Angiotensin converting enzyme inhibitor induced cough: experience in Siriraj Hospital.

With the increasing use of angiotensin converting enzyme inhibitors (ACEI) in the treatment of hypertension, particularly in diabetic patients, and heart failure, an annoying cough has frequently been observed. According to the post marketing surveillance studies, the prevalence of cough associated with ACEI was only 0.1-4 per cent. However, many recent studies have observed a very much higher frequency. To examine the incidence and pattern of cough associated with the usage of ACEI (C-ACEI) in a Thai population, mixed retrospective and prospective studies were performed in hypertensive patients who attended the out-patient department, Siriraj Hospital between December 1999 and August 2000. A thousand cases who had used or have been using ACEI were studied. C-ACEI was present in 179 cases of 760 retrospective studied cases (23.6%) and 75 cases of 240 prospective studied cases (31.3%). Cough was typically described as irritative (93.8% retrospectively and 98.7% prospectively, p = 0.05) and nocturnal in onset (74.9% retrospectively and 80% prospectively, p = 0.12), and usually appeared within the first 4 weeks of treatment (41.3% retrospectively and 46.7% prospectively, p = 0.43). Patients who received a full dosage of ACEI did not have to posses an increasing risk of C-ACEI. There was no difference in the prevalence of C-ACEI among types of ACEI, except cilazapril and quinapril which were found to be higher than enalapril in the retrospective study (p < 0.0001 and p = 0.002, respectively). Types of study were shown to influence the prevalence of C-ACEI. Prospective studies yielded a higher rate of C-ACEI than retrospective ones.

Surgery of the abdominal aorta: experience of a university hospital in Thailand.

One hundred and thirty two patients who underwent aortic surgery at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1991 to December 2000 were studied. Twenty three patients (17.4%) were aged less than 60 years, 102 (77.3%) aged 60-80 years, and 7 (5.3%) were older than 80 years. Ninety eight patients (74.2%) underwent elective operations and 34 (25.8%) underwent emergency operations. Elective abdominal aortic aneurysms (AAA) repair was the most common indication for abdominal aortic surgery (56.0%). Eighteen patients (13.6%) underwent surgery for infected AAA. The incidence of infected AAA was 16.1 per cent among patients with AAA. Fifteen patients (11.4%) had ruptured AAA and 19 patients (14.4%) had aortoiliac occlusive disease. The overall mortality rate was 15.2 per cent. The mortality of elective aortic surgery was 5.1 per cent and of emergency aortic surgery was 44.1 per cent. The mortality of elective AAA repair was 4 per cent. Multiple system organ failure was the most common cause of death (80%), followed by acute myocardial infarction (10%) and exsanguination (10%). The authors conclude that elective surgery on the abdominal aorta is safe and should be performed when indicated to prevent the development of complications requiring emergency surgery which carries a much higher risk.

Anesthesia and laparoscopic adrenalectomy for primary aldosteronism.

Adrenalectomy is the curative treatment of primary aldosteronism or Conn's syndrome. Laparoscopic adrenalectomy, a new method, should result in less pain and shorter hospitalization. We reported 25 patients who received anesthesia and laparoscopic adrenalectomy from 1995-1999. There were 17 females and 8 males. The mean age was 41.9 years (range 25-59). Ninety-six per cent had hypertension, 76 per cent had weakness of the extremities. When these patients sought medical care, their serum potassium and bicarbonate were 2.4 and 30.9 mEq/l respectively. Before operation, after treatment with spinorolactone, they were 4.3 and 24.4 mEq/l respectively. Associated diseases and cardiovascular abnormalities were reported. General anesthesia was the anesthetic technique of choice. Laparoscopic adrenalectomy was described in detail. Sixteen patients had adenomas on the left adrenal gland, 9 were on the right. Twenty-four patients had unilateral adrenalectomy, one had enucleation of the tumor. The size of the adenoma was 1.8 cm (range 1-3). There was no morbidity or mortality. All patients were discharged on the third postoperative day.

