Volume 9 (2015): Issue 2 (April 2015)

Asthma is a chronic inflammatory disease of airways. Gastroesophageal reflux disease (GERD) is known to be associated with worsening asthma. We hypothesized that treatment of GERD in asthmatics will improve asthma control and quality of life. We reviewed our experience of treatment of GERD in asthmatics in Thailand.

To study the effects of omeprazole for treatment of GERD in patients with poorly controlled asthma on pulmonary function tests and asthma control test (ACT) scores.

This study was conducted at King Chulalongkorn Memorial Hospital between August 2009 and December 2010. Patients with partly controlled and uncontrolled asthma who were found to have GERD by 24 hour esophageal pH monitoring were administered omeprazole 40 mg per day for 8 weeks. Pulmonary function tests and ACT scores before and after treatment were compared at 4-weeks and 8-weeks follow up.

Twenty four patients were included in this study. None of them had asthmatic attacks during the study. After 4 and 8 weeks of omeprazole treatment, the mean FEV1 (2.20 ± 0.64 L, 2.36 ± 0.58 L, respectively) and the mean ACT score (20.82 ± 3.30, 23.00 ± 1.69, respectively) were significantly higher than the pretreatment values (mean FEV1 1.99 ± 0.56 L and ACT score 16.36 ± 3.97) (P < 0.05).

High-dose omeprazole may improve pulmonary function and the level of asthma control in Thai patients with partly controlled or uncontrolled asthma and coexisting GERD.

Stapled transanal rectal segmental resection (STARR) is a technique for treatment of obstructive defecation syndrome (ODS) when associated with rectocele and/or intussusceptions.

To evaluate a simplified method using a single stapler device for isolated anterior rectal wall correction of structural abnormalities (single-STARR technique).

Patients who were diagnosed with ODS underwent the single-STARR procedure. Their baseline symptoms were measured by using a modified obstructed defecation syndrome (MODS) questionnaire score. Evacuation proctography was performed to exclude functional anorectal disorders. Colonoscopy was selectively performed and for all patients older than 50 years. Single-STARR procedure was performed in cases where there was no evidence of an inflammatory, metabolic, neoplastic process, or functional disorders. The summed global score of ODS ranged from 0 (normal) to 24 (severe). Outcomes were determined by evaluating the postoperative improvement using a MODS score.

A total of 9 patients (mean (SD) age 53 (13.6) years) with ODS were eligible for the study. Both rectocele and intussusceptions were diagnosed from preoperative defecography in 7 of the patients. Single-STARR was successfully performed without intraoperative complications in all patients with a mean operative time of 52 (12.7) min. The mean severity of symptoms decreased significantly at the 3^rd and 6^th (P < 0.01) month after surgery. However, one-third of patients experienced persistence of symptoms or symptom score deterioration on the 12^th month after surgery.

The single-STARR procedure provided short-term symptom relief with no serious postoperative complication in a small series of 9 cases.

The Royal College of Pediatricians of Thailand requires that all its residents complete a full thesis before their final Thai Pediatric Board Examination. The Department of Pediatrics of the Faculty of Medicine, Prince of Songkla University (PSU) has been certified for pediatric residency training since 1985.

To determine the number of articles published in medical journals that are based on the theses of residents during 25 years of pediatric resident training, and how long after finishing their residency training the articles were published.

Medical journal databases were searched for the names of former pediatric residents. The faculty staff who had supervised them during their training were asked to confirm whether the residents had published their work.

During the 25 years (1988–2012), we found records of 34 articles based on the theses of 130 residents published in a medical journal (26%). In the early phase (1988–2002), 15 articles from 67 theses (22%) were published: 10 (67%) in Thai or regional English language journals, and 5 (33%) in international peer-reviewed journals. In the second phase (2003–2012), 19 articles from 63 theses (30%) were published: 6 (32%) in regional English language journals, and 13 (68%) in peer-reviewed international journals.

The publication rate of PSU pediatric residency research theses during the 25 years was 26%. We recommend that our faculty devote more time to ensuring supervision of the thesis writing component of the residency training to increase the publication rate of research theses by our residents.

There is variation of the age of onset of puberty in a population. The secular trends in the timing of pubertal development have decreased in some parts of the world.

To determine the age of pubertal development in healthy Thai boys in Khon Kaen, Thailand and compare it with that in previous studies of Thai boys.

