Percutaneous balloon mitral valvulotomy with transesophageal echocardiographic monitoring: experience in Khon Kaen University.

To study the results and complications of Percutaneous Balloon Mitral Valvulotomy with Transesophageal Echocardiographic monitoring in patients with symptomatic mitral stenosis. From November 1996 to November 1998, PBMV with TEE monitoring was performed in 107 patients with symptomatic mitral stenosis. There were 72 females and 35 males, aged 19 to 65 years (mean 37.63). The mitral valve was successfully dilated in 104 patients. Immediately after PBMV, there was significant reduction of mean mitral valve gradient (17.89 +/- 6.7 mm Hg to 6.21 +/- 3.02 mm Hg), mean left atrial pressure (26.67 +/- 6.61 mm Hg to 13.97 +/- 4.7 mm Hg), mean pulmonary artery pressure (35.21 +/- 13.03 mm Hg to 27.71 +/- 10.31 mm Hg). Mitral valve area was increased from 0.80 +/- 0.24 cm2 to 1.75 +/- 0.42 cm2 and cardiac output was increased from 3.84 +/- 0.97 L/min to 4.74 +/- 1.09 L/min. Mitral regurgitation was detected in 20 patients, severe mitral regurgitaion appeared in one patient. None of these patients required emergency surgery. Cardiac tamponade was detected in one case and resolved by pericardiocentesis. TEE was well tolerated and no complications of TEE were detected. PBMV aided by TEE is safe and well tolerated.

Prevalence of cardiac arrhythmias in Thai community.

The resting 12 leads electrocardiogram was recorded in 3,822 men and 4,969 women (aged 30 years or over), who participated in the First National Health Examination Survey of Thailand and the data was used to determine the prevalence of cardiac arrhythmias. In this apparently normal population 362 subjects (the standard age adjusted rate was 39.2 per thousand) had cardiac arrhythmia. The prevalence rate of atrial fibrillation was 3.6 per thousand (males 3.6, females 3.6) and ventricular premature beat was 12.1 per thousand (males 7.3, females 15.6). For atrial premature beat, complete and incomplete right bundle branch blocks, sinus arrhythmia, first degree atrioventricular block and delta wave, the prevalence rates were 4.0, 7.0, 4.6, 2.7, 2.4 and 1.3 per thousand respectively. Complete and incomplete left branch blocks, left anterior hemiblock, second degree antrioventricular block and short PR interval were rare in this survey.

Atrial myxoma: a review of clinical experience at Srinagarind Hospital.

Thirty-two intracardiac myxoma patients who underwent tumor excision in Srinagarind Hospital between January 1, 1983 and January 30, 1997 were retrospectively reviewed. Clinical presentations, diagnostic method, operative findings, and postoperative course were also analysed. There were 20 female and 12 male patients, age range 10 to 60 years (mean 37.9). Clinical presentations included congestive heart failure (56.2%), atypical chest pain (25.0%), syncope (18.9), and constitutional symptoms (9.3%). In six patients, there was clinical evidence of systemic embolism. One patient was essentially asymptomatic and incidentally detected during clinical check-up. Diagnosis was all made by two dimensional (2-D) echocardiographic study. There were 29 left atrial, 2 right atrial and 1 combined right atrial and right ventricular myxomas. There were 3 postoperative deaths, two due to septicemia and the other due to cerebral embolism. One patient developed postoperative severe mitral regurgitation and complete heart block needed mitral valve replacement and permanent pacemaker insertion. One patient developed localized seizure 6 years after resection and was suspected of brain metastasis. The other was found to have two high echogenic liver masses, 2 years after resection, suggestive of hepatic metastasis. Unfortunately, we could not obtain the histologic confirmation from any of those suspected lesions. Because of the non-specific and various manifestations of atrial myxoma, a high index of suspicion is needed. The diagnostic method of choice is 2D-echocardiography. Clinical follow-up for at least 10 years may be needed to rule out recurrence or metastasis.

Variation in stated management of acute myocardial infarction in five countries.

