The Changes in Mean Platelet Volume after Using of Antiplatelet Drugs in Acute Ischemic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To measure the changes of mean platelet volume (MPV) after using four antiplatelet drugs in acute non-cardioembolic ischemic stroke patients and assess the association of antiplatelets and MPV and stroke outcome. MATERIAL AND METHOD: Ischemic stroke survivors with National Institute of Health Stroke Scale (NIHSS) 8 were randomly allocated intofour groups, receiving aspirin, clopidogrel, combined aspirin and dipyridamole, and cilostazol. The change of MPV NIHSS, and modified Rankin Scale (mRS) were recorded at baseline and week 4 in all studied groups. MPV was measured using the standard automated blood test for complete blood count. RESULTS: Twenty-one subjects were included in this study. They comprised of five cases in each antiplatelet group, except for aspirin, which had six subjects. Male was 57%, and hypertension was the most common risk factor (61.9%). Most of participants (76%) had small vessel disease. At 4-week, MPVwas reduced and NIHSS, mRS were improved in every studied group. Clopidogrel sign ficantly reduced NIHSS score (p = 0.003), and it produced the greatest reduction in MPV compared to others. CONCLUSION: Every type of antiplatelets included in this study reduced MPV NIHSS, and mRS in acute non-cardioembolic stroke patients. Clopidogrel improved NIHSS the most.

Non-motor symptoms in Thai patients with Parkinson's disease studied at Phramongkutklao Hospital.

BACKGROUND: Non-motor symptoms (NMS) ofParkinson's disease (PD) have been recently recognized to be as disabling as motor symptoms in PD. However these symptoms are still under recognized causing delay in treatment and inadequate management. This study aimed to identify NMS in Thai PD patients using the NMS screening questionnaire (NMSQuest). MATERIAL AND METHOD: Patients with idiopathic Parkinson's disease visiting the neurology clinic in 2008 were enrolled. NMSQuest-Thai version (NMSQ-T) was applied to patients to identify NMS. RESULTS: Collected data from questionnaires completed by 165 probable idiopathic PD was analyzed. The demographic profiles showed mean age of 68.6 years with mean disease duration 5.4 years, and male 56.4%. Patients had Hoehn & Yahrstaging, stage-2: 43%, stage-3: 24.8%, stage-I: 24.2% and stage-4: 7.9%. The average dosage oflevodopa was 456.4 mg/d. Mean total NMSQ-T score was 9.5. Most prevalent of non-motor symptom was nocturia (64.2%). The domains which gained most positive answers were urinary domain (54.55%). Inter-domain correlations were significantly found in all, except the sexual domain. Multivariate analysis revealed the duration ofPD and stages were significantly correlated with the total score ofNMS. Only three percent denied having any non-motor symptoms. CONCLUSION: Almost all Thai PD had NMS. Urinary domain is the most prevalent in our series. Screening using NMSQ-Tto recognize NMS would be a helpful tool to improve the quality of life in Thai Parkinson 's disease.

Excessive daytime sleepiness and obstructive sleep apnea in Thai epileptic patients.

BACKGROUND: Sleepiness is a common complaint in epilepsy. Also obstructive sleep apnea (OSA) is increasingly detected and would affect the epilepsy prognosis. We aimed to determine the frequency and predictors of sleepiness and OSA in epileptic patients. MATERIAL AND METHOD: This was a cross-sectional descriptive study using Epworth Sleepiness Scale questionnaire (ESS) and Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ) to identify excessive daytime sleepiness and OSA in our consecutive epileptic patients in Neurology out-patient clinic. RESULTS: Overall 113 patients (male 55%) answered a personal survey and completed ESS and SA-SDQ. Mean age was 47 years (range 15-93). Average body mass index (BMI) was 24. Excessive daytime sleepiness (ESS 10) was demonstrated in 37%, and the prevalence of OSA diagnosed by using SA-SDQ was 20% (male 18%, female 22%). OSA were identified 68% among individuals whose BMI of more than 25, which was significant higherfi-equency than in the nomnnal BMI group (32%). The predictors of having OSA were older age and higher BMI. Epworth Sleepiness Scale score was also higher in the OSA group than in non-OSA group. CONCLUSION: Excessive daytime sleepiness was identified around one third ofour epileptic individutals. Twenty percent had met the questionnaire criteria of having OSA. Overweight was the most important and modifiable risk factor ofOSA.

