The Journal of Prapokklao Hospital Clinical Medical Education Center

Editorial Ariticle

Assoc.Prof.Pipat Kongsap — 2024-09-16

Finasteride 5 mg

Chayanid Boonnasak — 2024-09-16

Finasteride is a specific competitive inhibitor of 5α-reductase to reduce dihydrotestosterone (DHT) production. Finasteride is approved for treatment Symptomatic benign prostatic hyperplasia (BPH), Male hair loss, Benign prostatic hyperplasia-Hematuria (Unlabeled use), Hirsutism (Unlabeled use) and Prophylaxis prostate cancer (Unlabeled use). The common side effect is Erectile dysfunction, Loss of libido and Breast enlargement.

Basic Principle of PET Scans

Wasit Kanokwongnuwat — 2024-09-16

Positron Emission Tomography (PET) imaging has revolutionized medical diagnostics by offering unique insights into the functional and molecular processes within the human body. PET utilizes radiotracers, typically biologically active molecules labeled with positron-emitting isotopes, administered intravenously, orally or inhalation to patients. As these radiotracers decay, they emit positrons, which subsequently annihilate with nearby electrons, producing pairs of gamma rays. Detectors surrounding the patient capture these gamma rays, enabling precise localization. By analyzing the emitted radiation patterns, PET scanners construct three-dimensional images reflecting the distribution and concentration of radiotracers in tissues and organs. Through the quantification of radiotracer uptake, PET facilitates the evaluation of metabolic and physiological processes, aiding in the diagnosis, staging, and monitoring of various diseases, including cancer, neurological disorders, and cardiovascular conditions. Moreover, PET’s ability to detect biochemical alterations at the molecular level holds promise for personalized medicine and therapeutic development. Understanding the basic principles of PET scans is crucial for optimizing their clinical utility and advancing medical research, leading the way for improved patient outcomes and enhanced healthcare practices. This article aims to introduce the fundamental principles underlying PET scans.

Viral Etiology of Acute Respiratory Infections, Before and After Relaxed COVID-19 Preventative Measures in Chanthaburi Province, Thailand

Patpong Udompat — 2024-09-16

Viruses are highly contagious and can evolve rapidly, leading to the emergence of new strains with different antigenic properties. These variations can influence the transmission dynamics and severity of viral diseases. The surveillance data indicates that the most prevalent viruses causing acute respiratory infections are rhinovirus/enterovirus, influenza, respiratory syncytial virus, SARS-CoV-2, and parainfluenza virus. After the relaxation of measures implemented to prevent coronavirus disease 2019 (COVID-19), the surveillance data revealed a statistically significant increase in the incidence of influenza (9.9%; 95%CI 6.0-13.7) and human metapneumovirus (5.9%; 95%CI 3.9-8.0). Conversely, there was a statistically significant decrease in the incidence of SARS-CoV-2 infection (14.8%; 95%CI (-18.9)-(-10.5)). A benefit of this analysis is the identification of the incidence of acute respiratory infections caused by non-influenza viruses. Studying the genetic metagenomics of viruses in the environment is challenging, yet crucial for advancing knowledge and developing surveillance systems for new viral strains and vaccines to prevent future outbreaks.

Clinical Quiz

Chitchanok Tantipat — 2024-09-16

severe keratoconus

The Study of Heart Rate Response During Treadmill Exercise Stress Test in Child and Adolescent 10-15 Years Old

Uthen Bunmee — 2024-09-16

BACKGROUND: The heart rate response during exercise reflects cardiovascular efficiency, which can be tested and assessed using a treadmill exercise test. This test also shows heart rate and other parameters during both rest and peak exercise periods; however, there is limited research number on the heart rate response of 10-15 years old Thai adolescents using the modified Bruce protocol.

OBJECTIVE: This study aims to analyze in the four study points, consist of (1) The heart rate response of children during exercise (2-3) The comparison in the heart rate responses between females and males, between those aged under 13 years old and those aged over 13 years old. (4) The study in correlation of heart rate versus speed of treadmill.

