Clinical inertia in thyrotropin suppressive therapy for low-risk differentiated thyroid cancer: A real-world experience at an endocrine center in Bangkok.

The management of low-risk differentiated thyroid cancer (DTC) has evolved over time toward treatment de-escalation. However, overtreatment with supraphysiological dose of levothyroxine (LT4) continues to be observed despite current clinical guideline. This study aimed to assess the actual thyrotropin suppressive therapy for low-risk DTC patients at an endocrine center in Bangkok. This retrospective study included patients with low-risk DTC who were regularly follow-up for at least 18 months at Theptarin Hospital between 2016 and 2022. The serum thyroid stimulating hormone (TSH) levels were stratified as TSH < 0.1 mIU/L; TSH 0.1 to 0.5 mIU/L; TSH 0.5 to 2.0 mIU/L; and TSH > 2.0 mIU/L. The initial risk stratification (IRS) and dynamic risk stratification were determined at 12 months of follow-up after completing the initial treatment and at the last visit. The clinical factors associated with overtreatment with LT4 were analyzed. A total of 102 patients (83.3% female, age at diagnosis 41.8 ±â€…13.6 years, mean tumor size 1.6 ±â€…1.0 cm) were evaluated with a mean follow-up of 5.9 years. The IRS classified 92.2% of patients after the initial treatment and 93.1% of patients at the last follow-up visit into the excellent response category. The mean LT4 daily dosage at the last follow-up was 121.3 ±â€…44.8 µg/day. Serum TSH levels were in an appropriate target range according to IRS in only 8.8% (9/102) of the patients and then improved to 19.6% (20/102) at the last follow-up visit. Further analysis showed that treating physicians with ≥10 years of practice was associated with severe TSH suppression therapy (TSH < 0.1 mIU/L). Despite the current clinical guideline recommendations and scientific evidences, less than one-fifth of low-risk DTC patients achieved the appropriate serum TSH target. While the proportion of an optimum LT4 suppressive had improved during the study period, further efforts are needed to overcome this clinical inertia.

Expert consensus guidelines for community pharmacists in the management of diabetic peripheral neuropathy with a combination of neurotropic B vitamins.

This consensus guidance is for community pharmacists in diabetic peripheral neuropathy (DPN) management with a combination of neurotropic B vitamins. A multidisciplinary team including endocrinology, neurology, and pharmacy from Thailand discussed and aligned the practical scheme of DPN management in the community pharmacy setting, using the literature review and having face-to-face meeting. Five major statements have been endorsed as consensus recommendations for DPN care with strong acknowledgment. The aims of DPN management included reducing symptoms and the risk of complications, minimising adverse reactions from treatment regimens, and improving patients' knowledge and adherence to the treatment strategies. An initial screening process using a 7 items interview of Douleur Neuropathique 4 (DN4) questionnaire should be implemented to identify patients at risk of developing DPN. Subsequently, pharmacologic, and non-pharmacologic treatment should be employed based on patient-centered care. An interesting approach is combination of neurotropic B vitamins, which may be used as monotherapy or combination therapy to control DPN symptoms. The combined therapy potentially exhibits a synergistic effect and improves patient adherence. The consensus would be further considered in context of harmonisation of routine practice and country requirements.

Real-World Use of Once-Weekly Semaglutide in Thai Patients With Type 2 Diabetes Mellitus in a Private Hospital Setting.

Objective: To evaluate the real-world use of once-weekly semaglutide among Thai patients with type 2 diabetes (T2DM) in a private hospital setting. Methodology: A retrospective review of Thai patients with T2DM who have initiated semaglutide for at least 1 month between June 2020 and March 2022 at Theptarin Hospital, Bangkok, Thailand. Results: A total of 58 patients (50% female, mean age 55.6 ± 15.9 years, with duration of diabetes 12.6 ± 10.3 years, BMI 31.5 ± 4.4 kg/m2, baseline HbA1c 7.9 ± 1.9%, with prior GLP-1 RA use 24.1%, and concomitant SGLT2i intake (41.4%) were included. During a median follow-up of 6 months, the mean serum HbA1c level reduction was 1.3 ± 1.7% with weight loss of 4.7 ± 4.1 kg. The proportion of patients who achieved optimal and sustainable glycemic control (HbA1c < 7.0%) increased from 43.1% to 55.8% at the last follow-up. The proportion of patients reaching both HbA1c targets of <7.0% and 5% weight loss was 27.8%. No cases of pancreatitis, cancer, or progressive retinopathy were observed. Conclusions: In this single center undertaking, it was shown that in among persons with T2DM and obesity in Thailand, semaglutide was associated with short-term glycemic control and weight loss comparable with what has been observed in randomized clinical trials and other RWE.