Risk of metabolic syndrome for stroke is not greater than the sum of its components: Thai Epidemiologic Stroke (TES) study.

Limited information is available on the association between the metabolic syndrome (MetS) and stroke. Whether or not MetS confers a risk greater than the sum of its components is controversial. This study aimed to assess the association of MetS with stroke, and to evaluate whether the risk of MetS is greater than the sum of its components. The Thai Epidemiologic Stroke (TES) study is a community-based cohort study with 19,997 participants, aged 45-80 years, recruited from the general population from 5 regions of Thailand. Baseline survey data were analyzed in cross-sectional analyses. MetS was defined according to criteria from the National Cholesterol Education Program (NCEP) Adult Treatment Panel III, the American Heart Association/National Heart, Lung, and Blood Institute (revised NCEP), and International Diabetes Federation (IDF). Logistic regression analysis was used to estimate association of MetS and its components with stroke. Using c statistics and the likelihood ratio test we compared the capability of discriminating participants with and without stroke of a logistic model containing all components of MetS and potential confounders and a model also including the MetS variable. We found that among the MetS components, high blood pressure and hypertriglyceridemia were independently and significantly related to stroke. MetS defined by the NCEP (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.32-2.04), revised NCEP (OR, 2.27; 95% CI, 1.80-2.87), and IDF definitions (OR, 1.70; 95% CI, 1.37-2.13) was significantly associated with stroke after adjustment for age, sex, geographical area, education level, occupation, smoking status, alcohol consumption, and low-density lipoprotein cholesterol. After additional adjustment for all MetS components, these associations were not significant. There were no statistically significant difference (P=.723-.901) in c statistics between the model containing all MetS components and potential confounders and the model also including the MetS variable. The likelihood ratio test also showed no statistically significant (P=.166-.718) difference between these 2 models. Our findings suggest that MetS is associated with stroke, but not to a greater degree than the sum of its components. Thus, the focus should be on identification and appropriate control of its individual components, particularly high blood pressure and hypertriglyceridemia, rather than of MetS itself.

Prevalence of stroke and stroke risk factors in Thailand: Thai Epidemiologic Stroke (TES) Study.

OBJECTIVE: To assess stroke prevalence and stroke risk factors in Thailand. MATERIAL AND METHOD: Thai Epidemiologic Stroke (TES) Study is an ongoing, community based cohort study that has been conducted in five geographic regions of Thailand. Baseline health status survey was started in 2004 and enrollment continued until the end of 2006. All participants who were suspicious of being stroke victims were verified. In this analysis, baseline data of 19,997 participants aged 45 to 80 years were identified and analyzed as a cross-sectional analysis. RESULTS: Three hundred and seventy six subjects were proved to have a stroke thus resulting the crude prevalence of stroke to be 1.88% (95% CI, 1.69 to 2.07). Age standardization to Segi world standard population was 1.81% (95% CI, 1.62 to 1.99). Crude prevalence among adults aged > or = 65 years was 2.70% (95% CI, 2.28 to 3.11). Stroke prevalence differed among five geographic regions of the country (Bangkok 3.34%, Central region 2.41%, Southern 2.29%, Northern 1.46% and Northeastern 1.09%). Using multiple logistic regression analysis, factors associated with higher stroke prevalence were male gender (p < 0.001), occupational class (p < 0.001), geographic region (p < 0.001), hypertension (p < 0.001), diabetes mellitus (p = 0.002) and hypercholesterolemia (p = 0.026). CONCLUSION: Stroke prevalence in Thailand from TES study is higher than previous studies, but it is lower than developed countries, probably due to high case fatality rate in Thai population. Geographic variation in stroke prevalence is found more in Bangkok, Central and Southern regions. Longitudinal follow-up of TES cohort study will provide further information on risk factors and incidence of stroke.

