Intestinal parasitic infections among human immunodeficiency virus-infected and -uninfected children hospitalized with diarrhea in Bangkok, Thailand.

A prospective observational study was conducted to determine the prevalence and the clinical impact of intestinal parasitic infections in diarrheal illness among HIV-infected and HIV-uninfected children hospitalized with diarrhea in Bangkok, Thailand. Stool samples were examined for intestinal parasites using a simple smear method, a formalin-ether concentration method, a modified acid-fast stain and a modified trichrome stain. Intestinal parasites (IP) were identified in the stool specimens of 27 of 82 (33%) HIV-infected and 12 of 80 (15%) HIV-uninfected children (p=0.01). Microsporidia and Cryptosporidium were the most common IP found. Eighty-two percent of HIV-infected and 97% of HIV-uninfected groups presented with acute diarrhea and 76% of each group had watery diarrhea. Pneumonia was the most common concurrent illness, found in 22%. Clinical findings were unable to differentiate children infected with IP. Sixty-three percent of HIV-infected and 83% of HIV-uninfected children who had IP made a satisfactory recovery without specific anti-parasitic therapy. However, 9 children (7 HIV-infected and 2 HIV-uninfected) with persistent diarrhea who also had cryptosporidiosis and/or microsporidiosis did not respond to azithromycin and/or albendazole respectively. HIV-infected children with cryptosporidiosis were older and had more advanced HIV infection than those with microsporidiosis. Routine stool examination for IP should be considered due to the absence of clinical markers. The lack of effective therapy for the major IP found underscores the importance of preventive measures.

Immunohistochemical study of c-erbB-2 expression in primary breast cancer.

An immunohistochemical (IHC) study of the c-erbB-2 protein was performed in paraffin-embedded tissues from 506 primary breast carcinomas. An overexpression of c-erbB-2 was detected in 32% of the tumors and was correlated with a negative estrogen receptor status, increasing tumor size as well as axillary lymph node involvement. The five-year disease free survival was analyzed in 183 patients who have been followed for at least five years. No statistically significant association of c-erbB-2 status with survival was shown. However, longer survival in women over 50 years compared to under 50 years of age was detected among the c-erbB-2 positive patients. In the multivariate Cox's regression analysis, lymph node and vascular invasions were independent prognostic indicators among these patients. But c-erbB-2 status and other factors did not predict the relapse of breast cancer. However, these data may not negate the benefit of c-erbB-2 detected by IHC for identification of patients who have a poor prognosis and require more aggressive adjuvant therapy. Further studies in a larger group of patients with longer follow-up time may provide more valid information.

A report case of Cyclospora and Cryptosporidium mixed infection in a HIV-negative child in Thailand.

The first case of cyclosporosis in a non HIV-infected child in Thailand, co-infected with Cryptosporidium, was reported. The patient was a 3 year-old malnourished orphan who presented with fever, abdominal distension and relapsing diarrhea. There was no leukocyte in her stool, however, numerous Cyclospora and Cryptosporidium oocysts were identified by modified acid-fast staining. The illness was cured by co-trimoxazole and fluid therapy. More coccidial infections in Thailand may be detected if modified acid-fast staining is routinely performed.

Penicilliosis-associated hemophagocytic syndrome in a human immunodeficiency virus-infected child: the first case report in children.

Infection-associated hemophagocytic syndrome (IAHS) has been found in many systemic infectious conditions with a high mortality rate. Disseminated Penicillium marneffei infection is a common opportunistic condition among HIV-infected patients in many regions in Southeast Asia. We report the first case of IAHS caused by penicilliosis in an HIV-infected child who presented with cytopenias and recovered promptly after antifungal and intravenous immunoglobulin therapy.

Nosocomial bloodstream infection in pediatric patients: Siriraj Hospital, Bangkok; 1996-1999.

A retrospective study on nosocomial bloodstream infection (NBSI) in pediatric patients hospitalized at Siriraj Hospital from January 1996 to December 1999 was performed. Of the 18,087 blood specimens sent for culture, 533 (3%) were positive for organisms after 72 hours of hospitalization and were defined as NBSI. The rate of NBSI detected in blood culture specimens was highest among neonates (5.2%). Gram-positive cocci and gram-negative rods caused NBSI in an equal proportion (46% and 44% respectively) and Candida caused 10 per cent of NBSI. Coagulase-negative staphylococci was the most common pathogen followed by K. pneumoniae and Enterobacter. Antibiogram showed that 15 of the 35 (43%) S. aureus identified were methicillin-resistant. Only 35-38 per cent of Enterobacteriaceae were sensitive to cefotaxime or ceftazidime. Cefoxitin was still effective against 95 per cent of K. pneumoniae. Compared with other third generation cephalosporins, combination of cefoperazone and betalactamase-inhibitor (sulbactam) possessed an increased in vitro efficacy against K. pneumoniae, Enterobacter, E. coli, Acinetobacter and non-fermentative gram-negative rods. Resistant rate of amikacin among all gram negative rods was 25-69 per cent. Ciprofloxacin sensitivity varied from 62-100 per cent among all gram-negative rods. Imipenem was excellent against all gram-negative rods with the sensitivity of 80-100 per cent. Epidemiological data of this study is important for the decision of the appropriate empirical antimicrobial treatment in our hospital.

