Risk factors for dementia and impaired cognitive status in Thai elderly.

OBJECTIVE: To examine the association of physical and biochemical risk factors for dementia and cognitive status in an urban population based Thai elderly. MATERIAL AND METHOD: This study was part of an integrated health research project from 1997 to 1999. Subjects were 550 elders who lived in a community within 10 km from Siriraj Hospital, Bangkok, Thailand. They were 55 years and older. Thai mental state examination (TMSE) was applied to all subjects as the screening test for dementia. Those who scored less than or equal to 24 out of 30 were categorised as having cognitive impairment or suspected of having dementia, and they were then examined in detail for the diagnosis of dementia using the DSM IV criteria. Blood pressure and body weight were recorded. Blood was drawn for biochemical and haematological analysis including the serology for syphilis and thyroid function test as the basic screening investigation for dementia. Descriptive data, expressed as the mean, standard deviation, Pearson Chi square and ANOVA tests were analysed with SPSS 9.0 in the study. RESULTS: Of 550 subjects, 261 (47.45%) were classified as the normal subjects group, 49 (8.91%) as the cognitively impaired group, and 240 (43.82%) as the dementia group. 377 subjects (68.55%) were female and the distribution of females in each subgroup ranged from 63.3-75.5 per cent. The mean age in the normal group was 67.47 +/- 6.05 years, the cognitively impaired group was 70.14 years and the dementia group was 69.63 +/- 9.21 years. Systolic blood pressure (BP), diastolic BP, serum cholesterol, SGOT, GGT, serum albumin, haemoglobin, MCHC, neutrophil counts and weight were statistically significant factors that were associated with cognitive status. Both systolic and diastolic BP were high in the higher cognitive status group. Serum albumin, serum cholesterol levels and body weight were also higher in the high cognitive status group. CONCLUSION: This study demonstrated an association between nutritional status and cognitive status in Thai elderly. Poorer nutritional factor in lower cognitive function individuals might explain a lower of both systolic and diastolic BP in the dementia subjects compared to the healthy subjects.

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.

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.

Antitriiodothyronine antibody in patient with Hashimoto's thyroiditis.

We described a 44-year-old female patient with a history of goiter for 2 months. Physical examination revealed a diffusely enlarged thyroid gland weighing 40 g firm to hard in consistency. She was clinically euthyroid and had neither ophthalmopathy nor dermopathy. Serum thyroid hormone levels revealed total T4 (RIA) of 4.8 micrograms/dL (normal, 4-11 micrograms/dL), total T3 (RIA) of above 600 ng/dL (70-175 ng/dL), and TSH (IRMA) of 54 mU/L (0.3-6 mU/L). Antithyroglobulin and antiperoxidase antibody titers were 1:5,120 and 1:409,260, respectively. Because of the discrepancy between the patient's clinical status and laboratory values, assay for thyroid hormone autoantibodies (THAA) was done and subsequently demonstrated antitriiodothyronine antibody with percentage of precipitation by polyethylene of 98.4 per cent (normal range, 3.06 +/- 8.58%). In conclusion, THAA should be suspected in patients whose clinical status is incoherent with the thyroid function test.

A study of cell-mediated immune response to pancreatic antigens in patients with fibrocalculous pancreatic diabetes.

In order to investigate whether there was any association between autoimmunity to pancreatic antigens with FCPD as well as IDDM, cell-mediated immune response to pancreatic antigens was studied by lymphoproliferation assay in 7 FCPD, 17 IDDM, 33 NIDDM patients and 102 normal controls. Optimal pancreatic antigen concentrations used were 100, 150 and 200 micrograms/ml. Positive results were considered for each concentration of antigens tested, at stimulation index (SI) > (mean +/- 2 SD) SI obtained from normal age-matched controls with the use of the corresponding concentration of antigen. The one who gave positive result with any of these optimal antigen concentrations was considered to be the responder to pancreatic antigens. With this criterion, the responders were found to be 3/7 (42.9%) FCPD, 6/17 (35.3%) IDDM and 6/33 (18.2%) NIDDM patients; while there were 11 of all 102 (10.8%) normal controls.

Effects of alpha-glucosidase inhibitor (acarbose) combined with sulfonylurea or sulfonylurea and metformin in treatment of non-insulin-dependent diabetes mellitus.

The effects of alpha-glucosidase inhibitor (acarbose) were studied in 36 patients with non-insulin-dependent diabetes mellitus (NIDDM), aged 34-67 years with a mean duration of diabetes of 8.8 +/- 0.9 years. They were poorly controlled with diet plus sulfonylurea alone or plus sulfonylurea combined with metformin drugs. Acarbose, 100 mg three times daily, was additionally given to these patients for six months. Results showed small but significant decreases (P < 0.001) in postprandial blood glucose level. Glycosylated hemoglobin level was lowered significantly (P < 0.001) and was normalised (level of < 8%) in 17 per cent of the patients. Fasting serum triglycerides level decreased significantly (P < 0.01), whereas, no significant changes in serum total cholesterol and HDL cholesterol levels were seen. Body weight also decreased significantly (P < 0.001) at the end of acarbose trial. Flatulence was the major side effect of acarbose found in 42 per cent of the patients but it was well-tolerated and may be transient and self-limited. We concluded that the addition of acarbose to the therapeutic regimens of diet therapy plus sulfonylurea or plus sulfonylurea combined with metformin drugs led to significant improvement of glycemic control. Acarbose may be a safe and valuable adjunct to diet and sulfonylurea and metformin treatments in obese, poorly-controlled patients with NIDDM.

