Siriraj Medical Journal

153-156

Authors: Katika Nawapun, M.D., Pharuhas Chanprapaph, M.D., Nisarat Phithakwatchara, M.D.

Objective: To establish a reference of normal fetal lung volume using three-dimentional ultrasonography in the second half of pregnancy. Methods: A prospective longitudinal study was conducted in 53 Thai healthy singleton pregnant women at 22-37 weeks of gestation. By using 3-D ultrasonography with Virtual Organ Computer-Aided Analysis (VOCAL), the whole fetal thorax was obtained as volume data and then calculated in each participant for 3-6 successions. Our method showed excellent intraclass correlation coef cients (ICC = 0.990-0.991) among three operators and validity ranged within 3% of the actual volume. Multivariate analysis was used to identify the relationship between lung volume and gestational age. This longitudinal data set was then analysed by mixed model regression analysis. Results: A total of 260 fetal lung volumes were obtained. Average maternal age, gestational age and birth weight were 26.9 ± 4.7 years, 38.9 ± 1.3 weeks and 3,007.5 ± 349.3 grams. With mixed model of regression analysis, the relationship between lung volume and GA was demonstrated as follows: left lung volume (ml.) = (-12.19) + (0.22*GA) + (0.03*GA2), right lung volume (ml.) = (-24.91) + (1.19*GA) + (0.02*GA2), total lung volume (ml.) = (-37.32) + (1.43*GA) + (0.05*GA2). Conclusion: This is the normal fetal lung volume in the Thai population using the rotational technique (VOCAL). It could be considered as a reference for prenatal diagnosis of pulmonary hypoplasia.

163-167

Authors: Saimai Chatree, Malika Churintaraphan, Nay Chi Nway, Chantacha Sitticharoon, M.D.

Neuropeptide Y (NPY) and Y2 receptor (Y2R) are found to be expressed in adipose tissue. This study aimed to compare Y2R mRNA expression in subcutaneous and visceral fat tissues as well as serum PYY levels between obese and normal weight subjects. We demonstrated that Y2R mRNA in visceral fat was greater (p<0.05) in normal weight subjects than in obese subjects with comparable expression in subcutaneous adipose tissue. Y2R mRNA was (p<0.05) expressed higher in subcutaneous than visceral fat tissue in obese subjects. Moreover, Y2R mRNA expression in subcutaneous fat tissue was positively correlated to its expression in visceral adipose tissues (R=0.932, p<0.001). In visceral fat, Y2R expression was negatively correlated with serum NPY levels (R=-0.415, p<0.05). Serum PYY was similar between obese and normal weight groups. In conclusion, higher Y2R mRNA expression in visceral fat tissue might be involved in lower adiposity. Further investigation regarding activation of Y2R action in visceral adipose tissue may reveal novel strategies for adiposity reduction.

173-177

Authors: Kriangsak Sirirak, M.D.

Objective: Nasal septal splint post manipulation in acute nasal bone fractures treatment can stabilize the septum in perfect position until healing unites which can provide good esthetic and functional long term end results. Methods: During October 2008-February 2012, there were 530 nasal bone fracture patients (417 male and 113 female ~ ratio 4: 1) admitted at Prapokklao Hospital, 375 isolated nasal bone fractures cases and 142 cases associated with other facial bone fractures. The total 517 treated cases were treated as closed reduction (359 cases) and open reduction (158 cases). After manipulation, tailor- made silastic sheets were placed along the correct position of the nasal septum as a xation splint with sutures, left in place for 7- 10 days before removal. Results: The success in closed reductions for isolated nasal bone fractures was 95.73 % (359 cases of 375 cases) and the success in open reduction was 100% (158 cases), with follow-up between 3 months to 3 years. Most cases had a good result and only 17 cases had post-traumatic deformities (3.29 %). Surgical corrections: 3- septorhinoplasty, 2- closed reduction after repeated trauma, 2- augmented rhinoplasty with calvarial bone graft, were done, and ten cases denied further treatment. Conclusion: Nasal septal splint after treatment with appropriate reduction in acute nasal bone fractures could straighten the nasal septum, providing good esthetic and functional long-term end results.

