Vajira Medical Journal: Journal of Urban Medicine

e266163

Authors: Phanthaphan Sureeyathanaphat, Padoemwut Teerawongsakul, Teetouch Ananwattanasuk

OBJECTIVE: Warfarin is primarily used for stroke prevention in atrial fibrillation (AF) patients in Thailand. Novel oral anticoagulants (NOACs) are used less commonly due to their high cost. This study aimed to evaluate the appropriate use of anticoagulants and clinical outcomes among nonvalvular AF (NVAF) patients. METHODS: This retrospective study collected data from the electronic medical records of patients who were diagnosed with NVAF between January 2014 and December 2019 at the Faculty of Medicine, Vajira Hospital. Baseline characteristics, prescribed indication, types and doses of anticoagulant, and ischemic and hemorrhagic outcomes were recorded and analyzed. RESULTS: We analyzed 783 patients with NVAF in this study. Of these, 539 (68.90%) were treated with oral anticoagulants (OAC), including 344 patients (43.90%) with warfarin therapy and 195 (24.90%) with NOACs. Meanwhile, 492 (73.10%) patients with CHA2DS2VASC score ≥ 2 received OAC therapy that was suitable for their indication. Of the 344 patients who received warfarin, 112 patients (32.60%) had an optimal time in therapeutic range (TTR) level of ≥ 65%. Of the 195 NOAC patients, only 98 (50.30%) received appropriate doses of NOACs. There was no statistically significant difference in the overall incidence rates of ischemic stroke/systemic embolism, bleeding, cardiovascular death, and all-cause death between the warfarin and NOACS groups. Appropriate TTR levels in the warfarin group was associated with significantly lower incidence rates of cardiovascular death (hazard ratio: 0.14; 95% CI: 0.02–0.79; p = 0.02) and all-cause death (hazard ratio: 0.36; 95% CI: 0.12–0.87; p = 0.01), than inappropriate TTR levels. CONCLUSION: Most NVAF patients received oral anticoagulants with the appropriate indication. Warfarin is the most prescribed oral anticoagulant for patients with NVAF. About half of the patients received inappropriate doses of oral anticoagulants that potentially adversely affected the study outcomes of cardiovascular and all-cause deaths.

e266185

Authors: Ingkarat Sarutipaiboon, Rungtiwa Dangtakot, Sudaluck Thunyaharn, Somchai Pinlaor, Ornuma Haonon

OBJECTIVE: To investigate the effect of a combination of a high dose of monosodium glutamate (MSG) and chronic Opisthorchis viverrini (O. viverrini) infection on kidney pathology and microbiota changes compared to either factor alone. METHODS: Forty male golden hamsters were divided into four groups (10 hamsters per group): non-infected hamsters fed with standard diet (NC), O. viverrini infected hamsters fed with standard diet (OV), non-infected hamsters fed with high doses of MSG in drinking water (MS), and O. viverrini infected hamsters fed with high doses of MSG in drinking water (OM). After 8 months, fecal samples were collected, DNA extracted and subjected to 16S-rRNA sequencing analysis to determine microbial diversity. Kidneys were also collected for histopathological study. RESULTS: Kidney histopathology showed tubular damages and tubular fibrosis were significantly prominent in the OM group, which showed higher pathology changes than in the OV group or MS groups. Next generation sequencing indicated that the levels of Firmicutes to Bacteroides ratio decreased in the OV group (0.28), MS group (0.43) and OM group (0.43) respectively when compared to control group (0.52). In genus levels, Methanobrevibacter, Ruminococcus_1, Escherichia-Shigella, Bacteroides, Akkermansia and Oligella were abundance in the OM group. CONCLUSION: The changing of gut microbiota distribution and kidney pathology changes were more severe in the cases of O. viverrini infection together with MSG consumption. This study provides a first step towards focusing on diet and parasitic infections.

e266094

Authors: Somchai Taosuwan, Varah Yuenyongviwat

Treating femoral neck fractures in the elderly demands careful strategies for optimal results. This review explores into the roles of total hip arthroplasty (THA) and bipolar hemiarthroplasty (BHA) in addressing these fractures, considering their distinct advantages. THA, catering to active elderly patients, delivers excellent pain relief, enhanced mobility, and sustained functionality. In contrast, BHA presents a more conservative option suitable for less mobile patients. Factors like surgery time and dislocation risks play a crucial role in selecting between the two options, while postoperative complications, including infections and joint issues, significantly impact recovery. Adequate post-surgical care and advancements in techniques are pivotal for overcoming these challenges. Continuous research and enhancements in diagnostic methods and post-surgical care are critical for refining strategies, ultimately improving the recovery and quality of life for elderly patients.

