Vajira Medical Journal: Journal of Urban Medicine

381-388

Authors: Woravipa Israsena Na Ayudhya, Worawan Rojanawong

Objective: This study aimed to assess the prevalence and risk factors of positional obstructive sleep apnea (POSA) among children with OSA. Methods: A retrospective study was conducted. One hundred and three children with OSA who were aged 3 to 18 years between April 2013 and July 2021 were included in this study. Demographic and polysomnographic data were gathered. Results: The prevalence of POSA was 42.7%. No significant differences were observed in age, gender, tonsil score, weight status and medical comorbidities. Children with POSA had a significantly higher supine AHI than non-POSA (9.6 [0.0-98.7] versus 4.7 [0.0-55.4], p = 0.012). The median non-supine AHI of POSA was significantly lower than non-POSA (0.0 [0.0-18.6] versus 5.3 [0.0-78.9], respectively p < 0.001). Conclusion: POSA among children with OSA occurs frequently, similar to adults with POSA. POSA is associated with higher supine AHI and lower non-supine AHI. Positional therapy might be beneficial in children with POSA.

397-406

Authors: Pruk Chaiyakit, Krittamuk Ompornnuwat, Natthapong Hongku, Pattanaphong Janphuang

Objective: Proximal tibial bone resorption and osteolysis after total knee arthroplasty occur despite improved design and manufacturing processes. We utilized finite element analysis to study these phenomena. Methods: We use SOLIDWORKS 2018 software to study stress and displacement of normal tibias and tibias implanted with a 4-mm-thick CoCr tibial tray (4mm-tray) or 2-mm-thick titanium alloy (2mm-tray). Under vertical loads of 1000 or 2000 N, the stress and displacement of both tibia tray models were analyzed. Stress on the supported proximal tibia 1 and 2 cm beneath the surface was analyzed and compared to stress in a normal tibia. Results: Stress concentrated around the central region compared to the peripheral region in all models, which caused more deformation of the material in the central region. However, the 4mm-tray exhibited a more rigid construct compared to the 2mm-tray. Under any load, the 2mm-tray exhibited more tray deformation, with a central–peripheral deformation difference of approximately five times more than the deformation difference for the 4mm-tray. Moreover, stress on the peripheral region of the supported proximal tibia was only 18–22% of that of a normal bone for the 4mm-tray compared to 54–66% for the 2mm-tray. Conclusion: Both tibial tray implant models exhibited some degree of stress shielding on the peripheral region of the supported proximal tibia. However, the greater modulus and thicker baseplate construct of the 4-mm CoCr tray exhibited a profound stress shielding effect. This stress shielding may correlate with a higher incidence of proximal tibia bone loss.

415-426

Authors: Peerapat Thanapongsatorn, Solos Jaturapisanukul, Torpong Claimon, Surazee Prommool

Objective: The purpose of the study was to investigate the efficacy and safety of spironolactone to prevent vascular calcification among peritoneal dialysis patients. Methods: This study was a randomised, double-blinded placebo-controlled trial conducted from August 2018 to December 2020 at Vajira Hospital, Thailand. We randomly assigned peritoneal dialysis patients to receive either 25 mg of spironolactone daily or a placebo for 6 months. Coronary artery calcium scores and laboratory tests were performed and compared at baseline, and 6 months thereafter. Results: Among the 40 patients initially randomised, 34 patients completed the study (17 patients in the spironolactone group and 17 patients in the placebo group). There was no difference in baseline characteristics or laboratory results between both groups. The spironolactone group showed a significant reduction in CACs at 6 months (169.97 AU [IQR 2.34 - 1146.29] to 92.29 AU [IQR 4.83 - 851.1], p=0.05). Compared to placebo, spironolactone had a lower percentage change in CACs (0% [IQR -47.1-14.7] vs 6.06% [IQR -1.9-40.8], p=0.07. However, the change in the absolute progression of CACs was not different (0 AU [IQR -30.5-58.3] in the spironolactone group vs 6.14 AU [IQR -13.9-331.2] in the placebo group). Spironolactone also showed significantly lower serum phosphorus and osteocalcin (3.8 ± 1.3 mg/dL vs 4.8 ± 1.1 mg/dL and 69.0 ng/mL [IQR 41.9-151.5] vs 178.0 ng/mL [IQR 86.8-269.5], p=0.02 and 0.014, respectively). No hyperkalaemia or hypotension was found in either group. Conclusion: Among peritoneal dialysis patients, spironolactone showed a potential benefit to prevent the progression of vascular calcification. Further studies with a larger population and long-term follow-up should be conducted.