A descriptive, cross-sectional study was performed in 316 school boys aged 5–16 years between May and July 2011. Development of the genitals and pubic hair was determined by Tanner staging, and testicular volume was assessed using a Prader orchidometer. All boys were examined by a male pediatrician.

Genital stage of puberty in boys occurred at a median age of 11.3 years and a mean ± SD age of 11.3 ± 1.3 (mean ± SD, range 8.0–14.9) years, and pubarche occurred at a median age of 12.8 years and a mean ± SD of 12.5 ± 1.2 years (range 9.1–14.9) years.

No secular trend towards earlier age at pubertal onset for gonadarche in Khon Kaen boys, but pubarche seems to be later than found in previous studies in Thai boys.

Fetal hemodynamics can be assessed by Doppler ultrasonography, but the normal Doppler waveform pattern and reference range of fetal renal artery blood flow indices in normal Thai fetuses during the second trimester have not been studied.

To study the pattern and establish the normal reference range of fetal renal artery blood flow indices in the normal Thai fetus during the second trimester.

This cross-sectional descriptive study included 512 normal singleton pregnant women, gestational age between 14⁽⁺⁰⁾ and 28⁽⁺⁶⁾ weeks. Ultrasonography was performed to assess the Doppler waveform pattern and estimate the normal reference range of fetal renal artery blood flow indices. All fetuses were delivered at term with normal outcomes at birth. The mean and 95^th and 5^th percentiles of the Doppler indices for each gestational week were estimated.

Doppler patterns with absence of diastolic flow in the entire cardiac cycle (type I), and absence of diastolic flow at the end of cardiac cycle (type II) were presented in about 10.4% of normal fetuses during the second trimester of pregnancy. Values for pulsatility index, peak systolic velocity, systolic-to-diastolic ratio, and resistance index (with absent end-diastolic velocity (AEDV) removed) each increased significantly with gestational age. The increase in end-diastolic velocity (with AEDV removed) with gestational age was not significant.

These normative data could serve as a basis for evaluation of the fetal renal artery blood flow, which should be of benefit for pregnancy management, especially in situations that interfere with fetal renal perfusion.

Hearing loss is among the most frequent sensory disorders. Preventable causes include medications given to genetically susceptible individuals. Several families around the world with an A1555G mitochondrial mutation who became profoundly deaf after receiving aminoglycosides have been described. However, none has been reported in Thailand.

To identify the cause of hearing loss of a large Thai family with 11 members who reportedly turned deaf after receiving antibiotics.

We obtained blood samples from 5 members; 4 of whom had hearing loss. Mutation analyses were performed using molecular techniques including polymerase chain reaction, Sanger sequencing, and restriction fragment length polymorphism.

All 4 affected members were found to harbor the same A1555G mitochondrial mutation, while the unaffected had only the wild-type A.

We have identified the mitochondrial mutation leading to aminoglycoside-induced hearing loss in a Thai population. Raising awareness for medical practitioners of this genetic susceptibility in Thailand is warranted. Avoidance of certain medications in these individuals would prevent this acquired permanent hearing loss.

Little is known about health-related quality of life (HRQoL) of Thai patients after heart surgery. The Thai government initiated a cardiac surgery project to celebrate the 80^th birthday anniversary of His Majesty The King.

To evaluate the HRQoL of Thai patients after heart surgery, as part of the Thai government’s cardiac surgery project, and to investigate the association of HRQoL instruments and patient characteristics.

Of 7,863 patients in the project, 386 were randomly selected for a telephone interview by trained researchers during June–November 2008. The HRQoL of Thai patients was measured using 12-item Short Form version 2 and EuroQoL (EQ-5D) plus an EQ-5D visual analog scale (EQ-VAS).

The mean age of patient participants was 50.4 ± 13.7 years (range 17–82) and 49.5% were male. The Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were reported as 46.91 and 54.44, respectively, compared with the US norm scores of 50. The EQ-5D and EQ-VAS utility scores of 0.81 and 0.84 were comparable to those of Thai general population (0.77–0.84), but higher than those of Thai patients with heart disease (0.73–0.75). Patients with older age, female sex, unemployment, and presence of comorbidity rated a lower HRQoL. The multiple linear regression models showed that both EQ-5D and EQ-VAS were associated with PCS and MCS and could be predicted by 40%–50%.

Overall, the HRQoL of patients after the heart surgery was satisfactory. The QoL in patients with a specific types of heart surgery warrants further study.

