Manat Panamonta

Rheumatic and congenital heart diseases among school children of Khon Kaen, Thailand: declining prevalence of rheumatic heart disease

Abstract Background: Rheumatic fever (RF), rheumatic heart disease (RHD), and congenital heart disease (CHD) are still major problems among Thai school children. Objective: To examine trends in the prevalence of RF/RHD and CHD along with the socioeconomic status of school children in urban Khon Kaen, northeastern Thailand. Methods: We conducted cross-sectional survey of 8,555 school children aged 5-15 years from 4 schools in urban Khon Kaen from January to March 2006. Pediatric cardiologists examined the school children and all cardiac diagnoses were confirmed by echocardiography. Socioeconomic data were also collected. Schools were divided into high and low socioeconomic status (SES) schools, based on the prevailing levels of parental education and household income. All positive cases of heart disease were followed and reviewed at a university hospital up to December 2013. Results: Of 8,555 children examined, 2 had RF/RHD, and 10 had CHD. The prevalence of RF/RHD was 0.23 per 1,000 (95% CI 0.03-0.84), and the prevalence of CHD was 1.2 per 1,000 (95% CI 0.56-2.15). Prevalence of RF/RHD among urban school children in the center of northeastern Thailand had declined from 1.13 to 0.23 per 1,000 since 1986. The indices of socioeconomic development revealed marked improvement during this 20 year interim. The prevalence of RF/RHD was higher among low SES schools (4.6 per 1,000) compared with high SES schools (0 per 1,000). Conclusion: There is a low prevalence of RHD in school children in this region compared with the period before 1986.

Historical assessment of diphtheritic myocarditis from a hospital in northeastern Thailand

Abstract Background: Although there have been many descriptive studies of diphtheria from resource limited countries, descriptions of the natural history of diphtheritic myocarditis in patients from these countries are scarce. Objective: To present the natural history of diphtheritic myocarditis from a hospital in northeastern Thailand. Methods: The clinical features of 38 patients with diphtheria admitted to the Khon Kaen University Hospital in northeastern Thailand between 1983 and 1996 were reviewed. Results: Of the 38 cases of diphtheria, 10 progressed to diphtheritic myocarditis (26%). Electrocardiographic findings of the 10 patients with myocarditis were myocardial and conduction abnormalities. The presence of a clinically severe (toxic) type (P < 0.001) or a swollen neck (bull neck) (P = 0.001) was a predictor of the occurrence of myocarditis. Five (50%) of the 10 patients with myocarditis had conduction abnormalities (third-degree atrioventricular block 3, left bundle branch block 1, and right bundle branch block 1). Four patients with severe symptomatic bradyarrhythmia (third-degree atrioventricular block 3, and left bundle branch block 1) received ventricular pacing, and 3 patients died after this pacing. Echocardiographic abnormalities of left ventricular dilatation and myocardial hypertrophy were found in all 5 patients with conduction abnormalities. All 6 of 7 survivors of diphtheritic myocarditis had normal 12-lead electrocardiographic results at 1-month follow-up. A patient who was the survivor of third-degree AV block had an electrocardiographic finding of flat T waves, and with a complete echocardiographic normalization of left ventricular dilatation and myocardial hypertrophy. Conclusion: The present study confirms that increasing diphtheria immunization coverage in the population remains the most important strategy for the control of diphtheria. In resource limited countries, clinical findings, electrocardiography, and sometimes where available, echocardiography are helpful in assessing the severity of diphtheritic myocarditis, decision making of acute management, and predicting fatal outcome.

