Correlation between magnetic resonance imaging proton density fat fraction (MRI-PDFF) and liver biopsy to assess hepatic steatosis in obesity

Obesity is highly associated with Non-alcoholic fatty liver disease (NAFLD) and increased risk of liver cirrhosis and liver cancer-related death. We determined the diagnostic performance of the complex-based chemical shift technique MRI-PDFF for quantifying liver fat and its correlation with histopathologic findings in an obese population within 24 h before bariatric surgery. This was a prospective, cross-sectional, Institutional Review Board-approved study of PDFF-MRI of the liver and MRI-DIXON image volume before bariatric surgery. Liver tissues were obtained during bariatric surgery. The prevalence of NAFLD in the investigated cohort was as high as 94%. Histologic hepatic steatosis grades 0, 1, 2, and 3 were observed in 3 (6%), 25 (50%), 14 (28%), and 8 (16%) of 50 obese patients, respectively. The mean percentages of MRI-PDFF from the anterior and posterior right hepatic lobe and left lobe vs. isolate left hepatic lobe were 15.6% (standard deviation [SD], 9.28%) vs. 16.29% (SD, 9.25%). There was a strong correlation between the percentage of steatotic hepatocytes and MRI-PDFF in the left hepatic lobe (r = 0.82, p < 0.001) and the mean value (r = 0.78, p < 0.001). There was a strong correlation between MRI-derived subcutaneous adipose tissue volume and total body fat mass by dual-energy X-ray absorptiometry, especially at the L2-3 and L4 level (r = 0.85, p < 0.001). MRI-PDFF showed good performance in assessing hepatic steatosis and was an excellent noninvasive technique for monitoring hepatic steatosis in an obese population.

Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry

Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.

Decreased bone mineral density is associated with an increased number of teeth with periodontitis progression: a 5-year retrospective cohort study

OBJECTIVE

Longitudinal studies on the systemic bone loss-periodontitis relationship are limited with disparate results. The aim of this study was to investigate the association between bone mineral density (BMD) and periodontitis progression, controlling for other covariables in a Thai population.

MATERIALS AND METHODS

In 2,418 participants, BMD values of the lumbar spine, femoral neck, and total hip were measured with dual-energy X-ray absorptiometry at baseline. Each participant's BMD status was classified as normal, osteopenia, or osteoporosis. Full mouth periodontal examinations on 6 sites/tooth were performed at baseline and 5-year follow-up visits. Periodontitis progression was defined as a tooth presenting an additional proximal CAL loss of ≥ 3 mm or an additional lost tooth with a baseline CAL ≥ 5 mm. The risk effects of BMD status on the number of teeth with periodontitis progression were analyzed using multivariate Poisson regression.

RESULTS

Baseline BMD status of osteoporosis was associated with an increased number of teeth with periodontitis progression in the subgroups of postmenopausal women, non-smokers, and participants with periodontitis stage III/IV with adjusted risk ratios of 1.31 (95% CI = 1.09-1.58), 1.19 (95% CI = 1.04-1.36), and 1.13 (95% CI = 1.00-1.28), respectively.

CONCLUSION

Baseline BMD in the osteoporosis range increased the risk of having a greater number of teeth with periodontitis progression in specific participant subgroups.

CLINICAL RELEVANCE

Decreased BMD is a potential factor affecting periodontitis progression risk in some individuals. Multidisciplinary approaches in educating and maintaining patients' bone-oral health may help improve their quality of life.

Summary of the Thai Osteoporosis Foundation (TOPF) Clinical Practice Guideline on the diagnosis and management of osteoporosis 2021

Objectives

The Thai Osteoporosis Foundation (TOPF) is an academic organization that consists of a multidisciplinary group of healthcare professionals managing osteoporosis. The first clinical practice guideline for diagnosing and managing osteoporosis in Thailand was published by the TOPF in 2010, then updated in 2016 and 2021. This paper presents important updates of the guideline for the diagnosis and management of osteoporosis in Thailand.

Methods

A panel of experts in the field of osteoporosis was recruited by the TOPF to review and update the TOPF position statement from 2016. Evidence was searched using the MEDLINE database through PubMed. Primary writers submitted their first drafts, which were reviewed, discussed, and integrated into the final document. Recommendations are based on reviews of the clinical evidence and experts' opinions. The recommendations are classified using the Grading of Recommendations, Assessment, Development, and Evaluation classification system.

Results

The updated guideline comprises 90 recommendations divided into 12 main topics. This paper summarizes the recommendations focused on 4 main topics: the diagnosis and evaluation of osteoporosis, fracture risk assessment and indications for bone mineral density measurement, fracture risk categorization, management according to fracture risk, and pharmacological management of osteoporosis.

Conclusions

This updated clinical practice guideline is a practical tool to assist healthcare professionals in diagnosing, evaluating, and managing osteoporosis in Thailand.

Risk-stratified papillary thyroid microcarcinoma: post-operative management and treatment outcome in a single center

PURPOSE

This article aims to review and assess the post-operative management and treatment outcomes of papillary thyroid microcarcinoma (PTMC) in risk-stratified patients.

METHODS

We retrospectively analyzed the data of PTMC patients who underwent thyroid surgery with or without radioactive iodine treatment (RAI) in a single center between January 2011 and December 2017. Demographic and clinicopathologic data were collected. Risk stratification according to the 2015 American Thyroid Association guideline was applied.

RESULTS

Three hundred forty PTMC patients were included. Post-operative RAI was performed in 216/340 (63.53%) patients. In the non-RAI scenario, there were 122 low-risk and two intermediate-risk patients. In total, 261 (76.77%), 57 (16.76%), and 22 (6.47%) patients were classified as low, intermediate, and high risk, respectively. With a median follow-up time of 36 months (interquartile range: 23, 52), we found unfavorable outcomes (evidenced by imaging or out-of-range serum tumor marker levels: high thyroglobulin [Tg] or rising Tg antibody [TgAb] levels) in 8/340 (2.35%) patients, all of which received RAI. PTMC patients with unfavorable outcomes were stratified as low risk (4/261 [1.53%]), intermediate risk (1/57 [1.75%]), or high risk (3/22 [13.64%]). One death occurred in a patient with initial distant metastasis in the high-risk group. Initial high-risk stratification and initial stimulated Tg (of at least 10 ng/mL) were demonstrated as independent predictors for PTMC unfavorable outcomes (persistent or recurrent disease). Five patients with unfavorable outcomes (four with persistent disease and one with recurrent disease) had abnormal Tg or TgAb values despite unremarkable imaging findings. Moreover, 79/124 (63.71%) patients in the non-RAI scenario were only followed up with neck ultrasound.

CONCLUSIONS

In general, at least 98% of low-risk and intermediate-risk PTMC patients showed favorable outcomes without persistent or recurrent disease, defined by either imaging or serum tumor markers. Nevertheless, aggressive disease could occur in few PTMC patients. Decisions on post-operative management and follow-up may be guided by initial high-risk stratification and initial stimulated Tg levels (≥10 ng/mL) as independent predictors for PTMC unfavorable outcomes. Monitoring using both imaging and serum tumor markers is crucial and should be implemented for patients with PTMC.

A case of acute suppurative thyroiditis caused by Streptococcus suis infection

INTRODUCTION

Acute suppurative thyroiditis (AST) is an uncommon but potentially life-threatening condition. The majority of AST cases are caused by bacterial infection. Streptococcus suis is a swine pathogen that mostly causes meningitis and septicemia. To date, AST caused by Streptococcus suis has not yet been reported.

