Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites.

A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.

Nitrous Oxide-Induced Cerebral Venous Thrombosis: A Case Report, Potential Mechanisms, and Literature Review.

Cerebral venous thrombosis can result from hypercoagulation, either genetic or acquired. Hyperhomocysteninemia was previously thought to be linked with thrombophilia, although this is still controversial to this present day. In recent years, there has been a notable surge in the recreational use of nitrous oxide, which could potentially lead to hyperhomocysteinemia. We present a case of a 19-year-old female who was diagnosed with cerebral venous thrombosis with intracerebral hemorrhage. She had a history of nitrous oxide abuse, which is known to cause dysfunction of vitamin B12. Additionally, we conducted a literature review of cerebral venous thrombosis following nitrous oxide usage. Investigation showed that her serum vitamin B12 level was <100 pg/mL (reference range 197-771 pg/mL), and homocysteine level was 100.6 µmol/L (reference range 5.0-15.0 µmol/L). After receiving a vitamin B12 supplement, both serum vitamin B12 and homocysteine levels returned to normal. No other risk factors for thrombophilia were detected. Previously reported cases predominantly demonstrated hyperhomocysteinemia. The most likely mechanism of her cerebral venous thrombosis was hyperhomocysteinemia due to vitamin B12 deficiency caused by nitrous oxide abuse. This finding supports the hypothesis that hyperhomocysteinemia can induce cerebral venous thrombosis.

Postprandial hypoglycemia after ileocolic interposition and Billroth-II gastrojejunostomy: A case report.

Postprandial reactive hypoglycemia, or late dumping syndrome, is a common but underrecognized complication from bypass surgery. We report an unusual case of postprandial reactive hypoglycemia in a patient with a severe esophageal stricture from corrosive agent ingestion who underwent ileocolic interposition and an antecolic Billroth-II gastrojejunostomy. A 22-year-old male patient with a one-year history of corrosive ingestion was referred to the hospital for a surgical correction of severe esophageal stricture. After the patient underwent ileocolic interposition and an antecolic Billroth-II gastrojejunostomy, he experienced multiple episodes of gastroesophageal refluxsymptoms during nasogastric feeding and had onset of hypoglycemic symptoms. His plasma glucose level was 59 mg/dL. After we had intraoperatively re-inserted a jejunostomy tube bypassing the ileocolic interposition, and reintroduced enteral nutrition, his hypoglycemic symptoms resolved. We performed a mixed meal tolerance test by nasogastric tube, but the results did not show postprandial hypoglycemia. Although the specific mechanism is unclear, this case suggests gastroesophageal reflux to the ileal interposition may have caused a state of exaggerated hyperinsulinemic response and rebound hypoglycemia. To the best of our knowledge, we are the first to report case of postprandial hypoglycemia after ileocolic interposition, which may have been caused by exaggerated hyperinsulinemic response due to gastroesophageal reflux to the ileal interposition. This syndrome should be considered in the patient who has had ileocolic interposition surgery and has developed postprandial hypoglycemia.

Effect of bioelectrical impedance analysis-guided dry weight adjustment, in comparison to standard clinical-guided, on the sleep quality of chronic haemodialysis patients (BEDTIME study): a randomised controlled trial.