MEDTHODS: In the retrospective study, we reviewed exercise stress test report of the modified Bruce protocol. We compared heart rate between male versus female, between under 13 years old versus greater by Sample t-test. We analyzed correlation of heart rate and speed by Spearman correlation.

RESULTS: All 37 participants have normal echocardiogram (M=20, F=17) and able to run on the treadmill for an average of 18 minutes (modified Bruce protocol stage 6). During the peak exercise, the heart rate increased to 191% from baseline. The heart rate response showed a strong correlation with the speed of the treadmill (r_s=0.85, p<0.05). Female gender group has significant increase in heart rate response when compared with male gender group (127±32.1 VS 123±29.8 beat/min., p<0.05). Also, the age 13-15 years group has significant increase in heart rate response when compared with the age 10-12 years group (127±28.2 VS 117±25.4 beat/min., p<0.05).

CONCLUSIONS: Thai adolescents’ age 10-15 years old achieved an average of 18 minutes or modified Bruce protocol stage 6 during exercise treadmill test. The heart rate increased 191% and showed a strong correlation with speed. At peak exercise, female and age greater than 13-year-old group have significantly higher heart rate compared with male and age lower than 13-year-old.

Thaiclinicaltrials.org number, TCTR20240607002

Effect of the Integrated Safety Program on Pesticide Use Behaviors Among Longan Farmers

Sutin Kantiyatep — 2024-09-16

BACKGROUND: Safety behaviors are considered the most important determinants of health consequences among longan farmers.

OBJECTIVES: This quasi-experimental study examined the effectiveness of an integrated safety program on pesticide use behaviors among longan farmers.

METHODS: Thirty-five longan farmers from two districts in Chiang Mai province in Northern Thailand were purposively selected and equally assigned into an experimental or a comparison group based on inclusion criteria and matching methods (35 cases). The experimental group received the integrated safety program while the comparison group received usual care from health professionals in the community. The integrated safety program was comprised of raising awareness, modifying behavior, and creating a supportive environment for safe pesticide behavior. Data was collected by using the questionnaire at the baseline and at 8 and 12 weeks after the intervention. Data were analyzed using descriptive statistics and two-way repeated measures analysis of variance (ANOVA).

RESULTS: The results revealed that participants in the experimental group had statistically significant higher mean scores of pesticide use behaviors including pesticide use, personal protective equipment use, and compliance with safety guidance was significantly higher than before the experiment in weeks 8 and 12 (p<0.001). In addition, participants in the experimental group had statistically significant higher mean scores of pesticide use behaviors, including pesticide use, personal protective equipment use, and compliance with safety guidance, than those in the comparison group (p<0.001).

CONCLUSIONS: The results from this study indicate that an integrated safety program focused on raising awareness and creating a supportive environment for health were effective in modifying pesticide use behaviors among longan farmers. Therefore, occupational health care professionals can apply this program to promote safe pesticide use behavior among this population.

Thaiclinicaltrials.org number, TCTR20240630002

Diagnostic Performance of Certain POCUS Parameters to Predict Blood Lactate Levels in Non-Hypotensive Sepsis Patients

Patchara Potiklang — 2024-09-16

BACKGROUND: Blood lactate levels are crucial indicators for the detection of hypoperfusion in sepsis. However, the facilities for testing remain limited in many emergency departments (EDs). Point-of-care ultrasound (POCUS) is used to help assess the hemodynamic status of emergency patients, including those with sepsis and may have the potential to predict blood lactate levels.

OBJECTIVES: This study aims to demonstrate the diagnostic performance of certain POCUS parameters regarding the prediction of blood lactate levels in non-hypotensive sepsis patients.