Profile of Levothyroxine Replacement Therapy in Graves' Disease Patients with Hypothyroidism Post-Radioactive Iodine Ablation: Focus on Different Weight-Based Regimens.

Objective: To evaluate the status of euthyroidism achieved among Thai patients with post-ablative hypothyroidism and to examine the difference between various weight-based daily levothyroxine (LT4) replacement regimens in these patients. Methodology: We conducted a retrospective review of Thai patients with Graves' disease (GD) who developed hypothyroidism following radioactive iodine treatment from 2016 to 2020 at Theptarin hospital. Daily LT4 dose was calculated based on actual body weight (ABW), ideal body weight (IBW), and estimated lean body mass (LBM). Results: We reviewed a total of 271 patient records. Of these, 81.2% were females with a mean age of 40.8±11.7 years, LT4 intake duration of 27.1±14.6 months, and LT4 dose/kg ABW of 1.4±0.5 µg/kg/day. At the final follow-up, 62.4% of patients achieved thyroid-stimulating hormone (TSH) levels within the reference interval, 15.5% had TSH levels over, and 22.1% had TSH levels under the reference range. Obese patients required a lower daily LT4 dose relative to ABW and higher daily LT4 dose relative to IBW to attain euthyroidism (ABW 1.1±0.4 µg/kg/day and IBW 2.0±0.8 µg/kg/day). Estimated daily LT4 dose based on LBM showed a constant dosage of 2.0 µg/kg/day in all BMI categories. Conclusions: Suboptimum LT4 replacement therapy was found in almost half of hypothyroid patients with GD treated with radioactive iodine. Estimated LBM was a better indicator for dosing calculation in these patients compared with ABW and IBW.

Diabetes mellitus and insulin resistance associated with Kabuki syndrome-A case report and literature review.

Kabuki syndrome (KS) is a genetic disorder characterized by distinctive facies, intellectual disability, and multi-organ anomalies. This case report highlights the importance of clinical recognizable phenotype in patients with diabetes. The development of diabetes should be considered an endocrine complication in KS patients.

Phenotypic and Genetic Heterogeneity in a Thai Glucokinase MODY Family Reveals the Complexity of Young-Onset Diabetes.

Glucokinase-Maturity-Onset Diabetes of the Young (GCK-MODY) is characterized by asymptomatic, non-progressive and fasting hyperglycemia, albeit not without phenotypic variability. We used next generation sequencing (NGS) to screen for 34 MODY genes in a non-obese person with familial young-onset diabetes followed by screening in 24 family members within three generations with varying presentations of young-onset diabetes and sensorineural hearing loss. The index patient was found to carry a paternally-inherited heterozygous missense variant (c.716 A>G) of GCK in exon 7 with amino acid change (Q239R). This variant was associated with phenotypic heterogeneity ranging from normal glucose tolerance to diabetes with complications amongst the siblings which might be modified by obesity and chronic hepatitis B infection. Two paternally-inherited variants of SLC29A3 encoding a nucleoside transporter protein and Apo-A1 genes also co-segregated with glucose and lipid traits. Co-occurrence of diabetes and deafness in maternal aunts led to discovery of WFS1 (Wolfram syndrome type 1) as a cause of non-syndromic deafness in multiple members of the maternal pedigree. Our findings highlight the complex causes of familial young-onset diabetes and the need of a multidisciplinary approach to interpret the clinical relevance of discoveries made by NGS in this era of genomic medicine.