Evaluation of susceptibility status of invasive pneumococcal isolates to various antibiotics and risk factors associated with invasive penicillin-nonsusceptible pneumococcal infection: Bangkok 1997-1998.

The antibiotic susceptibility pattern of Streptococcus pneumoniae isolated from specimens of invasive infections was examined at Siriraj Hospital, a tertiary care center in Bangkok, during December 1996 April 1998. The percentage of S. pneumoniae isolates intermediate and resistant to various antibiotics were: penicillin, 25% and 21%; amoxicillin-clavulanate, 24% and 0%; cefuroxime, 6% and 36%; cefotaxime, 6% and 1.4%; ceftibuten, 5% and 42%; imipenem 22% and 0%; co-trimoxazole, 6% and 41%; chloramphenicol, 2% and 26%; erythromycin, 12% and 16%; azithromycin, 0% and 30%; and roxithromycin 0% and 33%. Most of the penicillin-nonsusceptible S. pneumoniae (PNSP) were also nonsusceptible to other antibiotics except cefotaxime, and imipenem. The isolates from respiratory specimens have a higher rate of resistance to all antimicrobial agents with a significant rise in MIC50 of beta-lactam antibiotics. There was no difference in the outcome of infections caused by penicillin-susceptible and -nonsuscetible S. pneumoniae. The only identifiable risk factor associated with PNSP infection was prior use of antibiotic within 3 weeks.

Serum c-erbB-2 protein in breast cancer patients.

Measurements of c-erbB-2 protein were done in sera of 20 normal women, 22 benign breast disease patients and in respectively 43 and 51 samples from primary breast cancer patients obtained prior to and after surgical interventions. Mean value of serum c-erbB-2 in non-malignant women was insignificantly different from the value in the breast cancer group. Positivity rate of serum c-erbB-2 in the cancer group was 13.8 per cent. Increasing postoperative serum c-erbB-2 concentrations were in good association with severity, progressiveness and relapse of breast cancer independently of other variables such as age, menopausal status, tumor size, axillary node invasion, ER or PR status. Pretreatment serum c-erbB-2 positivity was inversely correlated to ER status but relation to other prognostic parameters of breast cancer was not found. Agreement between c-erbB-2 measured in serum by enzymeimmunoassay and in tissue by immunohistochemical assay was also found. Our data confirmed that in primary breast cancer patients, monitoring of circulating c-erbB-2 protein levels after operation are useful for detecting the recurrence and/or metastasis of the disease especially in ER positive breast cancer. Pretreatment serum c-erbB-2 concentrations do not have benefit for early diagnosis of the tumor.

Study of plasma hormones and lipids in healthy elderly Thais compared to patients with chronic diseases: diabetes mellitus, essential hypertension and coronary heart disease.

Simultaneous measurements of serum estradiol, testosterone, cortisol, prolactin, total cholesterol (TC), high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDLC) and triglycerides in Thai men and postmenopausal women aged over 50 years were carried out in four groups of subjects: healthy controls, and patients with essential hypertension, non-insulin dependent diabetes mellitus (NIDDM), and coronary heart disease. Hypertriglyceridemia and hypercholesterolemia were found more often in patients with essential hypertension than in patients with other diseases. Low levels of HDLC with high TC/HDLC and LDLC/HDLC ratios occurred more frequently in coronary heart disease patients. Hypertensive men had the highest plasma estradiol levels while men with coronary heart disease had the least testosterone levels compared with men with the other two diseases. Decreased testosterone and/or increased estradiol may have an adverse effect on lipid profiles in elderly men. However, neither the sex hormones, cortisol, nor prolactin, appeared to have any influence on serum lipids and lipoproteins in elderly women. These findings in the Thai population are consistent with those previously reported in other populations.

Comparison of BACTEC automated blood culture system and conventional system in hospitalized pediatric patients.