CASE REPORT

A 64-year-old Thai female presented with rapid enlargement of a preexisting large left thyroid nodule without compressive symptoms for one week. She had a fever and purulent discharge spontaneously drained from her fluctuated mass. Her thyroid function workup revealed elevated serum thyroid hormone levels with suppressed thyrotropin levels. Thyroid scan and uptake showed functioning thyroid tissue in the left lobe of the thyroid. Prompt antibiotic therapy and drainage were performed, and this led to significant improvement. However, thyroid cancer was suspected, and the patient underwent lobectomy. Pus cultures grew Streptococcus suis. She had a history of raw pork product consumption.

CONCLUSIONS

This case highlights the importance of correct identification of pathogens for proper antibiotic therapy. AST caused by Streptococcus suis should be included in the differential diagnosis, especially in areas with a high prevalence of Streptococcus suis diseases.

A Comparison of Bone Mineral Density and Its Predictors in HIV-Infected and HIV-Uninfected Older Men

OBJECTIVE

Bone health in older individuals with HIV infection has not been well studied. This study aimed to compare bone mineral density (BMD), trabecular bone score (TBS), and bone markers between HIV-infected men and age- and body mass index (BMI)-matched HIV-uninfected men aged ≥60 years. We investigated the associations of risk factors related to fracture with BMD, TBS, and bone markers in HIV-infected men.

METHODS

This cross-sectional study included 45 HIV-infected men receiving antiretroviral therapy and 42 HIV-uninfected men. Medical history, BMD and TBS measurements, and laboratory tests related to bone health were assessed in all the participants. HIV-related factors known to be associated with bone loss were assessed in the HIV-infected men.

RESULTS

The mean BMD, TBS, and osteopenia or osteoporosis prevalence were similar among the cases and controls. The HIV-infected men had significantly higher mean N-terminal propeptide of type 1 procollagen and C-terminal cross-linking telopeptide of type I collagen levels. Stepwise multiple linear regression analysis demonstrated that low BMI (lumbar spine, P = .015; femoral neck, P = .018; and total hip, P = .005), high C-terminal cross-linking telopeptide of type I collagen concentration (total hip, P = .042; and TBS, P = .010), and low vitamin D supplementation (TBS, P = .035) were independently associated with low BMD and TBS.

CONCLUSION

In older HIV-infected men with a low fracture risk, the mean BMD and TBS were similar to those of the age- and BMI-matched controls. The mean bone marker levels were higher in the HIV group. Traditional risk factors for fracture, including low BMI, high C-terminal cross-linking telopeptide of type I collagen level, and low vitamin D supplementation, were significant predictors of low BMD and TBS.

MO563HIGH DIALYSATE MAGNESIUM AND CORONARY ARTERY CALCIFICATION IN MAINTENANCE HEMODIALYSIS PATIENTS*

Background and Aims

Cardiovascular calcification is highly prevalent among patients with end-stage renal disease (ESRD). Low normal serum magnesium has been linked to a more severe degree of vascular calcification and a decrease in patient survival. An inhibitory effect of extracellular magnesium on osteogenic transformation of vascular smooth muscle cells and the upregulation of anti-calcification protein have been confirmed in vitro. Increased dialysate magnesium concentration has also been shown to lower calcification propensity of the serum of maintenance hemodialysis (HD) patients.

Method

This study is an investigator initiated, single-blinded, parallel-group, matched case-control clinical trial that investigated the effect of high dialysate magnesium concentration for 24 weeks on the progression of coronary artery calcification (CAC) in maintenance HD patients. The changes in laboratory data and bone mineral density (BMD) were also examined. Seventy-six ESRD patients underwent CAC screening by multi-slice computed tomography and BMD measurement by dual-x-ray absorptiometry. Only patients with Agatston score&gt;300 were included. They were matched according to the initial CAC score that fell within 20% of one another. Twenty patients were assigned to high dialysate magnesium concentration of 1.75 mEq/L and the matched controls were kept on standard dialysate magnesium concentration of 0.7 mEq/L. CAC and BMD measurements were repeated after 24 weeks. Laboratory data were obtained prior to dialysis at study entry, 8-week intervals during the study and 2 weeks after the study ended.

Results

There were no significant differences in age, sex, BMI, underlying diseases, dialysis vintage, medications, baseline CAC scores and BMD. The median baseline CAC Agatston score (Volume score) were 1923 (720) and 1672 (785) in the standard and high dialysate groups, respectively. At the end of the study, a significant increase in the CAC score was observed in both groups. Because majority of the included patients had severe calcification burden at baseline, patients were categorized into 2 subgroups using the median baseline CAC Agatston (1600) and Volume scores (700) as cut-offs. Among patients with CAC Agatston score &lt;=1600, CAC score increased significantly in the standard dialysate magnesium group (P&lt;0.01) but was stable in the high dialysate magnesium group (P=0.33). Among patients with CAC Agatston score &gt;1600, the severity of CAC worsened in both groups. The progression of CAC was analyzed by the difference between the follow-up and the baseline square root transformed Agatston and Volume scores. In subgroup of patients with less severe calcification, more patients in the standard dialysate magnesium group progressed compared to the high dialysate magnesium group (P=0.03). In subgroup of patients with more severe calcification, the number of progressors were comparable among the 2 groups. Serum and ionized magnesium levels increased substantially during the study and returned to baseline after the return to standard dialysate magnesium concentration. The highest predialysis serum magnesium was 3.8 mg/dL. Most patients who received high dialysate magnesium reported the disappearance of symptoms of muscle cramps (P=0.01) and requested the high dialysate magnesium be continued after the end of the study. There were no significant changes in serum calcium, phosphate or PTH levels. The decline in BMD was observed in both groups but the difference did not reach statistical significance.

Conclusion

High dialysate magnesium was well tolerated and could ameliorate the progression of CAC in maintenance HD patients with mild to moderate vascular calcification.

Precision and Effects of a Small Meal on DXA-Derived Visceral Adipose Tissue, Appendicular Lean Mass, and Other Body Composition Estimates In Nonobese Elderly Men

BACKGROUND

Information on precision errors and the least significant change (LSC) of dual energy X-ray absorptiometry (DXA)-derived body composition estimates is scarce, particularly for the appendicular lean mass (ALM) and appendicular lean mass index (ALMI). Overnight fasting is recommended for body composition measurements but has not been well tolerated by some elderly patients. This study aimed to establish precision errors and LSC values of body composition estimates in all regions-including visceral adipose tissue (VAT) and ALM-and the ALMI to assess the effect of a small meal on body composition and to estimate the changes it incurred.

METHODOLOGY

Our institutional review board approved the study protocol. Altogether, 36 non-obese men aged ≥60 years, having given written informed consent, underwent body composition assessment after fasting overnight except for water. They underwent DXA scans three times, each time with repositioning (to simulate the clinical setting), the last after consuming a standardized meal (210-250 g and 200 cc of water).

RESULTS

Precision errors and LSC values of DXA-derived body composition estimates in these elderly men tended to be higher than those in reports on younger subjects. Coefficients of variation (CVs (%)) of total bone mass (Tb.BMC) and total lean mass (Tb.LM) were <1%, whereas those of total fat mass (Tb.FM) and total %fat mass (Tb.%FM) were <2%, with LSCs of 45.8 g, 706.52 g, 731.4 g, and 1.15%, respectively. The CVs (LSC) of VAT, ALM, and ALMI were 8.9% (150.65 g), 0.93% (501 g), and 0.94% (0.19), respectively. After meal consumption, the mean changes in Tb.FM, Tb.BMC, and Tb.LM were -100, -8.2, and 440 g, respectively.