Prevalence of poststroke depression in Thai stroke survivors studied in Phramongkutklao Hospital.

OBJECTIVE: To study prevalence of depression in poststroke survivors in Phramongkutklao Hospital and factors associated with depression. MATERIAL AND METHOD: From 150 stroke survivors, therefor 101 patients who met inclusion criteria. These subjects were screened with Thai Geriatric Depressive Scale (TGDS) and interviewed. Demographic data that would effect depression were evaluated. RESULTS: During 9 months of studying period, 101 of 150 patients diagnosed with poststroke survivors were eligible. The prevalence of depression was 46.53%. Severity of depression were mild depression 20.79%, moderate 18.81% and severe depression 6.93%. There were no statistically significant among sex, diabetes mellitus, hypertension, smoking, hyperlipidemia, and site of stroke between depression and non-depression groups. Risk factors for severe poststroke depression were younger age, duration within one year after stroke onset and history of coronary artery disease. CONCLUSION: The prevalence of poststroke depression was 46.53%. Risk factors of severe depression were younger age, duration within one year of stroke onset and history of coronary artery disease.

Orthostatic hypotension: a non-motor complication assessment in 82 patients with idiopathic Parkinson's disease in Phramongkutklao Hospital.

OBJECTIVE: Parkinson's disease (PD) is one of the neurogenic etiologies of orthostatic hypotension, a non-motor symptoms complex, that tends to be under-recognized and under-treated leading to a major cause of disability for PD patients. This complication is associated with one or recurrent falls causing mortality and morbidity. To the authors' knowledge, there is no study about this condition in Thai PD population. The authors therefore aimed to determine the frequency, clinical and risk factors of orthostatic hypotension in PD patients treated in Phramongkutklao Hospital. MATERIAL AND METHOD: The authors enrolled consecutive patients with idiopathic PD over a 10-month period. Supine and standing blood pressure (BP) were measured sequentially as the standard techniques. Orthostatic hypotension (OH) was diagnosed if there was a reduction in systolic or diastolic BP of at least 20 or 10 mmHg respectively within 3 minutes after standing. The authors analyzed for the frequency of this condition as well as determined the risk factors between the OH and non-OH groups. RESULTS: The number of patients enrolled was 82 with the mean age of 69 years. The median duration of PD was 4 years. Eighty-five percent were in Hoehn & Yahr stage 1-3. Thirty-three patients (40.2%) had orthostatic hypotension and 70% of them were asymptomatic. By univariate and multivariate analysis, the risk factors for this condition were the longer duration of PD diagnosis, the more advanced staging and the use of selegiline. CONCLUSIONS: The frequency of orthostatic hypotension among the present PD was 40.2%. The longer duration of disease, the more advanced stage of Parkinson's disease and selegiline usage were the factors associated with this non-motor condition.

Prevalence of depression among epileptic patients at Phramongkutklao Hospital.

OBJECTIVES: To determine the prevalence of depression among epileptic patients in Phramongkutklao Hospital and to find the factors associated with depression. MATERIAL AND METHOD: One hundred and ten epileptic patients were enrolled and 60 patients met the inclusion criteria. These subjects were screened with Thai Geriatric Depressive Scale (TGDS) and were interviewed. Demographic data that effect depression were evaluated. RESULTS: During the 1-year study period, 60 of 110 patients diagnosed epilepsy were eligible. Prevalence of depression was 38.3%, which is similar to previous studies. Mild depression was found in 65.2% and moderate 34.8%, without severe depression. Comparing between male and female, there was no statistical significant difference (p = 0.75). The age group that compared between age equal or less than 25 years and more than 25 years had no statistical significant difference (p = 0.77). Other variables were not found to be significant risk factors of depression among epileptic patients including duration of seizures [equal or less than 5 and more than 5 per year (p = 0.43)], type of seizures [generalized tonic-clonic seizures and partial seizures (p = 0.69)], and number of antiepileptic drugs [monotherapy and polytherapy (p = 0.44)]. CONCLUSION: Prevalence of depression among epileptic patients was 38.3%, divided between mild (65.2%) and moderate (34.8%). There were no significant risk factors correlated with depression. Epileptic patients should be made aware of this and seek prompt treatment for depression.

