Siriraj Medical Journal

189-193

Authors: Nitipatana Chierakul, M.D., Kanokwan Boonyapisit, M.D., Nukool Keurueangkul, M.D.

Objective: Sleep loss affects function of humans in terms of cognition, learning, and also memory. Suboptimum sleep is inevitable during residency training especially in internal medicine. Regulation of maximum hours of work per week and duty period for in-training physicians has been established in some countries, but not yet in Thailand. This study aims to describe the sleep hygiene, perception of reduced sleep hours, and daytime perfor- mance of internal medicine residents during the rst year of training in one major teaching hospital in Thailand. Methods: Self-administered questionnaires were distributed to rst-year internal medicine residents after informed consent at the time of orientation before training for baseline data, then at 6 and 12 months after training. Results: Among 56 participants, the mean age was 27 ± 1 years, and 30 of them were female. Average sleep hours was signi cantly decreased (p < 0.001) from 7.0 hr at baseline (M0) to 6.0 hr at month 6 (M6) and 6.1 hr at month 12 (M12). On the contrary, the Epworth Sleepiness Scale (ESS) was signi cantly increased after being the trainee (5.7/24 at M0, 8.6 at M6, and 8.0 at M12, p < 0.001). Perception of reduced sleep hours did not change signi cantly after training (42.9/65 at M0, 43.5 at M6, and 43.0 at M12, p > 0.46). Daytime function in terms of fatigue, irritability, depressed mood, impaired memory, poor concentration, and decreased learning ability were signi cantly increased at M6 and remained stable at M12, except for the further increment of irritability and impaired memory (p < 0.05). Con ict events with colleagues were signi cantly increased at M12 and medical errors were signi cantly increased at M6 and stable at M12 (p < 0.05). Conclusion: Internal medicine residency training greatly in uences the sleep quality of physicians. Tendency towards sleep loss may be one of the stressful environments determining their self-reported impairment of day- time functions.

210-218

Authors: Kittikun Viwatpinyo, M.D., D. Troy Case, Pasuk Mahakkanukrauh, M.D.

Foot bones are of interest for forensic sexing because of high reported accuracy in recent studies and often good preservation. This study investigated 202 pairs of navicular bones (104 males, 98 females) obtained from the Chiang Mai University Skeletal Collection. Metric measurements of eight dimensions of the navicular bone were taken with a digital caliper and analysed statistically to determine mean differences between the sexes and to calculate discriminant functions. Discriminant functions obtained from a combination of all variables had a pooled accuracy of 91.1% for the left navicular and 92.1% for the right. Using a stepwise method, discriminant functions showed 89.6% and 92.1% accuracy for left and right bones, respectively. In addition, the functions from stepwise method from either left or right side can be applied to the opposite side with similar obtained accuracy. Variables from the articular facets of the navicular bone had a high effect size and were included in all of our derived discriminant functions. We suggest that detailed measurement of articular facets could be useful for skeletal sexing.

225-230

Authors: Bijaylakshmi Parija, M.D., Niranjan Sahu, M.D., Shakti Rath, M.Sc., Rabindra N. Padhy, Ph.D.

ackground: Normal ageing and dementia cause the increase of ventricular size in brain, and it is necessary to ascertain ageing related changes in ventricle size in normal Indo-Dravidian people of southern Odisha, India. Objective: To nd out age-related changes in ventricular system of brain in normal individuals from younger to elderly groups in both sexes. Methods: Sixty normal females and males within ages, 15 to 70 years were examined by computed tomography (CT) scan of brains. Measurements of lateral, third and fourth ventricles were considered by arranging the subjects into 3 age-groups, 15 to 30, 31 to 50 and 51 to 70 years. After taking due measurements, Schaltenbrand index was calculated. Results: Size of all ventricles had insigni cant increase or no change from the youngest (15 to 30 years) to the middle age-group (31 to 50 years), but the width of third ventricle was found to increase in most males and females in the elderly group. Males had higher values of enlargement than females in all ventricles. Measurements of AP length of frontal horn and frontal horn with body remained almost constant in the youngest age-group, which increased with ageing. Schaltenbrand index values decreased steadily from younger to higher age-groups. Conclusion: Sizes of all three ventricles were more in elderly individuals. In both higher age-groups, males had more expansion of ventricular system than females. Increase in ventricular size was more evident in the lateral ventricle. Changes in ventricular size did not show any effective change in cranial diameters.