CONCLUSIONS

Effects of a small meal on most parameters were trivial, including those for VAT, ALM, and ALMI, where changes were not statistically significant. None exceeded the LSC of ALM and ALMI, suggesting that a small meal is allowable before these measurements.

Iodine-131 metaiodobenzylguanidine (131I-mIBG) treatment in relapsed/refractory neuroblastoma

BACKGROUND

I-meta-iodo-benzylguanidine (I-mIBG) therapy has been used in treatment of for advanced neuroblastoma for many years with promising results. There are several studies regarding predictors and outcomes of I-mIBG therapies in relapsed/refractory neuroblastoma patients.

OBJECTIVE

To identify the predictors and outcomes of I-mIBG treatment in relapsed/refractory neuroblastoma.

METHODS

This study was a retrospective review of 22 patients with high risk stage IV relapsed/refractory neuroblastoma who received at least one cycle of I-mIBG therapy. Patient' characteristics, hematologic toxicity, scintigraphic semi-quantitative scoring, and overall survival were recorded. Factors predicting survival were analyzed.

RESULTS

Twenty-two patients (50% male) with mean age of 3.7 years (4.8 months to 8.3 years) received I-mIBG therapies at an average of 3.8 and mean dose of 136 mCi (5032 MBq) per treatment. Most common acute hematologic toxicity was thrombocytopenia. Overall 5-year survival rate was 37% (95% confidence interval: 16.3-58.0) and median survival time was 2.8 year (95% confidence interval: 1.38-6.34). Patients with rising Curie score of ≥25% upon the second therapy were major determinants of overall survival with poorer response to treatment. At least three treatments of I-mIBG were needed to identify some degrees of survival prolongation (crude hazard ratio: P-value = 0.003). Age, sex, metastatic status, and baseline Curie scoring system were good predictors associated with survival. Seven patients (32%) demonstrated objective responses.

CONCLUSION

Despite multimodality therapy, high risk neuroblastoma had a propensity of treatment failure in terms of relapsed or refractory, with some objective responses after I-mIBG treatments. The declined or non-rising Curie score upon second post-treatment total body scan was an important predictor of survival and aided a decision whether or not to proceed with bone marrow transplantation.

Sentinel lymph node biopsy after neoadjuvant treatment of breast cancer using blue dye, radioisotope, and indocyanine green: Prospective cohort study

Background

The breast cancer treatment paradigm has shifted to neoadjuvant treatment. There are many advantages to neoadjuvant treatment, such as tumor downsizing, in vivo tumor biology testing, treating micrometastasis, and achieving complete pathological response (a surrogate marker for overall survival). However, in the post neoadjuvant settings, sentinel lymph node biopsy can be done using a dual staining technique to decrease the false-negative rate (FNR) and increase the detection rate. However, many hospitals are not equipped to use radioisotopes. Here we investigate the detection rate and accuracy of sentinel lymph node biopsy in post neoadjuvant treatment breast cancer, comparing radioisotope, isosulfan blue, and indocyanine green (ICG) approaches.

Material and methods

This prospective study includes breast cancer patients (T2–4, N1–2) who had received neoadjuvant treatment. Carcinomas were confirmed by tissue pathology. Patients who had previous surgical biopsy or surgery involving the axillary regions, and those with a history of allergy to ICG, isosulfan blue, or radioisotope were excluded from the study.

Result

The study was done between July 1, 2019 to March 31, 2020. The mean age of participants was 53 years. Fourteen (60.87%) were post-menopause, two (8.7%) were perimenopause, and seven (30.43%) were premenopause. The clinical-stage distribution of the participants was: 2A (8.7%), 2B (34.78%), 3A (43.48%), and 3B (13.04%). The primary tumor size was 4.82 ± 2.73 cm. The lymph node size was 1.8 ± 0.96 cm. The detection rates at the individual level were 95.23% with ICG, 85.71% with isosulfan blue, and 85.71% with a radioisotope. The detection rate increased up to 100% when the ICG and blue dye methods were combined. The FNRs of sentinel lymph node biopsy at the individual level were: 10% using ICG, 30% using isosulfan blue, and 40% using radioisotope. At the lymph node level, the detection rates were 93.22% using ICG, 81.78% using isosulfan blue, and 53.87% using a radioisotope. The FNRs of sentinel lymph node biopsy at the lymph node level were 19.05% with ICG, 21.43% with isosulfan blue, and 18.03% with a radioisotope. However, the FNR was less than 10% when ICG, isosulfan blue, and a radioisotope were combined.

Conclusion

We can perform sentinel lymph node biopsy by combining blue dye with ICG as an optional modality and achieve a comparable outcome with combine radioisotope in locally advanced breast cancer after neoadjuvant treatment.

•

ICG alone has a high detection rate.93.22%

•

Detection rate will increase to 96.71% when combined with blue dye.

•

The accuracy of blue dye combined with ICG was statistically significant better than combine with isotope (p = 0.014).

•

The combined use of blue dye with ICG is appropriate for the detection of sentinel lymph nodes in locally advanced breast cancer patients.

Trabecular bone score, a new bone quality index, is associated with severe periodontitis

BACKGROUND

The association between systemic bone loss and periodontitis remains unresolved; and the trabecular bone score (TBS) is a new index for assessing decreased bone quality. Therefore, this cross-sectional study investigated the association between TBS and severe periodontitis.

METHODS

Eight hundred and five Thai participants, aged 30 to 82 years, underwent bone quality assessment. Their mean TBS was calculated from dual-energy X-ray absorptiometry images at the L1 to L4 lumbar spine using TBS software. Each participant was classified as normal, partially degraded, or degraded TBS. Full-mouth periodontal examinations determined plaque score, probing depth, clinical attachment level (CAL), and the number of remaining teeth. The participants were classified as non-severe or severe periodontitis. Differences in periodontal parameters between the TBS groups were analyzed using one-way ANOVA. The association between TBS and severe periodontitis was assessed with multivariate binary logistic regression. For severe periodontitis, the additive interaction between TBS and oral hygiene status was also analyzed.

RESULTS

The mean CAL was 0.9-mm higher in the degraded TBS group compared with the normal TBS group. Degraded TBS was associated with severe periodontitis with an adjusted odds ratio (OR) of 2.10 (95% confidence interval [CI] = 1.03 to 4.26). The combination of degraded TBS and plaque score ≥80% increased the adjusted OR to 5.71 (95% CI = 1.15 to 28.43).

CONCLUSIONS

Degraded TBS is associated with severe periodontitis and has a synergistic effect with poor oral hygiene, suggesting monitoring decreased bone quality and good oral hygiene for promoting the periodontal-systemic health of these individuals.

Significant association between skeletal bone mineral density and moderate to severe periodontitis in fair oral hygiene individuals

AIM

This cross-sectional study aimed to investigate the association between skeletal bone mineral density (BMD) and periodontitis in Thai adults and elders.

METHODS

This study comprised 3282 participants aged 30-82 years. BMD was assessed at 3 skeletal sites using dual-energy X-ray absorptiometry. Each participant's BMD status was classified as normal, osteopenia or osteoporosis. Periodontal assessments were the number of remaining teeth, plaque score, probing depth and clinical attachment level (CAL). The participants were classified into no/mild or moderate/severe periodontitis groups. The mean periodontal variables between BMD categories were compared. The association between the BMD status and moderate/severe periodontitis was analyzed using binary logistic regression.