In hyperendemic areas, concurrent multiserotype dengue virus (DENV) infections commonly occur in both humans and in mosquito vectors. Previous studies have focused on single blood specimens.

To illustrate and characterize the time course of mixed infection with DENV serotypes 2 (DENV2) and 4 (DENV4) in a single case.

Plasma, saliva, and urine were collected from a patient diagnosed with dengue hemorrhagic fever grade II and secondary DENV infection on days 7, 18, and 31 of his illness. DENV RNA detection was performed using 2 DENV-specific reverse transcriptase-polymerase chain reaction protocols. Cloning and sequencing were performed to quantify the major and minor viral populations in dual-serotype-infected specimen(s). Genotypes of both DENV serotypes were characterized.

DENV genome was detected in plasma and saliva only at the first time point (day 7 of illness), but in urine at both the first and second time points (days 7 and 18 of illness). DENV4 serotype was found in all DENV genome-positive specimens. DENV2 serotype was unexpectedly also detected in the first urine specimen. DENV4 as the major and DENV2 as the minor population. The DENV2 serotype was clustered in genotype Asian I and DENV4 serotype in genotype I.

To our knowledge, this is the first report of concurrent multiserotype DENV infection detected solely in urine. Prospective noninvasive investigations may determine the prevalence of this phenomenon. Clinical and public health implications of this finding need to be explored.

Stevens–Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening skin conditions with an etiology of drug exposure or infections.

To determine the cause, treatments, complications, and outcomes of SJS/TEN in children admitted to Srinagrind Hospital during 1992–2012.

Retrospective chart review. A diagnosis of SJS and TEN was confirmed by pediatric dermatologists.

A total of 38 patients was recorded. They consisted 31 (82%) SJS patients and 7 (18%) TEN patients. Mean age 6.6 years (range 1 to 14 years). Male to female was 1.1:1. Most cases (30 or 79%) were caused by drug exposure. Three cases (8%) by infection, and 5 cases (13%) were of unknown cause. The antiepileptic drug group was the most common cause. Systemic corticosteroids were used in 33 cases (87%). Intravenous immunoglobulin was used in one TEN patient (3%). There were 18 cases (47%) with acute complications. Ocular complications (7 cases, 39%), septicemia (4 cases, 22%), and secondary skin infections (3 cases, 17%) were the most common. Mean difference in length of hospital stay between those with and without acute complications was 12.3 days (P < 0.01, 95% CI 5.9–18.6). Ocular complications were the only long-term complications at 1-year follow up, and included symblepharon, corneal pannus, and dry eyes. Two patients (5%), both having cases of TEN, died.

Antiepileptic drugs were the most common causes of SJS/TEN in our study. Good ophthalmologic care of the prevalent acute eye complications in these patients is needed to prevent long-term ophthalmic complications.

Regular blood transfusion and iron chelation therapy have improved the quality of life of patients with thalassemia and increased their longevity, but transfusion also increases the frequency of endocrine complications, possibly because of iron deposition in the pituitary gland or the gonads, or both.

To evaluate testicular function in patients with thalassemia major by basal hormonal study, and identify risk factors for dysfunction.

We performed a cross-sectional study of 28 patients with thalassemia major aged 11.7 ± 1.8 (8–14.9) years (15 in prepuberty, 13 in puberty with no delayed puberty) who had regular blood transfusions. A normal control group comprised 64 boys who were matched for age and Tanner genital stage.

The mean level of serum ferritin in the previous year was 1,575 ± 642 ng/mL, and the onset of blood transfusion was at 3.8 ± 2.3 years and iron chelation therapy was 6.6 ± 2.8 years. The trend for anti-Müllerian hormone levels in patients and controls was similar with age, and although higher in the patients, particularly at Tanner stage II, was not significantly different. Testosterone levels were lower in the patients compared with controls; particularly at Tanner stages IV–V (290.88 vs. 537.4 ng/dL, P < 0.05). Serum follicle-stimulating hormone and luteinizing hormone levels were not significantly different between the groups at any Tanner stage.

Patients who received regular blood transfusions had normal Sertoli cell function. Leydig cell dysfunction may occur, even though the patients had a normal pubertal onset.

Hepatic resections conducted for malignant tumors can be difficult because of the need to create cancer-free margins.

To examine the outcome of hepatic resections after the introduction of a Cavitron Ultrasonic Surgical Aspirator (CUSA).

A retrospective study of patients who underwent hepatic resection by a single surgeon between April 1999 to March 2013.