Significance of a widened mediastinum in blunt chest trauma patients.

Eighteen blunt chest trauma patients who had mediastinal widening on chest roengenogram were studied for the correlation with traumatic ruptured of the aorta or its major branches. Seventeen patients were male and one was female. The age ranged from 18 to 39 years, mean 26.17+/-6.85SD. The Injury Severity Score (ISS) ranged from 9 to 34, mean 25.5+/-6.49SD. Fourteen patients (77.8%) sustained motorcycle accidents, 3 patients (16.7%) sustained car accidents and 1 patient (5.5%) fell from a 4 storey building. All patients underwent aortography to search for traumatic rupture of the aorta or its major branches. Six patients had computed tomography of the chest before aortography. Nine patients (50%) had normal aortography. The remaining 9 patients who had positive aortography underwent urgent thoracotomies, 8 of them had traumatic rupture of the aorta or its major branches, the remaining 1 patient had normal operative finding. Of the 8 patients who had traumatic rupture of the aorta or its major branches, 1 patient died. The mortality was 12.5 per cent. The rate of traumatic rupture of the aorta or its major branches in patients who had blunt chest trauma and widening of the mediastinum on chest roengenogram in our study was 44.4 per cent. The sensitivity of aortography for diagnosis of traumatic rupture of the aorta or its major branches was 100 per cent and the specificity was 90 per cent. On the basis of this study, we conclude that blunt chest trauma patients with widened mediastinum on chest roengenogram have a significantly high rate of traumatic rupture of the aorta or its major branches. All blunt chest trauma patients who have widened mediastinum on chest reongenogram should undergo further investigations to exclude traumatic rupture of the aorta or its major branches. We recommend aortography as the investigation of choice due to its accuracy and usefulness in management plan.

Abdominopelvic vascular injuries.

The clinical records of 25 patients with 32 abdominopelvic vascular injuries were reviewed. Sixty per cent of patients sustained blunt trauma and 40 per cent sustained penetrating trauma. Nineteen patients (76%) were in shock on arrival, 2 of them underwent ER thoracotomy when they first arrived in the emergency room. Nine patients (36%) had signs of lower extremity ischemia. The Injury Severity Score (ISS) ranged from 16-50, mean 29 +/- 10.0. Nineteen patients (76%) had 35 associated injuries. Of the 32 injured vessels; 8 were external iliac artery, 5 were renal vein, 4 were abdominal aorta, 3 were common iliac artery, common iliac vein, external iliac vein and inferior vena cava, and 1 was superior mesenteric artery, superior mesenteric vein and median sacral artery. Treatments included: 13 lateral repair, 4 prosthetic grafting, 4 nephrectomy, 3 ligation, 3 reversed saphenous vein grafting, 2 end to end anastomosis, 1 internal iliac artery grafting, 1 intravascular shunt and packing and 1 perihepatic packing. Nine patients (36%) died. High mortality was observed in injuries to the abdominal aorta (75%), inferior vena cava (66.7%), common iliac vein (66.7%) and associated major pelvic fractures (50%). Factors significantly associated with mortality were the presence of shock on arrival, associated injuries and high Injury Severity Score. The author concludes that short prehospital time, effective resuscitation and proper surgical decision making are important for survival in these critically injured patients.

Somatostatin receptor tumor imaging (Tc 99m P829) in pituitary adenoma.