181-183

Authors: Charussri Leeyaphan, M.D., Rattapon Thungtong, M.D., Panitta Sitthinamsuwan, M.D.

Introduction: Takayasu arteritis is chronic vasculitis involving large vessels. Accelerated atherosclerosis has been docu- mented in patients with Takayasu arteritis. Case presentation: We have described a 53 year-old Thai woman who presented with 2-weeks history of painful erythema- tous to purplish patches on both soles. She has had hypertension since she was 29 years old and she has diabetes mellitus, dyslipidemia and cerebrovascular disease. Physical examination revealed decreased pulsation of her left brachial artery, difference in systemic blood pressure between both arms and bruit over subclavian arteries and the abdominal aorta. Derma- tologic examination demonstrated multiple discrete ill-de ned painful non-blanchable erythematous to violaceous macules and patches on her toes and soles. Some lesions were reticulated blanchable erythematous patches. Ulcer, digital cyanosis and gangrene were found on the tips of her toes. Magnetic resonance angiographic nding of her aorta and its branch was compatible with Takayasu arteritis. Skin biopsy was obtained from the livedo reticularis area of her left foot. The section revealed occlusion of arterioles by cholesterol crystal emboli. Conclusion: Accelerated atherosclerosis has been reported in patients with Takayasu arteritis. Cholesterol emboli can be a rare presentation from atherosclerosis. Prevention and early recognition for atherosclerotic plaque should be performed in patients with Takayasu arteritis. Moreover, the effective control of traditional atherosclerotic risk factors is needed, in addi- tion to the effective suppression of disease activity, for the management of Takayasu arteritis.

128-131

Authors: Atiporn Thuangtong, M.D.*, Chonlada Wangvarunyoo, M.D.*, Tada Kunavisarut, M.D.**, Nitinun Phithakphaosakul, B.Sc.*

Objective: To evaluate the visual evoked potentials (VEP) in Graves’ disease patients in order to reveal the possible presen- tation of subclinical optic neuropathy. Methods: Forty-seven Graves’ disease patients without symptoms of optic neuropathy were enrolled. Flash visual evoked potentials (F-VEP) and Pattern visual evoked potentials (P-VEP) were evaluated. Comparison of VEP with normal values was done, between the groups with and without the presentation of eye sign(s) and also among the groups that had differ- ences in thyroid hormone function. Results: The mean F-VEP amplitude and latency were 17.56±6.20 microvolts (μV) and 114.02±14.92 milliseconds (ms), respectively. The mean P-VEP amplitude and latency were 10.82±4.88 μV and 99.67±5.87 ms, respectively. These values were within normal values. Only the latency of P-VEP was increased signi cantly (P<0.001) when compared between the groups with (101.81±5.70 ms) and without eye signs (97.43±5.21ms) and it also increased signi cantly (P=0.033) when compared with normal values. The hyperthyroid group also had a signi cant increase in the latency of P-VEP when compared to other groups (P=0.002). Conclusion: Increase in the latency of P-VEP should be sought for and reminded the clinician to conduct close follow-up of this as an early sign of optic neuropathy, especially in the patients with eye manifestation.

137-140

Authors: Uraiporn Siritep, MNS, R.N., Orapan Thosingha, DNS, R.N., Prangtip Chayaput,Ph.D. (Nursing), Jatuporn Sirikun, M.D.