BACKGROUND: Sleep disturbance is common among chronic haemodialysis patients, which leads to poor quality of life, in addition to increased instances of morbidity and mortality. Hypervolemia has been linked to sleep problems observed in chronic haemodialysis patients, which suggests that optimising one's fluid status could improve the sleep quality of this patient group. In our study, we subjectively examined and objectively measured sleep parameters, using actigraphy recordings, the Pittsburgh Sleep Quality Index (PSQI) questionnaire, and Epworth Sleepiness Scale (ESS), in order to compare bioelectrical impedance analysis (BIA)-guided and standard clinical-guided dry weight adjustment. METHODS: We randomly selected 19 chronic haemodialysis patients with subclinical hypervolemia, defined as a clinically euvolemic status, despite the ratio of extracellular water to total body water being more than 0.4 in BIA. Furthermore, these patients, who were poor sleepers (PSQI > 5), were assigned to either a BIA-guided dry weight group (BIA group) or a standard clinical-guided one (clinical group). The primary outcome was changes in sleep actigraphy parameters between the groups at 1, 3, and 6 months. Changes observed in the PSQI and ESS score between the two groups over the same period of time were the secondary endpoints. RESULTS: The mean age of the participants was 63.53 ± 11.12 years, and 42% of them were male. All sleep parameters measured by means of actigraphy were not significantly different between the two groups. Interestingly, at 3 and 6 months, the subjective sleep quality significantly improved in the BIA group, as reflected by a greater decline in the PSQI score, in comparison with the clinical group (3 months: mean difference - 1.82 [- 3.13 to - 0.51], P = 0.006; 6 months: mean difference - 3.16 [- 4.49 to - 1.83], P <  0.001). However, sleepiness assessed by the ESS was not significantly different between the groups throughout the study. CONCLUSIONS: Optimisation of the fluid status by employing BIA did not improves sleep actigraphy parameter, however, it significantly ameliorates the subjective sleep quality of chronic haemodialysis patients. This observation should be further explored in larger samples and longer clinical trials. TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov ( NCT02825589 ) on July 7, 2016.

The impact of introducing the early warning scoring system and protocol on clinical outcomes in tertiary referral university hospital.

PURPOSE: The aim of this study was to evaluate the impact of a hospital protocol in response to patient deterioration in general wards, stratified using the national early warning score (NEWS), on primary patient outcomes of in-hospital mortality and percentage of patients transferred to the intensive care unit (ICU). PATIENTS AND METHODS: We conducted a prospective observational cohort study among adult medical patients admitted to a university hospital in Bangkok. A 4-month pre-protocol period (November 2015 to February 2016) was assigned to a control group and a protocol period (March 2016 to June 2016) was allocated to a protocol group. On admission, vital signs (respiratory rate, pulse rate, systolic blood pressure, and temperature), oxygen saturation, presence of oxygen supplementation, and neurological status were used to calculate NEWS. Patients were categorized as low, moderate, or high risk based on the NEWS. During protocol period, when patients' conditions are critical and they are at imminent risk, the NEWS detects the event and triggers a systematic response. The response enables closed monitoring and early treatment by expert physicians to rapidly stabilize and triage the patient to a location where services meet the patient's needs. Primary outcomes were compared between the pre-protocol and protocol groups using historical controls for the intervention, which is the availability of NEWS to staff and an associated escalation pathway. RESULTS: A total of 1,145 patients were included in the analysis: 564 patients in the pre-protocol group and 581 in the protocol group. The mean NEWS of patients at admission was higher in the protocol group than in the pre-protocol group (2.4±2.4 vs 1.77±2.158; P<0.001). There was no significant difference for in-hospital mortality and percentage of patients transferred to ICU between the groups. Among 95 (8.3%) patients at moderate risk, in-hospital mortality and ICU transfer percentage were lower in the protocol group than in the pre-protocol group (2.9 vs 15.4%; P=0.026; RR 0.188, 95% CI 0.037%-0.968% and 8.7 vs 26.9%; P=0.021; RR 0.322, 95% CI 0.12-0.87, respectively). CONCLUSION: Implementing the NEWS with the hospital protocol did not change the overall patient's outcomes.

Effects of meal replacement therapy on metabolic outcomes in Thai patients with type 2 diabetes: A randomized controlled trial.

