Geographical inequality in service utilization for primary aldosteronism screening: spatial epidemiological study in Southern Thailand.

BACKGROUND: Primary aldosteronism (PA), the most common cause of secondary hypertension is considered as a "major public health issue" due to higher risk of cardiovascular complications compared to blood-pressure-match hypertension and increase in prevalence around the world. In Thailand, though PA screening is provided under the universal health coverage, the service can be offered only at some centers. Hence, the service availability affects an accessibility of health care in patients. Our study aimed to evaluate the service utilization in PA screening and diagnosis in terms of geographical inequality in health resources in Southern Thailand. METHODS: Data of 688 patients who underwent PA screening from 2011 to 2017 were obtained from the electronic database of Songklanagarind Hospital, a super-tertiary center in this region. The patients' residence in the province, district and subdistrict were transformed to a 6-digit numbers corresponding to the global one (GADM©). The areas with PA screening and diagnosis were visualized by disease mapping procedures. A general log linear model was used to identify the factors affecting patient's service accessibility. RESULTS: From the geographic distribution, patients living in or near the area of the super-tertiary center (Songkhla) had high probability of receiving PA screening. The analysis of factors contributing to PA screening by multivariate log-linear model demonstrated that the distance from the super-tertiary center was a predictive factor for screening while the presence of endocrinologists and cultural differences were not. The chance of patients living in Songkhla, living less than 200 km, and more than 200 km from Songkhla to receive PA screening was 100, 82, and 66%, respectively. The crude incidence rate of PA in Southern Thailand was 1.66/106 person-years. The provinces located adjacent to the Andaman Sea had the highest incidences of PA (3.62-5.17 patients/106 person-years). CONCLUSIONS: There is still geographical inequality and the strategy to decrease the barrier should be resolved. The policymaker should develop a transfer system of blood tests for PA investigation from the local hospital to reduce the burden such as transportation costs in patients who live far away from the super-tertiary hospital. In addition, PA screening should be implemented in hypertension care plan.

Pituitary hyperplasia mimicking thyrotropin-producing pituitary adenoma in the patient with resistance to thyroid hormone: a case report.

The syndrome of inappropriate thyroid-stimulating hormone (TSH) secretion is characterized by high circulating thyroid hormone concentrations in the presence of non-suppressed TSH. After exclusion of the laboratory interference, TSH-secreting pituitary adenoma (TSHoma) or resistance to thyroid hormone-beta (RTH-ß) should be suspected. The presence of a pituitary adenoma on the hypothalamic-pituitary imaging supports the diagnosis of TSHoma. However, the incidental findings of non-functioning pituitary adenomas may appear in patients with RTH-ß. Abnormal MRI finding in the RTH-ß patient also includes pituitary enlargement from thyrotroph hyperplasia. We herein reported a patient with inappropriate TSH secretion who has pituitary hyperplasia mimicking TSHoma. This case illustrates the diagnostic tests to distinguish an RTH-ß from TSHoma.

A case report of successful identification of ectopic parathyroid adenomas with a sequence of selective parathyroid venous sampling and 4D-computed tomography in a patient with recurrent hyperparathyroidism.

INTRODUCTION: Recurrent hyperparathyroidism is difficult to manage due to the difficulty in finding the missing adenoma. Herein we present a case of recurrent hyperparathyroidism from ectopic adenomas which basic investigations failed to locate but were finally localized by a 4DCT following selective venous sampling (SVS) of parathyroid hormone (PTH). PRESENTATION OF CASE: A young female presented with recurrent hyperparathyroidism. She had severe primary hyperparathyroidism and temporary normocalcemia after first parathyroidectomy. Her hypercalcemia recurred and required second operation. However, the second operation was unsuccessful due to the pre-operation ultrasound, computed tomography (CT) neck, and sestamibi failed to identify the culprit parathyroid adenoma. After the second operation, positron emission tomography (PET), CT neck and sestamibi failed to identify the tumor but a sequence of SVS PTH and four-dimensional computed tomography (4DCT) successfully identified several ectopic adenomas. DISCUSSION: Ectopic parathyroid tissue is the most common cause of recurrent hyperparathyroidism but precisely locating these ectopic glands is often challenging. Despite modern modalities such as PET scans, the success rate is not impressive. SVS PTH is a good method to regionalize the ectopic source of PTH. With the more specified area, fine-tuning imaging with a 4DCT can identify the specific location of the ectopic parathyroid tissue. CONCLUSION: A sequence of SVS PTH followed by 4DCT could identify the exact location of ectopic parathyroid adenomas in a patient when conventional non-invasive imaging studies failed.