Prolonged Honeymoon Period in a Thai Patient with Adult-Onset Type 1 Diabetes Mellitus.

OBJECTIVE: To describe a usual case of adult-onset T1DM with prolonged honeymoon period for more than 5 years. METHODS: Repeated mixed meal stimulation tests for a period of 6-12 months together with monitoring pancreatic autoantibodies and laboratory data were followed following the onset of diagnosis. RESULTS: We report a 24-year-old Thai patient with T1DM with sustained remission without antidiabetic medication for more than 5 years while maintaining low-carbohydrate intake and regular exercise. Repeated mixed meal stimulation tests for a period of 6-12 months revealed preserved beta-cell functions. Interestingly, repeated pancreatic autoantibodies at 5 years after diagnosis still showed positive anti-GAD, anti-IA2, and anti-ZnT8. CONCLUSION: Restored beta-cell function with complete insulin withdrawal in new-onset T1DM has been reported in very few cases with some common factors as in our patient (low-carbohydrate intake with regular exercise). Delaying autoimmune activity by reducing metabolic load in newly diagnosed T1DM might play a role in maintaining the honeymoon period and could lead to an innovative therapeutic option in new-onset T1DM.

Recurrence Factors and Characteristic Trends of Papillary Thyroid Cancer over Three Decades.

BACKGROUND: The prevalence of thyroid cancer is rising worldwide. Although thyroid cancer has a favorable prognosis, up to 20% of patients experienced recurrent disease during the follow-up period. The present study aimed to examine the trend of incidence and factors associated with recurrence and outcomes of papillary thyroid cancer (PTC) in Thai patients over the last 30 years. METHODS: We reviewed the clinical data of all patients with PTC who were treated between 1987 and 2019 at Theptarin Hospital. Clinical characteristics, epidemic trend, factors associated with the persistence/recurrence of the disease, overall disease-specific survival rate, and overall disease-free survival rate were analysed. RESULTS: A total of 235 patients with PTC who were registered between 1987 and 2019 were reviewed. The mean age was 42.5 ± 14.3 years, with a mean follow-up of 9.5 years. Papillary thyroid microcarcinoma (PTMC) was consistently increased and accounted for 21.4% (50/235) of total cases. The American Thyroid Association (ATA) risk stratification was high in 24% of all PTMCs in the last decade, and 16.0% of these patients experienced local recurrence during the follow-up period. Coexistence with Hashimoto's thyroiditis (HT) was found in one-fifth of the patients with PTC and was correlated with a low recurrence rate (HR: 0.16, P=0.013). Only age ≥55 years associated with the persistence/recurrence of the disease. The overall disease-free survival and disease-specific survival rates were 77.4% and 98.3%, respectively. CONCLUSIONS: The prognosis of PTC is generally considered favorable. However, approximately one-fourth of patients with PTMC demonstrated more aggressive clinical behavior, particularly in the last decade of the study. Coexistence of HT contributed to a better prognosis.

Impacts of the American Joint Committee on Cancer (AJCC) 8th edition tumor, node, metastasis (TNM) staging system on outcomes of differentiated thyroid cancer in Thai patients.