601-610

Authors: Areeya Jirathananuwat, Thira Woratanarat, Pramote Papukdee

OBJECTIVE: This study aimed to survey the health status of undergraduates during the outbreak of COVID-19 in Thailand. METHODS: This cross-sectional descriptive study recruited undergraduate students from a university in an urban area in Thailand. The survey was conducted online by the electronic mailing of questionnaires to the studied participants. The daily health behaviors questionnaire, the 28-item General Health Questionnaire (Thai GHQ28), and the participants’ satisfaction with the online learning questionnaire were used in this study. RESULTS: There was a total of 390 undergraduate students who participated and responded to the survey. The results showed they scored poorly in the areas of controlling food consumption, such as salt and sweet intakes, and exercise or continuous movement. The majority of the surveyed students (303 out of 390 students or 77.7% of the total) have shown a normal health status in response to the Thai GHQ28 except for social dysfunction. There was a strong association between daily health behaviors (p = 0.015) and general health (p = 0.019) status with the online satisfactory level. CONCLUSION: At-home online learning was found to be directly associated with the health behaviors and the health status of the surveyed students. Based on the findings, counseling centers should be set up to offer advice to students on how to stay healthy and socially connected during the online learning period.

621-630

Authors: Suphakrit Limpornpugdee, Panida Thanawirattananit, Kwanchanok Yimtae, Nichtima Chayaopas, Aroonsri Priprem, Cheardchai Soontornpas, Rattapol Uppala, Yuttapong Wongswadiwat, Supawan Laohasiriwong

OBJECTIVE: To compare the success rate of auditory brainstem response (ABR) testing after the application of melatonin niosome gel (MNG) versus chloral hydrate in children aged 1 to 6 years. METHODS: A double-blinded, randomized, controlled trial was conducted. Participants in the MNG group were given 250 mg of MNG (5 mg melatonin) for sedation prior to the ABR test, and those in the chloral hydrate group were given chloral hydrate syrup, 50 mg/kg with an additional dose of 25 mg/kg if they didn’t fall asleep within 30 min. The study was conducted in the morning; all the participants were prepared in accordance with protocols similar to the regular ABR protocols. RESULTS: Twenty-four children were enrolled, and 16 participants passed the screening and were randomized into 2 groups. The success rate of ABR in the MNG group was 25.0% compared to 100.0% in the chloral hydrate group (p-value = 0.01). Twenty-five percent of the subjects in the chloral hydrate group required a second dose of choral hydrate. The average sleep onset latency of the chloral hydrate group was 25.1 min, which was approximately the same as the MNG group (25.4 min). The average sleep duration of the chloral hydrate group was 89.3 min, which was significantly longer than the MNG group (45.6 min), with a mean difference of 43.6 min (p-value = 0.01). There were minor adverse events in both groups, including vomiting (12.5 – 25.0%) and irritability (25.0%), without any serious adverse events reported. CONCLUSION: The sedative effect of trans-mucosal MNG was unfavorable comparing with the chloral hydrate. The sublingual delivery was intolerance for uncooperative children and sedation for neurodevelopment disordered children were challenging. However, the sleep onset latency by behavioral observation induced by MNG tended to be comparable to chloral hydrate. Further adjustment of trans-mucosal administration and dosage could provide adequate pediatric sedation.

641-646

Authors: Pichayut Wattanapreechanon, Natthapong Hongku

A ruptured pseudoaneurysm is a rare but potentially fatal complication during revision total hip arthroplasty. We report a case of a 46-year-old female with a rupture of a pseudoaneurysm at the branch of the left profunda femoral artery during revision total hip arthroplasty. The patient presented with dislocation of the left total hip arthroplasty, which failed closed reduction. During the revision surgery, a massive pulsatile bleeding occurred, which required an emergent vascular surgeon consultation to repair the ruptured pseudoaneurysm. It was later confirmed to be located at the branch of the left profunda femoral artery. Although rare, we recommend performing pre-operative CT angiography and consulting with a vascular surgeon before attempting revision total hip arthroplasty in patients with atypical symptoms, such as unusual thigh swelling and unexplained anemia.