We examined the variation in stated practice in the management of acute myocardial infarction (AMI) among doctors in Australia, Brazil, Chile, India and Thailand. Hospitals were identified as primary, secondary or tertiary by investigators from around their own region. All doctors within each hospital who would be expected to treat patients with AMI were asked to indicate which investigations and treatments they would offer to a patient with an AMI who develops angina on Day 3 after admission. The numbers of hospitals ranged from 5 to 26 per country, and doctor response rates varied from 70 to 100%. Within-country variation was large, and statistically significant variations were seen between countries in the use of most interventions. The large variation both between and within a range of countries across the economic spectrum suggests a widespread need for agreement about what constitutes appropriate management after AMI.

Prevalence of coronary heart disease and major cardiovascular risk factors in Thailand.

BACKGROUND: Coronary heart disease (CHD) is expected to become one of the major health problems in developing countries such as Thailand where prevalence data are scarce. This study reports the prevalence of CHD, as indicated by electrocardiogram (ECG) Minnesota coding, and its risk factors in Thailand. METHODS: In 1991 we conducted a cross-sectional ECG survey in a multistage random sample of the Thai population, aged > or =30. All major cardiovascular risk factors were measured. Standard supine 12-lead ECG data were collected; amplitudes and intervals were measured manually and entered into a computer. Abnormal tracings were verified by five cardiologists, and agreement among at least three of them was accepted as final. RESULTS: The total sample included 3822 men and 4967 women aged > or =30 years. The age-standardized prevalence rate of CHD was 9.9/1000 (men 9.2/1000, women 10.7/ 1000). The age-standardized level of major cardiovascular risk factors among men and women respectively were: total cholesterol 4.8 mmol/l (187.3 mg/dl), 5.1 mmol/l (197.7 mg/dl); hypercholesterolaemia (> or =6.2 mmol/l) 12.2%, 16.9%; systolic blood pressure (mmHg) 117.8, 117.7; diastolic blood pressure (mmHg) 76.9, 75.8; body mass index (kg/m2) 21.7, 22.8; fasting blood sugar 4.8 mmol/l (87.9 mg/dl), 5.0 mmol/l (90.3 mg/dl); hypertension (> or =160/95 +/- on antihypertensive drugs) 6.3%, 8.1%; smoking 65.1%, 8.5%; diabetes mellitus (> or =7.8 mmol/l) 2.4%, 3.7%; obesity (>25 kg/m2) 15.2%, 27.2%. CONCLUSIONS: Most of the age-adjusted mean values and proportion of major cardiovascular disease risk factors as well as the prevalence of total CHD in the Thai population were much lower than the median of those values found in developing countries.

Arrhythmogenic marker for the sudden unexplained death syndrome in Thai men.

BACKGROUND: Between 1981 and 1988, the Centers for Disease Control and Prevention reported a very high incidence of sudden death among young male Southeast Asians who died unexpectedly during sleep. The pattern of death has long been prevalent in Southeast Asia. We carried out a study to identify the clinical markers for patients at high risk of developing sudden unexplained death syndrome (SUDS) and long-term outcomes. METHODS AND RESULTS: We studied 27 Thai men (mean age, 39.7+/-11 years) referred because they had cardiac arrest due to ventricular fibrillation, usually occurring at night while asleep (n=17), or were suspected to have had symptoms similar to the clinical presentation of SUDS (n=10). We performed cardiac testing, including EPS and cardiac catheterization. The patients were then followed at approximately 3-month intervals; our primary end points were death, ventricular fibrillation, or cardiac arrest. A distinct ECG abnormality divided our patients who had no structural heart disease (except 3 patients with mild left ventricular hypertrophy) into two groups: group 1 (n=16) patients had right bundle-branch block and ST-segment elevation in V1 through V3, and group 2 (n=11) had a normal ECG. Group 1 patients had well-defined electrophysiological abnormalities: group 1 had an abnormally prolonged His-Purkinje conduction time (HV interval, 63+/-11 versus 49+/-6 ms; P=.007). Group 1 had a higher incidence of inducible ventricular fibrillation (93% for group 1 versus 11% for group 2; P=.0002) and a positive signal-averaged ECG (92% for group 1 versus 11% for group 2; P=.002), which was associated with a higher incidence of ventricular fibrillation or death (P=.047). The life-table analysis showed that the group 1 patients had a much greater risk of dying suddenly (P=.05). CONCLUSIONS: Right bundle-branch block and precordial injury pattern in V1 through V3 is common in SUDS patients and represents an arrhythmogenic marker that identifies patients who face an inordinate risk of ventricular fibrillation or sudden death.