We included 101 patients with 104 hepatectomies. Most hepatic parenchymal transections were performed using a CUSA under intermittent hepatic inflow occlusion (Pringle maneuver). Thirty-five patients underwent a right hepatectomy, 11 a left hepatectomy, 6 a right hepatectomy and segment I resection, 6 a right lobectomy, and 46 underwent segmentectomies, wedge resections, or other types of hepatic resections. Biliary-enteric reconstruction with a Roux-en-Y limb of the jejunum to a hepatic duct of the hepatic remnant was performed in 28 patients. Operative time was 90–720 min (median 300 min, mean 327 ± 149 min). Operative blood transfusion was 0–17 units (median 3 units, mean 3.9 ± 3.6 units). Twenty-one hepatectomies were conducted without blood transfusion. Thirty-four postoperative complications occurred in 30 patients with a 9% reoperation rate. Perioperative mortality was 6%. Age, operative time, operative blood transfusion, reoperation, and complications were significantly associated with mortality.

Careful preoperative diagnosis and evaluation of patients, faultless surgical techniques, and excellent postoperative care are important to avoid potentially serious postoperative complications and mortality. The CUSA is an effective assisting device during hepatic parenchymal transection with a concomitant Pringle maneuver, apparently reducing operative blood loss.

Bone complications are common in patients with thalassemia.

To assess risk factors for osteoporosis in patients with nonmajor thalassemia and its prevalence in randomly selected adult patients in Thailand.

We included 190 adult patients (58 men and 132 women) with thalassemia intermedia or minor in this cross-sectional study. Patients with untreated hypogonadism, untreated hypothyroidism, menopause, and with a history of treatment with medications that have effects on skeletal or bone metabolism were excluded. Bone mass density (BMD) of the femoral neck was measured by calibrated dual-energy X-ray absorptiometry. Independent factors likely to be associated with osteoporosis were determined and included in the analysis to ascertain possible associations.

Mean age was 35.48 ± 14.11 years (range 18–87 years). The mean Z score of femoral neck was − 0.86 ± 1.14 (range −3.7–2.40). Prevalence of osteoporosis was 22/190 (11.6%). Correlation between the pretransfusion hemoglobin level and BMD score was r = 0.192, P = 0.008. Univariate analysis found low BMI was a risk factor for osteoporosis (OR = 3.09, 95% CI 1.09–8.76, P = 0.039) and iron chelation therapy was a protective factor (OR = 0.24, 95% CI 0.09–0.69, P = 0.005). Multivariate analysis did not find these factors to be significant.

All patients with thalassemia at risk of osteoporosis should be screened periodically for bone disease. The uncertainty and disagreements as to the potential role of different factors indicate the necessity for further studies to recognize the pathophysiological basis of this serious complication of thalassemia.

A National Survey on the Effect of Nutrition conducted in 1996−1997 showed a 14% overall prevalence of obesity in Tunisia with a female predominance. Leptin and ghrelin play crucial roles in regulating body weight and energy balance. Leptin, an anorectic hormone, and ghrelin, an orexigenic hormone, appear to interact with glucose and lipid metabolism.

To determine the circulating levels of ghrelin and leptin in obese Tunisian women and to investigate the correlations of these hormones with body mass index (BMI), and circulating lipids and glucose.

Forty obese women were recruited from patients in the “C” Unit of the National Institute of Nutrition and Food Technology. Twenty normal women were recruited as controls. Plasma levels of the studied variables were measured in patients from both groups and findings were analyzed.

Circulating levels of leptin were significantly higher, while high-density lipoprotein (HDL)-cholesterol and ghrelin levels were significantly lower in the obese women. In the obese women, significant positive correlations were found between circulating levels of leptin and low-density lipoprotein (LDL)-cholesterol, BMI, and glucose; and ghrelin and HDL-cholesterol. Significant negative correlations were found between circulating levels of leptin and HDL-cholesterol and ghrelin; and ghrelin and leptin, LDL-cholesterol, BMI, and glucose. Multivariate analysis revealed that ghrelin was significantly associated with HDL-cholesterol, LDL-cholesterol, and blood glucose.

The significant negative correlation between leptin and ghrelin suggests that these two hormones may be antagonistic. Increased levels of ghrelin are correlated with decreased circulating levels of HDL-cholesterol and increased levels of LDL-cholesterol.