The age of onset of pubertal development in healthy Thai girls in Khon Kaen, Thailand

Background: Onset of puberty has shifted toward a younger age in the 21 st century. The useful pubertal assessment in the individual child must be based on recent and reliable reference data from the same population. However, currently representative pubertal data for Thai girls are lacking. Objective: We determined the current prevalence and mean ages at onset of pubertal characteristics in healthy urban Thai girls in Khon Kaen Province, northeast Thailand. Methods: A cross-sectional study was carried out between January and July 2011. Five hundred and three schoolgirls aged 7 to 16 years were enrolled. All were in good physical health. Stages of breast and pubic hair development were rated on girls by Tanner’s criteria. Assessment was performed by a trained pediatrician. Data on menstruation were collected by the status quo method. Results: Median (range) ages of the onset of thelarche and pubarche were 9.3 (7.8 to 13.4) and 10.8 (8.9 to 14.5) years, with the mean±SD of 10.1±1.2 and 11.6±1.2 years, respectively. One hundred and eighteen girls had experienced menstruation. The median (range) age of menarche was 11.2 (10.0 to 14.0) years. Mean age was 11.6±0.8 years. The mean ages of pubarche and menarche decreased from the previous study significantly (p <0.001). Conclusions: The secular trend in decline of the ages of pubarche and menarche were observed in urban Khon Kaen Thai girls. These data can be used as the reference of normal pubertal development in Thai girls in Khon Kaen to determine precocious or delayed puberty.

Factors Associated with Failure to Receive Antenatal Care

EDITORIAL COMMENT: We seldom read why women in our community present late for antenatal care, fail to attend regularly or, heaven forbid, have no antenatal care at all. There are many countries where a large section of the population receives no antenatal care, even in nations where oil‐earned riches abound. It is an accepted fact that lack of antenatal care results in higher perinatal and maternal mortality nates. In Australia the causes of poor attendances are mainly socioeconomic (working mother, no baby minder, cost of fares), apart from general unreliability, and drug dependency with its associated problems. There is also the problem of communication with immigrant women who, in the editors experience, are very cooperative and willing attenders when the aforementioned factors are not operative (some will attend only when accompanied by their husbands who speak better English, even when the hospital provides a good interpreter service). Nonattendance seems related more to poverty than ignorance ‐ this statement is an opinion and is not the result of the painstaking investigation that characterizes this paper from Thailand. The authors found that education of the husband is needed for his wife to receive the care she deserves; the details of maternal age and parity, and affluence of the family of these dwellers in 120 villages, in terms of antenatal attendance, should please readers with an interest in the problems faced by our colleagues in other lands. It also suggests that a careful audit of the causes of poor antenatal attendance and its sequelae should be undertaken in every community. The editor was surprised and dismayed to learn that at the Mercy Hospital for Women where he works such a study has not been conducted; provoked by this paper we will try to do better ‐ perhaps improvement of antenatal creche facilities may be the first priority required.

Original article. Childhood infective endocarditis in Khon Kaen University Hospital from 1992 to 2011

Abstract Background: Infective endocarditis (IE) is an important cause of child morbidity and mortality, but the current burden of the disease in Thai children is unknown. Objectives: To determine the current burden of IE in Thai children. Patients and Methods: The records of all children aged <15 years admitted to Khon Kaen University Hospital from 1992 to 2011 were reviewed. Results: Of 69,822 admissions, 56 patients fulfilled the modified Duke criteria for definite IE giving a rate of 0.8 cases per 1,000 admissions. Age at diagnosis was 7.9 ± 3.8 years (range, 8 days to 14.8 years). There was congenital heart disease in 38 (68%) patients, rheumatic heart disease (RHD) in 10 (18%), and no previous heart disease in 8 (14%). RHD was a less frequent underlying disease during the latter half (2002-2011) of the period studied (1/34 vs. 9/22, P < 0.001). Blood cultures were positive for pathogens in 34 (61%) patients with 11 cases of Streptococcus viridians and 8 cases of Staphylococcus aureus infections. Vegetations on echocardiography were present in 46 (82%) patients. For 8 embolic events, patients with large vegetations had a higher rate (4/6) than patients with small and no vegetations (4/50) (P < 0.003). In-hospital mortality was 11%. Eight patients with S. aureus infection had a higher mortality (5/8) than 26 patients (1/26) infected with other pathogens (P < 0.001). Conclusion: The changing epidemiology of pediatric IE was toward fewer children with RHD. Mortality among children with IE was higher in those with S. aureus infection.