234-239

Authors: Chongdee Dangrat, B.Sc. (Biology), M.Sc. (Biochemistry)

Hyperprolactinemia is a common endocrine disorder which clinically manifestats in reproductive period and presents with hypogonadism, galactorrhea and symptoms related to tumor mass effects. Hyperprolactinemia is a state of excess total prolactin (PRL) concentration in serum. Three forms of PRL in sera are monomeric PRL with 23 kilo-dalton (kDa) MW which acts bioactively which is predominant in patients with prolactinomas, dimeric PRL; 45-60 kDa MW which is not clearly bioactive and macroprolactin with MW bigger than 100 kDa which is not bioactive. Macroprolactinemia is common and is associated with idiopathic hyperprolactinemia. Serum PRL is routinely screened for diagnosis of hyperprolactinemia. Nowadays, laboratory automatic analysis to measure serum PRL level using sandwich immunomatric methodology is accurate and reliable. Limitations of these immunoassays are interference from prolactin/IgG auto-antibody complex termed macroprolactin. This condition may lead to misdiagnosis and mismanagement of cases because the total PRL measurement comprises macroprolactin and active PRL. Using 25% polyethylene glycol (PEG) precipitation quantitatively provides the bioactive PRL by gel ltration chromatography which remains the gold standard to fractionate the level of PRL concentration. Recommended cut point recoveries of PRL less than 40% or 50% is indicative of the predominance of macroprolactin whereas more than 50% or 60% is diagnosed as true hyperprolactinemia. PEG precipitation is the best practice and recommended as the worldwide method to divide macroprolactin and active PRL for detection of the true origin because it is reproducible, easily performed and is effective screening. This review emphasizes about pathophysiology of hormone PRL and expresses the necessary method to clarify between macroprolactinemia and truly hyperprolactinemia.

131-138

Authors: Nantakan Ieumwananonthachai, M.D., Jiraporn Setakornnukul, M.D., Pawinee Mahasittiwat, M.D., Kanchana Amornpichethul, M.D., Kullathorn Thephamongkhol, M.D., Pittayapoom Pataranutraporn, M.D.

Objective: Cervical cancer is a major health problem for women. Concurrent Cisplatin-radiation therapy (CCRT) can improve survival, although result of treatment is still not satisfactory. Many prognostic factors have been known, but they cannot explain all the results. Cyclooxygenase-2 (COX-2) is one of the molecular factors related to angiogenesis that can lead to more accurate predictive outcome and modi cation of the treatment in the future. Methods: Retrospective study to nd relationship of COX-2 expression to overall survival (OS), progression free survival (PFS), distant metastasis free survival (DMFS), and loco-regional relapse free survival (LRRFS) of locally advanced cervical cancer in patients who were treated with CCRT at Siriraj Hospital from 2002 to 2007. In this COX-2 IHC study, the interpretations of results were based on both intensity and quantity score. Results: There were 49 patients included into the study. COX-2 was positive in 36 (73%). Median f/u time was 22 months. COX-2 expression was proven to be a signi cant prognostic factor to predict OS and PFS with HR 19.5 (95% CI 1.1-337.2) and HR 27.1 (95% CI 2.1-355.6) respectively. Total treatment time (>55 days) is the most signi cant prognostic factor for OS, PFS and DMF. Conclusion: Expression of COX-2 positive is a signi cant prognostic factor to predict worse OS and PFS com- pared to COX-2 negative group in multivariate analysis. The COX-2 scoring system used in this study was good to predict prognosis.