BACKGROUND: In 2018, the American Joint Committee on Cancer (AJCC) 8th edition (AJCC8) was introduced to replace the previous version (AJCC7) due to superiority of AJCC8 over AJCC7 for better prediction of survival from thyroid cancer. AIM: To compare AJCC staging systems with the American Thyroid Association (ATA) risk classification for the prediction of 5-year disease-free survival (DFS), and 5-year disease-specific survival (DSS) in Thai patients. METHODS: We retrospectively reviewed all patients with histopathologic diagnosis of DTC who were treated at Theptarin Hospital, Bangkok, Thailand from 1987 to 2019. RESULTS: The study cohort included 262 differentiated thyroid cancer (DTC) patients (papillary thyroid cancer 89.7% with a median time of follow-up 7.8 years). The number (%) of patients within each stage group by AJCC7 and AJCC8 respectively are as follows: Stage I: 173 (66.0%) vs. 232 (88.5%), Stage II: 33 (12.6%) vs. 24 (9.2%), Stage III: 36 (13.7%) vs. 2 (0.8%), Stage IV: 20 (7.7%) vs. 4 (1.5%). The ATA high risk group was found in 24.3% of AJCC7 Stage I compared with 23.7% of AJCC8 Stage I. The 5-year DFS rates in patients classified as stages I, II, III, and IV by AJCC8 were 87.9%, 45.8%, 0% and 25%, respectively. The 5-year DSS rates in patients classified as stages I, II, III and IV by AJCC8 were 98.7%, 100%, 100% and 0%, respectively. AJCC8 was more predictive of DFS rate than AJCC7. CONCLUSIONS: Our study is in accord with previous studies that AJCC8 downstage a significant percentage of patients with DTC and correlated with better prognostic validity. However, even a person at low risk for mortality can be at high risk for recurrence.

Serum T3 Level and Duration of Minimum Maintenance Dose Therapy Predict Relapse n Methimazole-Treated Graves Disease.

BACKGROUND: Methimazole (MMI) has been advocated as a preferred option for most Graves disease (GD) patients. However, long-term remission after a course of MMI treatment is achieved in only 20% to 40% of patients, depending on the duration of follow-up. OBJECTIVE: To evaluate clinical factors for predicting relapse of GD in Thai patients after MMI treatment. METHODS: A retrospective analysis was performed of newly diagnosed patients with GD who achieved remission of hyperthyroid GD after at least 12 months of MMI treatment. Long-term outcomes were assessed and predictive factors of early and late relapse were evaluated. RESULTS: A total of 443 patients with newly diagnosed GD who were treated with MMI for at least 12 months from 1985 to 2019, and were able to discontinue medication, were studied. The mean age at diagnosis was 37.0 ±â€…11.4 years and 81.7% were female. Of the 320 patients (72.2%) who achieved initial remission after MMI treatment for 23 months, 106 patients (33.1%) experienced late relapse during the mean follow-up duration of 9.7 years after MMI withdrawal. The remission rates decreased from 36.4% at the first year after stopping MMI to only 20.7% at 10 years. High initial serum triiodothyronine (T3) level and duration of minimum maintenance dose therapy (MMDT) of <6 months were associated with late disease relapse after remission. CONCLUSION: The long-term remission rate of Graves hyperthyroidism was achieved in one-fifth of MMI-treated Thai patients. Predictive markers for late relapse included high initial serum T3 level and a duration of MMDT of <6 months.

Clinical Features and Outcomes of Dipeptidyl Peptidase-4 Inhibitor-Associated Bullous Pemphigoid (DPP4i-Associated BP) in Thai Patients.

The use of dipeptidyl peptidase-4 inhibitors (DPP4i) appears to be associated with a small but significantly elevated risk of bullous pemphigoid (BP). Although the pathogenic mechanism of DPP4i-associated BP remains unclear, this adverse event is reported with multiple gliptins, suggesting a class effect. However, previous studies from various countries showed that vildagliptin had been implicated in most cases. The aim of this study was to illustrate a case series of DPP4i-associated BP in Thai patients. We conducted a retrospective study from consecutive cases of BP in people with type 2 diabetes mellitus (T2DM) from January 2008, the year in which the first DPP4i was introduced in Thailand, until December 2019. During the study period, 10 BP patients with T2DM were identified. A total of 5 DPP4i-associated BP (3 on vildagliptin, 1 on linagliptin, and 1 on sitagliptin) were found. All patients were male with a mean age at BP development of 80.4 years (73-86 years). All patients had a long-standing duration of diabetes (median duration 34 years), and mean A1C was 7.5 ± 1.4%. The median time to BP development after the introduction of DPP4i was 64 months (range 20-128 months). The severity of BP was classified as mild in 2 cases. In all cases, the association between the drug intake and BP onset was classified as "possible" according to the Naranjo causality scale. All of the patients continued taking DPP4i after BP diagnosis, and one patient died of lung cancer 18 months after BP diagnosis. Only 2 patients could achieve complete remission at least 2 months after stopping DPP4i. Our case series demonstrated a potential link between DPP4i and the development of BP, which mainly occurred in very elderly male patients. The latency period from an introduction of DPP-4i could be several years, and the clinical course after DPP4i discontinuation varied. Clinicians prescribing DPP4i should be aware of this association and consider stopping this medication before a refractory disease course ensues.

