Volume 72, Number 6, November-December 2020
Siriraj Medical Journal
SMJ
ISSN 2629-995XE-ISSN 2228-8082
ORIGINAL ARTICLE
451 Albumin Versus Gelatin Solution for the Treatment of
Refractory Septic Shock: A Patient Baseline-Matched-
Cohort Study
Surat Tongyoo, et al.
462 Predictor of In-hospital Mortality among Acute Coronary
Syndrome Patients after Treatment with an Intra-aortic
Balloon Pump in Tertiary Hospital, Thailand
Chorchana Wichian, et al.
470 Short-term Effect of Transcutaneous Electrical Nerve
Stimulation (TENS) on Pain in Patients with Bone
Metastasis: An Uncontrolled Pretest-Posttest Study
Thipawan Bowornkitiwong, et al.
476 Pre-class versus In-class Video Lectures for the Flipped
Classroom in Medical Education: A Non-randomized
Controlled Trial
Monton Wongwandee, et al.
483 Correlation of Medical Knowledge and Non-Technical
Skills Assessment in Anesthesia Residents
Kasana Raksamani, et al.
488 Pattern Recognition using Morphologies of Anthropophilic
and Zoophilic Dermatophytosis Lesions: Comparison
between Final-Year Medical Students and Dermatology
Residents
Sumanas Bunyaratavej, et al.
492 Effects of Four Noble Truths Practice on Hypertension
Control
Sadudee Rojanapirom, et al.
502 Granular Myringitis Treatment at Siriraj Hospital
Kanokrat Suvarnsit, et al.
REVIEW ARTICLE
508 Social Transmission of Corona Virus: An Overview
Rabindra Nath Padhy, et al.
512 miRNAs: Perspective Towards the Use for Body Fluid
Identification
Pairoa Praihirunkit
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International Association of Surgeons
Gastroenterologists & Oncologists
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Thai Association for Gastrointestinal
Endoscopy
Indexed by
By Kanokrat Suvarnsit, et al.
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George S. Baillie (University of Glasgow, UK)
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Volume 72, No.6: 2020 Siriraj Medical Journal
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451
Original Article
SMJ
Surat Tongyoo, M.D., Chawanee Chayakul, M.D., Siwanat Kanoknatsiwattana, M.D., Chairat Permpikul, M.D.
Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Albumin Versus Gelatin Solution for the Treatment
of Refractory Septic Shock: A Patient Baseline-
Matched-Cohort Study
ABSTRACT
Objective: Although albumin solution is the colloid of choice to resuscitate septic shock patients who do not
respond to crystalloid solutions, its usage is limited by its cost. Gelatin solution, is less expensive, but its ecacy
has not yet been identied. is study aimed to compare the outcomes of gelatin and albumin solutions for septic
shock resuscitation.
Methods: is baseline-matched-cohort study, enrolled septic shock patients who had a mean arterial blood
pressure (MAP) below 65 mmHg aer receiving at least 30 mL per kilogram of crystalloid resuscitation uid, and
who required either an albumin or gelatin solution as uid therapy. e primary outcome was the 28-day mortality.
Results: In all, 224 patients who were administered either an albumin or gelatin solution were examined. Aer
adjusting for dierences in their baseline characteristics, 206 patients were included (104 receiving albumin, and
102 given gelatin). A comparison of the albumin and gelatin groups revealed no signicant baseline dierences in
their respective mean APACHE II scores (22.8±8.5 vs. 23.2±8.1), MAPs (55.1±8.0 vs. 54.6±9.1 mmHg), and lactate
levels (5.6±4.7 vs. 6.3±4.9 mmol/L). e 28-day mortality rates were 27.9% and 38.2% for the albumin and gelatin
groups, respectively, with adjusted p=0.02. Moreover, the accumulation of uid intake over output at 72 hours was
signicantly lower for the albumin than the gelatin group (5,964.5±4,959.7 vs. 8,133.2±3,743.2 ml; p=0.01). e
RRT rate was higher for the albumin group (30.8% vs. 15.7%; p=0.01).
Conclusion: Albumin resuscitation associated with lower 28-day mortality than gelatin resuscitation. e patients
in the albumin group had a higher RRT rate and a lower uid accumulation as at 72 hours.
Keywords: Septic shock; colloid solution; albumin solution; gelatin solution; crystalloid solution; uid resuscitation
(Siriraj Med J 2020; 72: 451-461)
Corresponding author: Surat Tongyoo
E-mail: surat.ton@mahidol.ac.th
Received 15 April 2020 Revised 20 May 2020 Accepted 26 May 2020
ORCID ID: http://orcid.org/0000-0003-3772-2990
http://dx.doi.org/10.33192/Smj.2020.61
INTRODUCTION
According to the Surviving Sepsis Campaign:
International Guidelines for Management of Sepsis and
Septic Shock 2016, crystalloid solutions are the fluid
of choice for the initial resuscitation of septic shock
patients.
1
In the case of patients who do not respond
to a certain volume of crystalloid resuscitation (usually
at least 30 mL per kilogram of body weight), colloid
solutions should be used. Albumin is recommended as
the rst-choice colloid, based on the evidence of two large
randomized controlled trials
2,3
and two meta-analyses.