Objective: To study the predictive power of systemic in ammatory response syndrome (SIRS) scores, platelet count, and blood glucose level for multiple organ dysfunction syndrome (MODS) in patients with major trauma. Methods: The sample was 87 patients with major trauma, hospitalized within 24 hours after injury. SIRS score, platelet count and maximum blood glucose level were measured within the rst 24 hours after injury, while MODS was measured by the Denver post-injury multiple organ failure (MOF) score at the 3rd day after injury. Multiple regression analysis, using the enter method, was employed to analyze the data with a signi cance level of .05. Results: The majority of the samples were male (85.1%) with an average age of 40.39 years. Most of them sustained multiple organ injuries and received surgical treatment within the rst 24 hours. It was found that 25.3% of these patients developed organ dysfunction on the 3rd day after injury while 9.2% experienced MODS. SIRS score, platelet count and blood glucose level could predict MODS in patients with major trauma, with 41.7% of the variance explained (R2= .417, p < .001). Conclusion: Patients with major trauma should receive close monitoring on their SIRS score, platelet count and blood glucose level within 24 hours after injury. Moreover, Denver post-injury MOF score should be routinely used for detection of organ dysfunction so that preventative measures can be appropriately implemented.

145-148

Authors: Somphong Wajajamroen, M.D., Chuda Srisukonth, M.D., Anchalee Aramtiantamrong, M.D.

Intranasal tooth is a rare phenomenon. The clinical manifestations of an intranasal tooth are quite variable. Unila- teral nasal obstruction is a common complaint. In this case, a 14-year-old girl presented with left nasal obstruction. Anterior rhinoscopy and endoscopic examination showed the tooth-like lesion in the left nasal cavity. Computed Tomography (CT) scanning is helpful in the diagnosis and treatment planning. After a complete evaluation, the patient underwent transnasal endoscopic removal of the lesion. In the present study, the clinical and radiological ndings of a nasal tooth is reported.

96-99

Authors: Waranya Boonchai, M.D., Rasthawathana Desomchoke, M.D., Pacharee Iamtharachai, B.Sc., Daranee Sornmek, B.N.

Background: Patch testing is a well-established method of diagnosing contact dermatitis; although it is a complex and time consuming process. Objective: To determine the factors in uencing patients’ awareness of the bene t of patch testing by using a questionnaire survey. Methods: This is a descriptive study using 28 questions to survey in the patients who consecutively visited the contact dermatitis clinic, Siriraj Hospital during 2010. The survey concerned about patients’ perceptions about our contact dermatitis clinic services in several dimensions. The satisfaction score ranges from least (1) to most (5) satisfaction. Results: There were 150 patients, 22 males (15%) and 128 females (85%) (M:F ratio: 1:6) with mean age of 40.8 years (range, 16-71 years). The patients with bachelor degree or higher background showed statistically signi cant increases associated with the ability to remember, avoid allergens and recognize allergens in personal products (p=0.02, p < 0.00 and p=0.03, respectively). There was a signi cant difference in patients’ satisfaction regarding the test procedure (p=0.04) in age groups of 21-40 years old and >40 years old (Mean=4.17 and 4.43, respectively). The lower educational group had signi cantly more satisfaction about medical educational sheet than the higher educational level group (Mean=4.40 and 4.18, respectively, p=0.05). Conclusion: The patients have the high level of satisfactions towards the service at the contact dermatitis clinic, Siriraj Hos- pital. Factors in uencing patients’ awareness of the bene ts and results of patch testing are age and educational background.

105-111

Authors: Sarayut Vattananupon, Pranee Chadvongvan, Pravit Akarasereenont, M.D., Ph.D., Sompol Tapechum, M.D., Ph.D., Kanokwan Tilokskulchai, B.Sc.(Pharm.), Ph.D., Narawut Pakaprot, M.D., Ph.D.

Background: Vascular dementia, a learning and memory af icted disease, is caused by chronic cerebral hypoperfusion which leads to neuronal injury and death. Brahmi extract is used in Indian Ayurvedic medicine to enhance learning and memory and to promote brain functions. Objective: To examine the therapeutic potential of Brahmi extract as an alternative treatment for vascular dementia in the rat model of chronic cerebral hypoperfusion. Methods: The chronic cerebral hypoperfusion was induced by permanent bilateral common carotid artery occlusion (2-VO), causing vascular dementia. After the occlusion, Brahmi extract was given for 2 months, and the spatial learning and memory tests were then performed after 2 months of drug administration. At the end, all animals were sacri ced, and the brains were removed for histological examination and counting of the hippocampal CA1 neurons. Results: The 2-VO induced cerebral hypoperfusion reduced the hippocampal CA1 neuron count and impaired the spatial learning and memory. Brahmi extract, on the other hand, could attenuate the memory de cit and neuronal reduction. Conclusion: Brahmi extract attenuated the de cit induced by the permanent bilateral common carotid artery occlusion, suggesting the neuroprotective effects of Brahmi extract against the cerebral hypoperfusion.