BACKGROUND: A meal replacement (MR) with a low glycemic index (GI) is possibly beneficial for glycemic control. However, the effects of MR on diabetes mellitus have not been studied among Thai patients with type 2 diabetes (T2DM). AIM: To compare metabolic outcomes between T2DM patients receiving the new MR formula (ONCE PRO) and normal controlled diets. METHODS: A multicenter, open-labeled, randomized controlled trial was conducted. Eligible patients received either ONCE PRO for one meal daily with controlled diets or only controlled diets for 3 months. The differences in metabolic profile between the baseline and end point of each group and between groups were measured. RESULTS: 110 participants were enrolled; the mean difference and standard deviation in hemoglobin A1C (HbA1c) (%) from baseline were -0.21 ± 0.78 (p = 0.060) and -0.27 ± 0.60 (p = 0.001) in the MR and control groups, respectively; however, there was no significant difference between groups (p = 0.637). Patients consuming a MR instead of breakfast had a significant decrease in HbA1c (p = 0.040). Body weight (BW) and body mass index (BMI) were significantly reduced in both groups. There were no significant change in waist circumference, fasting plasma glucose, total cholesterol and triglycerides. Low-density lipoprotein cholesterol (LDL-C) was significantly decreased in the MR group compared with the control group (p = 0.049). CONCLUSIONS: Short-term conventional diet control and the low-GI MR product were associated with a decreased BW and BMI. Changes in the other metabolic outcomes, HbA1c, total cholesterol and triglycerides, were comparable despite ONCE PRO as the MR having a better effect on LDL-C lowering.

Unusual manifestation of vitamin A deficiency presenting with generalized xerosis without night blindness.

Vitamin A deficiency from malabsorption syndromes, including bariatric surgery, has become an emerging problem in developed countries. Early detection and prompt treatment lead to rapid and complete recovery. Nevertheless, it may result in irreversible blindness or death if left untreated. Health care personnel should be aware of this condition.

Using Ice Cream for Diagnosis of Diabetes Mellitus and Impaired Glucose Tolerance: An Alternative to the Oral Glucose Tolerance Test.

BACKGROUND: Oral glucose tolerance test (OGTT) is a sensitive and reliable test for diabetes mellitus and impaired glucose tolerance (IGT). However, poor patient tolerance of glucose solutions is common. We aim to compare the diagnostic value of an ice cream test with a standard OGTT. MATERIALS AND METHODS: A total of 104 healthy adults were randomly assigned to either 75-g OGTT or ice cream, followed by a crossover to the other test. RESULTS: Most patients were females (71%). Mean age was 37 ± 12 years, and body mass index was 24.2 ± 3.9kg/m2. Diabetes mellitus and IGT, as diagnosed by 75-g OGTT, were 4.8% and 6.7%, respectively. The 2-hour plasma glucose levels were 110 ± 55.5mg/dL with 75-g glucose and 97.52 ± 40.7mg/dL with ice cream. The correlation coefficient of 2-hour plasma glucose for the 2 tests was 0.82 (95% CI: 0.75-0.87; P < 0.001). Discordant diagnostic results, based on 2-hour plasma glucose levels, were 9.61%. By using a combination of fasting plasma glucose and 2-hour plasma glucose values, the ice cream test would have missed 5.76% of those at high risk for diabetes mellitus (impaired fasting glucose and IGT) or diabetes. CONCLUSIONS: An ice cream test may serve as an alternative to a 75-g OGTT. Before applying this test in clinical practice, it needs to be validated in a larger population.

Vitamin D status is a determinant of skeletal muscle mass in obesity according to body fat percentage.

