Volume 9 (2015): Edition 1 (February 2015)

Cartilage degeneration is considered as the initial defect in osteoarthritis. Measurement of cartilage volume is important to monitor disease progression and therapeutic response.

To measure tibial cartilage volume using magnetic resonance imaging (MRI), and to evaluate the accuracy and interobserver reliability of tibial cartilage volume measurement using MRI.

The outline boundaries of the medial and lateral tibial cartilage were drawn manually on 1 mm slices using a track-ball to calculate the volume of each slice. Total calculated MRI-derived tibial cartilage volume was determined by summation of the slice volumes. The calculated tibial cartilage volume was compared to the actual tibial cartilage volume.

There was a strong correlation between the calculated and actual tibial cartilage volumes determined by a radiologist and a researcher (98% and 89% agreement in medial tibial cartilage, 99% and 97% agreement in lateral tibial cartilage, respectively). High observer reliability was identified (92% agreement in medial tibial cartilage and 97% agreement in lateral tibial cartilage).

Tibial cartilage volume measurement using MRI can be easily performed by well-trained personnel such as radiologists or residents, and can be used to estimate tibial cartilage volume preoperatively in total knee arthroplasty, and to monitor disease progression and response to therapy.

Monounsaturated fat (MUFA) also has glucose-lowering action, but its effect on ketone bodies is unknown.

To examine the effects of high-MUFA diet alone or in combination with exercise training, which can improve glucose and ketone body metabolism, in a rat model of diabetes.

Wistar rats were administered streptozotocin to induce diabetes and then randomly divided into five groups: sedentary rats fed a regular diet (1), a high-saturated-fat diet (2), a high-MUFA diet (3); and exercisetrained rats fed a regular diet (4), and a high-MUFA diet (5). Training was by a treadmill twice daily, 5 days/week. At 12 weeks, glucose, glycated hemoglobin (HbA_1c), insulin, nonesterified fatty acids (NEFA), and β-hydroxybutyrate levels were measured in cardiac blood. Activity of the overall ketone synthesis pathway was determined in liver and 3-ketoacyl-CoA transferase activity determined in gastrocnemius muscle.

A high-MUFA diet tended to lower plasma glucose without affecting other biochemical variables. Training did not change glucose metabolism, but significantly reduced serum NEFA. Only the high-MUFA diet plus training significantly decreased HbA_1c levels. Hepatic ketone synthesis was decreased and 3-ketoacyl-CoA transferase activity was increased by training alone or in combination with a high-MUFA diet. Changes in NEFA, β-hydroxybutyrate, and the enzymatic activities in response to training plus a high-MUFA diet were comparable to those caused by training alone.

A high-MUFA diet alone does not alter ketone body metabolism. Combination of a MUFA-rich diet and exercise training is more effective than either MUFA or exercise alone for lowering HbA_1c.

Acute myocardial infarction (MI) is a leading cause of cardiovascular (CV) mortality and hospitalization. Survivors of acute MI have higher risk of subsequent CV events and death, compared to individuals without MI. Evidences have demonstrated the CV benefits of n-3 polyunsaturated fatty acids (PUFAs) in patients who experienced MI.

We assessed the cost-effectiveness of highly concentrated n-3 polyunsaturated fatty acids (PUFAs) in addition to standard therapy compared with standard therapy alone in post-MI patients in Thailand.

A Markov model was constructed to assess costs, life years, and quality-adjusted life years (QALYs) with lifetime horizon in post-MI patients, on the basis of provider perspective. Input data were based on information from the Thai Acute Coronary Syndrome (ACS) Registry, a meta-analysis of mortality data and published articles. Outcomes have been presented as incremental cost-effectiveness ratios of life expectancy and quality-adjusted life expectancy. Deterministic and probabilistic sensitivity analyses were performed for key variables in the model.

n-3 PUFAs increased life expectancy by 2.34 life-years at an incremental cost-effectiveness ratio (ICER) of 256,199 Thai baht (THB) per life-year gained (LYG), compared to the standard therapy alone in the base case analysis. The quality-adjusted life years (QALY) increased by 2.01 with ICER of 297,193 THB per QALY from n-3 PUFAs supplementation. Both ICER/QALY and ICER/LYG decreased as the age of patients increased. The incremental cost per QALY gained in post-MI patients aged 45 to 85 years old ranged from 216,200 THB to 414,049 THB.

Considering the current willingness-to-pay threshold of 160,000 THB/QALY, highly concentrated n-3 PUFAs as secondary prevention of MI appears not to be cost-effective compared to standard treatment alone in Thailand.