Nocturnal physiological and biochemical changes in sudden unexplained death syndrome: a preliminary report of a case control study.

Sudden nocturnal deaths among "healthy" workers in Southeast Asia have been termed "sudden unexplained nocturnal death syndrome (SUNDS)" or "sudden unexplained death syndrome (SUDS)". The pathogenesis is still unknown. The paucity of publications on nocturnal monitoring and scientific data stimulated us to perform this study, which included biochemical tests and physiological monitoring during the night in 11 males north-eastern Thai workers. Group 1 (G1) consisted of 5 subjects with neither a previous history of near-SUDS (NSUDS) nor a familial history of SUDS (FHSUDS). Group 2 (G2) consisted of 6 subjects with a family history of either SUDS or NSUDS. Two subjects in G2 presented with NSUDS. Two-day nocturnal monitoring included blood sugar, electrolytes, and respiratory parameters. 24-hour Holter ECGs were monitored for 2 days. The subjects underwent exercise stress tests on the 2nd day of this study. Significant nocturnal hypoxia was more common in G2 than G1 and this abnormality was aggravated by exercise. There were no significant findings in sleep apnea (apnea indices) or in nocturnal biochemical changes, eg blood sugar, electrolytes, thiamine. The recordings of the Holter-ECGs were within normal limits in both groups. We conclude that nocturnal hypoxia might be the primary abnormality in SUDS, and this abnormality was aggravated by the day-time exercise. The cause of nocturnal hypoxia requires further studies.

A prevalence survey of lipids abnormalities of rural area in Amphoe Phon, Khon Kaen.

A population survey in 13 villages and 3 sub-districts of a rural area in Amphoe Phon, Khon Kaen showed that mean cholesterol and high density lipoprotein cholesterol (HDL-C) level were 163.0 +/- 35.3 and 29.6 +/- 9.1 mg/dl respectively which is very low compared to Bangkok and other affluent countries. The cholesterol level in females was higher than in males (male 158.0 +/- 33.2, female 166.6 +/- 36.4) and the HDL-C level in males was higher (30.2 +/- 9.0 vs 29.1 +/- 9.2). The cholesterol level increased with age and obesity while HDL-C decreased with obesity. The prevalence of hypercholesterolemia and low HDL-C was 3.0 and 74.9 per cent respectively. The diet of the survey population was high in carbohydrate (80% of calories) and fat intake was very low (8% of calories). The factors which were associated with high cholesterol levels were age, female sex, obesity and increased fat intake while those of low HDL-C were obesity and being a farmer. The low fat intake may explain for the low total cholesterol, HDL-C HDL-C/cholesterol ratio observed in our population compared to other studies.

An analytic cross sectional study of anemia in rural area, Amphoe Phon, Khon Kaen.

Anemia is a major public health problem in Thailand with the estimate prevalence of 25 per cent. The last survey of the prevalence of anemia was done in 1979, so we performed another survey to observe the trend of change in prevalence of anemia in Khon Kaen. We conducted a community survey by multistage random sampling. In a population aged 30-65 years in 13 villages in Amphoe Phon. The mean hematocrit level was 40.1 +/- 5.1 per cent (42.8 +/- 4.6% in males, 38.1 +/- 4.5% in females). The prevalence of anemia (Hct < 39% in males, < 36% in females) was 22.2 per cent (16.4% in males, 26.4% in females). The mean level of hematocrit of patients admitted for elective surgery in Srinagarind Hospital was 38.6 +/- 5.5 per cent which was significantly lower than in the rural area (P < 0.001) and the prevalence of anemia was 25.9 per cent. The prevalence of anemia increased with age and decreased with high education and body mass index. Comparing to the data in 1979, the prevalence in males increased from 13.9 to 16.4 per cent and from 23.3 to 26.4 per cent in females. The prevalence of anemia in Khon Kaen is still high and has increased compared to the data in 1979, and thus, remains a major public health problem.

Sudden and unexplained deaths in sleep (Laitai) of young men in rural northeastern Thailand.