4,5
Unfortunately, albumin usage in resource-limited countries
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452
is restricted by its cost, with many patients unable to
aord albumin-based resuscitation. In our hospital,
when the cost of albumin therapy would prove to be
prohibitive for a patient, the alternative colloid utilized
for the resuscitation of refractory septic shock is gelatin
solution. Gelatin is a small fragment of collagen, and it
is one of a number of synthetic colloids that have long
been used for volume expansion in certain situations.
6
A previous study demonstrated that resuscitation with
a gelatin solution expanded the intravascular volume by
about 1.4 times that gained through resuscitation with a
crystalloid solution.
7
A similar ratio was achieved with a 5%
albumin solution. In addition, data from a meta-analysis
showed that resuscitation with a gelatin solution was not
only associated with better hemodynamic stabilization
than resuscitation with a crystalloid alone, but may also
be associated with lower mortality.
8
Although there
has been evidence from a few randomized controlled
trials relating to the ecacy of gelatin solution relative
to that of other colloid solutions, those clinical trials
employed small sample sizes and were not performed
on septic shock patients.
9,10
Moreover, there is limited
information concerning the comparative outcomes of
albumin versus (vs.) gelatin solutions for septic shock
patient resuscitation.
11
Septic shock resuscitation typically requires a high uid
volume.
12,13
is raises concerns about the extravasation
of colloid molecules, which may be associated with organ
dysfunction. Acute kidney injury is associated with
hydroxyethyl starch administration among critically ill
patients.
14
Although data in a meta-analysis suggested
that gelatin solution resuscitation might be associated
with subsequent acute kidney injury, the ndings were
not statistically signicant.
7
Even though the lower-
priced gelatin solution is used as an alternative colloid
to albumin for septic shock resuscitation, its ecacy
and safety outcomes have not yet been identied. e
aims of this study were to compare the ecacies and
safety outcomes of gelatin and albumin solution usage
for septic shock resuscitation.
MATERIALS AND METHODS
Study design and ethical considerations
is patient baseline-matched-cohort, retrospective
study enrolled septic shock patients who had been admitted
to the Internal Medicine Ward, Faculty of Medicine
Siriraj Hospital, Mahidol University, Bangkok, ailand,
15 December 2014 - 31 October 2018. We used database
of a study protocol number: 100/2018(EC1), which was
approved by the Siriraj Institutional Review Board (Si
421/2018).
Participants
We screened for patients who were aged over 18
years and had been diagnosed with septic shock, as
dened in the Surviving Sepsis Campaign guidelines
of 2012.
15
e septic shock patients had been diagnosed
and treated by attending physicians at the emergency
room, internal medicine ward, or the medical intensive
care unit. e treatments followed the Surviving Sepsis
Campaign guidelines of 2012 and 2016, which required the
initiation of antibiotics coupled with the administration
of uid resuscitation with a crystalloid solution (30 mL/
kg) and norepinephrine to reach a target mean arterial
blood pressure (MAP) ≥ 65 mmHg.
1
In the event that
a patient’s hemodynamic state subsequently remained
unstable, the use of a colloid solution was considered.
e decision to initiate the colloid infusion as well as
the type and dose to be used were dependent on each
attending physician’s clinical judgment. We enrolled
those patients who, despite having received at least 30 mL/
kg of crystalloid solution resuscitation, still had either a
MAP < lower than 65 mmHg or evidence of inadequate
tissue perfusion requiring additional uid resuscitation.
e inadequate tissue perfusion was dened as a urine
output of < 0.5 mL/kg of body weight or a serum lactate
concentration of ≥ 4 mmol/dL.
16
e requirement for
additional uid resuscitation was indicated by the following
criteria: a central venous pressure of < 12 mmHg or 15
cmH
2
O; a pulmonary wedge pressure of < 18 mmHg;
or evidence of uid responsiveness from one or more
non-invasive tests, specically, an inferior vena cava
diameter variation of > 15%, a pulse pressure variation
of > 15%, or a positive passive-leg-raising test. Patients
receiving a 5% albumin solution but no gelatin solution
were classied as members of the albumin group, while
those administered a gelatin solution without an albumin
solution were enrolled in the gelatin group. We excluded
all patients who received both the albumin and gelatin
solutions for septic shock resuscitation, as well as any
patient who was given a colloid other than an albumin
or gelatin solution. Also excluded were patients who had
prolonged shock exceeding 24 hours; were pregnant;
had suspected cardiogenic shock (demonstrated by
an echocardiogram showing a le ventricular ejection
fraction of < 35%); had a chest X-ray revealing cardiogenic
pulmonary edema; or had a history of an allergy to colloid
solutions causing anaphylaxis.
We performed the patient-matching process following
the STROBE recommendations.
17
The patients who
received albumin were matched with those administered
gelatin in a 1:1 ratio. e matchings were based on each
patient’s age (± 5 years), Acute Physiology and Chronic
Tongyoo et al.
