Prolonged Honeymoon Period in a Thai Patient with Adult-Onset Type 1 Diabetes Mellitus

Context. The “honeymoon” phase among people with type 1 diabetes mellitus (T1DM) refers to the period (mostly less than 1 year) in which beta-cells remain functional and are able to produce insulin to maintain good glycemic control shortly following the development of diabetes. This phenomenon is still not completely understood. Previous studies have shown that the absence of diabetic ketoacidosis (DKA) at initial presentation, short duration of symptoms, older age at presentation, and strenuous exercise could be potential factors that influence the honeymoon phase. Objective. To describe a usual case of adult-onset T1DM with prolonged honeymoon period for more than 5 years. Methods. Repeated mixed meal stimulation tests for a period of 6–12 months together with monitoring pancreatic autoantibodies and laboratory data were followed following the onset of diagnosis. Results. We report a 24-year-old Thai patient with T1DM with sustained remission without antidiabetic medication for more than 5 years while maintaining low-carbohydrate intake and regular exercise. Repeated mixed meal stimulation tests for a period of 6–12 months revealed preserved beta-cell functions. Interestingly, repeated pancreatic autoantibodies at 5 years after diagnosis still showed positive anti-GAD, anti-IA2, and anti-ZnT8. Conclusion. Restored beta-cell function with complete insulin withdrawal in new-onset T1DM has been reported in very few cases with some common factors as in our patient (low-carbohydrate intake with regular exercise). Delaying autoimmune activity by reducing metabolic load in newly diagnosed T1DM might play a role in maintaining the honeymoon period and could lead to an innovative therapeutic option in new-onset T1DM.

Prolonged Honeymoon Period in a Thai Patient With Adult-Onset Type 1 Diabetes Mellitus - Metabolic Flexibility in Autoimmune Diabetes?

Background: ‘Honeymoon’ period among people with type 1 diabetes mellitus (T1DM) refers to the period of time (mostly less than 1 year) which beta-cell is still able to produce insulin to maintain good glycemic control shortly following the development of diabetes. This phenomenon remained incompletely understood but previous studies showed that absence of diabetic ketoacidosis (DKA) at initial presentation, short duration of symptoms, older age at presentation, and strenuous exercise could be potential factors. Herein, we report a 24-year old Thai patient with T1DM who has been in sustained complete remission for more than 5 years while he is maintaining low carbohydrate intake and regular exercise. Clinical Case: A 24-year-old male presented with a 6-month history of polyuria, polydipsia and weight loss of 15 kilograms (baseline BMI at 27.8 kg/m2). His initial laboratory data showed plasma glucose 398 mg/dL and A1C 9.3%. No ketonemia was found. He was diagnosed with stage 3 of Type 1 DM based on clinical presentation and positive pancreatic auto-antibodies (anti-GAD and anti-IA2). Euthyroid Hashimoto’s thyroiditis was also diagnosed based on his enlarged thyroid gland and positive thyroid auto-antibodies. He was started on basal-bolus insulin regimen for only 2 month and then A1C reversed to 5.9% within 2 months. Insulin was gradually withdrawn and completely stopped. Mixed meal stimulation test (MMST) was firstly evaluated at the second year of his diagnosis. The result revealed stimulated C-peptide at 5.5 ng/dL. Next-generation sequencing panel for monogenic diabetes revealed negative results. The patient maintains healthy lifestyle habit with low carbohydrate intake and regular exercise 5–6 times per week. His body weight was maintained at 60–63 kilograms during the past 4 years. His A1C was maintained between 5.0 to 6.0% without any anti-diabetic medication for more than 5 years. Repeated MMST in every 6–12 months still revealed preserved beta-cell functions and normal stimulated plasma glucose. Interestingly, repeated pancreatic auto-antibodies at 3 years after diagnosis showed negative anti-GAD and anti-IA2, but positive anti-ZnT8. The patient was advised to maintain his bodyweight and healthy behavior together with closely regular OPD follow-up. Conclusion: Restored beta-cell function with completely insulin withdrawal in new-onset T1DM has been reported in very few cases which have some common factors as in our patient (low carbohydrate intake with regular exercise). Delaying autoimmune activity by reducing metabolic load in newly diagnosed T1DM might play a role in maintaining a honeymoon period and could lead to an innovative therapeutic option in new-onset T1DM.

NoduleNet: A Lung Nodule Classification Using Deep Learning

Background: Accurate detection and classification of lung nodules at an early stage can help physicians to improve the treatment outcomes of lung cancer. Several lung nodule classifications using deep learning have been proposed but they are lag of external validation to Thai patient data. Objective: To propose a deep learning model called NoduleNet for lung nodule classification and perform internal and external validation of the proposed model. Methods: Two datasets were performed; internal validation using LUNA16 (the public lung CT database), and external validation using ChestRama (37 chest CT scans retrospectively identified from the CT database of Ramathibodi Hospital between 2017 and 2019). The NoduleNet was built on top of pretrained architecture, VGG16, and VGG19 with customization. Results: The NoduleNet showed impressive results in nodule classification. The best model achieved accuracy of 0.95 (0.94 - 0.96), sensitivity of 0.84 (0.82 - 0.86), and specificity of 0.97 (0.97 - 0.98) for internal validation, where the external validation results was accuracy of 0.95 (0.87 - 1.00), sensitivity of 0.91 (0.82 - 1.00), and specificity of 1.00 (1.00 - 1.00). There were 3 misclassified samples in external validation which are all false-negative. Conclusions: The NoduleNet is able to generalize from non-Thai patient data to Thai patient data. It could be further improved by taking sequence of images into account, integrating with an automatic nodule detection algorithm, and adding more nodule types.