146-153

Authors: Tamnit Ansusinha, M.D., Woranuj Tangcharoensathien, M.D., Kidsada Choosri, M.D., Pacharavadee Towanasutr, M.D., Naparat Viravan, M.D., Alisa Thammarat, M.D., Chulaluk Komoltri, DrPH

Objective: Mammography has been recognized as the gold standard for screening breast cancer. To achieve the effectiveness of mammography performance, mammography audit is recommended as a method for evaluating the accuracy of mammography interpretation. This study aimed to evaluate the key parameters of screening and diagnostic mammography audit in our dedicated breast imaging center. Methods: Retrospective analyses of 54,204 out of 64,049 mammography with or without breast ultrasound at Thanyarak Breast Center, Siriraj Hospital, Mahidol University during 1 Jan 2001 to 31 Dec 2005 were performed. These comprised of 26,735 screening (SCR) and 27,469 diagnosis (DX). Demographic data, image assessment category, biopsy results and mammography audit were analyzed base on BI-RADS (4th edition) recommendation. Results: The mean age of SCR group was 50.1 years compared to 46.2 years for DX. Family history of breast cancer found in SCR and DX were 9.9 and 10.9%. The positive predictive value (PPV2 or biopsy recommended) were 19.5% and 33.7% in SCR and DX respectively. The cancer detection rate (CDR) in SCR and DX were 3.8 per 1,000 and 40.0 per 1,000. The sensitivity/ speci city in SCR and DX were 73.6%/98.4% and 96.3%/ 75.1 % respectively. Conclusion: Signi cant difference key parameters among SCR and DX mammography were well established. Our study represents key parameters of mammography audit of SCR and DX of Thai women comparing to other reports. However, variation in these key parameters of mammography audit depends on de nition when com- paring to other institute outcomes.

161-167

Authors: Patama Suttha, M.D.

Background: HIV-infected patients are commonly found with fever of unknown origin (FUO), leading to high morbidity, prolonged hospitalization, and extensive diagnosis. Other than the noninvasive investigations, such as blood cultures or sputum examination and cultures, bone marrow aspiration or culture and biopsy can be undertaken with speci c diagnostic yield for FUO. Objective: To investigate diagnostic yield of bone marrow examination in HIV infected patients with FUO. Methods: This study was a retrospective review of bone marrow aspiration, culture and biopsy in 84 HIV infected patients with FUO hospitalized between January 2003 and January 2013 at Bamrasnaradura Infectious Diseases Institute, Nonthaburi, Thailand. Results: Overall, abnormal ndings were found in 46 cases (diagnostic yield, 54%), with speci c diagnosis by bone marrow examination in 36 cases (diagnostic yield, 42.8%). Two types of diseases were observed: 1) Infectious diseases in 34 cases [17 with non tuberculous mycobacterial (NTM) infection, 8 with histoplasmosis, 6 with cryptococcosis, and 3 with tuberculosis (TB)], 2) Hematological malignant diseases in 2 cases. The clinical predictor of positive bone marrow examination (BME) was leucopenia (p< 0.05). Conclusion: Bone marrow examination should be recommended as a useful diagnostic tool to yield speci c diagnosis for the evaluation of appropriate treatments in HIV-infected patients with FUO.

179-184

Authors: Santosh K. Swain, MS, DNB, Mahesh C. Sahu, M.Sc., Rankanidhi Samal, MS., Rabindra N. Padhy, Ph.D., Post-Doc

Background: Diabetes mellitus has been a cause of many a health ailment. The relationships between inner ear manifestations such as hearing loss (HL), tinnitus and vertigo as well as diabetes are not established. Objective: To assess prevalence of HL, tinnitus and vertigo among diabetic patients in a typical Indian tertiary care hospital in a cross-sectional study. Methods: 240 patients were categorized according to their age (< 60 years and > 60 years), gender, chronicity of diabetes mellitus (<10 years and >10 years), related complications (hypertension, nephropathy and retinopathy) and modalities of diabetic treatment taken by patients. Detailed examinations of their ears with an otoscope and the tuning fork test, including the pure tone audiometry were done in a sound proof room at frequencies of 500- 8000 Hz. Results: Ear manifestations were found among 240 diabetes patients: HL in 148 cases (61.67%), tinnitus in 70 cases (29.17%) and vertigo in 17 cases (7.08%). The association of age (p=0.21) and sex (p=0.58) with HL, tinnitus and vertigo were not statistically signi cant. Nevertheless, the duration of diabetes as well as the treatment modalities for it, in relation to these ailments were statistically signi cant (p=0.07) and (p=0.05), respectively. Conclusion: HL, tinnitus and vertigo were better controlled by intake of insulin than oral hypoglycemic agents and diet regulation.