Sulfonylurea-induch hypoglycemia in 33 diabetics.

We analyzed 33 diabetic patients (12 males and 21 females) receiving sulfonylurea drug who were hospitalized for severe hypoglycemia during the period 1980-1991. Most patients (46%) had diabetes for 1-5 years and were aged between 50 and 59 years. There were associated hypertension (65%), cataract (55%), retinopathy (50%) and renal failure (45%). Sixty-one percent of them had received glibenclamide, 36 percent were on chlorpropamide and 3 percent on glipizide. Seven of them (21%) died. Among those survived, there were neither sequelae nor disability. Patients who were comatose on admission were likely to die. We suggest that sulfonylurea should be avoided or used carefully in elderly diabetic patients having renal impairment because of the potential risk of hypoglycemia which might be fatal.

The epidemiology of insulin-dependent diabetes mellitus (IDDM): report from Thailand.

The epidemiology of diabetes mellitus in Thai children aged 0-15 years was studied in 1985 and compared with a previous study done in 1984. Four hundred and seventy-six questionnaires were sent each year to hospitals in Thailand. In 1984, thirty-six cases of newly diagnosed diabetes mellitus were found of which 35 were IDDM and one was NIDDM. In 1985, twenty-seven cases of new IDDM were found, no case of NIDDM was reported. Two cases of MRD were reported from the Northeastern and Southern part of Thailand. The incidence of IDDM in the whole kingdom of Thailand was 0.19/100,000/year in 1984 and 0.14/100,000/year in 1985. The male to female ratio was 1:1.5 in 1984 and 1:2 in 1985. The peak age at diagnosis showed the main peak at 14 years old in boys. The peak age of girls preceded boys by 1-2 years in 1984 and 1985. Similar findings in 1984 and 1985 were the onset of symptoms showing a seasonal variation with highest frequency in winter with a slight change of increased incidence in the rainy season of 1985. There was an increased incidence of IDDM in families with lower educational and socioeconomic levels. The newly diagnosed IDDM with DKA was 16.2, and 19.5 per cent in 1984 and 1985. The incidence of IDDM in Thai children, aged 0-15 years seems to be the lowest compared to other countries previously described which might be due to some genetic and environmental including diet, micronutrient, eating habits and life-style which might play a role in the difference.

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.

Diabetic education, special consideration of Oriental patients.

The important of patient education program in the management of diabetes has been widely recognized. We studied to find out in general what the patients and their parents know about diabetes and their self-care by using a questionnaire. Then, the diabetic education was given by one-to-one basis to every patient. Thirty four insulin-dependent diabetes mellitus attended the diabetic the clinic at Siriraj Hospital, Bangkok age ranged from 4 to 22 years with peak age at 11 to 15 years. Male to female ratio was l:i. Majority came from low socioeconomic families. 23.5 percent were from separated families, one patient lived with neither her mother nor father. Only one patient had home glucose monitoring. Fourteen cases (41.2%) had been hospitalized with diabetic ketoacidosis (DKA) over the past year, however, there was no statistically significant difference between admission with DKA and low socioeconomic status. In addition to insulin, there were 8 patients taking herbs to cure diabetes. Only 6 patients were able to follow their meal plan and only one case ever used the food exchange list. Most patients accepted being diabetic and attended the clinic regularly mainly to get financial supports. The situation in our country is different from that in the western countries as the patients are low in literacy and socioeconomic status. A well-planned educational programme is essential to cater to the need to the oriental patients.

Insulin Dependent Diabetes Mellitus (IDDM): Clinical data and HLA antigen.

We studied 34 cases of IDDM attending diabetic clinic at Siriraj Hospital from May to November 1988. The study covered background personal, clinical history, diabetic control, diabetic knowledge, socioeconomic status, frequency and cause of admission. HAL antigen was performed in 20 cases. The age of IDDM ranged from 4 to 22 years with peak age at 11 to 15 years. Male to female ratio was 1:1 Majority had low socioeconomic status. Total admission of 26 IDDM were 57 occasions in the part 10 years, consisted of diabetic ketoacidosis (DKA), poor control and infections, malnutrition and hypoglycemia in 29, 20, 4 and 4 episodes respectively. However there was no statistically significant between socioecomic status and frequency of DKA. HLA DR3 is the most important genetic marker in IDDM. HLA DR4 alone was not significantly increased in IDDm, but is combination with DR3 and DR4 was important genetic marker in Thai IDDM. However there was no relationship between HLA DR3 and/or HLA DR4 and DKA. However further investigation should be done to clarify the etiologic factor of Thai IDDM.

Cross-sectional study of prevalence and risk factors of hypertension in Thai diabetic population.

Hypertension and diabetes mellitus are risk factors of cardiovascular and cerebrovascular diseases. Greater morbidity and mortality from cardiovascular and cerebrovascular diseases was found in hypertensive patient with diabetes mellitus than without diabetes mellitus. The prevalence of hypertension in diabetes mellitus patients was about 10-68% in general. To know the prevalence of hypertension in Thai diabetic patients and risk factors related, a cross-sectional study was done in 408 diabetic patients at the Diabetic Clinic, Siriraj Hospital, between June to September 1986.The prevalence was 29.4% and the risk factors which related significantly, especially in female subjects, were ogre and duration of diabetes. Body mass index, sex and proteinuria were not related to hypertension in diabetes mellitus significantly in this study.