Impact of first-line treatment choice on long-term outcomes of hyperthyroid Graves' disease patients with thyrotoxic periodic paralysis.

BACKGROUND: Thyrotoxic periodic paralysis (TPP) is a unique manifestation of Graves' disease. While it is uncommon in Asian, it is extremely rare in Caucasian patients (0.1-0.2%). Previous studies suggested that TPP indicate more severity of Graves' disease and definitive treatments should be used to prevent relapses. AIM: To describe clinical features and impact of first-line treatment on long-term outcomes of TPP patients. METHOD: A retrospective cohort study over 35 years (1985-2019) of TPP from Graves' disease patients was conducted. All cases were analyzed and their clinical courses were compared between those who received anti-thyroid drugs (ATD) versus radioactive iodine (RAI) as a primary treatment. None of them underwent surgery. RESULTS: A total of 2964 hyperthyroid Graves' disease patients were treated and followed-up at least 3 months over the study period. TPP was identified in 63 cases (2.1%) of all patients. There were 60 males and only 3 females with age at presentation of 35.0 ± 8.2 years. TPP was the first presentation of hyperthyroid Graves' disease in 82.5% of them. During the acute attack of TPP, all patients presented with bilateral lower limb flaccid weaknesses with median serum potassium of 2.1 mmol/L. No fatal TPP cases were found. RAI was selected as primary treatment in 27 patients (42.9%). Nearly all RAI-treated patients rendered hypothyroidism with the median RAI dose at 15 mCi. No patients who were in remission after RAI treatment developed recurrent attack of TPP. In the remaining 36 ATD-treated patients with mean follow-up time at 9.1 years, relapse was found in 10 patients (27.8%) after the drug discontinuation and 6 patients suffered recurrent TPP. Only 8 ATD-treated TPP patients (22.2%) went into remission. CONCLUSIONS: TPP is a rare complication of hyperthyroid Graves' disease. Definitive treatment with RAI or thyroidectomy should be employed to prevent relapse and further attacks of TPP.

Clinical characteristics and outcomes of care in adult patients with diabetic ketoacidosis: A retrospective study from a tertiary diabetes center in Thailand.

BACKGROUND: Diabetic ketoacidosis (DKA) is a metabolic catastrophe which could occur in any type of diabetes. Even when fundamental key points of DKA treatment had been followed, some differences exist in treatment protocols in each physician, highlighting the need to assess adherence to DKA guideline. AIM: This study aimed to examine trend of hospitalized DKA patients and outcomes of treatment over a decade at Theptarin Hospital, a multi-discipline based diabetes center in Thailand. METHOD: A retrospective study of DKA episodes admitted over a 14-year period (2005-2018) was done. Clinical characteristics, laboratory data, type of diabetes, severity of DKA were collected and analyzed. RESULTS: A total of 94 DKA episodes occurred in 81 diabetic patients (females 61.5%, mean age 47.4 ±â€¯20.4 years, T1DM 41.5%, T2DM 50.0%, Ketosis-prone diabetes 8.5%, baseline A1C 10.8 ±â€¯3.0%). While infection was the common precipitating factor in T2DM, omission of insulin was the usual precipitating factor in T1DM. During ongoing management, 26.6% of patients developed hypokalemia and supplementation was not prescribed as per protocol in this group of patients. Almost 13% of patients experienced hypoglycemia in the first 24 h. Median time to resolution of DKA was 8.5 h. Four T2DM patients expired from the precipitating cause of DKA which accounted for mortality rate at 4.3% in our study. CONCLUSIONS: Inadequate metabolic monitoring and iatrogenic hypoglycemia remain areas of concern for DKA management. Occurrence of hypokalemia was related to poor adherence to protocol guidance on potassium supplementation. A strengthened educational program for nursing and medical staffs should be emphasized.