Glycemic effect of post-meal walking compared to one prandial insulin injection in type 2 diabetic patients treated with basal insulin: A randomized controlled cross-over study.

Studies demonstrate that post-meal walking decreases postprandial hyperglycemia in type 2 diabetic patients but it has never been tested with the active treatment comparator. The objective of this study was to determine the effect of post-meal walking on glycemic control compared with one prandial insulin in type 2 diabetic patients who failed basal insulin. A randomized controlled cross-over study of post-meal walking or one prandial insulin was done in type 2 diabetic patients who were being treated with basal insulin between May 2017 and March 2018. In post-meal walking group, patients walked after meal for 15-20 minutes one meal a day every day for 6 weeks. In prandial insulin (basal plus) group, one prandial insulin was injected before breakfast or main meal with rapid-acting insulin. The primary outcome was a difference in HbA1c reduction in post-meal walking compared with basal plus groups. Fourteen patients completed the study. By intention-to-treat analysis, HbA1c was reduced by -0.05(range:-1.08 to 0.74) and -0.19(range:-0.8 to 0.56) % in post-meal walking and basal plus groups respectively. By per-protocol analysis, post-meal walking and basal plus groups decreased HbA1c by 0.13(range:-0.74 to 1.08) and 0.2(range:-0.56 to 0.8) %, respectively. There was were no significant differences in HbA1c reduction from baseline in each group and between groups in both intention-to-treat and per-protocol analysis. Fructosamine levels were decreased by 17.5(-59 to 43) and 10(-15 to 40) µmol/L, respectively at 3 and 6 weeks in post-meal walking group whereas the respective changes in basal plus group were 12.5(-17 to 64) and 17.5(-28 to 38) µmol/L and there were no significant differences in fructosamine reduction from baseline in each group and between groups. In conclusion, although post-meal walking might be as effective as one prandial insulin to improve glycemic control in type 2 diabetic patients who failed basal insulin but the magnitude of reduction was small. A longer-term study with a larger sample size or with a different walking protocol is required.

Performance of the unilateral AV/IVC index in primary hyperaldosteronism subtype prediction: A validation study in a single tertiary centre.

BACKGROUND: Failure of cannulation of the right adrenal vein is frequent during AVS for investigation of primary aldosteronism (PA). The aldosterone:cortisol ratio of either adrenal vein compared with the inferior vena cava (AV/IVC index) has been proposed to differentiate between unilateral and bilateral disease, and aid in lateralization of unilateral disease. METHODS: Sixty-two patients with unilateral or bilateral PA identified by either successful bilateral (45 patients) or unilateral (17 patients) adrenal vein cannulation, and with biochemical remission following surgery were enrolled into the analysis. The diagnostic performances of the previously identified AV/IVC index cut-offs of ≥5.5 to predict ipsilateral disease and ≤0.5 to predict contralateral disease were validated using data from the entire cohort. RESULTS: Fifty-three patients had unilateral PA and 9 patients bilateral PA. The area under ROC curve (AUROC) of the AV/IVC cut-off ≤0.5 for identifying unilateral aldosterone secretion from the contralateral adrenal was 0.95 (95% CI; 0.88-0.99), whereas the AUROC of the AV/IVC cut-off ≥5.5 for identifying unilateral aldosterone secretion from ipsilateral adrenal was 0.96 (95% CI; 0.92-0.99). The AV/IVC index cut-off value of 0.5 had 93% sensitivity and 91% specificity, and the AV/IVC index cut-off value of 5.5 had 21% sensitivity and 100% specificity. The optimal AV/IVC cut-offs to achieve 100% specificity for our cohort were >2.4 and <0.1 to predict ipsilateral and contralateral disease. CONCLUSION: Our data confirm that the AV/IVC index is a potential tool for subtype classification and lateralization in patients with PA in the setting of failed bilateral, but successful unilateral, adrenal vein cannulation during AVS.

Construction of a predictive scoring system as a guide to screening and confirmation of the diagnosis of primary aldosteronism.