117-119

Authors: Rajesh Thangarajan, M.Sc., Biswabina Ray, M.S., Alok Saxena, M.Sc.

The ulnar artery shows different patterns in hand and provides major contribution in the formation of super cial palmar arch. We have dissected twenty four hand specimens to follow the course of the ulnar artery and its branches. Classi- cal radio-ulnar arch was observed in all hand specimens except one female cadaveric specimen where four common palmar digital arteries were arising from the convexity of the SPA instead of three as seen in classical radio-ulnar arch. The rst common palmar digital artery was dividing into arteria radialis indicis and arteria princeps pollicis. The arch was completed by super cial palmar branch of radial artery. One exclusive communication was reported between radial artery proper and arteria princeps pollicis. Knowledge about arterial variations will be useful for cardiovascular surgeons, radiologists and anatomists working in this area. Occlusion of the arteries may lead to ischemia characterised by claudication, rest pain and gangrene if untreated. Therefore, anatomy of the arteries and the possibility of developing collateral circulation is of utmost importance.

69-72

Authors: Angsu Chartrungsan, M.D., Pansak Laksanabunsong, M.D., Akarin Nimmannit, M.D.**, Bundarika Suwanawiboon, M.D.***, Naravat Poungvarin, M.D.****, Wanchai Wongkornrat, M.D.*, Kriangkrai Tantiwongkosri, M.D., Worawong Slisatkorn, M.D., Pranya Sakiyalak, M.D., Punnarerk Thongcharoen, M.D., Thaworn Subtaweesin, M.D., Somchai Sriyoschati, M.D., Teeravit Phanchaipetch, M.D.

Objective: The ACCP guideline 2008 recommended cessation of warfarin ve days before surgery. However, based on the observation of the clinical practice at Siriraj Hospital, we suggested a shorter period of three days before surgery. Prior studies have shown multiple factors had effected warfarin dosage, but few studies have shown factors that in uenced normalization of prothrombin time after discontinuation of warfarin. Previous studies have shown the genetics factors, vitamin K epoxide reductase (VKORC1) and cytochrome P450 2C9 (CYP2C9) enzyme conjointly determine the warfarin maintenance dose. We wanted to nd out the proper timing of warfarin cessation before surgery and relationhip to genetic factors. Methods: Sixty-eight patients on warfarin were randomized to stop warfarin for three or ve days. Blood samples were acquired at three or ve days after interruption of warfarin in each group and assayed for INR, VKORC1 and CYP2C9. We started bridging therapy when INR was less than 2.0 and accepted an INR value of 1.5 or less on the day of surgery. Results: A total of 68 patients were enrolled in the study. Thirty-three patients (48.5%) were male. The mean age was 50.8 ± 6.6 years (range 16-88 years). The mean BMI was 22.5 ± 3.6 kg. All patients had mechanical heart valve replacement, and 22 (32.4%) patients had AF. The mean cumulative weekly dose of warfarin was 27 ± 11.3 mg and baseline INR was 2.4 ± 0.3. Thirty (88.2%) patients in the three days group had INR ≤ 1.5 and thirty-three (97.3%) patients in the ve days group had INR ≤ 1.5. There was no signi cant difference between interruption of warfarin for three and ve days (p =0.16). Female sex, BMI and weekly warfarin dosage were associated to the longer cessation of warfarin. Only weekly warfarin dosage was a signi cant factor after multivariate analysis. From 68 patients, CYP2C9 *1/*1 was found in 93% and CYP2C9 *1/*3 was found in 7%. Neither mutant CYP2C9*2 allele nor individuals homozygous for CYP2C9*3 were observed. Regarding VKORC1, haplotype AB was found in 32% and haplotype AA was found in 63%. Haplotype BB (wild type) was found in 4%. Five patients who had INR > 1.5 after interruption of warfarin had VKORC1 haplotype AA, four patients had CYP2C9*1/*1 and one patient had CYP2C9 *1/*3. Neither VKORC1 nor CYP2C9 was related to normalization of INR (p=0.10, p=0.17). Conclusion: Temporary interruption of the warfarin therapy between three days and ve days with bridging therapy before surgery is not signi cantly different in the Thai population. This study recommends discontinuing warfarin three days before surgery. The proper timing of interruption for warfarin does not only depend on the half-life of warfarin but also depends on age, co morbidity, sex, BMI, lower maintenance warfarin dose, and concomitant drugs. If patients have cardiac or liver disease, they may spend longer time to discontinue warfarin before surgery.Warfarin, interruption, surgery, anticoagulant, cessation