Sudden and unexplained death in sleep (SUDS) is a significant cause of death of young adults in several Asian populations, but its distribution and incidence are not well known. We conducted a survey by mail of SUDS (known as 'laitai' in the local dialect) that occurred in adults during 1988-1989 in 3867 villages in northeastern Thailand with a total population of 5.42 million. Headmen of 2651 villages (68.6%) returned the questionnaire and sudden deaths of adults 20-49 years old were reported in 396 of these villages. The validity of reports was assessed by interviewing next of kin and witnesses in a sample of 92 villages reporting sudden deaths; 60 of 127 reports of SUDS from these villages were verified (47.2%). Officials and villagers in seven villages that did not respond to the questionnaire were also interviewed and no cases of sudden death were found. The verified SUDS victims were all men wth a mean age of 35.9 years (SD 7.8). A family history of SUDS was reported in 40.3% of index cases and 18.3% had brothers who had died similarly; no such deaths were reported among sisters. The estimated annual rate of death from SUDS among men 20-49 years was 25.9 per 100,000 person years (95% confidence interval (CI): 21.0-30.7). The sudden deaths were seasonal with 38% occurring during March-May and 10% during September-October (chi 2 = 9.45, P = 0.02). Sudden death in sleep is a leading cause of death of young men in rural northeastern Thailand and the characteristics of Thai victims are similar to those of other Asian victims of this unexplained syndrome.

The prevalence and risk factors of hypertension in population aged 30-65 years in rural area, Amphoe Phon, Khon Kaen.

The prevalence of hypertension in a population aged 30-65 years in a rural area in Amphoe Phon, Khon Kaen was 18 per thousand (22 per thousand in males and 16 per thousand in females). The prevalence of isolated systolic hypertension was 5 per thousand (10 per thousand in males and 2 per thousand in females). The risk factors of blood pressure elevation were age, body mass index, level of development of village and non farmer occupation.

Intervention of inappropriate antibiotic use at a university teaching hospital.

The magnitude of inappropriate antibiotic use is high (52.3%). In the empiric treatment group, 41.1 per cent were inappropriate, mostly due to no indication of use. In the surgical prophylaxis, 79.7 per cent were inappropriate, mostly due to delayed prophylaxis and length more than 3 days. In documented infection, 40.2 per cent were inappropriate, mostly due to wrong choice and too many drugs. Intervention by education decreased the overall inappropriate use, empiric inappropriate use and prophylactic use, while there was no change in inappropriate documented infection use and inappropriate economic use. We propose further interventions by other strategies, repeated education and a wider scale of intervention.

Familial clustering of presumptive sudden unexplained death syndrome (PSUDS).

Regarding the suggestion that presumptive sudden unexplained death syndrome (PSUDS) may be genetically associated, we recently conducted a study to reveal the clustering of the PSUDS in extended families. The data collection was done through case searching, interviewing using structured questionnaires and cross-referencing among informants. The precise criteria were used to identify the SUNDS cases. The collected data were age, sex, time and place of death, details of events at death, and vital statistics of relatives. There were forty-nine families with 418 family members included in the study. Twenty-five cases of PSUDS were reported from 14 families. All were men, with the mean age (+/- SD) 31.26 (+/- 7.01) years and the age range was 25-50. There were 6 clusters of SUNDS in sibling groups. Three of the clusters consisted of three siblings each and the other three clusters consisted of two siblings each. Most of the individuals in the siblings clusters had different occupations and died in different places and in different years. The aggregation of PSUDS in families is demonstrated. However, whether it is genetically related needs further study.

Antibiotic use at a university hospital. Antibiotic Working Group of Srinagarind Hospital.

A prospective survey of antibiotic use in 5 departments (MED, SURG, OB-GYN, PED, ORTHO) in Srinagarind Hospital was done during May 1988. The majority of prescribers were interns and residents, except in the department of OB-GYN. Out of 400 prescriptions, 52.3 per cent were inappropriate and 5 per cent were inappropriate for economic reasons. For empirical use, the inappropriateness was 42.3 per cent mostly due to no indication of use. For surgical prophylaxis, 82.4 per cent were inappropriate mostly due to delayed prophylaxis and excessive length of treatment of more than 72 hours. For the treatment of documented infection, 39.6 per cent were inappropriate, mostly due to wrong choice and too many drugs used. There were no statistical differences in mortality, total hospital stay, hospital stay after treatment between the appropriate and inappropriate use.