82-91

Authors: Vimolluck Sanansilp, M.D., Petchara Boonsang, B.N.S., B.P.H., Sunee Thongtanee, B.N.S., M.A., Rattana Pernchareonsin, B.N.S., M.N.S., Tidawun Chaimanee, B.N.S., M.Sc., Varaluk Boonchai, B.N.S., Muntana Charoenloet, B.N.S., B.Ed., Benjawan Kongmuang, B.N.S., Suppat Petcharatana, B.N.S., Nongyao Kumvijitraporn, B.N.S., Taworn Detpetch, B.N.S., Ampun Netphisuth, B.Sc., Piengchai Vichaidith, B.N.S.

Objective: To determine the current postoperative pain status in the postanesthesia care unit (PACU) and nursing practices that may affect pain relief outcomes. Methods: We performed a prospective observational study in 259 postsurgical patients who underwent general anesthesia only, and were admitted to 5 PACUs in Siriraj Hospital during of cial work hours. We silently observed the pattern of nursing management for postoperative pain according to the hospital work instructions (WIs). We interviewed the patients once about their pain scores (PSs) at the time they were discharged to wards. The man- power in each PACU was determined. All nurses working in 5 PACUs were asked to ll in the questionnaire. Results: The PS after gaining consciousness, the overall PS, and the PS at discharge time were (mean±SD) 1.3±2.9, 4.1±2.7 and 3.1±2.4, respectively. The time to re-evaluate PS after each intravenous analgesic, to determine the adequacy of treatment, was longer than was recommended, so were the time of giving the additional doses which were 21.9±16.7 minutes, and 20.9±14.7 minutes, respectively. Other instructions in the WIs were followed in >75% of these patients. The Registered Nurse-to-patient care ratio was 1:1.5 (0.2-8.0). Nurses considered that to adjust manpower according to the varied numbers of patients during the day could improve their work. Nurses’ attitude to intravenous analgesic administration was positive. Conclusion: The overall PS was 4.1±2.7. Pain control system in Siriraj Hospital PACU was mostly in accordance with the hospital WIs, except that the time to re-evaluate the adequacy of analgesia was too long. Adjusting the manpower to suit the varying workload during the day was suggested to improve their work.

97-102

Authors: Kriangsak Sirirak, M.D.

A bed for burn wound care: a stainless steel grating-top table is used as a moveable sterilized table for burn wound cleansing or an operating table. Its top can be sterilized by autoclaving and after sterilization; burned patients can lie on this sterilized area for burn wound cleansing or surgical manipulation. The grating-top table can be moved room to room like a trolley by the wheel and its brake at each leg. In Prapokklao hospital, the grating-top table has been used for burn wound cleansing (using sterile solutions: warm saline, sterile water, and chlorhexidine scrub), and as an operating table when there is an indication for surgical manipulation. This study covered a total of 88 inpatients (during October 2009 - August 2012), and there were 213 times of wound cleansing (bathing and dressing) and 141 times of surgical manipulation (excision debridement and skin coverage operations). Follow with standard burn wound care principles: the grating-top table has been shown not only to be easy to use and comfortable for patients, but also results in less infection rate with good healing resulting in 86 success healing cases (97.73%) and 2 death cases (2.27%). The bed provides very cheap cost in burn wound care with appropriate outcomes.

113-119

Authors: Pornsuk Cheunsuchon, M.D., Atthanisa Punyashthira, M.D., Jantima Tanboon, M.D., Tumtip Sangruchi, M.D.

Objective: To describe accuracy, identify diagnostic discordances and pitfalls of intraoperative neuropathology diagnosis in Siriraj Hospital. Methods: All central nervous system lesions requested for rapid intraoperative consultation in Siriraj Hospital from 1998 to 2011 were reviewed. Accuracy rate and causes of diagnostic discrepancies were identi ed and discussed. Results: Intraoperative neuropathology consultation was performed in 774 cases during the study period. Non- representative specimens (40 cases, 5.2%) and cases with deferred diagnosis (36 cases, 4.7%) were excluded from the study. Of 698 cases analysed, 85.5% were neoplastic and 14.5% were non-neoplastic. The overall accuracy rate was 89%. In the neoplastic category, the most common pitfall was tumor type misclassi cation (66.7%) especially misclassi ed astrocytic and oligodendroglial tumors as other tumors (23.8%). In non-neoplastic category, the most common error was misdiagnosis of non-tumor pathology as gliomas (64.3%). Conclusion: Intraoperative neuropathology diagnosis has a crucial role in clinical management. Multidisciplinary and systematic approaches are required to overcome diagnostic limitations on small tissue samples and increase diagnostic accuracy.