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Original Article
SMJ
Health Evaluation (APACHE) II severity score (± 3
score), MAP (± 5 mmHg), and baseline lactate level
(± 1 mmol/L).
Data collections and outcomes
We compiled the patients’ baseline information
and hemodynamic parameters (age, gender, APACHE
II score, comorbidities, baseline serum albumin, source
of infection, pathogenic details, MAP, and initial serum
lactate). In addition, details of the treatment strategies
employed (uid resuscitation volume, and vasopressor
type and dosage) were collected. Also recorded was
information on the crystalloid and colloid solution volumes
received during the rst 3 days aer each septic shock
diagnosis, and the uid balance volumes on Days 1, 2 and
3. e uid balance was determined from the dierence
between the uid resuscitation volume (consisting of the
crystalloid and colloid solutions) that a patient received
minus all uid output, which was comprised of the urine
output and, in cases where a patient underwent renal
replacement therapy, the ultraltration volume.
e primary outcome of this study was the all-cause
mortality at 28 days. e secondary outcomes were the
hospital mortality; the cumulative uid balance 72 hours
aer the septic shock diagnosis; and the days alive and
free of organ support, ventilator support, vasopressor
usage, and renal replacement therapy to Day 28 aer
the diagnosis.
18
Statistical analyses
e categorical variables were expressed as number
and percentage per group, and the group results were
compared using Fisher’s exact test or Chi-squared test, as
appropriate. e continuous variables were described as
mean ± standard deviation and compared using Student’s
t-test. A Kaplan–Meier curve analysis was performed
to reveal the 28-day mortality dierences between the
albumin- and gelatin-receiving groups. We used PASW
Statistics for Windows, version 18 (SPSS Inc., Chicago,
Ill., USA) to analyze the data.
RESULTS
In all, 555 patients were diagnosed with septic shock
and screened during the study period. Of those, 219
saw their hemodynamic state restored aer receiving a
crystalloid solution and vasopressor, and they were thus
excluded from the study. Another 112 patients were not
enrolled as they were given a mix of colloid solutions.
e remaining 224 patients received either the albumin
solution or the gelatin solution; aer their baseline ages,
severity scores, MAPs, and lactate levels were matched,
18 of those patients were eliminated from the study. at
le a total of 206 enrolled patients: 104 in the albumin
group, and 102 in the gelatin group (Fig 1).
e patients’ baseline characteristics are summarized
in Table 1. ere were no signicant dierences in the
mean ages, gender proles, APACHE II scores, sites
Fig 1. Flow diagram illustrating screening, enrollment, and baseline matching of patients
555 Septic Shock
219 Improved after crystalloid
336 Received colloid
112 Received mixed colloid
115 Gelatin 109 Albumin
Matched
-Age
18 Unmatched -APACHE ll
-Mean ABP
-Lactate
102 Gelatin were included 104 Albumin were included
in the final analysis in the final analysis
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454
of infection, and hemodynamic parameters of the 2
groups. However, the patients in the albumin group
had a higher proportion of the underlying conditions of
hypertension and diabetes mellitus than the patients in
the gelatin group. e most common infection source
was pneumonia, followed by intra-abdominal and urinary
tract infections. As to the respective degrees of septic
shock severity at baseline enrollment of the albumin-
and gelatin-receiving groups, there were no signicant
dierences between the data of the 2 groups. e mean
APACHE II scores were 22.8 ± 8.5 vs. 23.2 ± 8.1; the
mean Sequential Organ Failure Assessment scores were
9.7 ± 3.4 vs. 9.7 ± 3.8; the average MAPs were 55.1 ±
8.0 mmHg vs. 54.6 ± 9.1 mmHg; and the average initial
serum lactate levels were 5.6 ± 4.7 mmol/L vs. 6.3 ± 4.9
mmol/L. Finally, the average initial serum albumin levels
were not statistically dierent (2.5 ± 0.6 g/dl vs. 2.4 ±
0.7 g/dl; p = 0.16).
e septic shock treatments that the patients were
provided are detailed in Table 2. e total uid volume
and total crystalloid volume received on the rst, second,
and third days of resuscitation did not dier. However,
the albumin group was given a signicantly lower colloid
volume on the rst day than the gelatin group (1,068 ±
1,002 mL vs. 1,366 ± 1,020 mL; p = 0.04). e cumulative
uid balance at 72 hours was also signicantly lower for
the albumin group than the gelatin group (5,964 ± 4,960
mL vs. 8,133 ± 3,743 mL; p = 0.01). On the other hand,
there were no signicant dierences in the two groups’
vasopressor requirements, maximum vasopressor doses,
hydrocortisone doses, or levels of mechanical ventilator
support. e most common vasopressor used in this study
was norepinephrine. In addition, a higher proportion of
patients in the albumin group received renal replacement
therapy than in the gelatin group (30.8% vs. 15.7%; p =
0.01).
e 28-day mortality was 27.9% for the albumin group,
compared with 38.2% for the gelatin group; nevertheless,
the dierence was not statistically signicant (p = 0.11;
Table 3). e Kaplan–Meier curves for 28-day mortality
are illustrated in Fig 2. e hospital mortalities (39.4% vs.