Pakistan is highly endemic with hepatitis B virus (HBV) and the incidence of HBV infection is rising steadily. The reasons may include poor public awareness about the transmission of HBV and HCV.

To assess the awareness of HBV and HCV among students in nonmedical universities.

The study instrument was a structured 36 item questionnaire. After obtaining permission from the respective administrations, students were approached within their university campuses and were included by convenience sampling. The results were expressed as frequencies.

Five hundred students from 5 different institutions participated in the survey, with 100 students representing each institute. Most students did not recognize the possible modes of infection of hepatitis B that include reuse of syringes (57.2%), blood transfusions (62.6%), and sexual contact (57.4%). However, most (67.8%) students correctly believe that there is a vaccination available for the prevention of HBV. Most students did not recognize the possible modes of infection of hepatitis C that include reuse of syringes (61.8%), use of intravenous drugs of addiction (71.4%), sexual contact (55.6%), and blood transfusions (55.2%) as possible modes of transmission. Most students (51.8%) incorrectly believed that there is a vaccination available for the prevention of HCV.

There is a prominent lack of awareness regarding the risk factors for HBV and HCV infection among the student community of nonmedical universities in Karachi, and an immediate need to conduct nationwide awareness programs to raise the awareness of HBV and HCV transmission in the Pakistani population exists.

The relationship between endothelial dysfunction, a risk factor for coronary artery disease, and the incidence of cardiovascular disease (CVD) in the general population is not well known.

To determine the utility of an exercise treadmill test (ETT) combined with inflammatory markers to show endothelial dysfunction for individuals with a low risk of adverse cardiovascular (CV) events.

Biomarkers of inflammation (lipoprotein-related phospholipase A₂ (Lp-PLA₂) and high-sensitive C-reactive protein (hs-CRP)) and biomarkers of endothelial dysfunction (nitric oxide, oxidized low-density lipoprotein (Ox-LDL), and sialic acid) were assessed in 60 apparently healthy patients with a positive (+) or negative (−) ETT and across endothelial function assessed by flow mediated dilatation (FMD) and Lp-PLA₂ tertiles.

Lp-PLA₂ levels were increased in ETT (−) compared with ETT (+) patients. Half of ETT (−) patients were found to have levels of Lp-PLA₂ in the highest tertile. There was a significant inverse relationship between ETT and inflammatory biomarkers when adjusted for age, Lp-PLA₂ (r = −0.28, P = 0.04), or hs-CRP (r = −0.35, P = 0.01). No differences were found for biomarkers of endothelial dysfunction. All variables were reassessed across FMD tertiles. Total lipids, Ox-LDL, triglyceride, and Lp-PLA₂ were higher for the lowest FMD tertile.

The elevation of Lp-PLA₂ in ETT (−) patients and the inverse relationship with inflammatory biomarkers, suggest that ETT cannot address endothelial dysfunction for individuals with apparently low risk of adverse CV events, and cannot be used for risk stratification of the general population.

Pituitary stalk interruption syndrome (PSIS) is characterized by a thin or interrupted pituitary stalk, impairing delivery of hypothalamic hormones to the pituitary, and anterior pituitary dysplasia.

To summarize the manifestations and treatment of PSIS.

We performed a meta-analysis of PSIS research published between January 1, 2004 and December 31, 2013. Chinese databases were searched using the terms “pituitary stalk interruption syndrome”, “PSIS”, and “vertebral handle interrupts syndrome”; and results limited to clinical studies. Age of onset and diagnosis, sex, symptoms at presentation, main clinical signs, magnetic resonance imaging (MRI), laboratory results, and other data were extracted from qualifying studies.

We included 311 cases from 33 papers in the meta-analysis. The male:female ratio was 257:54, and 183 of the 311 patients had a history of abnormal birth or cerebral hypoxia. MRI showed 239 cases of missing and 62 cases of tapered pituitary stalk. Multiple pituitary hormone deficiency was identified in 190 cases, and single growth hormone deficiency in 75. There were significant associations between missing pituitary stalk and multiple pituitary hormone deficiency, and pituitary stalk tapering and single hormone deficiency (P < 0.01). The clinical signs included growth retardation and the absence or delay in development of secondary sexual characteristics. Therapy was usually inadequate, with only 12 patients (3.86%) undergoing growth hormone replacement.

Abnormal delivery and cerebral hypoxia may be important causes of PSIS, and MRI is valuable for its diagnosis. Measuring the levels of pituitary hormones is necessary for timely diagnosis and treatment.