METHODS: This cross-sectional diagnostic study focused on patients aged 18 and above without hypotension, but were suspected of sepsis with a National Early Warning Score (NEWS) of more than 4, who visited the ED of Maharaj Nakorn Chiang Mai Hospital between January and October 2023. Trained physicians performed relevant POCUS measurements on all participants, and the results were recorded. Positive POCUS parameters, including IVC-CI >50% collapsibility in spontaneous ventilation or >18% distensibility in mechanical positive pressure ventilation, LVOT VTI <18 cm, or LVEDD <25 mm or ‘LV kissing’, were blinded to assess the prediction of blood lactate levels ≥2 and ≥4 mmol/L. Diagnostic performance analysis was performed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of POCUS parameters to predict blood lactate levels. The ROC curve was utilized to determine the area under the curve (AUC) to evaluate the accuracy of the predictions.

RESULTS: A total of 95 non-hypotensive sepsis patients were included. For identification of participants with blood lactate levels ≥4 mmol/L, any single positive POCUS parameter exhibited a sensitivity of 90.9% (70.8-98.9), specificity of 37.5% (26.4-49.7) (AuROC 0.64), and NPV of 93.1% (77.2-99.2). The POCUS parameter with the highest sensitivity was LVEDD <25 mm (72.7%), and with the highest specificity was LVOT VTI <18 cm (70.8%). The sensitivity of triple positive POCUS parameters was 18.2%, while specificity was 91.7%.

CONCLUSIONS: Sole utilization of ultrasound parameters may not be feasible for the prediction of lactate levels. However, in situations where the facility to measure blood lactate levels is not available, the absence of any positive findings in POCUS parameters such as IVC-CI, LVOT VTI, or LVEDD can be employed as an initial screening method for sepsis patients without hypotension in the emergency department, aiming to exclude lactate levels ≥4 mmol/L.

Thaiclinicaltrials.org number, TCTR20231011003

Evaluation of Renal Function in Patients with Atrial Fibrillation who Received Warfarin Compared with Aspirin

Pisut Greetanukroh — 2024-09-16

BACKGROUND: Aspirin is a drug commonly chosen to prevent strokes in patients with atrial fibrillation (AF) and those who are unable to receive warfarin, which the drug of choice. In the past, reports showed that both drugs had side effects on kidney function, but there have been no studies comparing the effects on kidney function in patients taking these drugs.

OBJECTIVE: This study aimed to evaluate kidney function in a group of patients with AF who received aspirin compared with a group that received warfarin.

METHODS: This retrospective study examined 360 AF patients treated at Phrapokklao Hospital, who were divided into 2 groups comprising 1 group of 24 patients who received aspirin and another group of 336 patients who received warfarin. To assess the renal function of the patients during a 1-year period of receiving the drug, the glomerular filtration rate (GFR) utilizing the dependent t-test and independent t-test were used, while various factors were analyzed using logistic regression.

RESULTS: In a 1-year period, the mean GFR of the patients in the warfarin group increased by 3.9 ml/min/1.73m² (95%CI 2.87-4.96) compared to the aspirin group, which decreased by 8.0 ml/min/1.73m² (95%CI (-10.30)-(-5.72)). The percentage change in GFR of the warfarin group increased by 11.9% (95%CI 7.98-15.87) more than the aspirin group (p<0.001). When using logistic regression for univariate analysis and multivariate analysis, it was found that the aspirin group had a 10% chance of a decrease in GFR compared to patients receiving warfarin with a crude odds ratio=14.33, p<0.001, 95%CI 5.84-35.16 and adjusted odds ratio=149.9, p=0.003, 95%CI 5.70-3,940.05.

CONCLUSION: In a 1-year period, AF patients who received aspirin were 10 percent or more likely to experience deterioration in kidney function compared with patients who received warfarin.