Effects of a Transitional Telehealth Program on Functional Status, Rehospitalization, and Satisfaction With Care in Thai Patients with Heart Failure

Limited functional status is a common health problem in patients living with heart failure (HF), which often requires rehospitalization.Home-based transitional telehealth programs (TTPs) focused on health monitoring, education, promotion of self-management, and multidisciplinary team consultation have been shown to improve functional status and satisfaction with care while reducing rehospitalization rates in this population. Nonetheless, these variables and outcomes have yet to be assessed in a Thai patient with HF. Thus, the aim of this study was to investigate the effectiveness of a TTP on functional status, rehospitalization, and satisfaction with care in Thai patients with HF. Eligible participants (N = 146) were randomly assigned to either the control or TTP group. The TTP included in-hospital discharge planning and 6-week telemonitoring via a mobile phone application to provide follow-up home care. Data on the outcome variables were collected at 6 and 8 weeks post-enrollment and analyzed by descriptive statistics, independent t-tests, repeated measures ANOVA, and Z-tests. Functional status and satisfaction with care scores in the TTP group were significantly higher than those of the control group, and rehospitalization rates in the TTP group were significantly lower than those of the control group at 6 and 8 weeks post-enrollment. Thus, the TTP effectively improved functional status, increased satisfaction with care, and reduced rehospitalization rates in Thai patients with HF. TTP implementation could be considered to improve the quality of transitional care in Thailand.

Ablepharon macrostomia syndrome in a Thai patient: case report and literature review

Ablepharon macrostomia syndrome (AMS) is a rare congenital disorder. To our knowledge, only 20 cases have been reported to date, and all in patients from Western countries. We report a case of AMS in a Thai patient, who presented at age 3 months with severe ectropion of both upper and lower eyelids, alopecia totalis, no palpable clitoris, and hypoplasia of both labia minora and labia majora. Trio whole exome sequencing analysis was performed, which revealed a heterozygous missense c.223G>A (p.Glu75Lys) variation in TWIST2. To our knowledge, this is the first reported case of AMS in a patient from Thailand and the first reported case of AMS in Asia.

Chronic Dyspepsia Due to an Unusual Cause Outside the Gastrointestinal Tract: A Case Report

The majority of cases with dyspepsia usually have normal gastroscopic finding, so some unusual causes may be easily neglected under the umbrella of nonulcer dyspepsia as in this case. We report a 64-year-old Thai patient who suffered from dyspepsia and fatigue for many years. Her latest physical examination was unremarkable. Although she did not have any warning signs, many abdominal investigations including the ultrasonography, computerized tomography, barium enema with air contrast, esophagogastroduodenoscopy, and colonoscopy were repeatedly performed in different hospitals and all revealed unremarkable. The last esophagogastroduodenoscopy showed only mild acute gastritis that was not expected to account for the many-year dyspepsia and fatigue. The unusual and rare causes of long term dyspepsia were extensively investigated. Finally, she was found to have serum cortisol less than 0.8 , normal serum calcium, phosphorus, and electrolytes but minimally abnormal thyroid function test. Therefore, she was diagnosed as having adrenal insufficiency and concurrent subclinical hyperthyroidism. She was fully treated with many dyspeptic drugs such as pantoprazole, sucralfate, simethicone, ondansetron, and intravenous hydrocortisone infusion 300 mg a day. She responded well to therapy in 2 days and was discharged home with oral prednisolone 15 mg a day with many dyspeptic drugs. Adrenal insufficiency is a very rare entity and most cases have no specific signs and symptoms, so it could be easily overlooked as the very rare and unusual cause of chronic dyspepsia. In this report, the association between the adrenal insufficiency and the gastrointestinal upset is discussed.

Dominant β-thalassaemia with unusually high Hb A2 and Hb F caused by βCD121(−G) (HBB:c.364delG) in exon 3 of β-globin gene

We describe a dominant β-thalassaemia caused by a deletion of G at nucleotide position 364 in exon 3 of the β-globin gene. The heterozygosity of this mutation was found in a 36-year-old Thai patient who had moderate hypochromic microcytic anaemia with haemolytic blood picture. Haemoglobin (Hb) analysis revealed relatively higher Hbs A2 (6.8%) and F (4.7%) as compared with those of β0-thalassaemia (n=278) and β+-thalassaemia (n=55) carriers in our series. Secondary structure prediction of the elongated β-globin chain showed that the α-helix at the C-terminal is disrupted dramatically by the random coil and β-sheet, which should result in a highly unstable β-globin variant, undetectable in peripheral blood and a dominant clinical phenotypic feature.

A somatic PIK3CA p.H1047L mutation in a Thai patient with isolated macrodactyly: a case report

Background Macrodactyly is a rare congenital deformity characterized by gigantism of all structures of the digits. Previous reports showed that the mosaic PIK3CA variants were associated with overgrowth syndromes including macrodactyly. Objectives To determine the genetic alteration in a Thai patient with enlarged soft tissue of the left middle and left fourth fingers with abnormal enlarged phalanges. Method A nerve and a skin piece were separated from a therapeutically surgically removed part of the enlarged digit. Skin fibroblasts were cultured from the removed skin piece. DNA was isolated from the nerve tissue, cultured skin fibroblasts, and peripheral blood leukocytes. Polymerase chain reaction (PCR) followed by Sanger sequencing of PIK3CA was performed. Results Mutation analysis revealed the c.3140A>T (p.(H1047L)) variant of PIK3CA in the nerve tissue and the cultured dermal fibroblasts but not in leukocytes from the peripheral blood. Conclusion The somatic c.3140A>T (p.(H1047L)) variant of PIK3CA was found in a Thai patient with isolated macrodactyly, the same as those previously identified in other populations.