OBJECTIVES: Vitamin D deficiency is now being recognized as an emerging problem worldwide. Obesity has been found to be associated with lower serum 25-hydroxyvitamin D [25(OH)D] concentrations due to various mechanisms. There is increasing evidence showing the extraskeletal health benefit of vitamin D. Previous studies demonstrated the relationship between vitamin D and adiposity. However, the association between vitamin D status and skeletal muscle mass has not been established in healthy obese individuals in tropical countries. The aim of this cross-sectional study was to assess vitamin D status and its relationship to serum 25(OH)D concentrations and body composition, including skeletal muscle mass (SMM) and adiposity in healthy obese individuals without diabetes who live in Thailand, which is located near the equator. METHODS: We enrolled 163 obese Thai individuals (59.5% women) from the obesity clinic at the Ramathibodi Hospital, Mahidol University, in Bangkok, Thailand. RESULTS: The prevalence of vitamin D deficiency (<20 ng/mL) and vitamin D inadequacy (<30 ng/mL) were 49 (30.1%) and 148 (90.8%), respectively. In all, 98% of the individuals with body mass index >35 kg/m(2) had vitamin D inadequacy. Serum 25(OH)D concentrations were negatively associated with percent body fat (%BF) (r = -0.23; P = 0.003). Moreover, vitamin D status was positively associated with SMM (r = 0.18; P = 0.03) and the association remained after controlling for body fat mass and age (P = 0.003). Interestingly, in the individuals with lowest tertile of %BF, multiple linear regression analysis revealed that the significant positive predictors of %SMM were vitamin D status and male sex; the negative predictor was the body mass index after adjusting for age and exercise duration. CONCLUSIONS: Our study demonstrated the high prevalence of vitamin D deficiency in obese, Thai populations without diabetes. Vitamin D status was an independent predictor of %SMM of patients with lowest tertile of %BF. We speculated that adiposity might play a role in the relationship of vitamin D and SMM.

Low plasma zinc levels and immunological responses to zinc supplementation in HIV-infected patients with immunological discordance after antiretroviral therapy.

Immunological discordance in HIV-infected patients is associated with a higher risk of mortality and disease progression. Zinc is an essential micronutrient for immune function. A two-phase pilot study including a cross-sectional study to determine plasma zinc levels and a prospective, randomized, placebo-controlled trial to determine immunological responses after zinc supplementation was conducted in HIV-infected patients with immunological discordance in a medical school hospital. Immunological discordance was defined in patients who received antiretroviral therapy, had HIV RNA < 40 copies/mL, and a CD4(+) cell count < 200 cells/mm(3) that increased <30% from baseline after receiving ART with undetectable HIV RNA for 12 months. Of 31 patients, 12 (39%) had low plasma zinc levels (<75 µg/dL). Five of 12 patients with low plasma zinc levels and 8 of 19 patients with normal plasma zinc levels were randomized to receive zinc supplementation. The median changes in plasma zinc levels after supplementation versus placebo in patients with low plasma zinc levels were 29 versus 4.5 µg/dL, respectively. The CD4(+) cell count significantly increased (176 versus 250 cells/mm(3), P = 0.042) after zinc supplementation in patients with low plasma zinc levels. Further large-scale studies to determine long-term benefits of zinc supplementation in patients with immunological discordance are required.

Effect of daily egg ingestion with thai food on serum lipids in hyperlipidemic adults.

Thai food is one of the healthiest foods. In fact, several Thai dishes, such as Tom Yum soup, are currently under scientific study for their incredible health benefits. Limited data are available on the effects of egg consumption with Thai food in hyperlipidemic patients. To assess the effects of daily egg consumption with Thai food, which is known as low fat diet, on serum lipids profiles in hyperlipidemic subjects without medication treatment, the randomized crossover trial of 71 hyperlipidemic adults (8 men, 63 women) were randomly to one of the two sequences of one and three eggs/day for 4 weeks. Each treatment was separated by a four-week washout period (egg-free). Our data indicated that one or three eggs/day consumption were significantly increases total serum cholesterol (221.54 ± 42.54 and 225.31 ± 45.06 versus 211.57 ± 39.98 mg/dL) and LDL-C levels (141.38 ± 38.23 and 145.48 ± 39.33 versus 133.44 ± 34.52 mg/dL) as compared to egg-free period. No significant change of serum TG, HDL-C, TC/HDL-C, and LDL-C/HDL-C levels was observed after 1 or 3 eggs consumption daily in this study.

Essential fatty acid deficiency while a patient receiving fat regimen total parenteral nutrition.

A 32-year-old man was diagnosed with lymphoma and underwent Billroth's II operation because of upper gastrointestinal haemorrhage. Although the patient received fat regimen total parenteral nutrition (TPN), the patient developed typical skin rash of essential fatty acid deficiency after 2 weeks of starting TPN. The diagnosis was confirmed by biochemical and histological analyses. After increasing the lipid infusion, the rash was gradually improved with complete resolution after 19 days.