Siriraj Medical Journal

สมเด็จพระมหิตลาธิเบศร อดุลยเดชวิกรม พระบรมราชชนก

สุธ เลขยานนท์ — 2024-09-24

ท่านผู้มีเกียรติทั้งหลาย

ก่อนที่ข้าพเจ้าจะเริ่มต้น ข้าพเจ้าต้องขออภัยเสียก่อนว่าในระหว่างนี้จะเป็นเพราะประสาทหรือยาไม่ทราบ ทำให้ปากคอข้าพเจ้าแห้งเสมอ, และถ้าพูดมากบางครั้งถึงแห้งผาก พูดต่อไปไม่ได้ทีเดียว, จึงต้องขอน้ำมาเตรียมไว้. ถ้าข้าพเจ้าจิบน้ำในระหว่างพูด ขออภัยด้วย.

ข้าพเจ้ารู้สึกเป็นเกียรติอย่างยิ่งที่ได้รับเชิญมากล่าวสุทรพจน์ ณ ที่นี้

Preemptive Analgesic Efficacy of Parecoxib for Reducing Postoperative Pain in Patients Undergoing Gynecological Surgery

Pasu Tuangjaruwinai — 2024-12-01

Objective: This study aimed to evaluate the effectiveness of preemptive parecoxib in reducing postoperative pain following gynecological surgery.

Materials and Methods: A double-blind, randomized study involved 168 patients undergoing laparotomy gynecological procedures, including total hysterectomy, adnexal surgery, and surgical staging, between November
2023 and July 2024. Patients were randomly assigned to receive either intravenous parecoxib (n = 82) or normal saline (n = 86) 15 minutes before surgery. Postoperative pain was measured using a visual analog scale at 2, 6, 12, and 24 hours. Morphine consumption within the first 24 hours post-surgery was recorded, along with any adverse events related to parecoxib and the length of hospital stay.

Results: Mean pain scores at 2, 6, 12, and 24 hours postoperatively were lower in the treatment group compared to the control group (5.3 vs. 5.7, p = 0.261; 3.7 vs. 5.0, p < 0.001; 3.3 vs. 5.1, p < 0.001; 3.5 vs. 4.0, p = 0.164, respectively). The mean 24-hour postoperative morphine consumption was significantly lower in the treatment group (4 ± 8 mg vs. 8 ± 5 mg, p < 0.001). No significant adverse events occurred between the groups. The total length of hospital stay was similar between the two groups (3.4 ± 1.8 vs. 3.5 ± 1.4 days, p = 0.698).

Conclusion: Preemptive parecoxib significantly reduced pain at 6 and 12 hours post-surgery and reduced morphine use within 24 hours, with no significant effect on hospital stay duration in gynecological surgery.

Post-biopsy to Surgery Interval Tends to Increase Axillary Nodal Metastasis, Especially in Early Breast Cancer Patients

Phatcharawan Prasitviset — 2024-12-01

Objective: Delays between diagnosis and breast cancer surgery may raise concerns about tumor progression. Tumors of the same size should exhibit same proportions of N staging. We aimed to evaluate the impact of time to surgery (TTS) on the proportion of metastatic axillary lymph nodes (N-Staging), controlled by tumor size.

Materials and Methods: A cross-sectional study of primary breast cancer patients treated between October 2021 - December 2022 at the Division of Head Neck and Breast Surgery, Siriraj Hospital, Thailand examined the association between lymph node staging and TTS, stratified by primary tumor size. Patients with neoadjuvant therapy, DCIS, or underwent excisional biopsy were excluded.

Results: Of 424 patients, mean age 60.95 years, had an average tumor size 17±13.38 mm, and 20.8% LNs metastasis. The mean TTS was 7 ± 3.11 weeks. The proportion of + LNs patients stratified by tumor size was 10.6% for T1, 34.56% for T2, and 43.75% for T3 lesions. There was no significant difference between TTS and the proportion of
N-staging for all T2 and T3 tumors. In contrast, a significant finding was observed among T1 tumors. Axillary nodal metastasis became more advanced as TTS increased (p-value = 0.022); and increased N2 and N3 nodal staging was noted in patients with delayed surgery. No significant additional differences were found concerning breast cancer subtype, pathological grading, or lympho-vascular/perineural invasion.