Thaiclinicaltrials.org number, TCTR20240509001

An Experimental Study on the Effect of Biotin on Measurement of Thyroid Function Test in Healthy Adults

Apanaree Bhekasuta — 2024-09-16

BACKGROUND: The inaccuracy of Streptavidin-based diagnostic tests in a laboratory may be associated with the ingestion of over-the-counter biotin. In the case of competitive immunoassays, which are usually used for low molecular weight targets (such as T4, T3, and cortisol), biotin interference causes an erroneously high result. In immunometric (sandwich) assays such as TSH, it gives a misleadingly low result.

OBJECTIVES: The aim of this study was to assess the effect of consuming 10 mg per day of biotin on thyroid function test interference.

METHODS: This experimental research study was done at Somdech Phranangchao Sirikit Hospital from August 2023 to January 2024. The study enrolled healthy volunteers aged 18 years or older, who were instructed to take 10 mg/d of biotin. Thyroid function tests were measured at baseline, during biotin supplementation, and 7 days after withdrawal. The primary outcome was percent change in mean FT3, FT4 and TSH. Laboratory results were compared with baseline (day 0) measures on the 7th day of biotin treatment and 7 days after stopping biotin. The proportion of patients with biotin interference (Beckman UniCel DxI 800 vs Roche Cobas Elecsys e801) was assessed as a key secondary outcome.

RESULTS: A total of 25 participants were enrolled. After biotin supplementation, there was a significant increase in FT3 and FT4 in the Beckman group (1.43 [95% CI 0.11, 2.75]; p=0.04), (0.55 [95% CI 0.16, 0.95]; p=0.008) compared with baseline, which returned to baseline 7 days after biotin washout. No difference in the Roche Hyperthyroid pattern from biotin interference occurred in 6 of 25 patients (24%) in the Beckman assays.

CONCLUSIONS: Biotin can interfere with thyroid laboratory tests. It is also necessary to stop taking biotin for at least 7 days before testing.

Thaiclinicaltrials.org number, TCTR20240411004

Incidence of New-onset Diabetes Mellitus after COVID-19 Infection in Bangchak Hospital

Tharawut Mekthara — 2024-09-16

BACKGROUND: During the COVID-19 pandemic, many patients were diagnosed with diabetes after COVID-19 infection.

OBJECTIVE: To study the incidence of new-onset diabetes after COVID-19 infection in Bangchak Hospital.

METHODS: This study was a retrospective analytic study. The population of the study consisted of 601 persons with COVID-19 infection who were admitted to Bangchak Hospital as non-diabetes patients from March 1, 2021 to September 30, 2022, and had their blood tested for fasting plasma glucose or HbA1c levels within 3 months after infection in order to monitor the occurrence of diabetes and analyze the factors involved with diabetes.

RESULTS: Regarding the 601 COVID-19 patients, 64.6% were female, and the mean age was 60.5±18.7 years old. The incidence of new-onset diabetes was 63 cases (10.5%), while non-diabetes patients accounted for 538 cases (89.5%). The factors affecting the incidence of diabetes included receiving steroids (COR=5.08, 95%CI (2.27-11.36), p<0.001), receiving steroids for more than 14 days (COR=3.46, 95%CI (1.48-8.10), p=0.004), length of stay for hospitalization of more than 14 days (COR=2.21, 95%CI, 1.21-4.06, p=0.01), a high initial random plasma glucose level (COR=1.02, 95%CI, 1.01-1.03, p=0.003), and high serum creatinine (COR=1.38, 95%CI, 1.00-1.91, p=0.05), especially among patients receiving steroids (adj OR=4.58, 95%CI, 2.02-20.36, p<0.001). These factors were found to be related to diabetes with statistical significance.

CONCLUSIONS: The blood sugar levels of COVID-19 patients should be monitored after infection for observation of the occurrence of diabetes, especially among people with the risk factors for diabetes.