Effectiveness of self-care and treatment of diabetes mellitus depends upon patient awareness of their own health and disease outcomes. Physician decisions are improved by insight into patient perspectives.

To develop an instrument for patient-reported outcomes in Thai patients with type 2 diabetes mellitus (PRO-DM-Thai).

The study consisted of: (1) content development using a literature review and in-depth interviews of providers and patients, and validity testing using a content validity index (CVI); (2) construct validity and reliability testing by confirmatory factor and Cronbach’s α analyses of data from a cross-sectional descriptive survey of 500 participants from May to June, 2011; and, (3) criterion-related validity from a cross-sectional analytical survey of 200 participants from September to November, 2011.

PRO-DM-Thai passed all of the validity tests. The instrument comprises seven dimensions and 44 items, including physical function, symptoms, psychological well-being, self-care management, social well-being, global judgments of health, and satisfaction with care and flexibility of treatment. The CVI at the item-level (I-CVI) were between 0.83 to 1.00 and the scale-level average agreement (S-CVI/Ave) was 0.98. All dimension models had overall fit with empirical data, while the hypothesized model demonstrated a good fit (χ² = 5.23; (df = 6), P > 0.05, AGFI = 0.986, RMSEA = 0.000). Cronbach’s α for the total scale was 0.91 and for the subscales was 0.72-0.90. The total scores effectively discriminated groups of patients with different levels of disease control.

PRO-DM-Thai showed satisfactory levels of validity and reliability when applied to Thai diabetic patients.

The current epidemiology of upper gastrointestinal bleeding (UGIB) in Thailand is poorly understood and the reported prevalence of Helicobacter pylori infection is outdated.

To investigate the etiologies of UGIB and prevalence of H. pylori infection in Thailand, including its association with UGIB.

We retrieved information regarding patients attending the endoscopic unit of King Chulalongkorn Memorial Hospital from June 2007 to January 2013. A database search using keywords “upper gastrointestinal bleeding” and “iron deficiency” was used. From 4,454 diagnoses, after exclusion criteria, 3,488 patients (2,042 male (58.5%) and 1,446 female (41.5%); mean age 63.3 ± 15.94 years, range 13–103 years) were included.

The three most common causes of UGIB were peptic ulcer (38.2%), nonulcer-mucosal lesions (23.4%), and esophageal-related causes (20.4%). The 5 year-incidence of H. pylori was 25%–30%. The overall prevalence was 27%. The prevalence of H. pylori infection was found to decrease with age from 43.8% at <40 years to 21.7% at >79 years old. H. pylori infection was significantly associated with duodenal and gastroduodenal ulcers. Cirrhosis and nonulcer-mucosal lesions were significantly unrelated to H. pylori infection. Patients with concurrent cirrhosis with peptic ulcer were found to be negative for H. pylori infection.

Peptic ulcer is the leading cause of UGIB in Thailand. However, its incidence is declining. Patients who presented to hospital with UGIB were older, compared with those a decade ago. H. pylori infection plays an important role in UGIB and its incidence was stable during the past 5 years.

Osteoporosis is a metabolic bone disease with a risk factor of being female, particularly after the onset of menopause.

To evaluate the influence of age, anthropometric, and reproductive variables on spinal bone mineral density (BMD) in women with postmenopausal vertebral osteoporosis.

The study was retrospective and included data from 171 patients with postmenopausal vertebral osteoporosis. We performed both simple and multiple regressions considering BMD in spine as the dependent variable. Coefficients of correlation (r), coefficients of determination (r²), and their level of significance were calculated.

The associations between spinal BMD and each of the following variables were extremely significant: age at menarche (P = 0.0003), weight (P < 0.0001), stature (P = 0.0004), and BMI (P < 0.0001). The associations between spinal BMD and age (P = 0.004), and between spinal BMD and number of years after menopause were very significant (P = 0.0093). BMD was not associated with age at menopause or number of reproductive years. For multiple regressions there was an increasing trend of r² with increasing number of independent variables included in the analysis: r² = 21.84% (2 variables), r² = 24.93% (3 variables), 26.45% (4 variables), and r² = 27% (5 variables).

BMD is positively associated with weight, BMI, and stature, and is negatively associated with age, time of menarche, and years after menopause. BMD is not associated with age at menopause and reproductive period.

Respiratory failure is a most serious neonatal disorder. A severity of illness assessment should be performed for mechanically ventilated infants to predict the probability of hospital mortality and to assist clinical decision making.

To evaluate the ability of the Score for Neonatal Acute Physiology, version II (SNAP-II) to predict the mortality risk for the infants who are mechanically ventilated with positive pressure ventilation (PPV) at a neonatal intensive care unit (NICU).

