Siriraj Medical Journal

Number 2, 2017

51-56
Computed Tomography in Differential Diagnosis of Exudative and Transudative Pleural Effusions

Authors: Phakphoom iravit, M.D., Piyanus Juengsomrasong, M.D., Shanigarn iravit, M.D.

Abstract

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Objective: To di erentiate between exudative and transudative pleural e usions by using CT attenuation values and CT appearances. Methods: e retrospective study reviewed 132 patients who were diagnosed of pleural e usions in 2007-2014. All patients were evaluated by chest CT images before or a er pleural tapping within 2 days. Pleural e usions were classi ed as exudates or transudates based on Light’s criteria.1 Pre-contrast and post-contrast CT images were reviewed by measuring the mean attenuation values of pleural e usions and the associated CT ndings. Results: Pleural e usions were 112 exudates and 20 transudates. Exudate group had signi cant higher mean attenuation values, compared with a transudate, in both pre-contrast (12.8±5.0 HU vs. 9.4±5.2 HU; p<0.001) and post-contrast images (13.8±5.1 HU vs. 10.2±5.7 HU; p=0.006). For di erentiation between types of pleural e usions, the CT attenuation cuto value of 8.5 HU showed highest sensitivity of 84.5% and the cuto value of 16 HU showed highest speci city of 95%, respectively. e CT ndings of pleural nodule, pleural thickening and loculation were more common in exudates, compared with transudates with the statistical signi cance and speci city of those ndings as high as 100%, 90%, and 75%, respectively. Conclusion: e mean attenuation values of ≥16 HU favor exudates. However, the use of CT attenuation values for di erentiating types of pleural e usions alone, showed poor diagnostic performance. Correlation with clinical context and pleural uid analysis are still essential. We suggest the three helpful CT ndings for diagnosis of exudates which are pleural thickening, pleural nodules and loculation.

57-64
Comparison of Laparoscopic versus Open Surgery after Insertion of Self-Expandable Metallic Stents in Acute Malignant Colorectal Obstruction: A Case-Matched Study

Authors: Vitoon Chinswangwatanakul, M.D.,Ph.D.*, Chotirot Angkurawaranon, M.D.**, Asada Metasate, M.D, Ph.D.*, Atthaphorn Trakarnsanga, M.D., Jirawat Swangsri, M.D., Ph.D., Chainarong Phalanusithepha, M.D., awatchai Akaraviputh, M.D.

Abstract

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Background: Self-expanding metallic stents (SEMS) have been acknowledged in management of acute colorectal obstruction. e surgical approach a er SEMS insertion varies from open approach to laparoscopic-assisted approach. e primary objective of this study was to compare the outcomes of laparoscopic approach and open approach a er SEMS insertion. Methods: From January 2007 to December 2010, cross-sectional medical records reviewed a total of 76 patients who underwent colorectal stenting with SEMS. Patients and tumor characteristics, complications, morbidity and mortality were obtained. Results: Forty-three patients underwent SEMS placement as a bridge to surgery. Laparoscopic-assisted surgery (LS) was performed in 24 patients (55.8%), and open surgery (OS) was performed in 19 patients (44.2%). All clinicopathological parameters were matched. e technical success of SEMS was found in 42 patients (97.7%), and the clinical stent success was 100%. LS had a higher chance of primary anastomosis than OS (p=0.012; Odd ratio 2.717; 95%CI: 1.79-4.012). LS had a lower permanent ostomy rate (p=0.031; Odd ratio 0.385; 95%CI: 0.259-0.572) and lower estimated blood loss (p=0.024; Odd ratio 0.23; 95%CI: 0.006-0.086). e post-operative complications, mortality rate, recurrence rate, disease free status, and overall survival rates between the two groups were non-signi cant. Conclusion: Colonic stent is an e ective treatment of acute malignant colonic obstruction. e authors suggest the advantage of laparoscopic approach resection a er colonic stenting results in a higher primary anastomosis rate, and lower blood loss than open surgery.

65-69
Clinical Features of Sympathetic Ophthalmia in a Tertiary Referral Center in Thailand

Authors: Sutasinee Boonsopon, M.D.*, Pitipol Choopong, M.D.*, Nattaporn Tesavibul, M.D.*, Southida Lounmivong, M.D.**, Varittha Laksanapuk, M.D.***