77-80

Authors: Tanita Thaweethamcharoen, Ph.D.*, Prapaporn Noparatayaporn, B.Sc.Pharm., Cherdchai Nopmaneejumruslers, M.D., Thitinan Bunrod, B.Sc.Pharm.*

Objective: To study drug expenditure and the pattern of Non-Essential drug (NED) use after the restriction policy at a large University Hospital in Thailand. Methods: The computerized data of the large University Hospital in Thailand was analyzed using a ‘I control chart’ with a statistically process-controlled method for the three highest oral drug expenditure groups of the hospital which included statins, proton pump inhibitor (PPIs), and non steroidal anti-in ammatory drugs (NSAIDs). The data of prior periods were collected before (December 2009-November 2010) and after (January 2011-August 2012) the implementation of the restricted policy of NED reimbursement was launched in December 2010. Results: Both statins and PPIs expenditure were decreased more than 30% while NSAIDs was decreased about 25% after implementation of the policy. Drug expenditure cost was decreased about 177 million Baht per year in the three groups. The patterns of drug usage were changed from NED to Essential drug (ED) about 36%, 26% and 7% in statins, PPIs and NSAIDs groups, respectively. Conclusion: The restriction of the NED prescribed policy was able to reduce the drug expenditure of the large university hospital. However the sustainable cost saving must be followed for the long term period.

85-87

Authors: Alok Saxena, M.Sc., Sachin Soni, M.S., Tuhin Ghulyani, MS., Amal Rani Das, MS.

Variations are important ndings for anatomists, radiologists and surgeons. Variations may be either skeletal or neurovascular. It may simulate the normal/abnormal (malignant) structures and misguide the radiologists and surgeons during diagnostic and surgical procedures. Hence, it becomes essential to disseminate the knowledge of variations. Keeping this in mind, we report a case of a third head of gastrocnemius in a male cadaver. This muscle was observed in the right popliteal fossa, arising from lateral condyle of femur and merging with two heads of gastrocnemius.

31-35

Authors: Lalida Tuntipumiamorn, M.Sc., Piyanan Liammookda, M.Sc., Sutee Dechawongsuwan, M.Sc., Satjah Chaikreng, B.Sc., Porntip Iampongpaiboon, M.Sc., Chumpot Kakanaporn, M.Sc.