RESULTS

Among the BMD categories, the greatest mean CAL and the lowest mean number of remaining teeth were found in the osteoporosis group. The mean CAL difference between the osteoporosis and normal BMD groups was 0.3 mm. In 337 participants with a plaque score of less than 40%, there was a significant association between osteoporosis and moderate/severe periodontitis.

CONCLUSION

Skeletal BMD in the osteoporosis range was associated with moderate/severe periodontitis in individuals with fair oral hygiene, suggesting the benefit of special attention to the skeletal bone health of these individuals.

The differences in the relationship between obstructive sleep apnea severity and trabecular bone score in men and women with type 2 diabetes

Aims

Type 2 diabetes mellitus (T2DM) and obstructive sleep apnea (OSA) may adversely affect bone. Gender is a well-established factor influencing bone health. We investigated the impact of OSA on bone mineral density (BMD) and trabecular bone score (TBS) in T2DM.

Methods

Eighty-one T2DM patients [33 men and 48 women] participated. OSA was diagnosed using an overnight monitor, with its severity assessed by an apnea hypopnia index (pAHI). The measurements of hypoxia, including the percentage of total sleep time in which oxygen saturation remains below 90% (pT90), the oxygen desaturation index (pODI) and minimum O₂ (min O₂), were reported. Lumbar spine (L1-4) and femoral neck (FN) BMD were measured using dual-energy X-ray absorptiometry (DXA). TBS was computed from DXA images.

Results

Sixty-five patients (80.2%) had OSA. pAHI, pT90, pODI and min O₂ were not correlated to L1-4 BMD, FN BMD or TBS in all participants by multiple regression analyses adjusting for age, gender and BMI. However, an interaction between gender and pAHI, and gender and pODI were significantly associated with TBS (b = 0.003, p = 0.034 and b = 0.004, p = 0.046, respectively). We therefore reassessed an association between pAHI or pODI and TBS separately between men and women. After adjusting for age and BMI, more severe OSA (higher pAHI) and higher pODI significantly associated with lower TBS (b = -0.002, p = 0.034 and b = -0.003, p = 0.021, respectively) in men. On the other hand, higher pAHI non-significantly associated with better trabecular microarchitecture as indicated by higher TBS (b = 0.002, p = 0.059) in women. When considered only postmenopausal (n = 33), higher pAHI and higher pODI were significantly associated with higher TBS (b = 0.004, p = 0.003 and b = 0.004, p = 0.008, respectively).

Conclusions

In T2DM patients, there is a complex interrelationship among OSA severity, gender and TBS. More severe OSA predicted lower TBS in men, but predicted higher TBS in postmenopausal women.

Errors in Patient Positioning for Bone Mineral Density Assessment by Dual X-Ray Absorptiometry: Effect of Technologist Retraining

Improper positioning is one of the factors that can lead to incorrect bone mineral density (BMD) results. This study aimed to assess the frequencies of erroneous positioning during three periods: before retraining of the technologists (BR), after retraining (AR), and at the current timepoint 8 years after retraining (C). The BMD images of the first 150 consecutive patients who underwent DXA of the lumbar spine and hip during each of the three periods were retrospectively reviewed. Patients were excluded if they had severe scoliosis, rendering proper positioning impossible. Each BMD image was assessed by an International Society of Clinical Densitometry certified clinical densitometrist who was blinded to the date of the initial examination. For the lumbar spine in the BR group, the criteria frequently not met were inclusion of both iliac crests (33.8%), straightness (30.3%), and midline positioning (20.4%); the respective frequencies were significantly reduced to 0.8%-5.6%, 2.1%-3.0%, and 0%-2.8% in the AR and C groups (p < 0.05). For the hip in the BR group, the criteria frequently not met were straightness (52.8%) and internal rotation (21.8%); the respective frequencies were significantly reduced to 0%-4.2% and 8.3%-8.4% in the AR and C groups (p < 0.05). Overall improper positioning in the BR group was 49.3% and 57.3% at the lumbar spine and the hip, respectively; the respective frequencies were reduced to 9.3% and 12.7% in the AR group, and to 2.7% and 7.3% in the C group. The least significant change values for the lumbar spine, femoral neck, and total hip also became smaller after retraining. Retraining the technologists improved patient positioning, as evidenced by the decreased frequencies of erroneous positioning and the improved least significant change values after the retraining.

Effect of Obesity on Left Ventricular Mass: Results from 320 Multi-Slices Computed Tomography

OBJECTIVE

To determine effects of obesity and gender on left ventricular mass in normotensive and hypertensive Thai patients using 320-slice cardiac computed tomography (CT).

MATERIAL AND METHOD

Left ventricular mass (LVM) obtained from 320-slice coronary CT angiogram was compared in 597 normotensive subjects (175 men [65 obese] and 422 women [133 obese], aged 55±7 years) and 483 hypertensive patients (180 men [104 obese] and 303 women [170 obese], aged 60±7 years). Obesity in Asian population was defined by body mass index (BMI) ≥ 25 kg/m2 in both genders. LV mass was normalized for body surface area (BSA)and height2.7.

RESULTS

The upper normal limit of LVM/ height2.7 developed from 244 (197 women, 47 men) low risk subjects (non-smoking normal-weight adults free from hypertension, diabetes, coronary artery disease & dyslipidemia) was lower than the established criteria for left ventricular hypertrophy (LVH) (31 versus 44 g/m2.7 in women; 36 versus 48 g/m2.7 in men). There is statistical difference between men and women in all groups of analysis. Among both hypertensive and normotensive subjects, the prevalence of LVH and LVM/height2.7 are higher in the obese group than normal-weight group in both genders (LVM/height2.7p<0.001; prevalence of LVH – obese versus normal-weight hypertension: 58% versus 34% in women, 43% versus 14% in men; obese versus normal-weight normotension: 35% versus 16% in women, 40% versus 15% in men). The same differences between obese and normal-weight groups were also present when normalizing LVM for height but not with LVM/BSA. Logistic regression analysis revealed that systolic blood pressure and BMI were the main predictors of LVH in the entire population (p<0.001 in both genders). Equations for predicting LVH in men and women were: Risk of LVH = 1/(l+e-w) where w is as follows: w (men) = 0.02* systolic pressure + 0.25*BMI – 9.86, w (women) = 0.03* systolic pressure + 0.17*BMI – 8.82.

CONCLUSION

Obesity is an independent stimulus to increase LVM in normo-tensive subjects, and its effect is additive in hypertensive patients. Gender and obesity affect LVM and prevalence of LVH.

Thai Osteoporosis Foundation (TOPF) position statements on management of osteoporosis

The adjusted incidence rate of hip fracture in Thailand has increased more than 31% from 1997 to 2006. Mortality and morbidity after hip fracture are also high. One year mortality after a hip fracture has increased from 18% in 1999 to 21% in 2007. The Thai Osteoporosis Foundation (TOPF) developed the first Clinical Practice Guideline (CPG) in 2002 and keeps updating the CPG since then. This latest version of the CPG is our attempt to provide comprehensive positional statement on the diagnosis, prevention and treatment of osteoporosis in Thailand. The study group who revised this position statement contains experts from the TOPF, Four Royal Colleges of Thailand, includes the Orthopaedic Surgeons, Gynecologists and Obstetricians, Physiatrists, Radiologists and 2 Associations of Endocrinologists and Rheumatologists which have involved in the management of patients with osteoporosis.

