Thep Himathongkam

Outcomes of hospitalized diabetic foot patients in a multi-disciplinary team setting: Thailand's experience

Aims The aims of this study were to evaluate the outcomes of treatment among hospitalized patients with diabetic foot ulcers, the risk factors for non-healing ulcers, and the rate of major amputation among Thai patients. Methods A retrospective study of hospitalized diabetic foot patients treated at Theptarin Hospital during the period of 2009–2013. The complete healing rate was assessed at 12 months after admission. Results During the study period, 232 patients (123 males and 109 females) with 262 admissions were included (mean age 65.6 ± 11.9 years, mean duration of diabetes 17.2 ± 9.9 years) with a mean follow-up of 17.5 ± 16.7 months. Major amputations were performed in 4.2% of the patients and peripheral vascular disease (PVD) was a predictive factor (OR 5.25; 95% CI [1.43–19.29]; p-value 0.006). Complete healing (including minor amputations) was achieved in 82.1% of the admissions. Only DFU of the heel was a statistically significant (OR 3.34; 95% CI [1.11–10.24]; p-value 0.041) predictor of non-healing ulcers. Three patients (1.1%) died during hospitalization. Conclusions Management of diabetes-related foot ulcers with a multidisciplinary approach resulted in a limb salvage rate that was greater than 90% and a complete healing rate that was greater than 80%. Successful management of diabetic foot ulcers might be possible in Thailand utilizing this approach.

The Alterations of Erythrocyte Phospholipids in Type 2 Diabetes Observed after Oral High-Fat Meal Loading: The FTIR Spectroscopic and Mass Spectrometric Studies.

Little is known about the postprandial remodelling of erythrocytes phospholipids (PLs) in type 2 diabetics (T2DM). Therefore, this study aims to compare the alterations of erythrocyte PLs in T2DM to those of healthy subjects after ingestion of a high-fat meal. Eleven T2DM and ten healthy subjects underwent a high-fat meal loading. Erythrocytes were isolated from blood obtained after fasting and 4 h after the meal. Fourier Transform Infrared (FTIR) spectroscopy was initially used to screen erythrocyte PLs by monitoring C-H stretching vibrations. Phosphatidylcholine (PC) molecular species were further investigated by Liquid Chromatography-Electrospray Ionisation-Mass Spectrometry (LC-ESI-MS). For the control group, FTIR revealed postprandial changes in C-H stretching vibrations, particularly of the olefinic band. These findings were supported by LC-ESI-MS data, showing marked changes in PC molecular species, especially of the PC34:1 (where 34 and 1 mean the summed number of carbons and double bonds, respectively). However, similar changes of those were not apparent in the T2DM group. Our results reveal marked postprandial alterations of erythrocyte PC species in healthy subjects whereas only mild alterations are observed in T2DM. The discrepant effects of high-fat meal loading suggest abnormal PC remodelling in the diabetic erythrocyte that may affect its membrane fluidity and integrity.

Association of genetic variants in GABRA3 gene and thyrotoxic hypokalaemic periodic paralysis in Thai population

Background  Genetic predisposition has been suggested to play role in the pathogenesis of thyrotoxic hypokalaemic periodic paralysis (THPP).

Salient features and outcomes of Charcot foot – An often-overlooked diabetic complication: A 17-year-experience at a diabetic center in Bangkok

Background Charcot foot is a rare but a serious diabetic condition. Recognition of this often overlooked condition to provide timely and proper management is important for a better prognosis. Limited data on Charcot foot was available in Asians. Aims The aim of this study is to describe salient features and outcomes of Charcot foot in Thai patients. Method We presented our experience of 40 cases of Charcot foot patients who were treated from 2000 to 2016 at Theptarin Hospital, Bangkok, Thailand. Results A total of 40 Charcot foot patients were identified (13 acute, 27 chronic; mean age 58.7 ± 10.2 years; duration of diabetes 18.0 ± 8.8 years; T2DM 95%). The average serum HbA1c level was 9.2 ± 1.9%. While acute Charcot foot was frequently misdiagnosed as cellulitis in almost one-third of patients, osteomyelitis was a leading cause of misdiagnosis in 15% of chronic Charcot foot patients. Ulcer-free rate at 6 and 12 months were observed in 60% and 58% of patients, respectively. The mortality rate was 13% during a median follow-up period of 57 months. Only 61% of the patients resumed walking normally while almost one-fourth of them were wheelchair-bound. Conclusions Charcot foot in Thai patients mainly developed in long-standing poorly controlled type 2 diabetes with neuropathy, and presented late in the course of the disease. It was often misdiagnosed resulting in improper management and poor outcome which included amputation.

A Novel Mutation in Thyroid Peroxidase Gene Causing Congenital Goitrous Hypothyroidism in a German-Thai Patient.

Thyroid dyshormonogenesis is responsible for 10-15% of all cases of congenital hypothyroidism and is usually inherited. We report a 26-year-old German-Thai male with congenital hypothyroidism caused by a compound heterozygous mutation in the thyroid peroxidase (TPO) gene. He was diagnosed with congenital goitrous hypothyroidism at 4 months of age and had been treated with levothyroxine replacement therapy. His goiter size had increased due to poor compliance to treatment. Ultrasonography of the thyroid gland showed a pattern suspicious for malignancy. The patient later underwent near-total thyroidectomy. Pathologic examination results were consistent with a multinodular goiter and no malignancy. Genetic analyses by direct sequencing of the entire exons and flanking regions of the TPO gene were performed in the index case and family members. The analyses revealed a compound heterozygote of novel TPO mutation of c.1727C>T in exon 10 resulting in amino acid substitution (p.Ala576Val) and c.2268_2269insT in exon 13 causing a frameshift mutation which introduced a stop codon after the insertion site. The latter has been reported in Chinese subjects. However, there is no previous report of c.1727C>T mutation in the literature. We found the allele contained a novel exon 10 mutation inherited from the patient’s German mother and an exon 13 mutation from his Thai father. Analysis using two bioinformatic software programs indicated that this variant was likely to cause damage in the resulting protein molecule. The present report emphasizes the importance of regular follow-up and patient compliance to levothyroxine replacement in patients with goitrous congenital hypothyroidism to avoid prolonged stimulation of thyroid tissue by thyroid-stimulating hormone.

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

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