Abstract

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Number of views: 530

Background: Sympathetic ophthalmia is a rare bilateral granulomatous intraocular in ammation, developed a er ocular injury in one eye. If untreated, there is a potential risk of developing visual impairment in both eyes. An awareness of this disease is crucial. Studies related to clinical characteristics, treatment outcomes and disease complications would help us more understand about the disease and visual prognosis. Objective: To report clinical features of sympathetic ophthalmia and potential ocular complications of the disease. Methods: is study was a descriptive retrospective study. Medical records of patients who were diagnosed with sympathetic ophthalmia at Siriraj Hospital between January 2006 and January 2015 were reviewed. Patient’s demographic data, history and details of ocular injuries or surgeries, details of ocular examinations, follow up duration and treatment outcomes were recorded. Results: Twenty-three sympathetic ophthalmia patients were found. Eighteen patients (78.3%) had histories of ocular trauma and 5 patients (21.7%) had histories of ocular surgery. Duration between ocular injuries and onset of intraocular in ammation ranged from 24 days to 50 years. No associated risk factors of developing sympathetic ophthalmia were identi ed due to incomplete data and small sample size. e most common complication was secondary glaucoma. ere were wide varieties of treatment regimen. Some patients were treated with only corticosteroid eye drops, whereas some patients were treated with systemic corticosteroids and/or immunosuppressive medications. Most patients (17/23; 74%) had visual improvement on their last visit. Conclusion: Early diagnosis, early detection of disease complications and early initiation of proper treatments can alter disease prognosis and visual outcome in most patients.

70-74
Ef cacy of Selective Laser Trabeculoplasty in Phakic and Pseudophakic Patients with Open-Angle Glaucoma

Authors: Sakaorat Petchyim, M.D., Naris Kitnarong, M.D., Chutima Wongsiwaroj, M.D.

Abstract

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Objective: To compare the e cacy of selective laser trabeculoplasty (SLT) in terms of intraocular pressure (IOP) reduction between phakic and pseudophakic patients with open-angle glaucoma (OAG). Methods: Phakic and pseudophakic patients with OAG who had IOP ≥15 mmHg treated with ≥2 topical anti- glaucoma medications were enrolled. Pseudophakic eyes with history of complicated phacoemulsi cation were excluded. SLT was performed 270 degrees by one surgeon under the same protocol. IOP was measured with applanation preoperatively and at 1 hour, 1 week, 3 weeks and 3 months postoperatively. Results: ere were 59 eyes (38 phakia and 21 pseudophakia) from 38 patients enrolled between September 2011 and August 2012. e mean IOP signi cantly decreased from 19.5±2.5 and 20.2±3.2 mm Hg preoperatively to 15.6±3.4 and 15.3±3.1 mm Hg postoperatively at 3 months in phakic and pseudophakic group respectively. Mean IOP reduction was not signi cantly di erent between phakic (3.9± 3.1 mmHg) and pseudophakic group (5.0±3.06 mmHg, p=0.197). e non-inferiority test indicated that mean IOP reduction in pseudophakic group was non- inferior to phakic group (p=0.012). Conclusion: SLT was e ective for IOP reduction in both phakic and pseudophakic eyes with OAG. e e cacy of SLT in pseudophakic eyes was not inferior to phakic eyes.

75-79
Effect of Misoprostol on the Pharmacokinetics of Sustained Release Diclofenac in Myanmar Healthy Male Volunteers

Authors: Htet Htet Aung, M.B., B.S., Aye Soe, Nu Nu Aye

Abstract

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Background: Sustained release diclofenac (diclofenac SR) is the commonly used non-steroidal anti-in ammatory drug for chronic in ammatory conditions such as rheumatoid arthritis. Misoprostol, prostaglandin analogue, is the agent that enhances gastrointestinal mucosal defense. Concomitant administration of misoprostol with diclofenac SR can prevent the gastrointestinal side e ects of diclofenac SR. Objective: e purpose of the study was to explore the e ect of misoprostol on the pharmacokinetics of diclofenac SR in healthy volunteers. Methods: Crossover study was evaluated in 14 male volunteers. Single oral dose of 100 mg diclofenac SR was concomitantly administered with 200 μg misoprostol with one-week wash out period. Plasma concentrations at 0, 0.5, 1, 1.5, 2, 3, 6 and 10 hrs were determined by high performance liquid chromatography (HPLC). Pharmacokinetic parameters such as area under concentration-time curve (AUC0-α), peak plasma concentration (Cmax), time to achieve peak plasma concentration (Tmax), absorption half-life (T1⁄2(ab)), elimination half-life (T1/2(el)), absorption rate constant (Kab), and elimination rate constant (Kel) were determined. Results: With misoprostol, the mean AUC0-α of diclofenac SR was signi cantly reduced from 12.11±5.25μg/ mL×hr to 4.17±2.72μg/mL×hr (p<0.001). e mean Cmax was also signi cantly decreased from 1.43±0.46 μg/mL to 0.98±0.48 μg/mL (p<0.05). e mean Tmax was decreased from 1.61±0.53hr to 1.46±0.41hr (p>0.05). e mean T1⁄2(ab) was decreased from 0.56±0.23hr to 0.54±0.19hr (p>0.05). e mean Kab were almost the same 1.43±0.54hr-1 and 1.43±0.48hr-1. e mean T1/2(el) was decreased from 3.68±1.64hr to 3.03±1.08hr (p>0.05). e mean Kel was increased from 0.21±0.09hr-1 to 0.25±0.09hr-1 (p>0.05). Conclusion: ere was a signi cant reduction in the extent of absorption of diclofenac SR when concomitantly administered with misoprostol. erefore, the dose of diclofenac SR may need to be increased to avoid therapeutic failure of diclofenac SR or concurrent use with misoprostol may need to be changed to other gastroprotective agents.

