Siriraj Medical Journal

1-4

Authors: attapon uangtong, M.D., Supenya Varothai, M.D., Charussri Leeyaphan, M.D., Daranporn Triwongwaranat, M.D., Rasthawathana Deesomchoke, M.D., Sunatra Nitayavardhana, M.D.

ackground: Alopecia totalis (AT) and alopecia universalis (AU) have a high rate of recurrence and are very di cult to treat. To date, no consensus has been reach among clinicians regarding the best way to treat these conditions. It was recently proposed that botulinum toxin type A (BT) injection in alopecia areata may inhibit unmyelinated C bers from releasing substance P and calcitonin-gene-related protein (CGRP), which showed a favorable clinical response in cephalalgic alopecia areata. Objective: To investigate the e cacy of botulinum toxin type A (BT) in the treatment of recalcitrant AT and AU. Methods: Twenty patients with either recalcitrant AT or AU were enrolled in this study. One half of the scalp was injected with BT 50 units 2.5 ml intradermally (dilution 20 units/ml) and the other half of the scalp was injected with normal saline 2.5 ml. Clinical assessments were performed using Severity of Alopecia Tool (SALT) score, scalp mapping, and photography. Patients were followed up monthly for 4 months a er treatment to evaluate terminal hair regrowth. Results: Based on patient results at the 4-month follow-up, no clinical improvement in either recalcitrant alopecia totalis or alopecia universalis was observed. Conclusion: Although BT has been demonstrated to improve the clinical features of cephalalgia alopecia areata, BT was not shown to improve the clinical features of recalcitrant AT or AU in this study. In order to understand and explain the di erences in these two clinical outcomes using BT in alopecia, further investigation is needed.

11-17

Authors: Aungsumat Wangdee, R.N., Arunotai Siriussawakul, M.D., Bencharatana Yokubol, M.D., Chanya Chansawad, Sirirat Rattana-arpa, M.D.

Objective: e authors aimed to determine the interobserver reliability during routine preoperative airway assessments by experienced and inexperienced assessors. For the current, ai registered-nurse-anesthetist-student training curriculum for preoperative airway assessment classes, the accuracy of airway evaluations performed by those trainees has not yet been evaluated. Methods: An experienced anesthesiologist, a resident, a nurse anesthetist and thirty-one registered nurse anesthetist students were enrolled in a prospective observational study to assess eight obese and ten lean volunteers using seven airway assessment methods at the beginning of an academic year. e sternomental distance (SMD), the thyromental distance (TMD), the hyomental distance (HMD), the inter-incisor gap (IIG), malformation of the teeth, the Mallampati classification (MPT) and the range of neck movement (RNM) were assessed. Interobserver reliability was determined using intraclass correlation coe cient (ICC) and kappa coe cient (K). Results: Higher strengths of interobserver agreements; and good to very good agreements were found among the two, more experienced assessors, namely, the resident and the nurse anesthetist. When seven airway assessment methods were evaluated by registered nurse anesthetist students, the interobserver agreements ranged from poor to moderate. For the subgroup analysis of lean and obese volunteers, higher reliabilities of airway assessments were found for the lean volunteers. Conclusion: e accuracies of the airway assessments performed by the registered nurse anesthetist students were lower than those of the more-experienced groups. us, there is some room for improvement in the current nurse- anesthetist curriculum.

24-31

Authors: rasert Sawasdiwipachai, M.D., Karuna Phatangjaijing, M.D., Nattawut Maneekut, M.D., Sukanya Dejarkom, M.D., Sirilak Suksompong, M.D., Sathit Chairattanavanich, M.D.

Background: Glycopyrrolate has been widely used globally as an adjunct in anesthesia since early 1970’s. However, this agent has never been used in ailand until recent introduction of the Glyco-P® (0.2 mg IV glycopyrrolate). e clinical e cacy and safety of intravenous glycopyrrolate in ai population was unknown. Objective: To evaluate the clinical e cacy of intravenous glycopyrrolate in 3 areas 1) antisialagogue 2) e ect on heart rate and 3) anticholinergic e ects when used with neostigmine for neuromuscular blockade reversal. Methods: Single-centered, prospective observational study, which enrolled 121 ASA 1-3 patients receiving intravenous sedation or general anesthesia. e patients were given an IV glycopyrrolate and had their data collected and categorized by clinical indications into 3 groups-secretion group (SCR), heart rate group (HR) and reversal of neuromuscular blockade group (NMR). We recorded heart rate and blood pressure at baseline and every 5 minutes and recorded secretion score every 10 minutes a er treatment. Results: Intravenous glycopyrrolate demonstrated good antisialagogue properties as 76.1-85.6% of patients in SCR group recorded minimal secretion score, between 0-1 out of 5, at 10-20 minutes. A mild to modest chronotropism was observed as mean heart rate was increased from 72.85 to 79.85 within 5 minutes. When used with neostigmine for reversal of neuromuscular blockade, the well-balanced anticholinergic e ect was seen as stable heart rate and minimal secretion. Conclusion: An intravenous Glyco-P® demonstrates its clinical e cacy in ais at the same recommended dose as previously described in western population for both antisialagogue and stable heart rate when used alone and used in conjunction with neostigmine for neuromuscular blockade reversal.

35-39

Authors: Pichaya Petborom, M.D., Prasit Upapan, M.D.

Pulmonary actinomycosis is a rare, slowly progressive infectious disease which is di cult to diagnose. e disease can mimic lung malignancy, given its nonspeci c clinical and radiological presentations, thus posing a diagnostic dilemma to the physician. Making the diagnosis can be complicated. Surgical procedures such as CT- guided trans-thoracic needle biopsy, bronchoscopic techniques, or even surgical resections may aid the diagnosis based on histopathological examinations and cultures of the lung tissues. Hence, with the frequent suspicion of a malignancy, physicians are usually prompted to resort to surgical diagnostic procedures. e authors report a patient with a rare case of pulmonary actinomycosis which presented as a mass-like lesion in his lung, which was diagnosed a er pneumonectomy.

44-46

Authors: Kamolwan Pongparit, M.D., Leena Chularojanamontri, M.D., Waranya Boonchai, M.D.

Necrolytic migratory erythema (NME) is a rare skin condition, which is the rst presenting manifestation in almost 70% of the patients with glucagonoma. It is characterized by well-de ned scaly erythematous patches with crusted erosion in annular appearance. e predominant areas are genital area, intertrigenous sites and lower extremities. is article has presented the case who had a 5-month history of progressive erythematous scaling patches with crusted erosion on acral, trunk and intertriginous areas. He had been treated for several months at another hospital without de nite diagnosis. Our investigations revealed diabetes mellitus and a 6.5x5.7x6.0 cm mass at pancreatic head without liver metastasis. Percutaneous biopsy revealed monomorphic round cells with pleomorphic nuclei which immunohistochemical staining revealed strongly positive for neuroendocrine tumor. e diagnosis of probable glucagonoma associated with NME was established. Zinc supplement was initiated resulting in marked improvement of his rash. He went to Fuda Hospital in China to receive cryosurgery for his pancreatic tumor. Up until now, there has been no recurrence of his rash and his general condition remains stable for 3 years. However, CT scan at 3 years a er cryosurgery showed slight increase in size of pancreatic mass and increased degree of di use dilatation of main pancreatic duct and side-branch. us, long term follow-up is mandatory to conclude the outcome of cryosurgery for pancreatic cancer.