Thaiclinicaltrials.org number, TCTR20240425002

The Lesson Learned Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Border Migrant Worker: A Case Study of Ban Laem, Pong Nam Ron District, Chanthaburi Province

Pisit Phumpunphol — 2024-09-16

BACKGROUND: The current situation of the COVID-19 pandemic has been relieved. Therefore, the Ministry of Public Health issued the announcement to remove the disease from the list of dangerous communicable diseases and included it as a communicable disease under surveillance from October 1, 2022. Inefficient prevention and control of COVID-19 in border migrant workers affects people, society, and the economy in a wide range. More specifically, migrant workers are severely affected, i.e., dismissals, lower income, and poverty. The country itself lacks labor force, which affects the national economy in the overall perspective. Additionally, so far there have been no lessons learned from the prevention and control of this communicable disease in border migrant workers.

OBJECTIVES: To identify the lessons learned, to summarize these lessons, and to synthesize the body of knowledge about prevention and control of the communicable disease in border migrant workers.

METHODS: The key informants included 15 samples and officers in charge of the prevention and control of the communicable disease in border migrant workers. The data was collected by in-depth interviews during April–August, 2023. The data were analyzed based on interpretative phenomenological analysis (IPA), aiming to narrate and describe the meaning of the phenomenon from the direct experiences of the informants, and to foster understanding with the researchers.

RESULTS: It was found that the policy for prevention and control of the communicable disease in border migrant workers in Ban Laem, Pong Nam Ron District, Chanthaburi Province, is unambiguous and supported by stakeholders from all sectors. The leaders of involved agencies have positive attitudes with common goals. The key mechanisms include leadership, policy setting, policy transfer, preparation for prevention and control, cultivation of the value of teamwork, quick operations, process reduction, and common interest-oriented operations, with coordination from the Thai-Cambodia Border Trade & Tourism Association of Chanthaburi at all levels. As a consequence, the disease can be prevented and controlled efficiently.

CONCLUSIONS: The model can be used in other bordering areas

Predictor for Endoscopic Intervention in Patient with Upper Gastrointestinal Bleeding in Trat Hospital

Kittichai Samaithongcharoen — 2024-09-16

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is an urgent medical condition. Endoscopic intervention is one type of management for patients with high-risk stigmata. However, sometimes it can be difficult to evaluate. Therefore, predicting which patients require endoscopic intervention is important.

OBJECTIVES: To determine the predictors for endoscopic intervention and to assess the clinical presentations, endoscopic findings, endoscopic interventions and outcomes of upper gastrointestinal bleeding patients.

METHODS: We conducted a retrospective cohort study in patients diagnosed with upper gastrointestinal bleeding from August 2022 to February 2024. Medical records and endoscopic results were reviewed. Data were obtained using descriptive statistics, the Chi-square or Fisher’s exact test, the Independent t-test or Mann-Whitney U test, and multiple logistic regression analysis.

RESULTS: A total of 269 patients were enrolled, with a mean age of 64 years, and 60.2% were male. Among the 97 patients (36%) who underwent endoscopic intervention compared to those who did not, it was found that they were more likely to present with melena and have fresh blood NG, higher NSAIDS use, more instances of systolic blood pressure (SBP) <100 mmHg, lower hemoglobin levels, and a drop in hematocrit greater than 20% from baseline. Peptic ulcer was the leading cause of UGIB (60.6%), and the most common intervention was combined epinephrine injection with coaptive thermocoagulation (61.9%). Both groups had similar lengths of hospital stay, re-bleeding rates, and mortality rates. The multivariate analysis indicated that significant predictors for endoscopic intervention were NSAIDS use (OR 2.42; 95% CI, 1.23-4.76; p=0.01), Hb level <7 g/dL (OR 4.02; 95% CI, 1.93-8.40; p<0.001), Hct drop >20% from baseline (OR 3.93; 95% CI, 1.97-7.88; p<0.001), SBP <100 mmHg (OR 5.44; 95% CI, 1.69-17.51; p=0.005) and fresh blood NG (OR 9.48; 95% CI, 2.40-37.39; p<0.001).

CONCLUSIONS: Significant predictors for endoscopic intervention in patients with upper gastrointestinal bleeding include NSAIDS use, hemoglobin level <7 g/dL, hematocrit drop >20% from baseline, systolic blood pressure <100 mmHg, and fresh blood NG.