44.1%; p = 0.50) was were also not signicantly dierent.
e days alive and free of organ support to Day 28 were
not dierent (11.2 ± 12.0 days vs. 11.9 ± 12.0 days; p =
0.56). ere was also no signicant dierence in the rates
of long-term renal replacement therapy for the septic
shock patients who survived until hospital discharge
(14.3% vs. 7.0%; p = 0.2).
To identify conditions that may be benecially
associated with the use of the albumin solution over the
gelatin solution for septic shock resuscitation, a subgroup
analysis was performed based on the patients’ baseline
APACHE II scores, serum albumin and serum lactate
levels, epinephrine requirements, maximum vasopressor
doses, need for ventilator support, and requirements for
renal replacement therapy. e septic shock patients in
the albumin group who had a baseline APACHE II score
≥ 20 or had a baseline serum albumin < 3 g/dL were
associated with a signicantly lower 28-day mortality
rate than the patients in the gelatin group (Table 4).
DISCUSSION
In this retrospective, baseline-matched-cohort study,
the resuscitation with an albumin solution for septic shock
patients who were refractory to crystalloid solution was
not statistically associated with a dierence in the 28-day
mortality rate, compared with the patients who were
resuscitated with a gelatin solution. Nonetheless, among
the patients who had either a baseline APACHE II score
of ≥ 20 or a baseline serum albumin level of < 3 g/dL,
resuscitation with the albumin solution was associated
with a lower 28-day mortality than that for the gelatin
solution. e occurrence of renal failure requiring renal
replacement therapy was higher among patients who
received the albumin than the gelatin solution. Still,
there was no signicant dierence in the long-term renal
replacement therapy requirements of the two groups of
septic shock hospital survivors.
To date, no study has directly compared the
ecacies of albumin and gelatin solutions for septic
shock resuscitation. One meta-analysis, which compared
albumin with other uids for the treatment of sepsis
patients, revealed that there was no mortality benet
in using albumin in preference to a hydroxyethyl starch
and gelatin solution.
5
at result corresponds with the
nding of our study. Moreover, the 28-day mortality
for the albumin therapy of the septic shock patients in
the current study was 27.9%, which was similar to the
rate of 31.8% for the albumin-treated group reported
by the Albumin Italian Outcome Sepsis (ALBIOS) trial.
Furthermore, patients in the present study who received
albumin resuscitation were associated with acute kidney
injury, for which 30.8% of cases required renal replacement
therapy; this is comparable with the corresponding gure
of 24.6% determined by the ALBIOS trial.
3
In terms of
the hospital mortality of the gelatin-solution users, a
previous prospective study on shock patients revealed
that the mortality rate of patients who received gelatin
solutions was 30%
11
, which was lower than the proportion
of 44.1% found by our study.
Tongyoo et al.
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Original Article
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TABLE 1. Patients’ baseline characteristics.
Patient characteristic Albumin (n = 104) Gelatin (n = 102) P-value
Age (years) 67.9 ± 14.8 64.9 ± 14.9 0.15
Male gender, n (%) 47 (45.2) 54 (52.9) 0.27
Body weight (kilogram) 61.0 ± 14.2 59.3 ± 13.6 0.38
APACHE II score
†
22.8 ± 8.5 23.2 ± 8.1 0.73
SOFA score* 9.7 ± 3.4 9.7 ± 3.8 0.87
Underlying conditions, n (%)
Hypertension 74 (71.2) 37 (36.3) 0.002
Diabetes mellitus 53 (51.0) 37 (36.3) 0.03
Chronic kidney disease 32 (30.8) 22 (22.6) 0.13
Cirrhosis 25 (24.0) 19 (18.6) 0.34
Malignancy 18 (17.3) 23 (22.5) 0.35
Ischemic heart disease 24 (23.1) 15 (14.7) 0.13
Site of infection, n (%)
Pneumonia 37 (35.6) 36 (35.3) 0.97
Intra-abdominal infection 28 (26.9) 17 (16.7) 0.08
Urinary tract infection 18 (17.3) 29 (28.4) 0.06
Skin and soft tissue infection 7 (6.7) 7 (6.9) 0.97
Primary bacteremia 15 (14.4) 13 (12.7) 073
Other 2 (1.9) 8 (7.8) 0.05
Initial vital signs and investigations
Temperature (
o
C) 37.4 ± 3.6 37.6 ± 1.4 0.57
Heart rate (per minute) 103.3 ± 23.0 108.0 ± 24.2 0.15
Respiratory rate (per minute) 27.9 ± 7.7 29.4 ± 7.1 0.16
Mean arterial blood pressure (mmHg) 55.1 ± 8.0 54.6 ± 9.1 0.72
Serum lactate (mmol/L) 5.6 ± 4.7 6.3 ± 4.9 0.26
Serum albumin (g/dL) 2.5 ± 0.6 2.4 ± 0.7 0.16
Fluid responsive test
Central venous pressure guide 58 (55.8) 43 (42.2) 0.07
Inferior vena cava diameter variation 37 (35.6) 37 (36.3) 0.92
Pulse pressure variation 9 (8.7) 22 (21.6) 0.16
Fluid responsiveness 91 (87.5) 95 (93.1) 0.26
†
e APACHE II (Acute Physiology and Chronic Health Evaluation) score, a severity-determining score, ranges from 0 to 71. Higher scores
indicate a more severe disease.