80-84
Hypoglycemic Effect of Terminalia Chebula Retz. Fruit on Alloxan-Induced Diabetic Rats

Authors: Ei Pye Phyo Aung, M.B., B.S.*, Shin Hnaung Lwin, M.B., B.S, M.Med.Sc. (Pharmacology), Ph.D. (Pharmacology), Dip.Med.Ed.*, Nu Nu Aye, M.B., B.S, Ph.D. (Med.Sc.), Dip.Med.Ed.*, Khin Phyu Phyu, M.D.**

Abstract

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Objective: To evaluate the hypoglycemic e ect of ethanolic extract of terminalia chebula Retz. fruits on alloxan- induced diabetic rats compared with standard oral hypoglycemic drug, metformin. Methods: A randomized controlled experimental animal study was done. 30 Wistar albino rats were induced diabetes by alloxan (100 mg/kg). 80%-ethanolic extraction of fruits of terminalia chebula Retz. was performed by using Soxhlet extraction method. Group 1 was normal control. Group 2 was alloxan-induced diabetic control, group 3 was metformin 100 mg/kg standard group, groups 4, 5 and 6 were extracts 100, 200 and 400 mg/kg orally administered fruit extract for 28-days, respectively. Fasting blood glucose (FBG) levels were measured at the end of the rst, second, third and fourth weeks by using standardized glucometer. Results: At the end of rst, second, third and fourth weeks, the FBG levels of diabetic control were 325.7±28.2, 308.5±69.8, 322.7±65.8 and 369.2±57.4 mg/dL, those of metformin (100 mg/kg) were 76.2±9.5, 92.5±14.9, 94.5±17.9 and 90.8±9.9 mg/dL, those of the terminalia chebula Retz. extract 100 mg/kg were 232.5±78.6, 122.8±41.4, 109.2±33.6 and 132.3±41.1 mg/dL, extract 200 mg/kg were 82.7±8.2, 82.7±8.2, 89.7±9.8 and 89±15.2 mg/dL, and extract 400 mg/kg were 80.2±9, 83.5±7.1, 91±11.5 and 82.7±5.9 mg/dL, respectively. When all treatment groups were compared with diabetic control, the FBG levels were signi cantly reduced (p<0.001). ere was no signi cant di erence in FBG levels between standard group and extract (200 and 400 mg/kg) groups. Conclusion: e 80%-ethanolic extract of terminalia chebula Retz. has signi cant hypoglycemic e ect on alloxan- induced diabetic rats and it was comparable with standard drug, metformin. e e ective dose was 200 to 400 mg/kg.

85-93
The Application of the Therapeutic Drug Monitoring (TDM) of First and Second-Line Drugs for Multidrug- Resistant Tuberculosis Patients (MDRTB)

Authors: Anun Chaikoolvatana, Pharm.D, Ph.D., Yun-Bae-Kim, Ph.D., Cholada Chaikoolvatana, Ph.D., Nawaporn Saisingha, Ms.C., Palakorn Suebsamran, Ms.C.

Abstract

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Number of views: 545

Objective: e study aimed to evaluate the e ectiveness, safety, and drug compliance among MDRTB-patients who either undergo therapeutic drug monitoring (TDM) or not to assess the full bene t of TDM related to the disease treatment. Methods: It was a quasi-experimental design. e study group underwent TDM process to measure serum drug concentrations of pyrazinamide (PZA) and cycloserine (CS), whereas the control group went through the regular process of treatment without taking TDM. All patient information and lab tests were investigated. Descriptive statistics including, frequency, percentage, mean, SD, percentage (s) as well as analytical statistics at con dence interval of 95% (p<0.05) including Fisher’s Exact test were used. Results: ere were no signi cant di erences between measuring and calculating PZA concentrations throughout 4-month periods (p>.05). Overall, the treatment success of MDR-TB among the subjects in both groups were still not satis ed. e common side e ects of both medications were reported. Serum concentrations of PZA and cylcoserine were not signi cantly related to the side e ects. Similarly, there was no signi cant relation between serum concentrations of PZA and drug compliance. Conclusion: TDM is described as an investigational tool to explore means of improving therapeutic outcomes and reducing toxicity of the current MDRTB medications. Further investigations are still needed.