Age-Adjusted Dual X-ray Absorptiometry-Derived Trabecular Bone Score Curve for the Lumbar Spine in Thai Females and Males

Trabecular bone score (TBS), which has been shown to discriminate patients with fractures from healthy individuals, decreases with age. This study was conducted to derive an age-adjusted normative TBS curve for each gender aged 30-80 + years to serve as reference data for Thai males and females. A cross-sectional study was conducted among employees from the Electricity Generating Authority of Thailand cohorts, after excluding those with conditions potentially affecting bone metabolism and analysis. The values of TBS at L1-L4 vertebrae were analyzed using a commercial software. Age-adjusted TBS curves were constructed using segmental linear regression analysis for each gender. Additional analysis was also performed on TBS with age, body mass index, and body mineral density (BMD) at L1-L4 vertebrae as covariates. A database of 848 healthy subjects (341 females and 507 males) aged 30-80+ years was created. The BMDs of both male and female subjects in the youngest decade were not statistically different from previous reports (p = 0.31 and 0.22 for females and males, respectively). In this age group, the mean TBS was higher in females, albeit not statistically significant (p = 0.12). Between the ages of 30-80+ years, female and male TBS dropped by 19.8% (0.40% per year) and 10.1% (0.20% per year), respectively. The association with TBS was weak for body mass index and moderate for BMD (coefficients of about -0.01 and 0.4-0.5, respectively). The age-adjusted reference curves for healthy Thai females and males aged 30-80+ years have been established.

The Optimal Cut-Points for Weight and Non-Weight Quantitative Ultrasound of the Calcaneus to Screen Osteoporosis in Postmenopausal Women

OBJECTIVE

To determine the optimal cut-off point of quantitative ultrasound (QUS) of the calcaneus, and optimized position for QUS of the calcaneus, between non-weight (sitting) and weight (standing) position, to screen osteoporosis in postmenopausal women.

MATERIAL AND METHOD

A cross-sectional study of postmenopausal women aged 65 years or older who came for bone mineral density (BMD) evaluation at the menopause unit, Department of Obstetrics and Gynecology, Ramathibodi Hospital between April 2013 and October 2015. Bone tissue was measured by using QUS of the calcaneus in the standard sitting (non-weight position) and in standing (weight position) consecutively of non-dominant calcaneus to compared with BMD that measured by dual energy X-ray absorptiometry (DXA) of lumbar spine and hip within the same visit of QUS measurement. The area under Receiver Operating Characteristic (ROC) curve and optimal of diagnostic properties to diagnosed osteoporosis were analyzed by sensitivity, specificity, positive and negative likelihood ratio (LR +/-).

RESULTS

One hundred sixty one postmenopausal women were enrolled, median age was 70 (65, 94) years old, median time since menopause was 22 (10, 55) years. Ten point five percent of subjects had history of osteoporotic fracture at wrist. The prevalence of osteoporosis was 23% at lumbar spine and 30% at femoral neck respectively. Area under ROC curve for diagnosed osteoporosis was 0.73 in the non-weight QUS of the calcaneus and correlated well with using DXA at neck of femur (gold standard). However the weight or standing position did not improve the diagnostic power of QUS of the calcaneus. The optimal cut-point value of QUS of the calcaneus to screen osteoporosis at stiffness index was determined by T-score of ≤ -2.6 with 81.42%, 45.83%, 1.5, and 0.41 for the sensitivity, specificity, LR +/- respectively.

CONCLUSION

QUS of the calcaneus was acceptable and promising to be alternative tool for screening osteoporosis in postmenopausal woman age older than 65 years by the optimal cut-point of stiffness index T-score at ≤ -2.6 measured in standard position or non-weight method.

Factors affecting disease-free status of differentiated thyroid carcinoma patients

PURPOSE

The study aim was to assess factors that impact on the outcome of radioiodine therapy in patients diagnosed with differentiated thyroid carcinoma (DTC).

MATERIALS AND METHODS

We performed a retrospective cohort study on 256 patients with DTC who underwent thyroidectomy and received radioiodine therapy during December 2003 to January 2012. All patients were followed up for at least 1 year. They were considered disease- free by the criteria of the revised American Thyroid Association Management Guideline for Patients with Thyroid nodules and DTC (ATA guideline 2009).

RESULTS

On Cox univariate analysis, factors associated with disease-free status were age<45, stage I tumor, low risk group by histopathology, unifocal tumor involvement, stimulated serum Tg level at 1st dose of radioiodine therapy and no distant metastasis from 1st post-treatment WBS (post RxWBS). On multivariate analysis, stage I tumor and stimulated serum Tg level at 1st dose of radioiodine therapy<30 ng/mL were the significant prognostic factors that increased disease-free rate by 1.73 times and 2.60 times, respectively (P-value<0.05).

CONCLUSIONS

Factors affecting the outcome of radioiodine therapy in our study were age, stage, risk of recurrence by histopathology, unifocal tumor involvement and 1st postRxWBS findings. From these factors, stage I tumor and stimulated serum Tg level at 1st dose of radioiodine therapy were independent prognostic factors that substantial increase the disease-free rate.

Relationship of vitamin D status and bone mass according to vitamin D-binding protein genotypes

BACKGROUND

Vitamin D-binding protein (DBP) may alter the biological activity of total 25-hydroxyvitamin D [25(OH)D]; this could influence on the effects of vitamin D in relation to bone mineral density (BMD) and fractures. Emerging data suggest that fetuin-A may be involved in bone metabolism. We aimed to investigate the influence of DBP gene polymorphism on the relationship of vitamin D status and fetuin-A levels to BMD and bone markers.

METHODS

This cross-sectional study was part of a health survey of employees of the Electricity Generating Authority of Thailand (1,734 healthy subjects, 72% male). Fasting blood samples were assayed for 25(OH)D, fetuin-A, N-terminal propeptides of type 1 procollagen (P1NP), C-terminal cross-linking telopeptides of type I collagen (CTx-I), and DBP rs2282679 genotypes. L1-L4 lumbar spine and femoral BMD were measured using dual-energy X-ray absorptiometry.

RESULTS

The DBP rs2282679 genotype distribution conformed to the Hardy-Weinberg equilibrium. There were no correlations between 25(OH)D levels and BMD and bone markers. But a trend of positive correlation was observed for the DBP genotypes with total hip BMD, and for the interaction between 25(OH)D and DBP genotypes with BMD at all femoral sites. We further analyzed data according to DBP genotypes. Only in subjects with the AA (common) genotype, 25(OH)D levels were positively related to BMD and bone markers, while fetuin-A was negatively related to total hip BMD, independently of age, gender and BMI.

CONCLUSIONS

The interaction between vitamin D status, as measured by circulating 25(OH)D and DBP rs2282679 genotypes, modified the association between 25(OH)D and BMD and bone markers. Differences in DBP genotypes additionally influenced the correlation of fetuin-A levels with femoral BMD.

Work- and travel-related physical activity and alcohol consumption: relationship with bone mineral density and calcaneal quantitative ultrasonometry

A number of healthy workers rarely exercise because of a lack of time or resources. Physical activity related to work and everyday travel may be more feasible, but evidence of its beneficial effect on bone health is scarce. We assessed if this form of physical activity was associated with higher bone mineral density (BMD) and stiffness index (SI) when adjusted for recreational physical activity, age, body mass index, smoking, alcohol consumption, education, and serum level of 25-hydroxyvitamin D. Healthy workers, aged 25-54 yr, of the Electricity Generating Authority of Thailand were surveyed. The outcomes were BMD (lumbar spine, femoral neck, and total hip) and calcaneal SI. Physical activity was estimated using the global physical activity questionnaire and considered active when >600 metabolic equivalent tasks (min). Of 2268 subjects, 74% were men. Active male subjects had significantly higher BMD at the femoral neck and total hip (p<0.005). However, the association was not significant with male lumbar spine BMD, male SI, or any bone parameters in women (p>0.05). In men, work and travel physical activity seems beneficial to male bone health; hence, it should be encouraged. Furthermore, smoking appeared harmful while moderate alcohol consumption was beneficial.