*e SOFA (Sequential Organ Failure Assessment) score, a severity-determining score, ranges from 0–24. Higher scores indicate greater
organ failure and disease severity.
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TABLE 2. Detailed treatment strategies.
Clinical parameters Albumin (n = 104) Gelatin (n = 102) P-value
Total uid resuscitation (mL)
Total uid received on the rst day 6,375 ± 2,227 6,203 ± 2,040 0.63
Total uid received on the second day 3,037 ± 1,470 2,944 ± 2,056 0.71
Total uid received on the third day 2,228 ± 1,637 2,232 ± 1,890 0.99
Crystalloid resuscitation (mL)*
Total crystalloid received before colloid administration 3,067 ± 2,935 2,967 ± 3,701 0.69
Total crystalloid received on the rst day 4,969 ± 1,898 4,662 ± 1,867 0.24
Total crystalloid received on the second day 1,783 ± 1,346 2,030 ± 1,764 0.27
Total crystalloid received on the third day 1,243 ± 1,224 1,969 ± 1,349 0.34
Colloid resuscitation (mL)
†
Total colloid received on the rst day 1,068 ± 1,002 1,366 ± 1,020 0.04
Total colloid received on the second day 512 ± 667 559 ± 768 0.65
Total colloid received on the third day 305 ± 608 402 ± 794 0.34
Fluid balance at 72 hours (mL) 5,964 ± 4,960 8,133 ± 3,743 0.01
Vasopressors, n (%)
Norepinephrine 98 (94.2) 97 (95.1) 0.78
Epinephrine 33 (31.7) 39 (38.2) 0.33
Dopamine 2 (1.9) 1 (1) 0.57
Dobutamine 8 (7.7) 3 (2.9) 0.13
Maximum vasopressor dose (mcg/kg/min) 0.38 ± 0.55 0.38 ± 0.45 0.93
Hydrocortisone, n (%) 72 (69.2) 68 (62.3) 0.77
Mechanical ventilator, n (%) 74 (71.2) 67 (65.7) 0.40
Renal replacement therapy, n (%) 32 (30.8) 16 (15.7) 0.01
* Crystalloid solution that was administration for septic shock resuscitation was 0.9% sodium chloride solution
†
For patients in albumin group, all of them received 5% albumin solution
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TABLE 3. Patient outcomes.
Unadjusted Adjusted
Clinical outcome Albumin Gelatin Odds Ratio P-value Odds Ratio P-value
†
(n=104) (n=102) (95%condence (95%condence
interval) interval)
†
28-day mortality, n (%) 29 (27.9) 39 (38.2) 0.63 (0.35–1.12) 0.11 0.46 (0.24-0.89) 0.02
Hospital mortality, n (%) 41 (39.4) 45 (44.1) 0.82 (0.47–1.44) 0.50 0.60 (0.32-1.12) 0.11
Days alive and free of 13.5 ± 12.6 13.5 ± 12.8 0.98
ventilator support to Day 28
Days alive and free of 15.7 ± 12.0 14.2 ± 12.2 0.35
vasopressor usage to Day 28
Days alive and free of renal 13.9 ± 13.3 14.3 ± 13.0 0.83
replacement therapy to Day 28
Days alive and free of organ 11.2 ± 12.0 11.9 ± 12.0 0.56
support to Day 28
Long term renal replacement 9/63 4/57 2.21 (0.64-7.61) 0.20 1.80 (0.47-6.95) 0.40
therapy requirement after (14.3) (7.0)
discharge, n renal replacement/n
survivors (%)
†
Performed by Logistic regression analysis adjusted for baseline underlying conditions (hypertension and diabetes mellitus) and site of
infection (intra-abdominal infection, urinary tract infection and other sites of infection)
Fig 2. Kaplan–Meier curve of 28-day survival. e hazard ratio for death in patients who received albumin solution (albumin group)
compared with patients who received gelatin solution (gelatin group) during septic shock resuscitation was 0.69 (95% condence interval,
0.42–1.11; p = 0.12).
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TABLE 4. Subgroup analysis of 28-day mortalities according to clinical parameters.
