Clinical study of non-gonococcal bacterial septic arthritis in Siriraj Hospital, Thailand.

Sixty-eight cases of non-gonococcal bacterial septic arthritis (SA) who admitted to Siriraj Hospital in 2003-2004 were retrospectively reviewed. Acute monoarthritis, oligoarthritis and polyarthritis were presented in 60.3%, 35.3% and 4.4% of the cases, respectively. Fever was presented in 51.5% of cases. The knee was the most commonly affected joint (40.2%). The organisms were identified from synovial fluid either by gram stained smears or cultures in 85.9% of cases. The microorganisms isolated were gram-positive cocci in 72.7%, gram-negative bacilli in 25.0% and mixed-organisms in 2.3%. The three most common causative organisms were Streptococcus spp. (40.1%), Staphylococcus aureus (33.4%) and Salmonella spp. (8.9%). Complications occurred in 39.7% of cases and the mortality rate was 11.8%. In conclusion, during the past two years, gram-positive cocci were the major isolated pathogen responsible for non-gonococcal bacterial SA in adult Thai-patients from Siriraj Hospital. Despite adequate treatment, bacterial SA continues to be associated with a considerable degree of morbidity and mortality.

A grandma with two years of fever and agony.

A 72 year old woman living in Namuen District, Nan Province, was referred from a local hospital for having two years of fever and back pain. Her symptoms started with feeling malaise, intermittent fever with chills and body ache. All the symptoms got worse at night making her unable to sleep. She also experienced back pain all day night in additon to anorexia. She had no cough, petechia or abnormal bleeding. After having had medical consultations at a local hospital, no definite cause of her suffering was found. She then underwent various further investigations including a bone marrow examination at a local university hospital which did not reveal any malignant conditions. She was referred back to her home town hospital. However, she still suffered from recurrent high pyrexia, anorexia, progessive weight loss, etc. leading to many more hospital admissions. One year later, her symptoms, including fever and back pain, seemed to get worse and she was once again admitted to the hospital. The laboratory tests at that time revealed hematocrit 27%, white blood cell count 21,600 / mL, neutrophil 95%, lymphocyte 5%, platelet 563,000 /mL, ESR 120 mm/hr., Ca 7.6 mg/dl, phosphorus 4.5 mg/dl, BUN 14 mg/dl, Cr 0.9 mg/dl, Coomb\'s test megative. T3 179 ng/dl, TSH 1.27 mU/ml. Echocardiography showed LVEF 66% without evidence of infective endocarditis. An abdominal ultrasound revealed a mild degree of renal parenchymal disease, normal size liver with homogeneous parenchymal disease and a normal-appearing spleen. Gastroscopy was also performed without any significant finding. Because the clinical scenario was so obscure, she was referred to Siriraj Hospital Medical School for further management on May 6, 2003. There was no significant chronic medical condition prior to this agonic episode. She neither smoked nor drank alcohol. Her adult children ran a family business within her home so she was closely looked after by her daughter and did not have any financial difficulties.

The epidemiology of osteoarthritis of the knee in elderly patients living an urban area of Bangkok.

An epidemiological study of 392 elderly Thai patients with osteoarthritis (OA) of the knee, 86 males and 306 females, with a mean age of 67.8 years, was performed. The prevalence of knee OA was 34.5-45.6 per cent. Most of the patients had completed primary education and had sufficient income. More than half of the patients had pain in both knees, but many of the elderly people used neither knee supports nor walking aids (82.7 and 90.6%). Sixty-four per cent had no previous knowledge concerning the value of exercise. Sixty-five per cent of the patients had never used any pain medication. Three-fourths of the subjects evaluated themselves to have fair to good health. Sixty per cent presented with knee pain when climbing the stairs, and 64.8 per cent had a fair quality of life. Almost all the subjects had mild to moderately severe grade of OA and their X-ray findings were level II-III. The average quadriceps strength and six-minute walking distance were 12.95 +/- 5.51 kilograms and 363.69 +/- 99.34 meters respectively. The five factors that significantly correlated with walking ability were age, sex, the functional incapacity score, using walking aids and level of severity found on X-ray. Previous knowledge about knee exercise did not affect walking ability, but may have been due to the irregularity of the exercise schedule they performed. The elderly should be encouraged to exercise regularly in addition to receive knowledge about proper exercise.

The efficacy of a muscle exercise program to improve functional performance of the knee in patients with osteoarthritis.

Osteoarthritis (OA) is a common chronic and progressive degenerative joint condition. A major consequence of knee OA is physical disability; especially difficulty with activities requiring ambulation and transfer, which are necessary to maintain independence and a good quality of life. The purposes of this study were to determine the efficacy of a muscle exercise program along with education about knee care, and investigate the clinical factors which influence its therapeutic efficacy. A prospective study was carried out among elderly Thai people aged 60 years and over, living in an urban community of the Bangkok metropolitan area around Siriraj Hospital, between October 1997 and September 1999. The number of elderly people with osteoarthritis of the knee was 392 (male:female=86:306) with a mean age of 67.7+/-6 years. They were interviewed for demographic data and information about their symptoms. The range of the knee movement, quadriceps strength and the six-minute walking distance and a knee X-ray were evaluated. Group exercise was arranged twice a week for 8 weeks for the intervention group only. The results of the study revealed that the quadriceps strength in the intervention group had a tendency to increase and the walking distance was significantly improved especially in the first two months but there was a tendency to decline by the sixth and twelfth month after enrollment. On the other hand, there was no statistically significant difference of both important outcomes for the control group when assessed in the second month. The findings at the sixth and twelfth month after enrollment were that the quadriceps strength was slightly increased but the walking distance was decreased when compared with the initial assessment. An exercise frequency of 12 sessions in two months was sufficient to improve muscle strength and walking distance. Group exercise produces a significant improvement in strength and walking ability, especially in the first two months. Deterioration over time could be due to multiple factors, such as lack of regular exercise, lack of motivation, lack of family support or poor economic status, so we should encourage the elderly to exercise regularly.

Comparison of rheumatoid factor testing methods: Nephelometric assay versus latex agglutination assay.

Rheumatoid factor (RF) is one of the criteria used for diagnosis of rheumatoid arthritis (RA). The method that has been used in our laboratory service for many years is latex agglutination assay that gives semi-quantitative results. We are going to change from this method to nephelometry that gives continuous results. The cut-off point of RF by nephelometry, comparison of these 2 methods and the 4 supplying companies were determined. Serum samples were collected from 70 patients with RA, 22 patients with various collagen diseases and 150 blood donors or normal old people. RF values by nephelometry and 4 commercial latex agglutination assays, that were latex Alexon, Shield diagnostics, Biosyste, and Behring diagnostics, were determned and compared. The results showed that the cut-off point of RF by nephelometry was 14 IU/ml and the sensitivity and the specificity was 81% and 95% respectively. The sensitivity and the specificty of latex agglutination assays by 4 companies were 76% and 94%, 68% and 97%, 62% and 98% and 64% and 98% respectively. We concluded that nephelometry gave higher sensitivity than latex agglutination asssay and Latex Alexon had the highest sensitivity when comparing among the 4 companies.