BACKGROUND: Primary aldosteronism (PA) is the most frequent cause of secondary hypertension. In Southern Thailand, the aldosterone-renin ratio (ARR) is only available within a small number of tertiary centres, necessitating need for a simple clinical assessment to determine the requirement for ARR. OBJECTIVE: This study aimed to identify predictive factors for the diagnosis of PA and generate a predictive scoring system (PSS) for use in screening and diagnosis of PA. PATIENTS AND METHODS: A total of 420 patients aged >15 years with paired plasma aldosterone concentration and plasma renin activity values allowing calculation of ARR were identified from the electronic hospital database between 2011 and 2016. RESULTS: The overall prevalence of PA was 16.7% (range; adrenal incidentaloma 5.6% to hypokalaemia 30%). Predictive factors for diagnosis of PA were as follows: age <60 years, BMI < 25 kg/m2 , presence of diabetes, ≥3 antihypertensive agents, serum sodium ≥ 141 mmol/L and serum potassium < 3.5 mmol/L. A predictive scoring system (PSS) (range -2 to 13) was generated by the coefficients of the variables with ROC curve AUC 0.87 [95% CI: 0.83-0.91]. Using the PSS, a total score <4 provided a robust negative predictive value (sensitivity, 0.97; specificity, 0.48; NPV, 0.99; PPV, 0.27) for PA. In patients at high risk of PA (PAC > 15 ng/dL and PRA < 1.0 ng/mL/hr), a PSS score > 9 had specificity and PPV of 100%, essentially confirming PA in these individuals. CONCLUSION: The proposed PSS for PA will enable more focused and cost-effective use of ARR screening and confirmatory testing. In our cohort, 40% and 42% of patients would not require ARR screening or confirmatory tests, respectively.

Lack of associations between thyroid function and obstructive sleep apnea severity in adults with prediabetes and diabetes mellitus.

PURPOSE: Hypothyroidism is associated with a high frequency of obstructive sleep apnea (OSA). However, the prevalence of OSA in hypothyroid patients is not different from the general population in many reports. The importance of thyroid function screening in sleep-disordered breathing is still controversial. This study aimed to explore the association between thyroid dysfunction and OSA in the adults with prediabetes or diabetes mellitus type 2, who have very high prevalence of OSA. METHODS: OSA was assessed using an in-home monitoring device, WatchPAT200. OSA severity was measured using apnea-hypopnea index (AHI), oxygen desaturation index (ODI), minimum oxygen saturation (minO2), and time spent under oxygen saturation < 90% (T90). Patients with pre-existing thyroid dysfunction were excluded. RESULTS: Participants included 70 men and 118 women with mean age 52.8 ± 10.9 years and body mass index 28.2 ± 4.9 kg/m2. One hundred forty participants (75%) had OSA, with a median AHI of 10.1 (interquartile range 4.8, 18.3). The percentage of positive thyroid autoantibody (thyroperoxidase and thyroglobulin antibody) was similar among the subjects with and without OSA. There was no correlation between the levels of thyroid function (TSH, FT3, FT4, TSH/FT3, and TSH/FT4 ratio) and the severity indices of OSA (AHI, ODI, minO2, and T90). CONCLUSIONS: These data do not support universal screening for thyroid dysfunction in OSA patients with diabetes or prediabetes.

A Comparison of Residents' Knowledge Regarding the Surviving Sepsis Campaign 2012 Guideline.

BACKGROUND: Recently, Surviving Sepsis Campaign (SSC) guideline was updated. Our objective was to evaluate the knowledge of residents in different departments regarding the SSC 2012. METHODS: A cross-sectional, descriptive self-questionnaire was distributed to interns and residents in the Departments of Internal Medicine, Surgery, and Emergency Medicine. RESULTS: The response rate was 136 (89%) from 153 residents. The residents included 46 (33%) interns, 42 (31%) internal medicine residents, 41 (30%) surgical residents, and 7 (5%) emergency residents. Regarding the definitions of severe sepsis and septic shock, only 44 (32.4%) residents were able to differentiate the severity of sepsis. The surgical residents had a significantly lower rate of correct answers than that of internal medicine residents (12.2% vs. 45.2, P = 0.001), emergency residents (12.2% vs. 57.1%, P = 0.005), and interns (12.2% vs. 34.8%, P = 0.014). Only 77 (51.5%) residents would measure blood lactate in patients with sepsis. In respect to the dose of fluid resuscitation, only 72 (52.9%) residents gave the recommended fluid (30 ml/kg) within the first 3 h. Surgical residents had a significantly lesser percentage of correct answers than that of internal medicine residents (29.3% vs. 69%, P < 0.0001) and interns (29.3% vs. 60.8%, P = 0.003). About 123 (90.4%) and 115 (84.6%) residents knew the appropriate targets for mean arterial pressure and vasopressors, respectively. Most residents could give antimicrobial drugs (73.5%) and steroids (93.4%) appropriately in the treatment of patients with septic shock. However, only half of the residents knew the target range of blood sugar control in patients with sepsis. CONCLUSIONS: Our residents' knowledge about the SSC 2012 is not satisfactory. Further instruction concerning sepsis management is required.