Albumin Gelatin Adjusted Odds
Clinical parameter n deaths/ n deaths/ Ratio P-value
†
npergroup(%) npergroup(%) (95%condence
interval)
†
APACHE II score*
< 20 10/46 (21.7) 9/45 (19.6) 1.09 (0.33–3.66) 0.88
≥ 20 19/58 (32.8) 30/57 (53.6) 0.28 (0.12–0.68) 0.005
Baseline serum albumin
< 3 g/dL 21/81 (25.9) 34/74 (45.9) 0.29 (0.14–0.63) 0.002
≥ 3 g/dL 8/23 (34.8) 5/28 (17.9) 2.87 (0.62–13.31) 0.18
Baseline serum lactate
< 4 mmol/L 9/55 (16.4) 12/43 (27.9) 0.34 (0.11–1.07) 0.06
≥ 4 mmol/L 20/49 (40.8) 27/59 (45.8) 0.61 (0.27–1.39) 0.24
Epinephrine
Not receiving 12/71 (16.9) 14/63 (22.2) 0.51 (0.19–4.36) 0.18
Receiving 17/33 (51.5) 25/39 (64.1) 0.56 (0.20–1.57) 0.27
Maximum dose of vasopressors
< 0.2 mcg/kg/min 12/68 (17.6) 12/56 (21.4) 0.64 (0.23–1.75) 0.39
≥ 0.2 mcg/kg/min 17/36 (47.2) 27/46 (58.7) 0.44(0.17–1.16) 0.10
Ventilator support
Not receiving 2/30 (6.7) 6/35 (17.1) 0.35 (0.05–2.22) 0.26
Receiving 27/74 (36.5) 33/67 (49.3) 0.46 (0.22–0.96) 0.04
Renal replacement therapy
Not receiving 13/72 (18.1) 28/86 (32.6) 0.37 (0.16–0.85) 0.02
Receiving 16/32 (50) 11/16 (68.8) 0.49 (0.09–2.53) 0.39
†
Performed by Logistic regression analysis adjusted for baseline underlying conditions (hypertension and diabetes mellitus) and site of
infection (intra-abdominal infection, urinary tract infection and other sites of infection)
*e APACHE II score, a severity-determining score, ranges from 0 to 71. Higher scores indicate a more severe disease.
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Interestingly, the results of our study demonstrated
the benets of using an albumin solution over a gelatin
solution for the resuscitation of the more severely ill
patients whose baseline APACHE II scores were ≥ 20
and of patients who had a baseline serum albumin level
of < 3 g/dL. As to the more severe patients, a subgroup
analysis conducted by the ALBIOS study identied that
septic shock patients who were resuscitated with albumin
were associated with a lower mortality rate than those
who were resuscitated with a crystalloid solution.
3
is
benet of albumin was not evident among the severe
sepsis patients participating in the ALBIOS trial. In the
case of our cohort, all of the enrolled patients had been
diagnosed with septic shock, and their hemodynamics
had not properly responded to crystalloid resuscitation;
it was therefore not possible for our study to compare the
ecacies of the use of the albumin and gelatin solutions
with the severe sepsis patients. Nonetheless, there were
no dierences in the ecacies of the two solutions among
the patients who received or did not received epinephrine,
nor among the patients who required maximum doses
of vasopressor of < 0.2 mcg/kg/min or ≥ 0.2 mcg/kg/
min (Table 4).
With regard to the inuence of the serum albumin
level and the benets of albumin over gelatin solution for
septic shock resuscitation, albumin is considered to be
the most important plasma protein to maintain oncotic
pressure.
19
Septic shock patients with a low baseline
serum albumin level and a low oncotic-pressure are at
risk of uid extravasation from the blood vessels into the
interstitial tissue (especially the lung parenchyma), which
causes hypoxemia due to non-cardiogenic pulmonary
edema. e clinical ndings from our cohort showed
that among the subgroup of septic shock patients who
had a baseline serum albumin level of < 3.0 g/dL, the
resuscitation with the albumin solution was associated
with a lower 28-day mortality than the rate achieved with
the gelatin solution. is nding correlates well with
information from a prospective randomized controlled
study that enrolled critically ill patients with an average
baseline serum albumin level of 2.3 g/dL. e results
of that research demonstrated that hypoalbuminemia
patients who received albumin administration were
associated with signicantly better Sequential Organ
Failure Assessment scores, especially improved PaO
2
/
FiO
2
ratios, cardiovascular scores, and Glasgow Coma
Scale scores.
20
e target serum albumin level of 3 g/dL
was also the same as that employed by the ALBIOS trial.
On the other hand, our study demonstrated that
there was a trend toward a higher 28-day mortality among
septic shock patients with a baseline serum albumin
level of ≥ 3 g/dL who received albumin than those who
received gelatin, although the dierence did not reach
statistical signicance. is can be partly explained in two
possible ways. e rst is that cardiac decompensation
might occur aer rapid volume expansion with exogenous
albumin in patients with a high baseline serum albumin,
which might lead to an abrupt increase in the venous
return and hydrostatic pressure. e second explanation
is that in the case of septic shock patients with increased
capillary permeability or capillary leak syndrome, albumin
administration may become detrimental when albumin
and water cross the capillary membrane and aggravate
severe hypoxemia due to acute pulmonary edema.