127-130

Authors: Sakda Sathirareuangchai, M.D.

Sudden unexpected death is commonly dealt by a forensic pathologists. sudden cardiac death being a major cause of death in Thai population. Even though dilated cardiomyopathy is the most common type of car- diomyopathy found, it rarely results in sudden death. The author described a case of Thai adult male who was found dead in his bed. The autopsy nding revealed the cause of death to be dilated cardiomyopathy (DCM).

53-55

Authors: Nitipatana Chierakul, M.D., Paka Kontee, B.BA, Chana Naruman, M.Sc.

Objective: To evaluate the impact of patient selection process by examination center and examiner subjectivity on scores from the Royal College of Physicians Thailand (RCPT) short case examination. Methods: Data of candidates who encountered short case examination as one part of clinical examination in RCPT board certifying examination in academic year 2010 were retrieved. For each examination center, overall scores given by internal and external examiners were compared. Among patient categories that were selected for the examination in all examination centers, comparison between scores in each category were also explored. Results: There were 25 examination centers involved with 24 patient categories encountered. The mean score from internal and external examiners ranged from 64.0±17.1 to 77.8±14.4 and 65.6±18.9 to 77.4±15.4 respectively. Stringent site categori- zation as determined by lower scores from internal examiners were established in 11 examination centers, and, vice versa, 15 were categorized as lenient site. The lowest mean score difference in stringent sites was -4.9 and the highest from lenient sites was +4.7, but no statistical signi cances were reached (p = 0.088 and 0.106 respectively). There were 2 patient categories which yielded a signi cantly higher score and 1 patient category with lower score (p < 0.05). Conclusion: In the current RCPT short case examination, the selected patient category appears to contribute variation in scores more than examiner subjectivity.

61-65

Authors: Natnicha Kampan, M.Sc., Apichat Sinthubua, M.Sc., Pasuk Mahakkanukrauh, M.D.

Age estimation is one of the major components of forensic identi cation. Cranial sutures have long been used as indicators for age estimation, because they vary in their timing of closure with age. The purpose was to estimate age in 100 Thai skulls with age ranging between 15-96 years from the Department of Anatomy, Faculty of Medicine, Chiang Mai University by using a new method for assessing ectocranial suture closure. Cranial sutures were the coronal, sagittal and lambdoid sutures on the ectocranial surface. In order to investigate the closure, obliteration of each suture was recorded using two techniques: photographing and tracing. The degree of suture obliteration was measured by counting the pixels of the remaining sutures using ImageJ software. The length of each suture was recorded in centimeters and the number of pixels per centimeter in each suture was analyzed using Pearson’s correlations at the 0.05 signi cance level. The results showed a signi cant negative correlation between age and the number of pixels per centimeter only in the coronal suture, and only when measured from tracing. A predictive model established using stepwise linear regression in this study was age = 76.872 – (19.609 x the number of pixels per centimeter in the coronal suture from tracing) + (3.710 x the number of pixels per centimeter in the lambdoid suture from tracing), with a standard error of ±13.9 years. Since this is the rst attempt at age estimation using this method in Thailand, these results may assist in estimating age in forensic anthropological contexts.

70-74

Authors: Sureeporn Tongsuntud, M.Sc., Vilai Kuptniratsaikul, M.D., Chompusakdi Pulket, Ph.D.

Objective: To assess the maximum compression forces of the back while laterally transferring patients from beds to stretchers with different heights of personnel and different types of stretcher. Methods: The maximum compression forces of the back when moving patients were used to record the movement of sub- jects by CCTV. SUTStructore Program was used to compute the maximum compression forces of the back. The independent variables, postures, heights of the subject, and type of stretchers were analyzed by SPSS version 13.0. Results: The maximum compression forces on the back with postural variables were the highest during the curve posture. The height variable revealed that the least maximum forces occurred to the subject with 160-165 centimeters height. Considering the maximum forces occurred at the back, the result showed that the maximum compression forces to move patients with adjustable stretchers could relieve force more than those which occurred with non-adjustable stretchers. Conclusion: The maximum compression forces of the back while transferring patients with adjustable stretchers was lower than the maximum compression forces with non-adjustable stretchers. Additionally, the height of subjects when transferring patients from beds with 70 centimeters to 70 centimeters and 84 centimeters height of stretchers reveals that patients with 160-165 centimeters height were suitable to transfer from beds to this height of stretchers.