549-556

Authors: Kesinee Leedumrongwattanakul, Apisit Leedumrongwattanakul

OBJECTIVE: The objective of this study was to investigate the prevalence, types, and risk factors of chronic heart failure in Thai patients with end-stage kidney disease (ESKD). METHODS: In this retrospective study, the authors examined patients with clinical heart failure in ESKD at Pranangklao Hospital between January 2021 and May 2022. RESULTS: The study enrolled a total of 128 patients, with an average age of 58.82 ± 14.44 years, of which 56.30% were male. The average body surface area was 883.48 ± 398.41 m2. The majority of patients received hemodialysis (65.60%). Hypertension and dyslipidemia were the most common comorbidities, and folic acid and statins were the most commonly prescribed medications. There were no statistically significant differences in left ventricular ejection fraction between patients receiving hemodialysis versus peritoneal dialysis. The study found that among the 3 different heart failure groups by left ventricular ejection fraction (LVEF) (LVEF < 40%, 41-49%, > 50%), the LVEF was 10 (7.81%), 7 (5.46%), and 111 (86.73%), respectively. Similarly, the diastolic function grades (grade I, II, III) were 62 (55.86%), 46 (41.44%), and 3 (2.70%), respectively. Patients with coronary artery disease had a significantly lower left ventricular ejection fraction. CONCLUSION: Diastolic dysfunction and grade I diastolic dysfunction are common in Thai patients with ESKD.

565-574

Authors: Chavisa Bunyavee, Kornwipa Hemarat

OBJECTIVE: To address the incidence, treatment outcomes, and risk factors of retinopathy of prematurity (ROP). METHODS: The medical records were retrospectively reviewed of preterm infants who were examined for ROP at Vajira Hospital during 2015-2020. All demographic data, prenatal, postnatal conditions, ophthalmic findings, and treatment were collected. RESULTS: Of 142 screened infants, 54 infants (38%) had ROP and 28 of them had sight-threatening ROP (24 infants with prethreshold type 1; 4 infants with prethreshold type 2). All ROP infants were born with a gestational age of fewer than 30 weeks or birthweight less than 1500 g. In multivariate analysis, low gestational age (≤ 30 weeks) and hypoglycemia were associated with any stage of ROP development. While duration of endotracheal intubation of more than 30 days and inguinal hernia were independently associated with severe ROP. Most ROP infants were finally regressed. Only 4 infants were referred out for vitreoretinal surgery. CONCLUSION: The overall ROP incidence was 38%. Even though a majority of ROP patients recovered, recognizing possible factors helped in ROP detection and progression awareness.

583-588

Authors: Pich Paholpak

Diabetes is a non-communicable disease that has become an epidemic in many countries around the world, with a significant increase in the number of cases. Patients are required to have good glycemic control and maintain a normal level of HbA1c. However, some patients are still uneducated and uninformed about their conditions, resulting in ineffective planning and treatment. Diabetes self-management and support (DSMES) is a service that can help patients practice their decision-making and goal-setting skills and improve their quality of life. DSMES can come in various styles, including websites, digital applications, and gamification. Each method has a different approach to patients in terms of the process; however, they share a common theme of patient-centered service.

499-506

Authors: Chakrit Eaimkijkarn, Radchapoom Ketkaew

OBJECTIVE: Lymphangitis is a complication often found in lymphedema. It affects patient’s quality of life, morbidity, cosmetic, and functional ability. Potential risk factors of lymphangitis were studied in lymphedema patients of Vajira Hospital. METHODS: This study is a retrospective study. That is, data of lymphedema patients of Vajira Hospital from January 2007 to December 2018 were collected. Demographic data of patients’ gender, age, underlying diseases, BMI, symptoms, site, onset, stages, causes, and types were analyzed to address risk factors using the SPSS program. RESULTS: There were 140 patients participating, consisting of 12 males and 128 females, 78 of which had lymphangitis while the other 62 patients did not have lymphangitis. The average age of patients was 60.09±12.05 years and the average body mass index (BMI) was 28.73±7.81 kg/m2. There were 75 patients having arm lymphedema and 65 patients having leg lymphedema. Additionally, 11 patients had primary lymphedema and 129 patients had secondary lymphedema. The most common complication of lymphedema was lymphangitis (p < 0.001). There was a higher chance for Campisi stages 3, 4 rather than Campisi stages 1, 2 (p < 0.01). The significant presence of wounds was a risk of infection (p < 0.044) in lymphedema patients. The average body weight of patients who had infection was estimated at 74.26 kg, which was higher than that of the non-infected patients, which was at 66.16 +/- 14.67 kg (p = 0.037). CONCLUSION: It is suggested to treat lymphedema since the initial stage, before the symptom reaches its late stage, to reduce the chance of lymphangitis. Besides, patients should be advised to beware of wounds and immediately receive wound treatment to lessen the rate of lymphangitis. Moreover, patients with lymphedema and higher weight are of major concerns as they have more chance to get infected.