The Atorvastatin Goal Achievement Across Risk Levels: (ATGOAL) study in Thailand.

OBJECTIVE: To evaluate the efficacy and safety of atorvastatin at the starting doses of 10, 20, 40 mg and evaluate the effectiveness of 1 step titrate up regimen. MATERIAL AND METHOD: Two hundred and forty two subjects with dyslipidemia were enrolled and assigned the appropriate dose in relation to their individual cardiovascular risk status and baseline LDL-C levels. If the NCEP targets were not achieved, the doses were titrated up at week 4 and the primary efficacy was evaluated at week 8. RESULTS: A majority of subjects (88.8%) achieved their LDL-C goals at week 8. Almost all of the subject's LDL-C levels reached their goals by week 2 and 4 (81.6% and 87.1%, respectively). Only 10.7% (n = 25) required the sole titration. Each dose provided significant decreases in LDL-C (average -46.4%). Only 36 subjects experienced treatment related adverse events, the majority of these were in the high-risk group (n = 22) with only one subject registering a serious adverse event. CONCLUSION: Atorvastatin is effective and safe for Thai patients with dyslipidemia. The appropriate starting dose has contributed in the achievement of cholesterol reduction.

An outbreak of botulism in Thailand: clinical manifestations and management of severe respiratory failure.

BACKGROUND: Northern Thailand's biggest botulism outbreak to date occurred on 14 March 2006 and affected 209 people. Of these, 42 developed respiratory failure, and 25 of those who developed respiratory failure were referred to 9 high facility hospitals for treatment of severe respiratory failure and autonomic nervous system involvement. Among these patients, we aimed to assess the relationship between the rate of ventilator dependence and the occurrence of treatment by day 4 versus day 6 after exposure to bamboo shoots (the source of the botulism outbreak), as well as the relationship between ventilator dependence and negative inspiratory pressure. METHODS: We reviewed the circumstances and timing of symptoms following exposure. Mobile teams treated patients with botulinum antitoxin on day 4 or day 6 after exposure in Nan Hospital (Nan, Thailand). Eighteen patients (in 7 high facility hospitals) with severe respiratory failure received a low- and high-rate repetitive nerve stimulation test, and negative inspiratory pressure was measured. RESULTS: Within 1-65 h after exposure, 18 of the patients with severe respiratory failure had become ill. The typical clinical sequence was abdominal pain, nausea and/or vomiting, diarrhea, dysphagia and/or dysarthria, ptosis, diplopia, generalized weakness, urinary retention, and respiratory failure. Most patients exhibited fluctuating pulse and blood pressure. Repetitive nerve stimulation test showed no response in the most severe stage. In the moderately severe stage, there was a low-amplitude compound muscle action potential with a low-rate incremented/high-rate decremented response. In the early recovery phase, there was a low-amplitude compound muscle action potential with low- and high-rate incremented response. In the ventilator-weaning stage, there was a normal-amplitude compound muscle action potential. Negative inspiratory pressure variation among 14 patients undergoing weaning from mechanical ventilation was observed. Kaplan-Meier survival analysis identified a shorter period of ventilator dependency among patients receiving botulinum antitoxin on day 4 (P=.02). CONCLUSIONS: Patients receiving botulinum antitoxin on day 4 had decreased ventilator dependency. In addition, for patients with foodborne botulism, an effective referral system and team of specialists are needed.