21
e strength of our study is that it is the rst to
compare the ecacies of albumin and gelatin solutions
for septic shock resuscitation. Given the nding that there
was no signicant dierence in the 28-day mortality rates
of the gelatin and albumin groups, gelatin solution could
be used as an alternative to colloid uid for septic shock
resuscitation, especially with patients whose baseline
serum albumin is ≥ 3.0 g/dL or whose APACHE II score
is < 20. As to the cost of each solution, albumin currently
costs 7,672 ai Baht/liter whereas gelatin is priced at 430
ai Baht/liter. In view of the marked price dierential,
gelatin solution could be used as an alternative colloid
for septic shock patients who cannot aord the cost
of albumin resuscitation. On the other hand, albumin
should be recommended for patients whose baseline
serum albumin is < 3.0 g/dL or APACHE II score is
≥ 20.
ere are certain limitations to our study. For one
thing, we did not calculate the number of patients who
needed to be enrolled to ensure that the study power
was adequate. is is because-to our knowledge-no
information was available from any previous study directly
comparing the ecacies of albumin and gelatin solutions
for septic shock resuscitation. Given our research result
that the 28-day mortality of the patients in the gelatin
group was 38.2%, then 200 patients per group would have
needed to be recruited to detect a 10% absolute mortality
dierence with a power of 20%. Our study may therefore
have inadequate power to detect the precise dierences
between albumin and gelatin resuscitation. Secondly, as
this was a retrospective observational study in which the
decisions to use particular colloid solutions were made
by the individual attending physicians, a selection bias
might have occurred. However, aer adjusting the patients’
baseline data (age, APACHE II scores, MAPs, and baseline
serum lactate levels), the baseline characteristics of the
two enrolled groups were well-matched. In addition, as
this was a single center study, generalization of the results
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460
could be limited. Physicians who would like to apply the
results could adjust the context of the study population
to better match their own situation. To conrm the
benets of using an albumin solution for septic shock
resuscitation and broaden the applicability of the results, a
large multicenter randomized study with adequate power
to evaluate the mortality dierences between albumin
and gelatin (and possibly other colloid solutions) could
be conducted.
CONCLUSION
For septic shock resuscitation, the albumin and
gelatin solutions did not have any dierences in their
28-day mortality rates or organ support-free survival
days in the overall populations. However, resuscitation
with albumin was associated with better outcomes among
patients who had hypoalbuminemia or high APACHE
II scores. Further study is required to conrm these
benets.
ACKNOWLEDGMENTS
We thank Mr. David Park for language editing and
Mr. Suthipol Udompanturak for statistics consultation.
Consent for publication: Not applicable.
Availability of data and materials: e datasets generated
and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Competing interests: e authors have no competing
interests to declare, or any real or perceived nancial
interests in any product or commodity mentioned in
this paper.
Funding: e trial was funded by Siriraj Critical Care
Research Funding.
Abbreviations: MAP: mean arterial blood pressure; RRT:
renal replacement therapy; APACHE II score: Acute
Physiology and Chronic Health Evaluation II score;
SOFA score: Sequential Organ Failure Assessment score
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Chorchana Wichian, M.D.*, otsaporn Morasert, M.D.*, Surat Tongyoo, M.D.**, Naruebeth Koson, M.NS.***
*Department of Internal Medicine, Suratthani Hospital, Suratthani 84000, **Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok 10700, ***Department of Cardiovascular and oracic Intensive Care Unit, Suratthani Hospital, Surat ani 84000, ailand.
Predictor of In-hospital Mortality among Acute
Coronary Syndrome Patients after Treatment with
an Intra-aortic Balloon Pump in Tertiary Hospital,
Thailand
ABSTRACT
Objective: Intra-aortic balloon pump (IABP), a mechanical hemodynamic support device, had widely been used to
treat cardiogenic shock patients for several decades. However, the information about the predictive factors associated
with mortality was scarce. is study aims to identify the predictive factors associated with in-hospital mortality in
acute coronary syndrome (ACS) patients who performed IABP for their hemodynamic support during admission.
Methods: We conduct a retrospective cohort study design. All admission records of ACS patients with IABP at
Suratthani Hospital between October 2015 and September 2019 were retrieved.
Results: Overall 75 ACS patients with IABP insertion were enrolled. irty-one patients died during admission,
in-hospital mortality was 41.3%. From the multivariable analysis, we identied 3 predictors associated with in-
hospital mortality included cardiac arrest at presentation (adjusted OR [aOR]=11.18, 95%CI: 2.42-51.57, P=0.002),
a higher number of inotropes or vasopressors (aOR 6.10, 95%CI 1.36-27.24, P=0.018) and Killip class IV (aOR 5.64,
95%CI 1.01-31.39, P=0.048).
Conclusion: ACS patients who required IABP support had high mortality. Cardiac arrest, Killip class IV (cardiogenic
shock) at presentation and requiring a higher number of inotropes or vasopressors were independent predictive
factors of in-hospital mortality.
Keywords: Acute coronary syndrome; in-hospital mortality; intra-aortic balloon pump (Siriraj Med J 2020; 72: 462-469)
Corresponding author: Chorchana Wichian
E-mail: chorchana@gmail.com
Received 30 July 2020 Revised 28 August 2020 Accepted 1 September 2020
ORCID ID: http://orcid.org/0000-0001-8929-644X
http://dx.doi.org/10.33192/Smj.2020.62
INTRODUCTION
Coronary artery disease (CAD), an important non-
communicable disease, is a leading cause of death in
adults which accounting for one - thirds of all death
in the subject over 35 years as reported by the World
Health Organization.