Normal Solid Gastric Emptying Values Measured by Scintigraphy Using Asian-style Meal:A Multicenter Study in Healthy Volunteers

BACKGROUND/AIMS

To report gastric emptying scintigraphy, normal values should be established for a specific protocol. The aim of this study was to provide normal gastric emptying values and determine factors affecting gastric emptying using Asian rice-based meal in healthy volunteers.

METHODS

One hundred and ninety-two healthy volunteers were included at 7 tertiary care centers across Thailand. Gastric emptying scintigraphy was acquired in 45 degree left anterior oblique view immediately after ingestion of a 267 kcal steamed-rice with technetium-99m labeled-microwaved egg meal with 100 mL water for up to 4 hours.

RESULTS

One hundred and eighty-nine volunteers (99 females, age 43 ± 14 years) completed the study. The medians (5-95th percentiles) of lag time, gastric emptying half time (GE T1/2) and percent gastric retentions at 2 and 4 hours for all volunteers were 18.6 (0.5-39.1) minutes, 68.7 (45.1-107.8) minutes, 16.3% (2.7-49.8%) and 1.1% (0.2-8.8%), respectively. Female volunteers had significantly slower gastric emptying compared to male (GE T1/2, 74 [48-115] minutes vs. 63 (41-96) minutes; P < 0.05). Female volunteers who were in luteal phase of menstrual cycle had significantly slower gastric emptying compared to those in follicular phase or menopausal status (GE T1/2, 85 [66-102] mintes vs. 69 [50-120] minutes or 72 [47-109] minutes, P < 0.05). All of smoking volunteers were male. Smoker male volunteers had significantly faster gastric emptying compared to non-smoker males (GE T1/2, 56 [44-80] minutes vs. 67 [44-100] minutes, P < 0.05). Age, body mass index and alcohol consumption habits did not affect gastric emptying values.

CONCLUSIONS

A steamed-rice with microwaved egg meal was well tolerated by healthy volunteers. Gender, menstrual status and smoking status were found to affect solid gastric emptying.

Causal relationship between the AHSG gene and BMD through fetuin-A and BMI: multiple mediation analysis

Using mediation analysis, a causal relationship between the AHSG gene and bone mineral density (BMD) through fetuin-A and body mass index (BMI) mediators was suggested.

INTRODUCTION

Fetuin-A, a multifunctional protein of hepatic origin, is associated with bone mineral density. It is unclear if this association is causal. This study aimed at clarification of this issue.

METHODS

A cross-sectional study was conducted among 1,741 healthy workers from the Electricity Generating Authority of Thailand (EGAT) cohort. The alpha-2-Heremans-Schmid glycoprotein (AHSG) rs2248690 gene was genotyped. Three mediation models were constructed using seemingly unrelated regression analysis. First, the ln[fetuin-A] group was regressed on the AHSG gene. Second, the BMI group was regressed on the AHSG gene and the ln[fetuin-A] group. Finally, the BMD model was constructed by fitting BMD on two mediators (ln[fetuin-A] and BMI) and the independent AHSG variable. All three analyses were adjusted for confounders.

RESULTS

The prevalence of the minor T allele for the AHSG locus was 15.2%. The AHSG locus was highly related to serum fetuin-A levels (P < 0.001). Multiple mediation analyses showed that AHSG was significantly associated with BMD through the ln[fetuin-A] and BMI pathway, with beta coefficients of 0.0060 (95% CI 0.0038, 0.0083) and 0.0030 (95% CI 0.0020, 0.0045) at the total hip and lumbar spine, respectively. About 27.3 and 26.0% of total genetic effects on hip and spine BMD, respectively, were explained by the mediation effects of fetuin-A and BMI.

CONCLUSIONS

Our study suggested evidence of a causal relationship between the AHSG gene and BMD through fetuin-A and BMI mediators.

Serum uric acid levels in relation to bone-related phenotypes in men and women

Serum uric acid levels have recently been found to be associated with bone mineral density (BMD) in elderly males. The purpose of the present study was to investigate the relationship between bone-related phenotypes and serum uric acid levels in young and middle-aged males and females. Subjects consisted of 1320 males and 485 females aged 25-54 yr. Bone densitometry and quantitative ultrasonometry (QUS) were performed on each subject. Serum uric acid and biochemical markers of bone turnover were measured in fasting serum samples. When adjusted for covariates including age, body weight, and serum creatinine in multiple linear regression models, it was found that there was a positive association between uric acid levels and BMD in males at the lumbar spine (p < 0.05). The association between uric acid levels and BMD was found in females after controlling for age, body weight, and serum creatinine at the femoral neck, but in the opposite direction (p < 0.05). Uric acid levels were related to the stiffness index (SI) as assessed by QUS in males, independent of age, body weight, and serum creatinine (p < 0.05). No association between uric acid and SI in females was found. The present study demonstrated a positive association in males between serum uric acid levels and BMD, and SI from QUS, suggesting a beneficial influence of uric acid on both the quantity and quality of bone in males.

131I-rituximab treatment in patient with relapsed non-Hodgkin's lymphoma: the first case report in Thailand

Radioimmunotherapy (RIT) with 131-rituximab is a safe and effective treatment in patients with relapsed, refractory follicular lymphoma. The authors demonstrated the first case of 131-rituximab treatment in the patient with relapsed non-Hodgkin's lymphoma (NHL) in Thailand. There was no immediate complication after treatment. Impressive treatment response occurred.

Causal inference of the effect of adiposity on bone mineral density in adults

OBJECTIVE

The causal effect of adipose tissue on bone mass and the direction of its net influence have not been directly assessed in adult humans. Using the Mendelian randomization analysis, we assessed the causality of adiposity in measurements of bone mass in adult males and females.

DESIGN AND METHODS

Subjects consisted of 2154 adults aged 25-54 years from a cross-sectional cohort of the employees of the Electricity Generating Authority of Thailand. Body composition was determined after at least 3 h of fasting using multifrequency bioelectrical impedance analysis. Bone mineral density (BMD) was assessed by dual energy X-ray absorptiometry. A polymorphism in the fat mass and obesity-associated gene (FTO rs9939609) was used as an instrument in the Mendelian randomization analysis.

RESULTS

The genotype distribution of the FTO rs9939609 polymorphism was 61·1% TT, 33·9% AT and 5·0% AA. The average body mass index (BMI), body fat mass and percentage body fat were 23·9 kg/m(2) (SD = 3·6), 17·9 kg (SD = 6·6) and 26·8% (SD = 7·2), respectively. The FTO rs9939609 polymorphism was significantly correlated with BMI (coefficient = 0·673 kg/m(2) , P < 0·001), body fat mass (coefficient = 0·948 kg, P < 0·001) and percentage body fat (coefficient = 0·759%, P < 0·01). An instrumental variable (IV) regression model, using BMI as the intermediate phenotype, suggested that FTO was a strong IV. Also, the FTO-BMI polymorphism was significantly associated with total hip and femoral neck BMD but was not correlated with total spine BMD, with estimated correlation coefficients of 0·0189 (95% CI: 0·0046, 0·0332), 0·0149 (95% CI: 0·0030, 0·0268) and 0·0025 (95% CI: -0·0131, 0·0136) g/cm(2) , respectively. The variances of BMDs explained by the FTO-BMI were 19·0%, 21·3% and 1·1%, respectively. Similar trends were also observed for the FTO-body fat mass and FTO-percentage body fat correlations.