321-330

Authors: Kritsana Kientchockwiwat, Sirikarn Tangcheewinsirikul

Objective: To investigate the prevalence of low back pain (LBP) and its associated factors among Thai medical students at a single university in Thailand. Methods: Using an anonymous self-administered survey, we collected demographic data and details of LBP and associated disability (modified Oswestry disability questionnaire [MODQ]). This was distributed online to medical students between January and March 2022. Univariate and multivariate analyses were conducted, and odds ratios (ORs) and confidence intervals (CIs) were reported. Results: Of the 150 eligible students, 146 responded (91 female, mean age 21.6 ± 1.8 years). The prevalence of lifetime LBP and significant LBP were 81 (55.5%) and 55 (67.9%), respectively. Assessed by the MODQ, 92.4% of students suffered mild disability due to LBP, which correlated with severity (rs = 0.600, p < 0.001). Alcohol drinking (OR 2.9, 95%CI 1.1–7.7), being underweight (<18 kg/m2 ; OR, 14.8; 95%CI, 1.9–117.1), not drinking caffeine (OR, 0.3; 95%CI 0.1–0.8), and a family history of LBP (OR, 3.1; 95%CI, 1.2–8.3) were significantly associated with significant LBP in the univariate analysis. In the multivariate analysis, family history (aOR, 3.5; 95%CI, 1.1–11.1) and being underweight (aOR, 15.6; 95%CI, 1.7–141.2) were independently associated with LBP. Conclusion: LBP was common among medical students and was associated with both low weight (<18 kg/m2) and having a family history of LBP. MODQ is practical for evaluating LBP disability

339-344

Authors: Chadet Toncharoen, Umaphorn Nuanthaisong

Objective: Prostate cancer is the second most common male cancer worldwide and the fifth leading cause of death in Thailand. This research aimed to evaluate the overall survival and disease-free survival of patients with localized prostate cancer who received different treatment options for the adjustment of future treatment policies. Method: This retrospective cohort study was conducted using secondary data analysis and phone checkup. The population included patients diagnosed with localized prostate cancer (T1 and T2) and treated by laparoscopic radical prostatectomy, radiation therapy, or active surveillance at Vajira Hospital from December 2009 to December 2019. Survival and disease-free survival were analyzed. Results: The median overall survival was 8.60 years (95% CI, 7.95–9.24) in the laparoscopic radical prostatectomy group and 7.98 years (95% CI, 6.13–9.82) in the radiation group. No statistically significant difference was found between these two treatments (p = 0.53). The median disease-free survival was 8.45 years (95% CI, 7.73–9.18) in the laparoscopic radical prostatectomy group and 5.89 years (95% CI, 5.60–6.18) in the radiation group. Statistically significant difference was found between these two treatments (p < 0.001). Conclusion: The disease-free survival in the laparoscopic radical prostatectomy group was significantly higher than that in the radiation group (p < 0.001). The overall survival was the same for both groups.