Performance of HbA1c versus oral glucose tolerance test (OGTT) as a screening tool to diagnose dysglycemic status in high-risk Thai patients.

BACKGROUND: Dysglycemic status defined by prediabetes and diabetes is known to be related with future risk of diabetic complications and cardiovascular diseases. Herein, we aimed to determine the diagnostic accuracy of glycated hemoglobin (HbA1c) when compared with oral glucose tolerance test (OGTT) as a reference test in identifying dysglycemic status among high-risk Thai patients receiving care in an out-patient setting. METHODS: An 11-year retrospective cross-sectional study of high-risk Thai patients who underwent OGTT during 2007-2017 was analysed. The OGTT was used as a reference test to identify subjects of dysglycemic status. The diagnostic accuracy of HbA1c and the agreement between HbA1c and OGTT were examined. Validated Thai diabetes risk score, Thai cardiovascular risk score (Thai CV risk score), and visceral fat area (VFA) were also compared in each glycemic status from OGTT as surrogate markers for future diabetes and cardiovascular diseases. RESULTS: A total of 512 subjects (females 60.5%, mean age of 50.3 ± 12.7 years, BMI of 26.5 ± 4.6 kg/m2) were reviewed. Normal glucose tolerance (NGT) was found in 220 patients (43.0%), impaired glucose tolerance (IGT) in 191 patients (37.3%), and diabetes in 101 patients (19.7%). The prevalence of diabetes using OGTT was approximately two times higher than those defined by HbA1c (19.7% versus 11.1%). There were poor agreements between the classifications of prediabetes and diabetes defined by OGTT and HbA1c (Cohen's Kappa 0.154 and 0.306, respectively). Using a cut-off value for HbA1c ≥6.5% as a threshold for HbA1c-defined criteria of diabetes, sensitivity was 32% (95% CI 23-41%) and specificity was 94% (95% CI 92-96%). The optimal cut-off HbA1c value for detecting diabetes by Youden's index was at HbA1c 6.2%. Thai CV risk score was much higher among the OGTT-defined diabetes group when compared with the NGT group (median score 10 vs. 3, p-value < 0.001). CONCLUSIONS: Despite the practicality and validity of HbA1c as a diagnostic test, our study suggested that HbA1c as a screening tool for diabetes in high-risk Thai patients is much inferior to OGTT. With limitations of HbA1c, physicians should continue to advocate OGTT as a screening tool for the identification of dysglycemic status in high-risk Thai patients.

Effectiveness of long-term treatment with SGLT2 inhibitors: real-world evidence from a specialized diabetes center.

BACKGROUND: Diabetes is a progressive disease needing multiple drugs for achieving and maintaining good glycemic control. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) is a novel class of anti-diabetic agent which offers several beneficial effects. However, the long-term effectiveness in clinical practice and safety data of SGLT2 inhibitors is limited, especially in Asian patients. To better understand the effectiveness of SGLT2i in clinical practice, we conducted a retrospective evaluation of patients with diabetes on SGLT2i. METHODS: This retrospective observational study uses data of patients with diabetes who had been prescribed SGLT2i and continued to use at least 6 months at Theptarin Hospital, Bangkok. The characteristics of patients, changes in glycemic control and body weight at 3, 6, 12, 18, 24 months and the last follow-up were evaluated. RESULTS: A total of 189 patients with diabetes (females 50.3%, mean age 59.9 ± 12.3 years, T2DM 97.3%, duration of diabetes 16.3 ± 9.2 years, baseline BMI 29.9 ± 6.1 kg/m2, baseline HbA1c 8.8 ± 1.6%) were prescribed SGLT2i during the study period. At the time of first SGLT2i prescription, 80.4% used three or more other anti-diabetic agents concomitantly and 34.6% used insulin concomitantly. 151 patients who continue to use at least 6 months were included in analysis. At the last follow-up (median time 16 months), overall median HbA1c reduction and weight reduction were 1.0% and 1.5 kg, respectively. While glycemic control could maintain up to 18 months, weight loss gradually rebounded after the first 6 months and then backed to baseline body weight at 18 months (78.2 ± 18.0 kg vs. 78.0 ± 17.8, p value = 0.324). The incidence of adverse drug reactions of special interest (polyuria, volume depletion-related events, urinary tract infection, genital infection, and hypoglycemia) was 2.1, 1.6, 2.1, 2.6, and 7.9%, respectively. DISCUSSION: This real-world study confirmed long-term durability of glycemic control with SGLT2i in not only monotherapy, but also add-on studies with other oral anti-diabetic drugs and/or insulin treatment. However, weight loss became evident early after 6 weeks then reached slightly rebounds after 24 weeks until the end of follow-up. Further studies should be done towards a better understanding of treatment with SGLT2i in routine clinical practice.