Objective: Setup accuracy of our head and neck intensity-modulated radiation therapy (IMRT) patients based on the non- extended standard thermoplastic masks was examined using a Varian onboard imaging system. Methods: Retrospective analysis of thirty head and neck IMRT patients treated during April 2009-July 2010 was performed. All two-dimensional kilovoltage (2DkV) and cone-beam computed tomography (CBCT) images were acquired weekly during the same session and reviewed by oncologists using an of ine review 8.6 program on an Eclipse treatment planning system. Couch shifts predicted by software between 2DkV and CBCT images were recorded. The planning target volume (PTV) margin using VanHerk’s margin formula was calculated. Results: Four-hundred and forty-four images of 2DkV and CBCT alignment were analyzed. Positioning errors within ± 3 mm. were shown in 84.07% of 2DkV radiographs and 85.84% of CBCT images. Average displacement found in antero- posterior (AP), cranio-cuadal (CC) and left-right (LR) axes , were 0.3±2.0 mm , 0±1.7 mm, 0.5±1.5 mm for the 2DkV, and 0.3±2.3, 0.7±2.1, 0.4±2.1 mm for the CBCT data set, respectively. Systematic and random variations from both methods which were seen in the range of 0.5-1.8 mm. PTV margins determined from 2DkV pair images, in AP ,CC and LR directions were presented at 4.60, 3.80 and 2.41 mm. when compared to 5.4, 4.32 and 4.35 mm from CBCT, respectively. Adaptive treatment planning on six patients were undertaken as well owing to the great bene t of CBCT to detect the patient’s contour changes ,which can be seen in the range of 1.20-3.12 cm. Conclusion: Based on our immobilization masks and laser-based positioning, the majority of treatment setups were accurate within our acceptable criteria. Both 2DkV and CBCT were shown to be effective methods to reduce the residual setup error. The results from this study will be used as a baseline for further improving the setup accuracy for head and neck IMRT patients at our institution.

41-46

Authors: Kattiya Manomayangkul, M.D., Arunotai Siriussawakul, M.D., Khemchat Wangtawesap, M.D., Onuma Chaiwat, M.D., Tipa Chakorn, M.D., Sudta Parakkamodom, RN, Panisara Saengsung, RN, Thanawin Chawaruechai, RN, Chulaluk Komoltri, Dr PH.

Objective: To assess the quality of nurses’ basic life support (BLS) and to determine pitfalls in BLS in relation to ward characteristics. Setting: A 2,400-bed university hospital in Thailand. Methods: A 1-year retrospective simulated audit for 2009 to assess nurses’ BLS performance at each step. Each observer as- sessed the subjects’ performance by using a scoring sheet and noting the objective manikin data related to chest compression. Results: A total of 57 wards from intensive care units, critical wards, procedural units, general wards or outpatient units were audited. Only 24 out of 57 (42.1%) did airway maneuvers correctly, while only 2 out of 57 (3.5%) could rescue breathing with chest movement. For the circulation maneuvers, carotid pulse check, hand position, the depth and the rate of cardiac compression were mostly performed incorrectly. Exactly 14.0% of subjects did not palpate the carotid pulse, and 52.6% palpated it incorrectly. Thirty-three nurses (57.9%) located and placed their hands on the wrong position. Forty-one nurses (71.9%) did not achieve the requisite chest compression depth, while thirty-one nurses (54.4%) did not achieve the target chest compression rate. The overall BLS performance of nurses in the High Risk Zone was better than that of nurses in the Low Risk Zone, except in the case of the airway sector. Conclusion: The CPR audit evaluated the resuscitation performance during simulated cardiac arrest in the service setting, and compared wards nurses in 2 categories related to the risk of cardiac arrest. Improvement in the organisation of training and the systematic approach to CPR should be adopted.

51-54

Authors: Samut Chongvisal, M.D., Suchitra Prasansuk, M.D., Siriporn Limviriyakul, M.D., Kanthong Thongyai, M.D., Sarun Prakairungthong, M.D., Suvajana Atipas, M.D.

Deafness and hearing impairment are globally increasing. The Otological Center, Bangkok Unit, Department of Otorhinolaryngology, Siriraj Hospital is the rst World Health Organization collaborating center in terms of hearing prevention since1985. A school survey in the southern part of Thailand was conducted in 1990 for a prevalence, strengthening network, early detection and management at different levels. Our center performed a school survey at the same area to nd out the prevalence and ear pathology of hearing impairment. It was found that the prevalence of hearing impairment decreased in all severities, when compared to the prevalence found in the survey in 1990. The most common cause of ear pathology was earwax impaction.

58-68

Authors: Michiaki Takahashi, M.D., Ph.D.

No abstract available.