A prospective study in pediatric patients compared the BACTEC system, an automated blood culture system using Bactec Ped Plus/F broth media, with the conventional system using Brain Heart Infusion broth media. Each single blood sample drawn for culture from hospitalized children was evaluated by both systems simultaneously. Of 244 pairs of blood samples, 44 (18%) were positive for microorganisms. Of these isolates, 24 (55%) were detected by both systems, 10 (23%) were detected by the BACTEC system only, and 10 (23%) were detected by the conventional system only. The mean turn around time of the BACTEC system (0.56 +/- 0.34, range 0.08-1.55 days) was significantly shorter than that of the conventional system (3.36 +/- 2.72, range 1-7 days, p < 0.001). Seven isolates strongly suspected to be due to contaminants grew out after 5 days of incubation and were detected by the conventional system only. In this study the BACTEC system and the conventional system were equally effective in detecting microorganisms in the patients' blood samples even if antibiotic therapy had been previously administered. However, the results from the BACTEC system were available much sooner and less likely to be contaminants.

The reference range of CD4+ and CD8+ T-lymphocytes in healthy non-infected infants born to HIV-1 seropositive mothers; a preliminary study at Siriraj Hospital.

The results of CD4+, CD8+ T-lymphocyte values as percentage, number, and ratio were studied in infants aged 1 to 29 months. The 283 subsequent blood samples from 89 infants born to HIV-1 seropositive mothers were investigated. From 208 sequential samples of 70 healthy non-infected infants, the reference values of CD4+ and CD8+ T-lymphocytes have been established and compared to Caucasian reference values. The results were analysed in 4 difference age groups (1-5, 6-11, 12-17 and > or = 18 months). At age 12 months, CD4 number and percentage declined significantly while CD8 percent increased. At age 6 months CD4/CD8 ratio decreased. Of 19 infected infants CD4+ percentage and number as well as CD4/CD8 ratio declined at age 6 months and showed significant differences from uninfected infants. A significantly elevated CD8 percentage was demonstrated in infected infants at age of 12 months. In 9 infants who showed symptoms at age 6-18 months, the CD4 and CD8 values were different from the reference range and 6 of 9 patients showed lower CD4 percentage, CD4 number and reversed CD4/CD8 ratio before the symptoms appeared. In 10 infants who were asymptomatic at age 18 months, there was no evidence of immunosuppression at age 6 months or before. After age 6 months, lymphocyte subset values of some asymptomatic infected children were beyond the reference range. These preliminary findings should be very useful for monitoring children born to HIV infected mothers. The results of CD4+ and CD8+ T-lymphocytes in uninfected infants could be used as reference values for the Thai and other Southeast Asian pediatric populations.

Response to JE vaccine among HIV-infected children, Bangkok, Thailand.

Since 1990, Japanese encephalitis (JE) vaccine has been part of EPI in northern Thailand, where there is a high prevalence of JE and HIV infection. To evaluate the immunogenicity and safety of JE vaccine among HIV-infected children, we conducted a retrospective study of HIV-infected and uninfected children who received 2 doses of JE vaccine at 12 months of age. Pre- and post-immunization plasma specimens were tested by plaque reduction neutralization for antibody levels to JE and dengue(1-4) viruses; titers of > or =10 were considered positive. Excluding 5 children with preimmunization antibodies, 5 of 14 (36%) HIV-infected children and 18 of 27 (67%) uninfected children had positive JE antibody titers after immunization [odds ratio (OR) 0.3, p=0.06]; 31% absolute difference [95% confidence interval (CI) 0-61.7%). The geometric mean titer of HIV-infected children with positive titers was lower than that of control children (15.1 vs, 23.8; p=0.17). No significant vaccine-associated adverse events were noted. We conclude that primary antibody response to JE vaccine was low among HIV-infected children and was approximately half of that seen among uninfected children. In endemic areas, HIV-infected children are likely to be at risk of acquiring JE despite routine immunization with 2 doses.

Maternal and viral factors in vertical transmission of HIV-1 subtype E.

Vertical transmission of HIV-1 is caused by multifactorial factors. To access the relationship of viral factors involving in perinatal transmission of HIV-1 subtype E, which is the predominant type in Thailand, plasma viral load, blood CD4+ lymphocyte level, heteroduplex mobility, and V3 sequence of the HIV-1 envelope gene were studied in 32 transmitting and 25 non-transmitting mothers. We found that HIV-1 subtype E vertical transmission was strongly associated with high maternal plasma viral RNA (> 4 x 10(4) copies/ml) and high genetic diversity of envelope gene determined by heteroduplex mobility (< 0.9). The variation of nucleotide sequences in envelope gene of subtype E vertical transmission could not determine in V3 region. Hence, plasma viral load and heteroduplex mobility can be used as prediction factors in vertical transmission of HIV-1 subtype E.

Cytosol cathepsin D in Thai women with breast cancer.