A prospective observational cohort study was performed in a 12-bed level III NICU at Hat Yai Hospital between January 2010 and December 2010.

During the study period, 46 infants were ventilated with PPV at admission. Of these, 8 died (17%) and 30 survived (83%). The overall mean SNAP-II score was significantly higher in the group of infants who died compared with those who survived (36.5 ± 11.5 vs. 22.3 ± 13.6, P < 0.01, respectively).The area under the receiver operating characteristic curve for the SNAP-II was 0.79 (95% confidence interval (CI) 0.66 to 0.92, P = 0.01). Every one-point increment of SNAP-II was associated with an odds ratio of 1.08 (95% CI 1.02 to 1.14, P < 0.01). The stratification of the two sets of scores when compared between groups showed that infants who had SNAP-II scores of ≥32 had the highest mortality risk with an odds ratio of 9.7 (95% CI 1.7 to 56.5) with sensitivity of 75.0% and specificity of 76.3%.

SNAP-II scores can significantly predict mortality in infants requiring mechanical PPV.

Premalignant and malignant cystic neoplasms of the pancreas are relatively rare, but absolute indications for surgical resection. Modern imaging modalities have increased recognition of asymptomatic cysts resulting in therapeutic dilemmas of whether surgery or observation is appropriate.

To examine our surgical experience with cystic neoplasms of the pancreas.

A retrospective study of patients who had cystic neoplasms of the pancreas and underwent surgical resections from June 2000 to April 2013. Presenting symptoms, surgical procedures, pathological diagnoses, and postoperative complications were analyzed.

Data from 16 patients were examined. Two patients had asymptomatic cystic neoplasms. Fourteen had symptoms ranging from 2 days to 6 years before diagnosis and surgery. Six patients underwent pylorus preserving pancreaticoduodenectomy, 4 underwent distal pancreatectomy with splenectomy, 2 underwent splenic preserving distal pancreatectomy, and 1 each underwent a classical Whipple operation, total pancreatectomy, distal pancreatectomy with splenectomy with partial resection of the posterior gastric wall, and distal pancreatectomy with splenectomy with left colectomy. The operative time ranged from 150 to 450 minutes. Operative blood transfusion ranged from 0 to 5 units. Four patients had mucinous cystadenoma, 4 had intraductal papillary mucinous neoplasia with varying degree of dysplasia and carcinomatous changes, 6 had other malignancies, and 2 had other benign cysts. Postoperative complications occurred in 3 patients. There was no perioperative mortality.

Any suspicion of malignant changes in asymptomatic cysts should have them considered for surgical resection. Meticulous surgical techniques are important for pancreatic resection to minimize the occurrence of postoperative complications.

KRAS, coding for a small G-protein downstream of epidermal growth factor receptor (EGFR) plays an important role in the EGFR signaling network. Mutation in KRAS is associated with resistance to anti-EGFR in patients with advanced colorectal cancer (CRC). According to the American Society of Clinical Oncology (ASCO) guidelines, screening for mutations in KRAS codons 12 and 13 in tumor samples is mandatory for all CRC patients who are candidates for anti-EGFR targeted therapy. However, some patients with undetectable mutations in codons 12/13 do not benefit from anti-EGFR treatment, and this might be because of mutations in codon 61, which is not currently recommended for screening.

To develop an in-house pyrosequencing method to screen for KRAS codon 61 mutations, and examine the prevalence of mutations in Thai patients with advanced CRC with no detectable mutation in codons 12/13.

DNA extracted from FFPE specimens was screened for KRAS codon 61 mutations using pyrosequencing. Our method was suitable for routine clinical samples (formalin-fixed, paraffin-embedded tissue), and was able to detect 5 common mutations in codon 61 of the KRAS gene, including c.182AT (p.Q61L), c.182AG (p.Q61R), c.182AC (p.Q61P), c.183AC (p.Q61H), and c.183AT (p.Q61H).

Of the 74 samples with undetectable codon 12/13 mutation examined, two (2.7%) were found to harbor mutation in codon 61.

Despite the low prevalence of KRAS codon 61 mutation in our population with advanced CRC, adding the mutation test into the routine molecular service deserves consideration because the cost of treatment is very expensive.

Rapid blood glucose estimation is required to prescribe treatments and to make dose adjustments in diabetic patients. However, measuring plasma glucose levels is time consuming. Therefore, the use of glucometers has greatly increased.

To measure the correlation between capillary and venous blood glucose levels.

Seventy patients with type 2 diabetes mellitus (T2DM) were enrolled in the present study and informed written consent was obtained from all participants. Demographic characteristics and clinical information was noted. Capillary and venous glucose levels were determined. Statistical Package for Social Sciences version 21 was used for data analysis.