79-81

Authors: Shanigarn Keoplung, M.D., Sitthipong Srisajjakul, M.D., Suchada Sarattha, M.D.

The solid pseudopapillary tumor of pancreas (SPT) is rare pancreatic tumor. There is a predilection for Asian and African-American women during the 2nd and 3rd decades of life. Clinical symptoms are usually slow-growing palpable mass, abdominal distension or incidentally discovered. Interestingly, diagnosis can be done with con dence by the classic imaging ndings. In this report, we would like to present one case of young Thai female patient with the solid-cystic pancreatic mass demonstrating a well de ned margin, internal hemorrhage and typical enhancing pattern.

28-32

Authors: Suruthai Kurasirikul, M.D., Orathai Jirapongsananuruk, M.D., Pakit Vichyanond, M.D., Nualanong Visitsunthorn, M.D.

Background: Chronic rhinosinusitis is a common problem in patients with allergic rhinitis or antibody de ciency. Topical antibiotic therapy for chronic sinusitis has been shown to improve symptoms and quality of life in adults. The objective of this study was to describe the clinical outcomes after using gentamicin nasal irrigation in children with recalcitrant rhinosinusitis. Methods: This retrospective cohort was performed in children with chronic rhinosinusitis who received gentamicin nasal irrigation from January 2005 through February 2011. The clinical symptoms, frequency of sinusitis, hospitalization and antibiotic treatment due to rhinosinusitis between pre- and during treatment of gentamicin nasal irrigation were compared. Results: Thirty-eight patients (23 males) with the mean age of 12.7±1.1 years were recruited. The most common comorbidities were allergic rhinitis and antibody de ciency. After the initiation of gentamicin nasal irrigation, there were signi cant improve- ments in nasal congestion, rhinorrhea, itching, post nasal drip, purulent nasal discharge, halitosis, chronic cough, sneezing and anosmia (p<0.05). The frequency of sinusitis and the frequency of antibiotic treatment were signi cantly decreased after the treatment (p≤0.001). Hospitalization due to sinusitis exacerbation and number of intravenous antibiotic infusions also signi cantly decreased (p<0.05). The success rate of treatment was 78.9% (CI 0.64-0.89). There was no reported complication. Conclusion: This study showed that gentamicin nasal irrigation was useful in the reduction of rhinosinusitis symptoms and hospitalization in children with chronic rhinosinusitis without reported complication.

39-41

Authors: Papapit Tuchinda, M.D., Ussanee Phongsai, B.B.A, Nungruethai Torsuwan, M.A., Kanokvalai Kulthanan, M.D.

Objective: The objective of this study was to determine the cost of the Division of Dermatoimmunology. Methods: This was a retrospective study using the database of the Division of Dermatoimmunology, Department of Derma- tology including number of investigations, labor cost, material cost, maintenance cost and depreciation cost of durable items and buildings during from 1 January 2011 to 31 December 2011. Results: The results showed that the total cost of direct immuno uorescence study, indirect immuno uorescence study, skin prick testing, and autologous serum skin testing were 516.80, 431.66, 233.73, and 132.48 Baht, respectively. Conclusion: This study helped us and the hospital to estimate the unit cost of investigations in the Division of Dermato- immunology and to x the price of each investigation.

45-48

Authors: Tuenjai Chuangsuwanich, M.D., Kleophant Thakerngpol, M.Sc., Nusara Chomanee, B.Sc., Anchalee Aramtiantamrong, M.D., Pichamonch Pengvanich, M.D., Mongkol Laohapensang, M.D.

We report a case of hepatic in ammatory myo broblastic tumor in an 11-year-old boy presented with chronic pyrexia. Investigations revealed anemia, leukocytosis, thrombocytosis, increased C-reactive protein and a liver mass. The resected 7 cm., mass displayed myo broblastic proliferation with ganglion-like morphology within dense chronic in am- matory background. The diagnosis was con rmed with immunoperoxidase and ultrastructural study.