Establishing apomorphine treatment in Thailand: understanding the challenges and opportunities of Parkinson's disease management in developing countries.

INTRODUCTION: The increasing global burden of Parkinson's disease (PD) poses a particular challenge for developing countries, such as Thailand, when delivering care to a geographically diverse populace with limited resources, often compounded by a lack of expertise in the use of certain PD medications, such as device-aided therapies (DAT). AREAS COVERED: A panel of local, regional, and international PD experts convened to review the unmet needs of PD in Thailand and share insights into effective delivery of DAT, focusing on experience with apomorphine infusion. Despite its proven efficacy and safety, implementation of apomorphine infusion as a new option was not straightforward. This has prompted a range of health-care professional and patient-focused initiatives, led by the Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders in Bangkok, to help establish a more coordinated approach to PD management throughout the country and ensure patients have access to suitable treatments. EXPERT OPINION: Overcoming the challenges of education, proficiency, resource capacity and standard of care for PD patients in developing countries requires a coordinated effort both nationally and beyond. The best practices identified in Thailand following the introduction of apomorphine infusion might be helpful for other countries when implementing similar programs.

Infectious causes of encephalitis and meningoencephalitis in Thailand, 2003-2005.

Acute encephalitis is a severe neurologic syndrome. Determining etiology from among ≈100 possible agents is difficult. To identify infectious etiologies of encephalitis in Thailand, we conducted surveillance in 7 hospitals during July 2003-August 2005 and selected patients with acute onset of brain dysfunction with fever or hypothermia and with abnormalities seen on neuroimages or electroencephalograms or with cerebrospinal fluid pleocytosis. Blood and cerebrospinal fluid were tested for >30 pathogens. Among 149 case-patients, median age was 12 (range 0-83) years, 84 (56%) were male, and 15 (10%) died. Etiology was confirmed or probable for 54 (36%) and possible or unknown for 95 (64%). Among confirmed or probable etiologies, the leading pathogens were Japanese encephalitis virus, enteroviruses, and Orientia tsutsugamushi. No samples were positive for chikungunya, Nipah, or West Nile viruses; Bartonella henselae; or malaria parasites. Although a broad range of infectious agents was identified, the etiology of most cases remains unknown.

The usage of proton magnetic resonance spectroscopy in Parkinson's disease.

BACKGROUND: Parkinson's disease is a degenerative disorder of the central nervous system resulting from neuronal loss in the substantia nigra (a region of the mid brain) and BSG. Proton magnetic resonance spectroscopy (1H-MRS) has been previously performed in Parkinson's disease (PD) to evaluate in vivo concentration of basal ganglia (BSG) and cerebral cortex metabolites. However this technique has never been used to evaluate the substantia nigra (SN) in PD patients. In this preliminary report, single voxel MRS of BSG and SN was performed in PD and normal control (non-PD) to evaluate the usage of MRS in PD patients. MATERIAL AND METHOD: Seventeen PD patients including 12 men and five women with a mean age 60.5 years (SD 9.4) and a mean duration of the disease 5.9 years (SD 4.2) based on Hoehn & Yahr stage I to III, and 14 healthy age-matched controls including eight men and six women with a mean age 55.5 years (SD 5.8) were enrolled. Patients with evidence of brain atrophy and cognitive impairment were excluded. RESULTS: A significant reduction in the NAA/Cr ratio was observed in the SN ofPD compared with controls (p < 0.05). BSG spectra did not allow any evaluation due to the presence of artifacts related to inorganic paramagnetic substances. CONCLUSION: 1H-MRS could be used as a sensitive tool for studying neuronal dysfunction in SN of PD patients and may be a useful technique to monitor the disease. The SN reduction of NAA/Cr ratio in PD patients may be the marker of neuronal loss in SN of patients with PD.

Japanese encephalitis virus remains an important cause of encephalitis in Thailand.

BACKGROUND: Japanese encephalitis virus (JEV) is endemic in Thailand and prevention strategies include vaccination, vector control, and health education. METHODS: Between July 2003 and August 2005, we conducted hospital-based surveillance for encephalitis at seven hospitals in Bangkok and Hat Yai. Serum and cerebrospinal (CSF) specimens were tested for evidence of recent JEV infection by immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) and a plaque reduction neutralization test (PRNT). RESULTS: Of the 147 patients enrolled and tested, 24 (16%) had evidence of acute flavivirus infection: 22 (15%) with JEV and two (1%) with dengue virus. Of the 22 Japanese encephalitis (JE) cases, 10 (46%) were aged ≤ 15 years. The median length of hospital stay was 13 days; one 13-year-old child died. Ten percent of encephalitis patients enrolled in Bangkok hospitals were found to have JEV infection compared to 28% of patients enrolled in hospitals in southern Thailand (p < 0.01). Four (40%) of the 10 children with JE were reported as being vaccinated. CONCLUSIONS: JEV remains an important cause of encephalitis among hospitalized patients in Thailand. The high proportion of JE among encephalitis cases is concerning and additional public health prevention efforts or expanded vaccination may be needed.

Cerebral venous sinus thrombosis in severe malaria.

Cerebral venous sinus thrombosis has been reported to be associated with various systemic illnesses and infections, including severe malaria. We report here a 43 year-old Thai male presenting with fever and seizures. He was diagnosed as and treated for severe falciparum malaria. After gaining consciousness he developed focal neurological signs and evidence of increased intracranial pressure. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain revealed a mid-superior sagittal sinus thrombosis with venous infarction. Investigations for other infections and thrombophilia were negative. The patient denied anticoagulant treatment. The clinical status and radiologic findings improved gradually. Physicians who care for malaria patients need to be aware of this rare complication when a malaria patient presents with focal neurological signs.

Necropsy in HIV-infected patients.

Human immunodeficiency virus (HIV)infection is usually followed by opportunistic infections, especially in the full-blown acquired immunodeficiency syndrome (AIDS). This study details the histopathological changes of different organs in relation to HIV infection, with particular emphasis on the opportunistic infections. Various organs from seventeen HIV-infected patients were collected by necropsy and analyzed for histopathological changes. The major histopathological changes included cytomegalovirus infection, cryptococcosis, penicilliosis, bacterial pneumonia, cryptosporidiosis, pneumocystosis, candidiasis, tuberculosis, granulomatosis of unknown etiology, early cirrhosis and chronic active hepatitis. General organ changes from seventeen cases of HIV-infected patients were described and discussed.