The necessity of screening high-risk patients with breast cancer who may require more intensive systemic therapy especially in the node negative subgroup was generally accepted. Cathepsin D, an estrogen induced protease, has been shown to be implicated in the proliferation and invasion of breast cancers. Retrospective assessment of cytosol cathepsin D in 151 primary breast cancers was done together with ER, PR and other clinico-pathological parameters. No significant relationship was shown between cathepsin D concentrations or cathepsin D status using median value of 56 pmol/mg protein as cutoff level with most studied parameters. High cathepsin D status was found in 47 per cent of patients with fibrocystic disease of breast and 30 per cent in node-negative, ER-PR negative tumors. Survival analysis after 5 or 10 year follow-up and evaluation in a larger scale are necessary before including cytosol cathepsin D measurement as a routine clinical investigation for breast cancers.

Detection of HIV-1 proviral DNA by polymerase chain reaction: a preliminary study in Bangkok.

Nested polymerase chain reaction (nested PCR) was used to separately amplify part of gag, pol, and env genes of human immunodeficiency virus type 1 (HIV-1) to evaluate that primer specific to either gag (SK380/390&SK38/39), pol (JA17/18&JA19/20), or env (JA9/10&JA11/12) genes is suitable for HIV-1 PCR based diagnosis in Thailand. The positive PCR results in 70 HIV-1 infected adults are 100, 97, 89 per cent and in 75 HIV-1 infected infants are 100, 94, 74 per cent by gag, pol, env primer, respectively. The specificity of all three primer sets is 100 per cent. The unamplified samples by pol and env primers were identified as HIV-1 subtype E by PELISA method. False negative in HIV-1 PCR based diagnosis caused by high genetic variation of HIV-1 can be overcome by using several primer sets as shown in this study.

Hormonal and metabolic responses to acute exercise in Thai women.

Physiological and hormonal changes after acute exercise of moderate intensity (75% VO2 max) by pedalling bicycle ergometer were studied during follicular and/or luteal phase of menstrual cycle in sixteen healthy Thai women compared to the other sixteen non-exercised women. Physiological recordings and hormonal determinations were performed at corresponding times as follows: before, immediately after and 30 minutes after stopping exercise. Exercise significantly increased lactic acid, pulse rate, respiratory rate, systolic and mean arterial blood pressure and decreased plasma glucose while diastolic blood pressure, hemoglobin and hematocrit were not significantly changed. Plasma LH, FSH and estradiol were unaffected by exercise either in follicular or luteal phase. Plasma progesterone and cortisol rose in response to acute exercise during luteal and follicular phase respectively. Testosterone and prolactin concentrations in blood decreased significantly 30 minutes after exercise during the luteal phase. The effects of acute exercise on studied hormones related to reproductive function in women were discussed.

Non-invasive hormonal analysis for ovulation detection.

The present study suggested that measurement of LH, E2 and P in blood may be replaced by non-invasive measurements of E2 and P in saliva and by assays of LH, E1-3G and P2-3G in urine. These alternative methods for determination of reproductive hormones in saliva and in urine provide similar and reliable information of endocrine status in both normal and abnormal reproductive functions. The advantages of these non-invasive methods should be brought into consideration whenever the physiological assessments or clinical investigations of ovarian functions are required.

Serum cortisol, academic performance and health of siriraj medical students.

A study of serum cortsol in second year medical students at Siriraj Hospital was performed in 1986 curriculum year. Ninety-one volunteers, 28 females and 63 males, participated in this study. Two blood samples were collected from each volunteer, one at the beginning of the second semester and the other at the end of the semester, a few days before the final examination in Physiology. Serum cortisol, which was measured by RIA technique, was used to determine the degree of stress and the ability to adapt to stress. By considering the two cortisol values on second examination, group 2-increased value from first normal value, group 3-decreased value from first high value and group 4-sustained or increased value from first high value. It was found that 57.14 percent of male and 60.71 percent of female students already had higher serum cortisol than normal in the first sample. The academic performance and health were Physiology examination was higher in the group 1+3 than the group 2+4 (p=0.034). Two students, one who was in the group 2 with increased serum cortisol and the other who was in the group 3 with decreased serum cortisol, developed psychological problems in the following year.

Faculty workload: Faculty of medicine Siriraj Hospital.

An analysis of the workload of staff of the Faculty of Medicine Siriraj Hospital, was carried out in line with the Faculty’s policy to improve medical education and for future manpower planning. The results indicate that many clinical faculty members in several departments are overloaded with their clinical responsibilities making it difficult for them to maintain academic objective, while young pre-clinic faculty members do not have to take full responsibility for their duties. Pre-clinic faculty members should therefore increasingly participate in the teaching programme for medical students.