Thaiclinicaltrials.org number, TCTR20240806005

Development of the Nursing Process for Elderly Patients Undergoing Total Knee Replacement Surgery at Suddhavej Hospital

Nathamon Yotkumlue — 2024-09-16

BACKGROUND: Osteoarthritis is one of the diseases faced by many Thai people, and it is one of the important causes of disability among the elderly. Recovering quickly after surgery, receiving proper care after a surgical procedure, and behaving properly after knee replacement surgery will help patients quickly return to their normal lives.

OBJECTIVES: To develop the nursing process for elderly patients undergoing knee replacement surgery at Suddhavej Hospital.

METHODS: A developmental research approach was used to examine a sample group comprising patients who had knee replacement surgery in the special ward, 11^th floor, Suddhavej Hospital between June and December 2023. A total of 19 people were selected by purposive sampling. Data were analyzed with descriptive statistics by frequency distribution mean and standard deviation.

RESULTS: It was found that all nurses (100 percent) agreed with the feasibility of implementing the guidelines in the ward at a high level. Most users of the guidelines had opinions on the feasibility of implementing the guidelines and were highly satisfied with the use of the guidelines. The clinical outcome assessment found that, on the day before discharge from the hospital, all patients (100 percent) could flex their knees to an average of 91.7±1.8 degrees. Two weeks after discharge, all patients (100 percent) could flex their knees to an average of 96.5±5.8 degrees. All patients (100 percent) could walk horizontally for the target distance of more than 20 meters within 6 minutes, both on the day before discharge from the hospital (41.8±8.5) and two weeks after discharge (54.7±1.6).

CONCLUSIONS: Nursing practice guidelines for promoting recovery among elderly patients undergoing knee replacement surgery can be applied in practice, covering the preoperative period, postoperative period, and pre-discharge period, resulting in patients being able to bend their knees 90 degrees, walk horizontally for a distance of not less than 20 meters within 6 minutes, and show an improvement trend.

A Development of Same Day Discharge Care Model for Patients Undergoing Elective Coronary Angiogram Transradial Catheterization in Prapokklao Hospital

Piyanun Tipsod — 2024-09-16

BACKGROUND: The Heart Center at Phrapokklao Hospital has seen an increased number of cardiovascular catheterization service recipients, but has a limited number of inpatient beds. This results in longer waiting times for coronary artery catheterization procedures. Developing patient care models can increase access to appropriate services and encourage nurses to have standard nursing practices.

OBJECTIVES: To develop a model and study the results after using a same-day care model for patients receiving coronary angiogram transradial catheterization.

METHODS: This study used a research and development approach to examine a multidisciplinary heart disease center population at Phrapokklao Hospital, comprising 17 patients and 20 pre-arranged coronary catheterization patients. The procedure consists of studying and analyzing the care situation for patients undergoing same-day coronary artery bypass catheterization at the Heart Center at Phrapokklao Hospital. The researcher developed a new model. Content validity was assessed by experts. The format included patient assessment before, during, and after coronary angiography until discharge within 1 day, follow-up by telephone, and evaluation of subcutaneous hematoma from post-procedure photographs 24 hours later. The model was piloted and evaluated for the results of subcutaneous hematomas after 24 hours of cardiac catheterization, and the number of patients who could be discharged within one day. The waiting times for cardiac catheterization, before and after using the developed model, were compared. Data were analyzed using descriptive statistics, the Mann-Whitney Test and content analysis.

RESULTS: Patients who received care according to this model did not develop hematomas under the skin of the wrist 24 hours after the procedure, accounting for 100%. Patients were successfully discharged within one day, accounting for 95%, and the waiting times for examination were comparable. During the same period in the previous year, the decrease was statistically significant (p<0.01).

CONCLUSIONS: The developed care model can be used as a guideline for patient care to meet increased standards.