A study of serum IgG4 levels in the clinical metamorphosis of autoimmune thyroid disease.

BACKGROUND: Measurement of serum IgG4 had been suggested to distinguish the unique subtypes of autoimmune thyroid disease (AITD) which demonstrated patterns of fluctuating between hyperthyroidism and hypothyroidism. However, the clinical utility of serum IgG4 measurement is inconclusive due to few studies having addressed these unusual patients compared with the specificity of serum IgG4 in healthy patients. AIM: To investigate whether elevated serum IgG4 levels could be used as a marker to identify fluctuating AITD patients. MATERIALS AND METHODS: 20 AITD patients who evolved from hyperthyroid Graves' disease to spontaneous hypothyroidism or vice versa were compared with 40 healthy subjects, 40 patients with hyperthyroid Graves' disease (GD) and 40 patients with subclinical or overt hypothyroid Hashimoto's thyroiditis (HT). Serum levels of total IgG and IgG4 were measured and the proportion of elevated serum IgG4 levels (defined by serum IgG4 levels ≥ 135 mg/dL) was compared with control patients. RESULTS: A series of 20 Thai patients with clinical evolution of AITD was analyzed with a median follow-up at 92 months (range 3-380 months). Elevated serum IgG4 levels were not found in fluctuating AITD patients but were found in 5% of the control GD patients, 2.5% of the control HT, and 2.5% of healthy subjects which were not statistically significant between each group. CONCLUSION: Our results contrasted with those of previous studies from Japan which reported elevated serum IgG4 as a marker to identify subset of AITD patients. At present, the clinical utility of serum IgG4 measurements in AITD is inconclusive and requires further investigation.

Permanent neonatal diabetes misdiagnosed as type 1 diabetes in a 28-year-old female: a life-changing diagnosis.

Many patients with monogenic diabetes are missed or misclassified. Herein, we report a 28-year-old Indian female who developed diabetes at the age of 3 months. An audit of our type 1 diabetes database led to her genetic testing. A KCNJ11 mutation was identified and she was successfully switched to sulphonylurea.

An innovative prognostic model for predicting diabetes risk in the Thai population.

OBJECTIVE: To estimate the prevalence and type 2 diabetes, and to develop a prognostic model for identifying individuals at high risk of undiagnosed type 2 diabetes. RESEARCH DESIGN AND METHODS: The study was designed as a cross-sectional investigation with 4314 participants of Thai background, aged between 15 and 85 years (mean age: 48). Fasting plasma glucose was initially measured, and repeated if the first measurement was more than 126 mg/dl. Type 2 diabetes was diagnosed using the World Health Organization's criteria. Logistic regression model was used to develop prognostic models for men and women separately. The prognostic performance of the model was assessed by the area under the receiver operating characteristic curve (AUC) and a nomogram was constructed from the logistic regression model. RESULTS: The overall prevalence of type 2 diabetes was 7.4% (n = 125/1693) in men and 3.4% (n = 98/2621) in women. In either gender, the prevalence increased with age and body mass index (BMI). Gender, age, BMI and systolic blood pressure (SBP) were independently associated with type 2 diabetes risk. Based on the estimated parameters of model, a nomogram was constructed for predicting diabetes separated by gender. The AUC for the model with 3 factors was 0.75. CONCLUSIONS: These data suggest that the combination of age, BMI and systolic blood pressure could help identify Thai individuals at high risk of undiagnosed diabetes.

