Is blood pressure adequately controlled in general medicine clinics?

To determine how well elderly-essential-hypertensives (EHT) were managed at the general medicine (GM) clinics at Siriraj Hospital when compared to those at the hypertension (HT) clinic. Adequacy of BP management (ADBP) was considered when DBP < 85 mmHg in diabetic patients with HT or < 90 mmHg in non-diabetic EHT. Sixty-seven and 63 cases were enrolled from the GM and HT clinics respectively from mid June to mid July 1999. Percentage of ADBP cases (69.8 vs 49.3%, p = 0.02, OR = 2.4, 95%CI = 1.2-4.9) were significantly higher in patients at the HT-clinic compared to that of the GM-clinic. Physicians' unwillingness to change the number or dosage of drugs when target BP was not achieved was found to be an independent risk factor that contributed to poor BP control of patients from both clinics (p = 0.003, OR = 9.7, 95%CI = 2.2-44.4). In conclusion, the BP of those EHT at GM-clinics was not adequately controlled compared to that of the HT-clinic. Methods to improve normalization of BP were proposed.

Diagnosis of intestinal amebiasis using salivary IgA antibody detection.

Attempts were made to use soluble antigen extract of strain HK-9 of Entamoeba histolytica to detect salivary IgA antibodies in intestinal amebiasis patients by using ELISA. Total salivary samples of 109 individuals were divided into four groups. Group I comprised 32 patients whose stools were positive only for E. histolytica cysts and/or trophozoites. Group II comprised 12 individuals whose stools were positive for E. histolytica and other intestinal parasites. Group III comprised 36 individuals whose stools were negative for E. histolytica but contained other intestinal parasites such as E. coli, E. nana, Blastocystis hominis, Trichomonas hominis, Giardia lamblia, Opisthorchis viverrini, and hookworm. Group IV comprised 29 healthy individuals whose stools were free from any intestinal parasitic infections. Based on the mean optical density, OD + 2SD of the results from 29 parasitologically negative healthy individuals, the cut-off OD value for salivary IgA antibodies was 1.265. Therefore, the assays were positive in 14 out of 32 (43.75%) of group I and 2 out of 12 (16.6%) of group II. The assays were positive in 16 out of 36 (44.44%) for group III whereas 2 out of 29 (6.90%) for group IV were positive. The overall sensitivity and specificity of the assays were 36% and 72%, respectively. The false positive rate was 28% and the false negative rate was 64%. The predictive values of positive and negative results were 47% and 63%, respectively. The diagnostic accuracy of ELISA for the presence of salivary IgA antibodies was 58%.

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.

Primary aldosteronism.

We studied retrospectively 25 cases of primary aldosteronism which had presented at Siriraj Hospital between 1980 and 1993. There were 10 males and 15 females (M:F = 1:1.5), aged from 26-64 years old (average 43 years). The duration of the illness varied from 1 to 20 years (5.64 + 4.48 years). The presenting symptoms were proximal muscle weakness of extremities, 16 cases (64%) ; headache, 9 cases (36%) ; unable to stand up after sitting, 6 cases (24%) ; exertional dyspnea, 5 cases (20%) ; nocturia, 3 cases (12%) ; orthopnea, 1 case (4%) and arrhythmia with fainting, 1 case (4%). The patients with cardiac arrhythmia had a very low level of serum potassium (1.8 mEq/L). Physical examination revealed left ventricular hypertrophy in only 5 cases (20%). There was very little change in the ocular fundi but every case had high blood pressure ranging from 150-240/100-150 mm.Hg. (average 176.67 + 24.50/114.26 + 12.46 mm.Hg). Serum sodium varied from 134-152 mEq/L (average 145.58 + 4.42 mEq/L). Serum potassium was 1.3-3.3 mEq/L (average 2.11 + 0.48 mEq/L). Serum bicarbonate was high, 25-50 mEq/L (average 31.84 + 5.81 mEq/L). No significant change in BUN and creatinine was observed. Potassium in a twenty four hours urine specimen was 11.04-78 mEq/day (average 40.84 + 5.81 mEq/day). To confirm the diagnosis and localize and lesion a CT scan of the adrenal gland was performed and tumor masses were found on the right, 9 cases (36%) and on the left, 16 cases (64%). Surgical removal was carried out in only 20 cases. Golden yellowish tumours were excised varying in size from 1*0.3 – 3.5*2 cms. Pathological studies revealed 18 cases (90%) of adenoma and 2 cases (10%) of hyperplasia. Of those with adenoma, blood pressure in 13 cases (72.22%) returned to normal after surgery but the other 5 cases (27.78%) still had high blood pressures still needed antihypertensive treatment. Serum potassium returned to normal in both groups of patients, adenoma and hyperplasia.

Diencephalic epilepsy resembling pheochromocytoma: a first reported case in Thailand.