Comparison of prevalence of post-dural puncture headache between six hour- supine recumbence and early ambulation after lumbar puncture in thai patients: A randomized controlled study.

OBJECTIVE: To compare the prevalence of Post Dural Puncture Headache (PDPH) between 6 hour- supine recumbence and early ambulation in Thai patients. MATERIAL AND METHOD: The present study was a prospective controlled study and enrolled the patients who underwent Lumbar Puncture (LP) from Phramongkutklao Hospital, Thailand. The background characteristics were recorded Standard LP method was done. The patients were randomized to 6 hour-supine recumbence and < or = 1 hour- (early ambulation) groups. Prevalence and characteristics of PDPH were compared. RESULTS: Of 65 patients, there were 33 patients (50.8%) in the 6 hour-recumbent group and 32 patients (49.2%) in the early ambulation group. The background characteristics and CerebroSpinal Fluid (CSF) findings were not different between the groups. Prevalence of PDPH was 16.9% (overall), 18.2% (6 hours) and 15.6% (early ambulation). There was no statistically significant difference in prevalence, pattern and severity of PDPH between the groups. CONCLUSION: The prevalence and characteristics of PDPH were not different between the 6 hour- recumbence and early ambulation groups.

Dural sinus thrombosis in melioidosis: the first case report.

Melioidosis which is infection with Burkholderia pseudomallei, is an important cause of sepsis in India, southeast Asia and northern Australia. Mortality is high and treatment is problematic. Neurological melioidosis is unusual but meningoencephalitis, encephalomyelitis and brain microabscess can occur Dural sinus thrombosis is not an uncommon cerebrovascular disorder with various etiologies. Hypercoagulable state, pregnancy, dehydration, certain blood dyscrasia and contraceptive pills are common causes however meningitis and local head & neck infections may lead to this condition. Dural sinus thrombosis complicating septicemic melioidosis has never been reported. The authors report a 42-year-old Thai man suffering from septicemic melioidosis with dural sinus thrombosis. He had high fever, headache, left hemiparesis, focal seizure and increased intracranial pressure. Diabetes and mild alcoholic cirrhosis were diagnosed in this admission. CT scan, MRI brain and MRV revealed superior saggital sinus thrombosis with complicating venous infarction over right posterior parietal lobe. Hemoculture demonstrated Burkholderia pseudomallei and CSF was acellular Investigations for causes of dural sinus thrombosis were all negative. This patient gradually improved after treatment with ceftazidime, antiepileptic drug and heparin without clinical recurrence. Neuromelioidosis is a rare syndrome that may present as brain abscess, encephalitis or meningoencephalitis. The authors report dural sinus thrombosis associated with septicemic melioidosis. The authors' hypothesis of venous thrombosis in the presented case is sepsis induced hypercoagulable state. Physicians should be aware of cerebral venous thrombosis in case of suspicious melioidosis with neurological involvement. Prompt treatment with intravenous heparin and antibiotic is potentially effective.

Comparison between aspirin combined with dipyridamole versus aspirin alone within 48 hours after ischemic stroke event for prevention of recurrent stroke and improvement of neurological function: a preliminary study.

OBJECTIVES: To determine efficacy and tolerability of aspirin plus dipyridamole (combination) versus aspirin alone in acute intervention treatment after acute ischemic stoke among Thai patients. MATERIAL AND METHOD: This pilot study enrolled ischemic stroke patients within 48 hours and randomized to aspirin 300 mg/d or combination (aspirin 300 mg/d+ standard release dipyridamole 75 mg thrice a day) and followed up for 6 months. Endpoints were recurrent ischemic stroke, transient ischemic attack and vascular death. Side effects were recorded. National Institutes of Health Stroke Scale was assessed at entry and at 6 months period for determining neurological functions. RESULTS: Of 38 patients, mean age was 64.3 years. Male and female were 52.6% and 47.4% respectively. There were 18 patients in the aspirin group and 20 patients in the combination group. No patient developed end point events or no significant adverse event in both groups. The combination group showed more improvement in neurological function than the aspirin group (p-value 0.009). CONCLUSION: This pilot study showed equal efficacy and tolerability of the combination group and aspirin alone in acute intervention treatment for prevention of recurrent stroke or vascular death within 6 months.