519-526

Authors: Oranooj Lertkovit, Daranee Isaranimitkul, Taweewong Tantracheewathorn

OBJECTIVE: To evaluate the clinical characteristics and outcomes of pediatric cancer with non-neutropenic fever (NNF) in pediatric cancer patients in the absence of a central venous catheter. METHODS: This single-center retrospective cohort study enrolled pediatric patients with cancer (age < 18 years) who received chemotherapy treatment at the Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand, from January 2016 to July 2020. Clinical characteristics and outcomes of NNF episodes were described. Descriptive statistics were analyzed. RESULTS: Fifty-one patients were reviewed, but the 97 NNF episodes were documented from 32 patients. Only One (of the 51 patients) had subcutaneous port. The most frequent cancer diagnosis was acute lymphoblastic leukemia (51%). NNF occurred in 3.8 per 1,000 days of chemotherapy period (95% confidence interval [CI] 3.1–4.6). The most frequently clinically documented infections were respiratory tract infection (35%), urinary tract infection (11%), and gastrointestinal infection (10%). The causative pathogens could not be demonstrated in 67.1% of NNF episodes. The commonly identified pathogens were viruses (12.3%), gram-negative bacteria (10.3%), and gram-positive bacteria (5.2%). Empiric treatment with antibiotic was initiated in 92.8% of the total episodes. Ceftriaxone was the most common antibiotic of choice. Only one episode had a positive hemoculture. Four (4.1%) episodes required intensive care unit admissions, and only one NNF-related mortality due to the human Bocavirus pneumonia and multi-organ failure occurred. The mortality rate of NNF was 3.1%. CONCLUSION: NNF episodes are common and life-threatening complications among pediatric cancer patients and generally lead to hospitalization. The incidence of NNF was 3.8 per 1,000 days of chemotherapy (95% CI 3.1–4.6). The causative pathogen in 67% of NNF episodes was unknown, and the commonly identified pathogens were viruses. However, many patients did not identify any causative bacteria, and they received intravenous antibiotics and were hospitalized. The results of our study suggest that patients with severe symptoms may indicate early evaluation and prompt management for viral infection, especially in a patient with a negative bacterial culture and poor respond to antibiotic treatment. This study reveals baseline information for future cohorts to provide guideline management of this common complication during cancer treatment.

535–542

Authors: Theerameth Pruangmethangkul, Thiraporn Kanjanaphan

OBJECTIVE: The results of adequate and inadequate empirical antibiotics remain unclear. This study aimed to evaluate the results of using adequate and inadequate empirical antibiotics. METHODS: A retrospective cohort analysis that covered January 2017 and December 2021 was conducted. At Vajira Hospital, we enlisted pediatric patients with bacteremia and urinary tract infections (UTIs). Patient attributes, empirical antibiotics, therapeutic results, financial expenditures, and antibiotic susceptibility patterns were assessed. RESULTS: In total, 286 pediatric patients were enrolled. There were 230 (80.4%), and 56 (19.6%) patients with UTIs and bacteremia, respectively. The organism that was found the most frequently was Escherichia coli (53.5%), while third-generation cephalosporin was the most often used empirical antibiotic (74.5%). Only 78.4% of Escherichia coli were vulnerable to third-generation cephalosporin. Of 220 patients (76.9%) were treated with adequate empirical antibiotics. The outcomes in the adequate empirical antibiotics group revealed better-improved symptoms than inadequate empirical antibiotics group (96.4% VS 84.8%, p = 0.002). CONCLUSION: Clinical outcomes among pediatric patients from adequate initial antibiotics groups were reported the better outcomes. The mortality rates were not different. Nonetheless, appropriate empirical antibiotics are needed. In UTI patients, amikacin is preferable options for empirical antibiotics.