Technetium 99m P829 (99mTc P829) is a somatostatin like structure labelled with Technetium-99m. Somatostatin receptor positive tumors such as pituitary tumors, neuroendocrine tumors, and lymphomas show positive scintigraphy. Eleven patients suspected of having a pituitary mass (12 studies) were studied with 99mTc P829. Three pituitary adenoma patients (4 studies) showed positive somatostatin receptor tumor imaging. Eight negative somatostatin receptor scintigraphy were one hypothyroid induced pituitary hyperplasia, one craniopharyngioma, one normal pituitary tissue with focal hyperplasia, one ACTH secreting pituitary tumor, one GH, PRL secreting pituitary tumor post transphenoidal partial tumor removal, and no surgery in 3 patients. Finally, somatostatin receptor imaging may be useful as a tumor localizing technique in addition to conventional CT and MRI imaging and identify patients who might potentially benefit from octreotide treatment. In addition, the development of peptide analogs coupling to beta-emitting radiopharmaceutical may lead to a situation in which diagnosis peptide receptor scintigraphy can be followed by radionuclide therapy.

Acute pancreatitis following resection of juxtarenal abdominal aortic aneurysm.

A case of acute pancreatitis following resection of a juxtarenal abdominal aortic aneurysm is reported. The patient was a 73 year old man who underwent resection of a juxtarenal abdominal aortic aneurysm. The aneurysm was repaired with a 20 mm. gelatin coated Dacron graft. Proximal control of the aneurysm was performed with supraceliac aortic cross clamping. The clamping time was 50 minutes. Postoperatively, he developed progressive abdominal distension with deterioration of renal and pulmonary function necessitating relaparotomy on the 7th postoperative day. The second operation revealed evidence of saponification and fat necrosis in the omentum. The pancreas was edematous and swollen compatible with acute pancreatitis. The aortic graft and other intraabdominal organs appeared normal. Despite intensive supportive care, the patient died 2 weeks later from multiple system organ failure. The possible causes of acute pancreatitis following aortic surgery described in the literature are 1. systemic and regional hypoperfusion, 2. atheromatous emboli to arteries supplying the pancreas and 3. direct trauma to the pancreas during the operation from retractors or surgical dissection. All of which may be the etiology of acute pancreatitis in our patient. Avoidance of such factors during aortic surgery is recommended to prevent this potentially fatal complication.

Behavior in self-care of the foot and foot ulcers in Thai non-insulin dependent diabetes mellitus.

A cross sectional study was conducted to examine behavior in self-care of the foot and foot ulcers in Thai non-insulin dependent diabetic patients. Fifty-five patients with foot ulcers (ulcer group; 42 females and 13 males) and 110 patients without foot ulcers (control group; 83 females and 27 males) were evaluated for self foot-care behavior using a questionnaire consisting of questions about foot inspection, foot cleaning, nail-care, and the use of footwear which possessed a total score of 20. The results showed that a mean total self foot-care score of the ulcer group was significantly lower than that of the control group (14.50 +/- 3.35 vs 15.74 +/- 2.31; p < 0.01). The patients with foot ulcers had lower mean scores in all of the four self foot-care categories than did those without foot ulcers. However, only the difference in foot cleaning score was statistically significant (7.35 +/- 0.21 vs 7.88 +/- 0.11; p < 0.05). A univariate analysis has shown that the risk of developing foot ulcers was significantly associated with a total self foot-care score of less than 15 with an odd ratio of 2.6 and a 95 per cent confidence interval of 1.3-5.6. Regarding the behavior in self foot ulcer-care, 45.5 per cent of the diabetic patients with foot ulcers had neglected them and 54.5 per cent had inappropriately cared for their ulcers. In conclusion, Thai non-insulin dependent diabetic patients with foot ulcers understood less about self foot-care practice than did those without foot ulcers. Incorrect self foot-care behavior particularly foot cleaning is associated with an increased risk of foot ulceration. In addition, diabetic patients should be advised about the correct self-care of their feet and foot ulcers in order to prevent foot ulceration and its complications.

Angiotensin converting enzyme gene polymorphism in healthy Thais and patients with non-insulin dependent diabetes mellitus.

Insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE) gene has been shown to be associated with various cardiovascular disorders in diabetic and non-diabetic patients. Its association with the development of non-insulin dependent diabetes mellitus (NIDDM) has been raised. This study was aimed to examine I/D polymorphism of ACE gene in healthy Thai subjects and patients with NIDDM. The I/D ACE genotypes were determined by polymerase chain reaction technique. Healthy unrelated subjects were 151 males and 147 females, 17-70 year old (mean +/- SD = 37.5 +/- 10.4). The unrelated diabetic patients were 42 males and 66 females, 20-79 years of age (mean +/- SD = 54.7 +/- 12.0). In healthy subjects, the ACE genotypes were DD 10.1 per cent, ID 39.2 per cent and II 50.7 per cent. Diabetic patients had similar distribution of ACE genotypes. The frequency of I and D alleles in diabetic patients was 0.69 and 0.31, similar to 0.70 and 0.30, respectively, in healthy subjects (p = 0.69). The frequency of I and D alleles in healthy Thai subjects was similar to the Japanese (I = 0.66 & D = 0.34) but different from Caucasians (I = 0.44-0.46 & D = 0.54-0.56). We conclude that I/D ACE gene polymorphisms may possess a racial difference. The similar frequency of both alleles in diabetic patients and healthy subjects suggests that there is no association between I/D polymorphism of ACE gene and diabetes mellitus in Thai individuals.

The efficacy and safety of gliquidone in Thai diabetics.

This study was aimed to evaluate the efficacy and safety of gliquidone, the latest available sulphonylurea, as a monotherapy for patients with non-insulin dependent diabetes millitus (NIDDM). Ninety patients attending diabetic clinics of Siriraj, Rajavithi and Pramongkutklao Army Hospitals were recruited in study. They were 21 males and 69 females, 27-82 years old (mean +/- SD = 52.3 +/- 11.2 years). The diabetic duration varied from newly diagnosed to 18 years (mean +/- SD = 1.5 +/- 2.8 years). Four weeks washout period was applied to 40 patients who had been treated with oral hypoglycemic agents. Before initiation of therapy, fasting venous blood samples were obtained for determination of fasting plasma glucose (FPG), Hemoglobin A1 (HbA1), lipid profile, chemistry profile and complete blood count (CBC). The starting dose of gliquidone was 15-60 mg by mouth once or twice daily. The dosage was adjusted every 4 weeks. FPG, HbA1 and lipid profile were assessed every 4 weeks. Blood chemistry profile and CBC were monitored at 4 weeks after treatment and at the end. After 12 weeks of therapy, FPG and HbA1 significantly declined from 220.8 +/- 55.5 mg/dl and 11.3 +/- 2.6 per cent to 159.1 +/- 38.6 mg/dl and 9.2 +/- 1.4 per cent, respectively (p < 0.001). A small but statistically significant decrease in serum total cholesterol from 229.3 +/- 46.9 to 219.8 +/- 40.7 mg/dl (p < 0.01) as well as serum low density lipoprotein cholesterol from 150.2 +/- 43.7 to 142.2 +/- 42.1 mg/dl (p < 0.05) were observed. Serum triglyceride and high density lipoprotein cholesterol did not significantly alter. Clinical follow-up, blood chemistry profile and CBC did not indicate any adverse reactions from gliquidone therapy. We concluded that gliquidone is an effective oral hypoglycemic agent for treating patients with NIDDM. Adverse effects were not experienced by this group of patients.

Efficacy of using basal plasma adrenocorticotropic hormone-radioimmunoassay (ACTH-RIA) level in the identification of the cause of Cushing's syndrome.