A 31 year old hypertensive patient suffered from a fluctuation of blood pressure. Pheochromocytoma was suspected because of the clinical history, and extremely labile blood pressure but did not respond to therapy with alpha adrenergic blocking agent and normal excretion rates of catecholamine and vanilly mandelic acid (VMA). An enlarged left adrenal gland from computerized tomographic scan was found. So left adrenalectomy was performed and the result was consistent with cortical adrenal hyperplasia. Fluctuation of blood pressure still occurred after surgery with the symptoms of epigastric oppression and focal epileptic attack of the left arm. Epileptic potential waves were seen during hyperventilation from electroencephalogram but showed normal magnetic resonance imaging computerized tomographic scan of the brain. Diencephalic epilepsy was diagnosed and treated with anticonvulsant (carbamazepine) and eventually all of the symptoms including labile blood pressure subsided.

Liver abscess in polycystic liver disease.

A case of an elderly female whose clinical manifestations were atypical in view of physiologic aging changes and multiple pathology commonly found in the geriatric group. The liver abscess had presented clinically and radiologically like a hepatic malignancy and pus was obtained during the process of liver biopsy. Even though anchovy-like pus suggested amebic in origin, the microscopic exam showed numerous polymorphonuclear leucocyte and the culture both from the blood and pus grew Klebsiella spp. as well as the study for E. histolytica antibody was also negative. Pyogenic liver abscess was the working diagnosis and indicated for surgical drainage. Adult polycystic liver disease was found intraoperatively and the liver pathology did reveal the presence of many amebae in the cavity of the right lobe of the liver. After the administration of ceftriaxone and metronidazole as well as the surgical drainage, the patient recovered uneventfully within sixteen days of admission.

Intestinal absorption studies in Fasciolopsis buski infection.

The intestinal absorption of carbohydrate, fat, protein and vitamin B12, serum vitamin B12, serum and red cell folate levels were performed in 10 patients harbouring F. buski. No disturbance of carbohydrate, fat and protein absorption was observed but vitamin B12 absorption was found to be slightly lower than normal in 8 out of 10 patients, and serum vitamin B12 was also lower than normal in 4 out of 9 patients. Red cell and serum flolate levels were within the normal limits. Histological study of jejunal biopsy was normal in 7 out of 8 patients.

ELISA testing in cases of clinical angiostrongyliasis in Thailand.

The sera from 116 Thais admitted to Nakhon Ratchasima hospital in northeastern Thailand with eosinophilic meningitis were tested for antibodies to Angiostrongylus cantonensis by ELISA. Ninety-six percent of the sera were considered positive with ELISA values exceptionally high for most patients. The clinical aspects of the disease are also presented. The ELISA test is considered to be of value in the diagnosis of the disease but tests for the antigen would provide a more definitive diagnosis.

Treatment of Opisthorchis viverrini with mebendazole.

Thirty-six hospitalized Thais (21 males, 15 females, 9 to 63 years of age) with Opisthorchis viverrini infection were treated with mebendazole in dosages of 20 mg/kg body weight for 4 weeks and 30 mg/kg body weight for 3 or 4 weeks. The drug was found to be effective when given in dosages of 30 mg/kg body weight for 3 to 4 weeks only a few eggs being found in the stool of one of 27 persons at 3 or 4 weeks post-treatment. In follow-up examination at 6 months, only two of 15 persons available were positive. These could have been reinfection, however. Side effects were essentially absent, except one person who vomited on the first day of treatment. The drug could be used in a mass treatment campaign because of effectiveness, low toxicity, and action against other helminthic infections.

Serum vitamin B 12 and folic acid levels in patients with fasciolopsiasis.

Serum vitamin B12, serum and red cell folate concentrations and vitamin B12 absorption were studied in 100 patients with fasciolopsiasis. A mean value of serum vitamin B12 level in the patient group was found to be significantly lower than that of normal subjects and 14% of these patients had serum vitamin B12 level less than 100 pg/ml. Serum UBBC and TBBC levels in the patients were significantly higher than those of the normal subjects. Serum TCI and TCIII increased significantly while TCII decreased. Vitamin B12 absorption was found to be impaired in 3 of 9 patients studied. There was no relationship seen between serum vitamin B12 level and vitamin B12 absorption. The mean values of serum folate and red cell folate levels in the patient group were significantly lower than those of normal subjects. Fifteen of 100 patients (15%) had serum folate level less than 3 ng/ml, while all of them had red cell folate higher than 100 ng/ml. Serum folic acid binding protein levels (FABP) in these patients, were not significantly different from those of normal subjects.

Coagulation studies in leptospirosis.

Coagulation and serum F.D.P. studies in 10 leptospirosis patients (5, L. bataviae, 2, L. autumnalis, 2, L. australis, and 1, L. akiyami A.)showed prolongation of prothrombin time, partial thromboplastin time and thrombin clotting time, slight low platelet count, depletion of factor V and slightly high serum F.D.P. in only four cases. Four cases had bleeding and one case died because of severe haemorrhage but with only slight changes in coagulation factors and slightly high serum F.D.P. These findings suggested that the damage of capillary endothelium was more pronounced than the coagulopathy which may be due to liver cell damage.