94-96
Ectopic Brain Tissue in a Child: A Case Report A Case of Ectopic Brain Tissue in the Nasophaynx in Thailand

Authors: Vannipa Vathanophas, M.D., Archwin Tanphaichitr, M.D., Kitirat Ungkanont, M.D.

Abstract

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Brain heterotopia is a benign tumor composed of di erentiated neural tissue that is located outside the cranial vault. is condition is uncommon and presents as a congenital pharyngeal mass. Here, we report a case of neuroepithelial heterotopia in the nasopharyngeal area of a six-month-old boy who presented with cle palate and stridor. e tumor demonstrated aggressive growth with oropharyngeal involvement. Radiologic nding revealed a large heterogeneous enhancement on the le side of the nasopharynx, involving the uvula, le lateral pharyngeal wall, and le tonsil. No connection to the brain or spinal cord was apparent on imaging. Histologic features included presence of neuroglial heterotopias, composed predominately of glial cells in a surrounding neuro brillary matrix. Surgery was the selected intervention, with wide excision performed via cle palate. Previously published literature relevant to this case were reviewed and discussed. Recurrence is common in incomplete resection, although there was no evidence of recurrence at the two-year follow-up in this patient.

97-101
Selective Management for Gastrointestinal Hemorrhage caused by Choledochoduodenal Fistula

Authors: Pawan Chansaenroj, M.D., Stephanie Wood, M.D., Stanley J Rogers, M.D. , John P Cello, M.D.

Abstract

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Number of views: 583

Background: To report a patient of choledochoduodenal stulae (CDF) who presented with melena and review a speci c treatment for CDF. Methods: is study was designed as a retrospective chart review using patient’s clinical data, imaging, endoscopic report, treatment review, and literature review for treatment options. Results: A 74-year-old female presented with di use, non-tender abdominal pain and associated melena for one week. Physical examination showed mildly icteric sclera and mild epigastric tenderness on deep palpation. Initial diagnoses included cholangitis with anemia and acute kidney injury. Computed tomography of the abdomen revealed dilated common bile duct (CBD) with a likely 1 cm stone at the distal common bile duct. e patient was given intravenous antibiotic and proper uid administration. An ERCP was performed noting a stula from the bile duct to the 2nd part of the duodenum with stone impaction. Sphincterotomy was performed from papilla to stula. Balloon extraction of 1 cm stone from the CBD was done. Conclusion: e clinical presentation of CDF is generally quite nonspeci c. In this case report, we present a presentation of a patient with gastrointestinal hemorrhage as an example of the presentation of CDF associated with a CBD stone. is study also discussed recent data concerning proposed treatment of CDF.

102-106
Laparobotic Duodenal Diverticulectomy: A Case Series and Operative Technique

Authors: Anuchit Lerstsirithong, M.D., awatchai Akaraviputh, M.D., Anusak Yiengpruksawan, M.D.

Abstract

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Objective: Duodenal diverticulum is not uncommon but most are asymptomatic. Surgery is recommended only for the patients with symptoms. Although laparoscopic diverticulectomy can be done, it is o en with signi cant di culties due to inherent limitations of the laparoscopic technique and posterior location of the lesion. e advent of the robotic surgical technology with superior imaging and instrumentation may provide an alternative minimally invasive approach for this situation. We herein report our case series utilizing the daVinci Surgical System (dVSS) for duodenal diverticulectomy. Methods: We retrospectively reviewed our robotic database for all duodenal procedures performed at a single institution (the Valley Hospital: VH). Only patients who underwent laparobotic duodenal diverticulectomy (LRDD) were included and their recorded videos reviewed. Data analyzed were patients’ demographic, perioperative outcomes, and technical details. We used the daVinci Si (Intuitive Surgical Inc. Sunny Vale, Calif.) for all cases. Results: 4 female patients underwent LRDD. All presented with abdominal pain. Diagnosis was made by CT scans or MRI with or without EGD. 3 patients had diverticula located in the second part of the duodenum (75%). Concomitant procedures (choledochoduodenostomy and CBD exploration) were performed in two patients. Mean operative time was 142.5 min. ere was one complication but no mortality. Average length of stay was 4 days. Conclusion: LRDD is feasible, e cient, and safe. e dVSS provides the surgeon improved visualization and enhanced dexterity to perform complex procedure.