Basal (8.00 a.m.) plasma ACTH-radioimmunoassay (ACTH-RIA) levels were studied in 32 cases of endogenous Cushing's syndrome (17 Cushing's disease, 13 adrenocortical tumors, and 2 ectopic ACTH syndrome) and 11 normal volunteers. There were overlaps in the ranges of plasma ACTH-RIA levels among patients with Cushing's disease, adrenocortical tumors, and normal volunteers but not ectopic ACTH syndrome. By using different plasma ACTH-RIA levels as cut-off points in differentiating ACTH-dependent from ACTH-independent Cushing's syndrome, the level of 30 pg/ml had the highest diagnostic efficacy with a 94.7 per cent sensitivity, a 84.6 per cent specificity and a 90.6 per cent diagnostic accuracy.

Vascular injuries of the upper arm.

Twenty eight patients who had subclavian, axillary, and brachial artery injuries were studied. Sixteen (57%) sustained blunt trauma and 12 (43%) sustained penetrating trauma. Motor cycle accidents were the most common cause of injuries (43%). Twenty patients (71.4%) were transferred from other hospitals. Nine patients (32%) were in shock on arrival. All patients had radial pulse abnormalities (3 decreased, 25 absent) of the affected limbs. Eighteen patients (64%) had associated injuries to other parts of the body. Eighteen patients (64%) also had associated nerve injuries, 7 of them had complete brachial plexus injuries from motor cycle accidents. Twelve patients (43%) had preoperative angiography. Twelve patients (43%) had brachial, 10 (35.7%) had axillary, 2 (7%) had axillary-subclavian, and 4 (14%) had subclavian artery injuries. Eight patients (28.6%) had concomitant venous injuries. Resection of the injured artery and reversed saphenous vein graft were performed in 23 patients (82%). The remaining had resection and end to end anastomosis in 3 patients (10.7%), lateral repair in 2 patients (7%), and ligation in 1 patient (3.6%). Concomitant venous repairs were performed in 5 patients. Fasciotomies were performed in 2 patients (7%). Excellent results of vascular repairs were obtained in all patients. Long-term disability occurred in patients who had associated nerve injuries. Avulsion injury of the brachial plexus usually resulted in severe impairment of limb function.

Arterial injuries of the lower extremity from blunt trauma.

Thirty patients with 33 arterial injuries from blunt trauma of the lower extremity at Chulalongkorn Hospital, Bangkok, Thailand from January 1989 to December 1995 were reviewed. Eight patients (26.6%) were in shock on arrival. Twenty four (80%) presented with signs of ischemia. Twenty six (86.7%) had associated fractures and/or dislocations, 14 of them were compound fractures. Nine (30%) had associated injuries at other parts of the body. Ten (33.3%) underwent preoperative angiography. The preoperative time ranged from 1 to 72 hours, median 4 hours. One patient who had intimal tear of the popliteal artery and was successfully treated conservatively. Popliteal artery was the most common injured artery; followed by common femoral, superficial femoral, and anterior tibial artery. Most arterial injuries were repaired by using reversed saphenous vein grafts. Associated venous injuries were repaired in 5 patients. Fracture fixation was performed in 18 patients; 8 of them were performed before arterial repair and 10 were performed after arterial repair. No intravascular shunt was inserted in this study. Fasciotomy was performed in 15 patients. Five patients had limb amputation (16.7%). Univariate analysis by Chi Square test revealed that associated venous injuries, severe soft tissue injuries, and fasciotomy were statistically significant factors associated with amputation. One patient who had external iliac artery injury died from severe head injury in spite of a successful arterial repair (mortality rate 3.3%).

Operative management of hepatic injuries.

Seventy-seven cases of hepatic trauma diagnosed during exploratory laparotomy were retrospectively studied. Blunt trauma comprised the majority of cases. Seventy-five per cent of cases had associated injuries and 58 per cent were in shock on arrival. The mortality rate was 19 per cent. Exsanguination and associated head injuries were the major causes of death. Aggressive resuscitation and immediate exploratory laparotomy are not overemphasized if survival is expected. During operation, suture ligature of the bleeding points or hepatorrhaphy stopped the bleeding in most circumstances. Hepatic artery ligation was seldom performed. Omental packing of the liver wounds was an effective procedure. Anatomical hepatic resections were performed with a relatively high mortality rate. Debridement of devitalized liver tissue should be done routinely to prevent postoperative infection. Perihepatic packing was a useful procedure when termination of the operation was considered necessary in order to prevent the development of hypothermia, acidosis and coagulopathy.