353-360

Authors: Pruk Chaiyakit, Tawipat Watcharotayangkoon

Objective: Current blood management programs for knee arthroplasty recommend avoiding blood transfusions and setting criteria for hemoglobin (Hb) < 7 g/dl or < 8 g/dl inpatients who have cardiac diseases or specific situations that do not concern the pre-operative HB level. This cutoff is safe for hemodynamically stable patients and those without cardiovascular complications. However, no study has shown the result of functional outcome, which is the primary objective of total knee arthroplasty (TKA). Methods: We conduct an 18-month prospective cohort study on patients diagnosed with primary OA knee and indicated for surgical treatment with total knee arthroplasty at a single medical school hospital. Patients were divided into two groups of HB loss <20% or ≥20%. Timed up and go information was collected and compared at pre-operative period and post-operative day 1, 2, 3 and 14. Results: A total of 154 patients were analyzed. No significant different in patient characteristics was found between the Hb loss <20% group (group 1, n=120) and HB loss ≥20% group (group 2, n=34). Comparison of mean TUG between the two groups found no significant difference on post-operative day 1 (81.34 ± 20.09 and 84.99 ± 25.59 (P=0.45)), 2 (56.85 ± 11.12 and 59.06 ± 13.67 (P=0.39)), 3 (44.14 ± 8.20 and 45.66 ± 9.19 (P=0.35)) and 14 (31.92 ± 6.02 and 34.04 ± 5.99 (P=0.07)). Conclusion: No significant difference in physical outcomes was found between the two groups. Current blood transfusion criteria after total knee arthroplasty can be used without concern about the physical outcome at the early post-operative period.

245-256

Authors: Pantri Kirdchok, Juthaporn Taepakdee, Chotiman Chinvararak

Objective: To study parent-adolescent relationship patterns of junior high school students in Ubonratchathani Province and its association with family factors. Methods: A cross-sectional descriptive study was conducted on students in a public junior high school in Ubon Ratchathani Province in 2018. Self-reported questionnaires consisted of demographic data of students and their parents, questionnaire about intrafamilial relationships and the Chulalongkorn Family Inventory. Descriptive statistics were presented as frequency, percent and mean. The chi-square test and logistic regression analysis were used to find the associated factors of a parent-child relationship. Results: There were 733 junior high school student participants; 63.4% were female. Eighty-eight percent reported a closed relationship with their mother, while 66.4% reported a closed relationship with their father. Fifty-two percent of students choose to consult with their parents, and 35.7% choose to consult with friends. The majority (82.8%) of parental marital status were married. Associated factors of closed relationships were 3 domains of family functions: problem-solving, communication and affective responsiveness, parental relationship, and parental marital status. Conclusion: Most junior high school students had a closed relationship with their mother and father. The associated factors of this closed relationship were family function on problem-solving, communication and affective responsiveness, parents’ marital relationship and parental marital status.

267-276

Authors: Nongnuch Polruamngern, Nitchawan Kerdcharoen, Tanita Ungrungseesopon

Objective: To study the level and relationship of resilience and mental health in urban late adolescents. Method: This is a cross-sectional descriptive study. The participants are undergraduate students in Navamindradhiraj University who are between the ages of 18-21 years. The outcome measures include general personal data, resilience quotient questionnaire and depression anxiety stress scale (DASS-21). The statistical analyses are Pearson Chi-square and multiple regression analysis. Results: From the total participants of 425, most of them is female (82.6%), domicile outside of Bangkok (59.8%), lives with family (74.6%), the eldest child (52.9%), with two siblings (46.4%), studied in health sciences (90.6%), average GPA 3.32 (S.D. = 0.43) and enrolled in a direct admission system (70.6%). Most of them had resilience quotient at normal level (56.5%). The average resilience scores were 54.6 ± 5.92 (mean ± S.D.). Mental health problems were mostly anxiety (65.6 %) followed by stress (58.8 %), and depression (51.3 %). The extremely severe mental health problems among participants were found in anxiety (7.8 %), stress (19.5 %), and depression (8.0 %). Resilience is inversely related to stress, anxiety and depression (r= -.399, -.345 and -.345 respectively, p<0.01). From stepwise multiple regression analysis, resilience in the domain of will power together with emotional stability can predict depression and stress. The variance of depression is 29.4 percent (R2 = 0.294, p<0.01). And the variance of stress is 16.6 percent (R2 = 0.166, p<0.01). Will power domain is the key predictor of depression (β =-0.318, p<0.01) and emotional stability domain is the key predictor of stress (β = -0.271, p<0.01). Emotional stability domain is also the only domain that can statistically predict anxiety (β = -0.343, p<0.01). The variance of depression is 11.7 percent (R2 = 0.117, p<0.01). Conclusion: Resilience is an important protective factor for late adolescents’ mental health problems. Therefore, in order to reduce stress, anxiety and depression in late adolescents, an enhancement of resilience is beneficial, particularly in the domain of emotional instability and will power.