448-454

Authors: Woravipa Israsena Na Ayudhya, Worawan Rojanawong

OBJECTIVE: This study aimed to determine the rate and risk factors of postoperative respiratory complications in children with obstructive sleep apnea (OSA) who underwent adenotonsillectomy. METHODS: A retrospective study was conducted on the date of children with OSA who underwent adenotonsillectomy between April 2013 and July 2021. Data on demographics, medical history, tonsil grading, polysomnography parameters, and postoperative respiratory complications including cough, position, airway intervention, and desaturation were collected. Chi-square test or Fisher’s exact test was performed to evaluate risk factors. RESULTS: Seventy-one children with OSA who underwent adenotonsillectomy were included in this study. The overall rate of postoperative respiratory complications was 32/71 (45.1%) and that of minor respiratory complications was 37/52 (71.2%), including desaturation, supplement oxygen, reposition, and cough. Statistically significant association with postoperative respiratory complications was observed for obese versus non-obese (p < 0.001), severe apnea–hypopnea index (AHI) (p = 0.001), and severe lowest oxygen saturation (p = 0.001). CONCLUSION: Despite the high rate of minor respiratory complications, postoperative respiratory complications are frequent after adenotonsillectomy among children with OSA. Obese versus non-obese and severity of AHI and lowest oxygen saturation are associated with postoperative respiratory complications following adenotonsillectomy.

463-470

Authors: Orawan Jedsadatud, Swangjit Suraamornkul

OBJECTIVE: A question exists as to whether people with diabetes can respond effectively to the COVID-19 vaccine. This study aimed to evaluate antibody response after COVID-19 vaccination in patients with type 2 diabetes. METHODS: This was a cross-sectional analytical study. Two hundred and twelve type 2 diabetes patients were enrolled after receiving a second dose of the ChAdOx1nCoV-19vaccine 3 months previously. Demographic data, medical history, and blood drawn were collected. Antibodies against receptor binding domain (anti-RBD) was investigated in the laboratory department. Other factors that could affect anti-RBD level, i.e. age, gender, BMI, glycemic control, duration of diabetes, and comorbidity, were collected and analyzed. RESULTS: Among 212 patients with type 2 diabetes 3 months after receiving a second dose of the ChAdOx1nCoV-19 vaccine, the anti-RBD level mean was 989.56 U/ml. Patients with type 2 diabetes, with or without cardiovascular disease as a comorbidity, had median anti-RBD levels equal to 258 U/ml and 442 U/ml, respectively. The median of anti-RBD levels between groups had statistically significant differences (p-value = 0.021). Age, gender, BMI, duration of diabetes, glycemic control, and other comorbidities showed no statistically significant differences in the median anti-RBD levels. CONCLUSION: Only patients with type 2 diabetes with cardiovascular disease as a comorbidity showed statistically significant differences in Anti-SARS-CoV-2 response 3 months after receiving a second dose of the ChAdOx1nCoV-19 vaccine. Therefore, patients with diabetes and cardiovascular disease require earlier revaccination to ensure protection against COVID-19 infection.

481-488

Authors: Papatsiri Suntavaruk, Solos Jaturapisanukul, Sathit Kurathong, Wanjak Pongsittisak

OBJECTIVE: Remote ischemic preconditioning (RIPC) is a new strategy to prevent organ injury from oxidative stress and ischemic reperfusion injury, particularly for the kidney, heart, and brain. Contrast-associated acute kidney injury (CA-AKI) is a complication of coronary angiography (CAG). Based on previous studies, whether RIPC prevents CA-AKI post-CAG remains unclear. Therefore, this study aims to compare the efficacy of standard (std) management and standard management with RIPC to prevent CA-AKI post-CAG. METHODS: This study was an open-label 1:1 randomized controlled trial. The elective CAG patients with an estimated glomerular filtration rate of 15–45 mL/min/1.73 m2 were enrolled. For the RIPC group, patients performed RIPC starting from inflating manual cuff pressure to 200 mmHg for 5 min on an extremity and then deflating 5 min alternate to four times before coronary angiogram at least 1 hr. All patients had received the usual standard management of pre-CAG. The AKI outcomes were evaluated at 48 hrs and 1 week post-CAG. The adverse events were also assessed. RESULTS: A total of 27 patients (RIPC group = 14, std group = 13) were enrolled in this study. Baseline characteristics were comparable between both groups except for male gender was higher in the RIPC group (std group 7 [53.85%] and RIPC group 11 [78.57%]), in part of the amount of contrast media volume and procedure duration was higher in the std group (mean contrast volume are 140 [120] mL in the std group and 40.00 [31.25] mL in the RIPC group). No AKI event was observed in the RIPC group. By contrast, AKI in the std group at 48 hrs included two (15.4%) participants and one (7.7%) participant at 1 week. Serious adverse events were not observed in both groups. CONCLUSION: RIPC may be implemented as a systematic strategy to prevent CA-AKI post-CAG. Some researchers tend to improve CA-AKI. Further studies in a larger number of participants may verify the benefit of RIPC and provide definite conclusion.