occurs remains in question, α2,3-linked sialic acid (SA), known for influenza virus receptors, could be a responsible factor for the greater susceptibility of B cells, as it was highly expressed on the surface of B cells upon H5N1 infection of B cell/monocyte co-cultures. Our findings reveal some of the factors involved with the permissiveness of human immune cells to H5N1 virus and provide a better understanding of the tropism of H5N1 in immune cells.

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