287-298

Authors: Sonsawan Sangprasert, Swangjit Suraamornkul

Objective: The study evaluated the effect of hemoglobin levels on non-invasive blood glucose measurement. Method: Retrospective study in Type 2 diabetic patient, who were treated at Vajira Hospital from October 2018 to January 2019, were collected including baseline characteristic data and laboratory data from Ephis program. The data will be analyzed to determine the effect of hemoglobin levels on non-invasive blood glucose beasurement. Result: A total of 200 type 2 diabetic patients were enrolled in the study. The average hemoglobin was 10.29±2.09 g/dL. The sample group with anemia accounted for 67%. The average glucose measured by non-invasive blood glucose meter was 109.57±31.38 mg/dL, by venous blood glucose was 154.37±57.27 mg/dL with statistically significant differences (p<0.001). The absolute relative difference values of the glucose measured by non-invasive blood glucose meter and venous blood glucose was 29.95±21.45 mg/dL. The result of study on effect of hemoglobin levels on non-invasive blood glucose measurement in type 2 diabetic patients with or without anemia were no significant differences in the absolute relative difference values of the glucose measured by non-invasive blood glucose meter and venous blood glucose (p=0.425). The analysis of subgroups with anemia was classified by severity into mild, moderate, severe, and very severe. There was no difference in the absolute relative difference values of the glucose measured by the non-invasive blood glucose meter between subgroups (p=0.266, 0.852, 0.335 and 0.493, respectively). Conclusion: The hemoglobin levels do not affect on the non-invasive blood glucose measurement in type 2 diabetic patients with or without anemia.

181-188

Authors: Varisa Piriyakitphaiboon, Thanyaros Sinsophonphap, Ornatcha Sirimongkolchaiyakul

Objectives: The present study aimed to explore the relationship between online formative outcomes and summative performance in the pediatric module among fifth-year medical students. Methods: We retrospectively collected and reviewed the learning data of 84 fifth-year medical students who enrolled in the pediatric module between August 2020 and July 2021. Results: Students who received individualized feedback had a higher mean summative score than their counterparts (61.17 ± 9.5 vs. 59.24 ± 9.6), and their summative outcome was significantly higher than their formative outcome (61.17% vs. 47.9%). The online formative scores were not correlated with summative scores, but there appeared a strong positive correlation between cumulative grade point average (CGPA) and summative scores (r = 0.685, p-value = 0.001) and a weak negative correlation between pediatric clerkship evaluation and summative scores (r = -0.380, p-value = 0.004). Univariate analysis revealed that lower average cumulative grade point average was significantly associated with an unsatisfactory grade in the pediatric module. Conclusion: The online formative assessment was not correlated with the summative assessment. Therefore, clinical teachers should consider other factors, especially CGPA to identify students who have a tendency for academic failure.