Spinal cord compression and bilateral sensory neural hearing loss: an unusual manifestation of neurocysticercosis.

Neurocysticercosis is the most common parasitic infestation involving the central nervous system in tropical countries. Common presentations are seizure, meningitis and increased intracranial pressure. The authors report a case of a 52-year-old woman with racemose neurocysticercosis in the subarachnoid space at the cistern of the brain through the lumbar cistern. She presented with progressive paraparesis due to spinal cord compression and finally had progressive bilateral sensori-neural hearing loss. MRI brain and the whole spinal cord revealed numerous rim-enhancing cystic lesions at the basal cistern, prepontine cistern, bilateral cerebellopontine angle, internal acoustic canals, intramedullary lesion at the 5th cervical spinal level, lumbar cistern lesions and secondary syringomyelia at the thoracic spinal cord. The histopathologic examination confirmed cysticercosis. After treatment by albendazole and surgical removal, she still developed recurrent spinal compression at a higher level and obstructive hydrocephalus. Finally, she died from status epilepticus and septic shock.

Efficacy and safety of piribedil in early combination with L-dopa in the treatment of Parkinson's disease: a 6-month open study.

BACKGROUND: Piribedil is a non-ergot D2/D3 dopamine agonist with antagonistic effect on alpha2-adrenoceptors and lack of agonist properties at 5-HT2A/2C receptors. Previous studies indicated its efficacy in monotherapy as well as in combinatio' s disease in L-dopa-treated parkinsonian patients. PATIENTS AND METHOD: A 6-month, open-labeled, multicenter study was conducted in Thai Parkinsonian patients who were insufficiently controlled by L-dopa (< or = 600 mg/day). Piribedil 50 mg in retard form was titrated upward to 150 mg/day (50 mg tid) by the 5th week and up to 6 months as an add-on treatment. L-dopa daily dose was kept stable until the 3rd month and could be adjusted afterwards. The main efficacy parameter was the change in UPDRS part III score versus baseline over Full Analysis Set, score variation, and percentage of responders defined by at least 30% decrease from baseline of total UPDRS part III score. The secondary efficacy criteria were changes in L-dopa dose between the third month and the end of the study, UPDRS part II score variation, Hoehn and Yahr stage variation and Schwab and England Activities of Daily Living Scale variation. The acceptability of piribedil was assessed by physical examination, weight, blood pressure and heart rate as well as the reported adverse events. RESULTS: Twenty-nine patients (55.2% male) with the mean age of 64.0 +/- 7.2 years and mean duration of disease of 18.3 +/- 8.2 months were recruited The mean UPDRS part III score at baseline was 19.8 +/- 11.4. After 6-month treatment with piribedil, mean UPDRS part III score significantly decreased to 6.6 +/- 4.7 (p < 0.0001) with mean score variation of 13.3 +/- 10.3. Twenty-seven patients (93.1%) were responders. Mean UPDRS part II score was significantly decreased from 7.2 +/- 5.4 at baseline to 2.7 +/- 2.1 at the end of 6 months (p < 0.0001). Hoehn and Yahr stage and Schwab and England Activities of Daily Living Scale were also significantly improved Reported adverse events were mainly gastrointestinal symptoms. Blood pressure and heart rate were not significantly changed during the study period. Peak dose dyskinesia was reported only in one patient. Two patients (6.9%) were withdrawn because of adverse events. CONCLUSION: Piribedil was effective on motor symptoms during a 6-month treatment in early parkinsonian patients insufficiently controlled by L-dopa and it was well tolerated.