CONCLUSIONS

Mendelian randomization analysis suggests that adiposity might be causally related to BMD at the femur but not at the spine.

Serum oncofetal fibronectin (onfFN) mRNA in differentiated thyroid carcinoma (DTC): large overlap between disease-free and metastatic patients

AIM

This study assessed if onfFN mRNA in the peripheral blood of patients with DTC can identify individuals with metastatic disease.

METHODS

Comparison of onfFN mRNA was made among 3 groups: disease-free, lymph node metastasis, and distant metastasis using real-time RT-PCR on 5 ml blood samples from each DTC patient.

RESULTS

Fifty-one patients were included: 30 (59%) were disease-free; 7 (13.7%) had lymph node metastasis; and 14 (27.5%) had distant metastasis. OnfFN mRNA levels in the 3 groups were significantly different (P=0.001) but with a large overlap and the expression being highest in the disease-free group. Subgroup analysis of the metastatic groups did not show any effect of age, cell type, and serum TSH, Tg, and antiTg on onfFN mRNA. The within-run and between-run root mean square coefficients of variations were <2%.

CONCLUSION

OnfFN mRNA in patients with DTC cannot identify those with metastatic disease.

Normal data of left ventricular parameters in non-hypertensive patients using 320-slice cardiac CT: a study on intra- and interobserver variability

OBJECTIVE

Delineate normal data in a Thai population for global left ventricular function, left ventricular mass (LVM), and LV mass index (LVMI) by gated volumetric CT angiography (CTA).

MATERIAL AND METHOD

Two hundred twenty seven patients with intermediate risk factors for CAD were referred for CT coronary angiography. The non-hypertensive and non-diabetic asymptomatic group was selected with negative coronary CTA. Pre-condition of mild stenosis or less than 50% area stenosis was consistently met for inclusion in the present study. One hundred fifteen patients were included (31 males, 84 females, age range 38-76 years, mean 54.6 +/- 7.2 for males and 54.0 +/- 6.8 for females respectively).

RESULTS

Mean EDV, ESV, SV, CO, and EF in male and females were EDV 122.6 +/- 17.3 vs. 94.9 +/- 16.6ml, ESV 48.2 +/- 9.9 vs. 34.1 +/- 9.1 ml, SV 74.5 +/- 14.2 vs. 60.8 +/- 10.6 ml, CO 4.2 +/- 0.8vs. 3.6 +/- 0.7 Land EF 60.6 +/- 6.6 vs. 64.3 +/- 5.6% respectively The mean LVM and LVMI were higher in males than females (LVM 134.6 +/- 21.4 vs. 96 9 +/- 20.3 g, and LVMI 76.8 +/- 12.4 vs. 61.1 +/- 11.56 g/m2). Altman and Bland plot for each of them showed that the mean and standard deviation of the differences was constant throughout the range of measurements. Each histogram of differences showed that these differences correspond to approximately normal distribution, indicating that the required assumptions held for the use of 95% limits of agreement are valid.

CONCLUSION

Data from this group represents healthy volunteers and this may serve as an important source of information representing normal reference values to be used for Thai patients.

Correlation between myocardial perfusion imaging findings and cardiac events

OBJECTIVE

The excellent prognostic value of a normal or near normal stress myocardial perfusion imaging (MPI) has been confirmed in numerous studies. The aim of the present study was to determine the association of MPI findings and cardiac events.

MATERIAL AND METHOD

Consecutive patients referred from January 2003 to December 2004 by Nuclear Medicine Unit in Ramathibodi Hospital for myocardial perfusion imaging were studied. Visual scoring of perfusion images used 17-segments and a scale of 0-4 was done. Sum stress score (SSS) was generated Cardiac death, death from any cause and nonfatal acute myocardial infarction (MI) were considered major cardiac events, and chest pain and late revascularization > 60 days after testing were considered minor cardiac events.

RESULTS

Of the 320 patients studied, 218 subjects who had complete 1-year follow-up, were enrolled. There were 99 patients with normal MPI (SSS < or = 3) and 119 patients with abnormal MPI (SSS > 3). Statistical significance between cardiac events in two groups (p < 0.001) was detected. Among hard events, there were three cardiac deaths (of these, 1 occurred in a patient with normal MPI and 2 in those with abnormal MPI) and no patients had non-fatal MI in both groups. Among minor cardiac events, 17 patients developed chest pain and 11 patients underwent late revascularization. No patient with normal MPI underwent revascularization (included early and late revascularization) was found.

CONCLUSION

These results show that SSS can be used to provide incremental prognostic information beyond clinical data, which confirms the conclusions drawn from the results of previous studies by using nuclear stress test results.

Associations between serum lipids and causes of mortality in a cohort of 3,499 urban Thais: The Electricity Generating Authority of Thailand (EGAT) study

The association between serum lipids and mortality has not previously been established in Thailand. Baseline data from the Electricity Generating Authority of Thailand (EGAT) cohort study, plus a resurvey of the cohort 15 years later were analyzed. Participants were employees of EGAT: 2,702 men and 797 women. Total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and triglycerides (TG) were taken as predictive variables; age, sex, hypertension, diabetes, cigarette smoking, alcohol drinking, and body mass index were taken as confounders. Dependent variables were all-causes and specific causes of mortality over 17 years of follow-up. The major cause of death among men was cardiovascular disease (CVD); among women, it was cancer. Relative risks (RR) for specific causes of death, for a mmol/L increase in each lipid, were estimated after adjustment for confounding factors using Cox proportional hazards regression. TC and LDL-C were negatively associated with liver cirrhosis mortality, although it was likely that the low cholesterol concentration was a consequence of the disease. HDL-C was negatively associated with CVD mortality (RR = 0.59; 95% confidence interval [CI], 0.39-0.93), coronary heart disease (CHD) mortality (RR = 0.36; 95% CI, 0.17-0.75) and all cause-mortality (RR = 0.68; 95% CI, 0.54-0.87). TG was not associated with mortality. HDL-C is an important risk factor for CVD in middle-class urban Thais. Health promotion programs to improve lipid profiles, such as effective exercise campaigns and dietary advice, are required to increase HDL-C and to help prevent CVD and premature death in Thailand.

Prevalence and Risk Factors of Peripheral Arterial Disease in a Selected Thai Population

Peripheral arterial disease (PAD) is a condition with high mortality, but it is amenable to secondary prevention. Data on its prevalence in Thailand are scarce. To study the prevalence of PAD in a middle-class, urban Thai population, a cross-sectional study was conducted at the Electric Generating Authority of Thailand's head plant, Nonthaburi, in 2002 and 2003 on all surviving and contactable employees and former employees who had participated in the first cardiovascular risk factors survey in 1985. Participants completed a structured questionnaire detailing their medical history, and they underwent a physical examination. A diagnosis of PAD was made when the ankle-brachial index (ABI) was < 0.9. Ankle-brachial index data were available for 98% of participants in the survey; 75% were men, and participants' ages ranged from 52 to 73 years. The overall prevalence of PAD was 5.2%. The age-standardized prevalence of PAD was 4% in men and 9% in women. Multiple logistic regression analysis found hypertension (OR = 1.7), female gender (OR = 1.9), current smoking (OR = 3.0), current alcohol drinking (OR = 0.41), and overweight (body mass index [BMI] > 25 kg/m 2, OR = 0.54) to be significant (P < .05) predictors of PAD. The prevalence of PAD in urban, middle-class Thais was similar to that in the population in developed countries.