199-210

Authors: Nathathai Suvitsakulwong, Peerayuht Phuangphung

Objectives: To determine the characters of traumatic brain injuries (TBI) related to the occurrence of coup-contrecoup phenomenon in blunt head trauma from velocity-related injuries Methods: The prospective case control study was conducted in Thai postmortem cases sent for autopsies at the Department of Forensic Medicine, Siriraj Hospital, Mahidol University between 11th February 2021 and 31st December 2021. Subjects recruited had the age of 18 years old or over and were dead from traffic accident or falling from height. Data including sex, age, height and weight, configurations of skull, sites of scalp contusion, skull and skull base fracture, brain weight, epidural and subdural hemorrhage, coup-contrecoup contusion and macroscopic spot hemorrhage in white matter were recorded. The comparison of the characters of TBI between the presence and the absence of coup-contrecoup phenomenon was analyzed using descriptive statistics, independent sample t-test, Mann-Whitney U test and contingency table Chi-square test. Results: There were 60 subjects recruited in this study (30 subjects with coup-contrecoup contusion and 30 subjects without coup-contrecoup contusion). The mean age and body mass index (BMI) between these two groups were not significantly different. The configurations of skull were also not significantly different for both temporal and occipital impacts. Brain weight in coup-contrecoup group was significantly greater than that in no coup-contrecoup group (1366.33 ± 84.42 g vs 1275.33 ± 105.63 g, p=0.001). Skull fracture with simple pattern, base of skull fracture without sella turcica involvement and subdural hemorrhage were significantly associated with the presence of coup-contrecoup contusion (p=0.027, p<0.001 and p=0.002, respectively). Conclusion: Brain with coup-contrecoup contusion had significantly higher brain weight than brain without coup-contrecoup contusion. The presence of coup-contrecoup contusion was influenced by the characters of skull and base of skull fracture and the presence of subdural hemorrhage.

221-228

Authors: Suwannee Surattanasophon

Objective: To compare the accuracy of radiographs (XR) imaging according to computed tomography (CT) scanning in the determination of fracture type (Schatzker classification), characteristics, and to identify indications for surgery in patients with tibial plateau fractures. Methods: A retrospective study was conducted in 108 patients with tibial plateau fractures who underwent both radiograph and CT scan in Saraburi Regional Hospital from October 2017 to September 2021 Results: According to diagnostic concordance between XR imaging and CT scan, among the 6 types of tibial plateau fractures, type III had perfect concordance; type I, type IV and type VI had weak concordance; whereas type II and type V had minimal concordance between XR imaging and CT scan in determining the fracture characteristics with indication for surgery. For the XR findings of intra-articular displacement of ≥ 2 mm, metaphyseal-diaphyseal translation > 1 cm and angular deformity of > 10° (when compared with CT scanning), all of these three characteristic features for indication of surgery had both specificity and positive predictive value of 100%, but the sensitivity was only 43%, 52% and 56%, respectively, with negative predictive value of 62%, 88% and 88%, respectively. The concordances between XR imaging and CT scan in determining intra-articular displacement of ≥ 2 mm, metaphyseal-diaphyseal translation > 1 cm and angular deformity > 10° were weak, moderate and moderate, respectively. Conclusion: Performing only XR imaging is insufficient to evaluate type of fracture and the indications for surgery in tibial plateau fractures, and additional CT scanning is needed for accurate assessment of severity, as well as surgical planning.

95-102

Authors: Kanisa Rongsriyam, Kamonrat Sueangamiam, Thanatip Tantivatana

Objective: To study the 5 and 10-year survival rate and prognosis factors in breast cancer patients receiving breast conservative treatment (BCT). Methods: A retrospective descriptive analysis of BCT patients who were treated in Radiation Oncology unit, Department of Radiology, Faculty of Medicine Vajira Hospital between 2009 and 2019. The Kaplan-Meier method was used for survival analysis. The authors analyzed association of patients and tumor characteristics with survival using the log-rank test and Cox models. Results: A total of 158 BCT patients were included. Five-year overall and disease-free survivals were 100% and 97.8%, respectively, with 10-year overall survival and disease-free survival were 100% and 95.7%, respectively. Numbers of positive nodes more than 4 (HR of 10.25; 95% CI:1.66-63.18) are significantly prognostic factors related to recurrence. Conclusions: Breast cancer patients who were treated with BCT had a favorable long-term survival outcome. Survival rates did not change much between 5 and 10 years. The important prognostic factor affecting disease-free survival was axillary lymph node metastasis.

