Vajira Medical Journal: Journal of Urban Medicine

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.

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.