Performance of the Khon Kaen Osteoporosis Study (KKOS) score for identifying osteoporosis in men.

OBJECTIVE: The present study evaluated the diagnostic performance of Khon Kaen Osteoporosis Study (KKOS) score in identifying osteoporosis in men. MATERIAL AND METHOD: This was a cross-sectional investigation in 230 men aged > or = 50 years. Bone mineral density (BMD) was measured at the femoral neck and lumbar spine by DXA (DPX-IQ densitometer LUNAR Corporation, Madison, Wisconsin, USA). The KKOS score was calculated for each man using his age and weight. Men with KKOS scores < or = -1 and > -1 were classified as "high risk" and "low risk", respectively. RESULTS: The prevalence of osteoporosis in the entire sample was 17% and 7.4% (n = 39, 17) by femoral neck BMD and lumbar spine BMD, respectively. Using the KKOS score, 80 (34.8%) men were classified as "high risk" (KKOS score < or = -1). The proportion of high risk individuals increased with advancing age, ranging from 16.2% in the 50-65 age group to 64.8% in the > 65 age group. Using BMD from DXA as a gold standard, the overall sensitivity and specificity of KKOS in identifying osteoporosis was 72.5% and 73.2%, respectively. However; the sensitivity was higher at the lumbar spine (94.1% vs. 71.8%) than the femoral neck, while the specificity was comparable. The PPV of KKOS was 36%; and was lower at the lumbar spine (20%) compared to the femoral neck (35%). In the present study, men were classified "high risk" from KKOS, the risk (odds ratio; OR) of osteoporosis at the femoral neck and/or lumbar spine was 7.19 (95% CI: 3.34-15.44). However, the risk of osteoporosis was higher in the younger age (50-65 yr) group (OR: 10.29, 95% CI: 3.31-31.94) compared with the older age (> 65 yr) group (OR: 3.65, 95% CI: 1.12-11.91). CONCLUSION: KKOS scoring system based on age and body weight, is a simple tool for clinicians to make a decision to further DXA testing for identifying osteoporosis in Thai men. This tool had a high sensitivity and specificity, but modest PPV.

Prevalence of metabolic syndrome and its relationship to weight in the Thai population.

BACKGROUND: Although the prevalence of the metabolic syndrome (MetS) has been well-documented in Western Caucasian populations, there are few studies in non-Caucasian populations. The objectives of the present study were to estimate the prevalence of MetS and to find an optimal BMI cut-off value for defining obesity in the Thai population. MATERIAL AND METHOD: A sample of 307 men and 295 healthy women aged between 20 and 90 years (average age of 45 years) who came for a health check-up clinic in Khon Kaen, a northeast province of Thailand, were studied. The present study was conducted between 2003 and 2004. The modified ATP III criteria were used to estimate the age-and-sex specific prevalence of MetS, in which a BMI of > or = 27 kg/m(2) for men and 25 kg/m(2) for women were used in place of waist circumference. In the Thai population, these BMI cut-offs were equivalent to a percent body fat of 25% and 35% in men and women respectively. RESULTS: The overall prevalence of MetS was 15%, with no significant differences between men (15.3%) and women (14.6%). In men, the prevalence increased from 9.5% among the 20-39 age group to 24.7% among the 50+ age groups. In women, the respective prevalence was 7% and 29.5%. When BMI was removed from the classification ofMetS, the overall prevalence of "MetS-without-BMI" (still defined by the presence of at least 3 abnormalities) in both men and women was 7.8%. However the prevalence of MetS-without-BMI increased with higher BMI levels: among those with BMI < 25, the prevalence was 4.6% in men and 5.0% in women; among those with BMI > or = 25, the prevalence was 13% in men and 16% in women. CONCLUSION: The prevalence of MetS in this semi-rural Thai population was 15%, which is as common as in Caucasian populations. In the Thai population, obesity was a major component of MetS.