Mean age of patients was 52 ± 12 years. It included 29% men; 71% women; 9% smokers; and 90% poor. Mean venous glucose was 11.73 ± 4.64 mmol/L and mean capillary glucose 12.57 ± 5.21 mmol/L. These findings demonstrated a significant intermethod mean difference of 0.84 mmol/L (P < 0.001). Inter-glucose difference was not significant at glucose levels near normal. However, it increased gradually with rise in glucose measurements and was significant at elevated glucose levels. Both concordance correlation coefficient and intraclass correlation coefficient demonstrated positive correlation and more consistency between glucose estimations. A Bland and Altman plot presented excellent agreement between glucometrically and photometrically determined glucose levels.

A positive correlation coefficient showed strong association between capillary and venous glucose measurements.

Multidrug resistance is a serious problem in the treatment of urinary tract infections. Horizontal gene transfer, directed by strong selective pressure of antibiotics, has resulted in the widespread distribution of multiple antibiotic resistance genes. The dissemination of resistance genes is enhanced when they are trapped in integrons.

To determine the prevalence of integrons among multidrug resistant Escherichia coli strains collected from regional hospitals and private clinical laboratories in Alborz province.

The susceptibility of 111 clinical Escherichia coli isolates was tested using a Kirby–Bauer disk diffusion method for common antibiotics. Isolates were screened for the production of extended spectrum β-lactamases (ESBLs) using a double disk synergy test. The existence of integrons was confirmed by amplification of the integrase gene and their class determined via analysis of PCR products by PCR-RFLP.

Isolates showed the highest resistance to amoxicillin. Nitrofurantoin, amikacin, and ceftizoxime were the most effective antibiotics in vitro. Eighty-eight isolates of 111 (79%) were resistant to more than three unrelated drugs. We found 30% of the multidrug resistant isolates harbor integrons. Class 1 and 2 integrons were detected in 25 and 1 isolates, respectively. ESBL screening of strains showed 45 isolates (40%) were positive; 22% of the ESBL-positive isolates carried class 1 integrons and the frequency of MDR in ESBLpositive isolates was 93%.

The existence of integrons in only 29.5% of multidrug resistant isolates showed that besides integrons, antibiotic resistance genes were probably carried on other transferable elements lacking integrons, such as transposons or plasmids.

Hypertrophic scarring from burn injuries on large skin areas is of great concern for both patients and attending physicians because of significant functional and cosmetic impairment. Surgery for scar corrections is challenging because of limitations on the availability of normal tissue. An alternative method for scar correction using artificial dermis is now possible. Artificial dermis can be used in the reconstruction of scars, burn injuries on large skin areas and in patients who do not have sufficient donor sites for skin grafts after scar excisions.

To report the efficacy of artificial dermis on a 20 years old Thai man with severe scar contracture from burn injuries.

An open-label case study, the severe contracture case underwent scar excision and was applied with artificial dermis.

A 20-year-old man had severe scar contractures on his left arm, forearm, and elbow, and a shearing wound with a scar at his left elbow. Total scar excision was done on his left arm, forearm, elbow, and hand, and then followed by application of artificial dermis on to the wounds. After 2 weeks, neodermis formation was observed, after which an ultrathin split thickness skin graft was applied to the wounds. One month after sugery, the patient could extend his left elbow fully and the cosmetic result is satisfactory.

Use of artificial dermis should be a new alternative modality in improving our strategy in correcting scar issues from burn injuries, especially on large burn scar areas with limited donor sites for skin grafts.

Classic galactosemia is an inherited disorder of galactose metabolism that is caused by a deficiency of galactose-1-phosphate uridyl transferase (GALT). As in other Asians, the prevalence of galactosemia in Thai people is very low. An accumulation of its toxic metabolites leads to acute neonatal toxicity and long-term complications.

To present the fourth known published case of classical galactosemia in a Thai infant and review the English language literature.

A 4-month-old boy who was born into a Thai family with no history of consanguinity developed persistent jaundice, hepatosplenomegaly, and lethargy, since introduction to breast-feeding.

Urine gas chromatography-mass spectrometry demonstrated a high level of galactose, galactitol, and galactonate. Liver biopsy confirmed severe hepatocellular damage and fibrosis. Breast-feeding was immediately replaced by a lactose-free diet and soy milk. His clinical features and subsequent laboratory measurements improved. Developmental delays and defects on speech presented at the last followed up.

Long-term complications are diet-independent and inevitable. However early recognition and immediate withdraw of galactose from the diet can prevent serious morbidity and mortality.