Conclusion: Increasing TTS was significantly associated with more advanced N staging. This finding highlights the need for timely intervention in early breast cancer, particularly in T1 tumors.

Comparative Evaluation of Phacoemulsification with Goniosynechialysis and Phacoemulsification with Viscogonioplasty in Angle-Closure: A Randomized Clinical Trial

Dechathon Asanathong — 2024-12-01

Objective: To compare the effects of phacoemulsification with goniosynechialysis (GSL) versus viscogonioplasty (VGP) on intraocular pressure (IOP) reduction and medication use in angle-closure patients.

Materials and Methods: This randomized controlled trial at Sisaket Hospital, Thailand, from November 2021 to May 2024, enrolled patients with angle-closure and cataracts. Group 1 underwent phacoemulsification with GSL, and Group 2 with VGP. Visual acuity, IOP, and medication use were assessed before surgery, then at 1 week, 1 month, 3 months, and 6 months post-surgery.

Results: 58 eyes were included: 30 in Group 1 and 28 in Group 2. The average age was 67.16±9.65 years in Group 1 and 67.78±7.38 years in Group 2 (P=0.79). Baseline IOP was 24.31±12.34 mmHg in Group 1 and 24.92±12.50 mmHg in Group 2 (P=0.85). After 6 months, IOP decreased to 12.84±2.88 mmHg in Group 1 and 13.62±4.28 mmHg in Group 2 (P=0.40). Glaucoma medications decreased from 3.47±0.94 to 1.93±1.20 in Group 1 and from 3.54±0.58 to 1.46±1.37 in Group 2 (P=0.17). Hazard ratio: 4.29 (P=0.066, 95% CI: 0.91–20.18).

Conclusion: Both Phaco-GSL and Phaco-VGP significantly reduce IOP, with no significant difference in efficacy. Phaco-GSL may sustain IOP reduction longer in extensive PAS cases. However, the short follow-up period and lack of postoperative gonioscopy are limitations. Longer-term studies with larger sample sizes are needed to confirm these results.

Predictors of Significant Fibrosis Among People Living with HIV with Metabolic Dysfunction- Associated Steatotic Liver Disease

Thaninee Prasoppokakorn — 2024-12-01

Objective: Metabolic dysfunction-associated steatotic liver disease (MASLD) is highly prevalent among people living with HIV (PLWH) due to comorbidities and factors related to HIV infection. This study aimed to identify clinical predictors of significant fibrosis among PLWH with MASLD.

Materials and Methods: A retrospective cohort study was conducted with PLWH having CD4 counts ≥200, enrolled between April and October 2023 at two tertiary hospitals. The primary outcome was identifying the clinical predictors of significant fibrosis (F≥2) defined by TE≥8 kPa. Secondary outcomes included MASLD prevalence
and characteristics.

Results: Among 96 PLWH, 52 (54.2%) had MASLD. The mean age was 49.7±8.0 years, 63.5% were male, and the mean BMI was 25.8±4.1 kg/m². Obesity, diabetes, and dyslipidemia were present in 17.3%, 19.2%, and 46.2% of participants, respectively. The mean CAP and TE were 285±36 dB/m and 8.7±7.8 kPa, respectively. Significant
fibrosis was present in 24 patients (46.2%). Fibrosis scoring systems (FIB-4, APRI, NFS) demonstrated good accuracy (AUROCs: 0.84, 0.85, 0.76, respectively). Multivariate analysis identified predictors of significant fibrosis: higher BMI (aOR 1.24, p=0.042), dyslipidemia (aOR 3.96, p=0.038), and higher AST (aOR 1.19, p=0.011). The AGA pathway using two steps (FIB-4 and TE) improved reclassification of significant fibrosis risk, reducing the number of individuals at indeterminate risk, 12 out of 52 in the first step to 7 out of 52 in the second step.

Conclusion: MASLD is highly prevalent in PLWH, with about half experiencing significant fibrosis. Predictors of significant fibrosis include dyslipidemia, higher BMI, and elevated AST levels. Fibrosis scoring systems accurately predict significant fibrosis.