The efficacy of I-131 metaiodobenzylguanidine (MIBG) treatment in previously heavily treated stage IV neuroblastoma patients (age more than 1 year): Preliminary experiences

20025

Background: The outcome of advanced stage neuroblastoma patients with multiple relapsed or refractory diseases is very dismal. We therefore would like to study the efficacy and the safety of I-131 MIBG treatment in this group of patients. Method: A retrospective study of six stage IV neuroblastoma patients (pts) (2 males and 4 females), age at the diagnosis range 3 to 8 years from January 2005 to December 2006 were studied. All pts were previously treated with multiple regimens of chemotherapy, high-dose chemotherapy with autologous peripheral stem cells (PBSCs) rescue, salvage surgery, and local radiation ( table ). All these patients had relapsed or refractory disease at the time of I-131 MIBG treatment. The therapeutic dose of I-131 MIBG activity per course was given on the basis of weight, the hematological parameter, and tumor response assessment. The cycle of treatment was more 4 weeks apart. The treatment response was evaluated by imaging. and neuron-specific enolase (NSE) levels. Results: A total of 21 courses of I-131 MIBG were administered: one patient received one course, two received three courses, two received four courses and one received six courses. The median therapeutic dose of I-131 MIBG was 5.5 GBq (range; 1.1–5.5). Median duration of response was 10 months (range, 1–19). A partial response achieved in 1, and stable response in 5 patients. Pain relief was observed in 1/1 patients with bone pain. The most common side effect found was thrombocytopenia which became more severe with increasing number of course, grade 2 thrombocytopenia occurring in 4/6 patients over 3 courses of therapy. Three children died whereas three are still alive. There is no morbidity from the therapy. Conclusion: It can be concluded that MIBG treatment is effective and less toxic in patients with relapsed or refractory neuroblastoma and further studies of the role of I-131 MIBG treatment in advanced neuroblastoma in Thailand are needed.

[Table: see text]

No significant financial relationships to disclose.

Cost-Effectiveness Analysis of Various Screening Methods for Osteoporosis in Perimenopausal Thai Women

OBJECTIVE

To perform a health economics analysis of 5 screening programs for osteoporosis in perimenopausal Thai women comparing two alternatives; without intervention and universal treatment without screening.

DESIGN

A decision analysis was performed to evaluate five screening strategies: Dual energy X-ray absorptiometry (DXA), Quantitative ultrasound sonography (QUS), risk index (clinical risk factors), two-step screening with QUS followed by DXA, and screening with risk index followed by DXA, comparing outcomes without intervention and universal treatment without screening.

RESULTS

The costs for universal treatment, screening by DXA with treatment, screening by QUS with treatment, screening by Risk index with treatment, screening by QUS and DXA with treatment, and screening by Risk index and DXA with treatment strategies to prevent one fracture were 207.82, 88.42, 147.05, 127.67, 71.33, and 60.30 USD, respectively. The cost for no intervention to prevent one fracture is 8.49 USD (1 USD = 40 Thai baht).

CONCLUSION

At present, no intervention is the most cost effective strategy. However, screening with risk index and DXA with treatment became the most cost effective when the patients reached the postmenopausal period and had a high risk index, for which the prevalence of osteoporosis will increase. Cost effective screening guidelines still cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk, are available.

Differentiation of dementia with Lewy bodies, Alzheimer's disease and vascular dementia by cardiac 131I-meta-iodobenzylguanidine (MIBG) uptake (preliminary report)

OBJECTIVE

Differentiation of dementia with Lewy bodies (DLB), vascular dementia (VAD), and Alzheimer's disease (AD) is difficult in clinical practice. Several new techniques have been used for differentiation of various types of dementia. Among these techniques 123I-meta-iodobenzylguanidine (MIBG) uptake was reported to have benefit in distinguishing DLB from AD. The authors study the role of MIBG as a tool for differentiation of DLB, AD and VAD.

METHOD

Patients with dementia were recruited to the study by DSMIIIR criteria. Diagnosis of each dementia type was made by standard clinical criteria. Brain imagings and 131I-MIBG uptake were performed in all the studied patients.

RESULTS

Five DLB, 3 AD and 3 VAD patients were clinically diagnosed. The heart/mediastinum (H/M) ratio in 4 out of 5 in DLB was significantly lower than H/M ratio in patients with AD and VAD. AD patients had the highest uptake of MIBG MIBG uptake of VAD patients was in the range between AD and DLB but the values were close to the AD group.

CONCLUSIONS

131I-MIBG is helpful in differentiating DLB from AD.

Detection of colorectal carcinoma by anti-CEA monoclonal antibody (IOR-CEA1) labeled with 99mTc scintigraphy

BACKGROUND/AIMS

This study shows that a new monoclonal antibody (IOR-CEA1) labeled with technetium-99m has high diagnostic efficacy for colorectal adenocarcinoma. This immunoscintigraphy is helpful in clinical management especially for patients whose serum carcinoembryonic antigen and computed tomography are questionable for recurrent diseases. The study aims to evaluate the efficiency of a new monoclonal antibody (IOR-CEA1) labeled with technetium-99m in the detection of colorectal carcinoma.

METHODOLOGY

Forty colorectal carcinoma patients were examined. They were divided into 2 groups: Group I (9 patients) with untreated primary tumor; and Group II (31 patients) who were suspected of recurrent or residual diseases from 1) equivocal computed tomography or magnetic resonance imaging, or 2) rising serum carcinoembryonic antigen but normal imaging or clinical findings. One milligram of the antibody labeled with 25mCi of technetium-99m was slowly infused intravenously and images were obtained by nuclear medicine techniques. Sensitivity, specificity, accuracy, positive and negative predictive values were determined.

RESULTS

99mTc-IOR-CEA1 had 86% sensitivity, 71% specificity, 83% accuracy, 94% positive predictive value and 50% negative predictive value for the detection of colorectal cancer in 42 studies (2 patients had repeated studies). Serum carcinoembryonic antigen had only 33% sensitivity for detection of the primary cancer and 58% sensitivity in detection of recurrent diseases. Carcinoembryonic antigen had 100% positive predictive value but only 31.3% negative predictive value for diagnosis of the recurrence of tumor. Fifty-two percent of the antibody scans provided more information than computed tomography scans with clinical impact on further management in group II patients.

CONCLUSIONS

The 99mTc-IOR-CEA1 scintigraphy is a promising investigative method which is safe and has high accuracy in the detection of recurrent colorectal carcinoma, especially in the patients whose serum carcinoembryonic antigen and computed tomography findings are equivocal for recurrent diseases.

Utilization of electron beam CT scan in diagnosis of pulmonary embolism

Pulmonary embolism is a difficult entity to diagnose clinically and pulmonary angiogram has been the gold standard for the diagnosis. Our objective was to evaluate the usefulness of electron beam (Ultrafast) CT scan in aiding the diagnosis of such an entity, thus avoiding an invasive procedure. Between April 1995 and March 1996 we prospectively studied 20 patients with clinical suspicion of pulmonary embolism by conventional perfusion scan of the lung, by invasive pulmonary angiography and by contrast enhanced electron beam CT scan. Simple statistic correlation between the 3 methods was obtained in regard to sensitivity and specificity utilizing the pulmonary angiogram as the gold standard. The sensitivity and specificity of contrast enhanced electron beam CT scanning was 95 per cent and 100 per cent respectively. The correlation of positive and negative result of all three imaging modalities was 60 per cent. Contrast enhanced electron beam (Ultrafast) CT scan is a good alternative diagnostic modality for pulmonary embolism.