Post-traumatic empyema thoracis in blunt chest trauma.

Three out of 42 patients who had isolated blunt chest injury requiring closed tube thoracostomy developed post-traumatic empyema thoracis. All of them were treated by thoracotomy and evacuation of the infected fluid with multiple chest tube drainage. Cultures of the pleural fluid grew Staphylococcus aureus in these 3 patients. Univariate analysis was performed by using Fisher's exact test which revealed the significance of age in association with the development of empyema thoracis. Multivariate analysis was performed by using Logistic Regression. Although no statistical significance was observed, the analysis revealed that the risk of empyema thoracis increased in elderly patients and in patients who had prolonged placement of thoracostomy tube. Intensive pulmonary care in elderly patients who sustained chest injury and early removal of thoracostomy tube is recommended in order to prevent the development of empyema thoracis.

Management of pancreatic injuries.

Pancreatic injuries from penetrating trauma are usually diagnosed early owing to the obvious indications for early abdominal exploration. Isolated injuries to the pancreas from blunt abdominal trauma are frequently diagnosed late since a period of time is required for the development of clinical signs of peritonitis or pancreatitis. A significant elevation of serum amylase level was found in all cases of delayed operation in this study. Distal pancreatectomy concomitant with splenectomy was the most frequent operation performed for injuries to the body and tail of the pancreas. Splenic preserving distal pancreatectomy was also performed in 3 cases. Adequate external drainage was required in all forms of pancreatic injuries. Although, the morbidity rate was 41 per cent, almost all recovered after a period of conservative treatment. Two patients died from intraabdominal sepsis and multi-system organ failure. The mortality in pancreatic trauma was related to associated injuries rather than to pancreatic injury alone.

Can unnecessary operations for abdominal stab would be safely reduced? A review of 255 patients.

Records of 255 patients who underwent laparotomies for stab wounds to the abdomen and lower chest were reviewed. Criteria for laparotomy were clinical and followed the conventional lines. Seventy-six patients (30%) were classified as having had an unnecessary laparotomy. Univariate analysis with the Chi-square test revealed 8 variables which differed significantly between the necessary and unnecessary laparotomy groups. Further stepwise discriminant analysis demonstrated 4 variables which had independent significance; they are the type of injury, generalized abdominal tenderness, haemoperitoneum and active intraabdominal bleeding. A mathematical model utilizing these 4 variables may be able to predict the need for laparotomy more accurately than utilizing any single variable. A prospective study is needed to test this hypothesis.

Sertoli-cell-only syndrome: a case report.

A 20-year-old male presented with a small hydrocoele in the left scrotal sac, bilateral small testes, and azoospermia with normal secondary sexual characteristics. Chromosome study revealed 46,XY. The results of hormonal and histopathological studies were consistent with Sertoli-cell-only syndrome.

Complete heart block complicating hyperthyroidism: a case report.

Complete heart block developed in a 29-year-old man with hyperthyroidism and acute febrile illness. The definite cause of acute febrile illness was unknown. The results of bacteriological and viral studies were negative. Endomyocardial biopsy revealed no evidence of carditis which is the common cause of heart block. All the abnormalities resolved completely after the fever subsided and the patient was treated with an antithyroid drug. Available information indicates that a high degree of heart block can sometimes occur in hyperthyroidism in either the presence or absence of additional factors which can independently impair atrioventricular conduction. This course of events which occurred in this patient suggest that complete heartblock may have been the direct manifestation of the hyperthyroid state, however, the acute febrile illness may have been an aggravating factor in the development of abnormal atrioventricular conduction.