115-124

Authors: Thanacom Thapananon, Rangsima Thiengthiantham

Objective: Bowel preparation is an important process before colonoscopy. Sodium phosphate (NaP) and polyethylene glycol (PEG) are the drugs mainly used in bowel preparation at Vajira Hospital. Since NaP is an osmotic laxative, it may cause dehydration and electrolyte imbalance. Hence, PEG is commonly utilized in patients admitted to the hospital. The fragile patients need to admitted for bowel preparation for colonoscopy. Thus, the current study aimed to compare the efficacy of NaP and PEG and their effect on electrolyte levels in these patients. Methods: Datas were collected from admitted patients who received either NaP or PEG for bowel preparation at Vajira Hospital from January 1, 2016, to December 31, 2016. Results: NaP and PEG did not significantly differ in terms of efficacy. However, compared with PEG, NaP significantly increased serum Na levels (+1.737 mmol/L) and decreased serum K levels (-0.517 mmol/L). Nevertheless, there was no remarkable difference in the changes in serum Na and K levels based on clinical data. Conclusion: Thus, NaP can be used with caution in bowel preparation among admitted patients as it has minimal side effects on electrolyte levels.

137-148

Authors: Pruk Chaiyakit, Weeranate Umpanpong, Tawipat Watcharotayangkoon

Background: The amount of blood transfusion after knee arthroplasty seem to vary in different reported study. We carried out a retrospective study to analysis pre-operative risk factors for blood transfusion in patient who underwent knee arthroplasty in our institution. Methods: A retrospective study of 190 patients treated with 194 procedure (186 unilateral knee arthroplasty, 4 bilateral knee arthroplasty) from November 2014 to October 2015 was analyzed. A univariate analysis was performed to establish the relationship between all variables and the need for postoperative transfusion. Variables that were determined to have significant relationship were included in a multivariable analysis. Results: The univariate analysis revealed a significant relationship between need for postoperative blood transfusion and preoperative hemoglobin levels, surgical technique, arthrotomy approach, DVT prophylaxis, surgical technique and surgeon experience. The multivariate analysis identified a significant relationship between need for transfusion and preoperative hemoglobin level and surgical technique. Patients with a preoperative hemoglobin less than 12 g/dL had a 5.1 times greater risk of having a transfusion than those with a hemoglobin level ≥ 12 g/dL. The surgical technique with computer assisted surgery had a 0.15 times lesser risk of having a transfusion than those with the conventional technique. Conclusion: The preoperative hemoglobin level < 12 g/dL was shown to increase risk of the need for blood transfusion after knee arthroplasty, while computer assist surgery total knee arthroplasty was shown to decrease risk of blood transfusion. We suggested that patients with preoperative hemoglobin < 12 g/dL need to be crossmatching PRC in pre-operative steps.

161-170

Authors: Kunnika Jermtienchai, Prapaiwan Danpradit

Objectives: To study and compare knowledge of foot ulcer prevention before and after program implementation and to compare foot ulcers prevention behavior before program implementation and confidence of foot ulcers prevention behavior after program implementation in the diabetic elderly of the Puranawat Temple Elderly Club, Bangkok. Method: The research was quasi experimental research with one group pre-post-test design. The purposively selected samples were thirty Diabetic elderly of the Puranawat Temple Elderly Club, Bangkok. The research tool was the modified program of the Self-Efficacy Theory of Bandura. Data were collected from questionnaire for the period of 3 days. Data were analyzed by percentage, mean, standard deviation and paired t-test. Results: Before and after program implementation, the diabetic elderly had good and very good level of knowledge about foot ulcers prevention respectively. After program implementation, the knowledge about foot ulcer prevention of the samples were statistical significantly higher than before the program (p < 0.01). Results of the compare the foot ulcers prevention behavior before program implementation. The samples had average level of behavior before program implementation. After program implementation, they had high level of confidence which was higher than the level of behavior before program implementation with statistical significance (p < 0.01) in overall and in each aspect. The aspect with the highest confidence was foot examination and the aspect with the least confidence was foot cleaning. Conclusion: The Self-Efficacy Enhancement Program on knowledge and confidence of foot ulcers prevention behavior in the diabetic elderly of the Puranawat Temple Elderly Club showed significant improvement of knowledge and confidence in the diabetic elderly. The program was designed for health teams, village health volunteers and other interested groups to enhance foot care self-efficacy and help the diabetic elderly in communities to prevent foot ulcers and leg amputation.