1
Data from ailand reported
that CAD caused 31 deaths per 100,000 population.
2
e CAD can be categorized according to the clinical
presentation into acute coronary syndrome (ACS) and
stable CAD. ACS is divided into ST-segment elevated
myocardial infarction (STEMI) and non-ST segmented
elevated myocardial infarction (NSTEMI) by initial
electrocardiogram. Patients who presented with ACS
had a signicantly higher mortality rate than those with
stable CAD. Data from the ai acute coronary syndrome
(ai ACS registry), reported high 1-year mortality in
both STEMI (14%) and NSTEMI (25%).
3
Wichian et al.
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Although, the restoration of epicardial coronary artery
blood ow by either percutaneous coronary intervention
(PCI) or coronary artery bypass gra surgery (CABG)
can improve the outcome of many ACS patients but the
in-hospital mortality was still high.
3
e previous study
identied factors associated with in-hospital mortality
among STEMI patients which included age older than
75 years, diabetes mellitus, cardiac arrhythmias and
cardiogenic shock.
4
e treatment of cardiogenic shock
composed of pharmacological treatment with inotropic
drug plus vasopressors and mechanical circulatory support
for the critically ill patients.
Mechanical circulatory support (MCS) takes an
important role in unstable conditions or high-risk
patients, especially patients with le main coronary
artery stenosis, severely impaired le venticular systolic
function, multivessel coronary artery stenosis disease,
elderly patients and anterior wall STEMI.
5
Following
the current guidelines
6
recommend using many types of
MCS systems include intra-aortic balloon pump (IABP),
Tandem heart, Impella, or veno-arterial extracorporeal
membrane oxygenation (VA-ECMO). e MCS can
increase forward blood flow from the left ventricle,
reduce le ventricular end-diastolic pressure result in
improving coronary artery blood ow as well as systemic
circulation. However, the level of augmented cardiac
output dierence by each type of MCS. Comparing
among the mechanical devices that can be a bed-side,
percutaneous insertion; ECMO is a device that can
increase systemic blood ow in the highest volume,
followed with Impella and IABP. In e recent years,
VA-ECMO and Impella had been recommended over
IABP for hemodynamic support for cardiogenic shock
patients. Although, IABP can increase cardiac output
only about 0.5 litres per minute, it still the most common
device that is widely used for hemodynamic support
among cardiogenic shock patients in ailand due to its
relatively low price and more available of experienced
physicians for device insertion and management.
Up to now, in the era that almost every ACS patient
received timely reperfusion therapy by either PCI or CABG.
To the best of our knowledge there is scarce information
about the result of IABP usage for hemodynamic support
among cardiogenic shock patients. erefore, the objective
of this study is to evaluate the predictors of in-hospital
mortality in ACS patients with cardiogenic shock receiving
IABP insertion for hemodynamic support.
MATERIALS AND METHODS
Study design and setting
We conducted a retrospective cohort design in
a university-aliated tertiary care centre, Suratthani
Hospital (SH), ailand. e study was approved by
the ethic committee review board of SH. e number
of approval was 34/2020.
Study participants
All admission records of ACS patients in the cardiac
catheterization unit of SH between October 2015 and
September 2019 were screened. e ACS patients, aged
18 years or more and required an IABP insertion were
included. e diagnosis of ACS is based on international
guidlines.
7-9
All patients were conrmed coronary artery
occlusion by the coronary artery angiography. Patients were
considered to have cardiogenic shock if their systolic blood
pressure (SBP) < 90 mmHg or required any vasopressor
to maintain SBP ≥ 90 mmHg. e exclusion criteria were
normal coronary angiography (CAG) or diagnosis of
non-obstructive coronary disease.
Data collection
e patients’ baseline clinical characteristic, initial
laboratory data, and complication during admission
included sepsis, performed hemodialysis, limb ischemia
and stroke were extracted from the medical records.
Patients were categorized to Killip classication (I-IV)
at the presentation by a cardiologist who was blinded to
the patients’ survival status. e le ventricular ejection
fraction (LVEF) results by transthoracic echocardiography
were obtained if they were performed within the rst
seven days of admission. e timing of IABP insertion
and information of revascularization procedures included
CABG and PCI were also collected. All patients admission
records were separated into two groups: non-survived
(all-cause in-hospital death) admission and survived
admissions based on the survival status of the patient.
Statistical analysis
We analyzed the characteristics of ACS patients
who performed IABP and compared non-survived cases
with survived cases. Categorical variables are presented
as percentages and were compared using Fisher’s exact
test. Continuous variables are presented as the mean ±
standard deviation (SD) and were compared using the
two-sample t-test. Non-parametric continuous variables
are presented as interquartile ranges (IQRs) and were
compared using the Wilcoxon rank-sum (Mann-Whitney)
test. All proportions and P values were calculated based
on variables with no missing data. Logistic regression
analysis was carried out to determine the factors associated
with in-hospital mortality. Odds ratios (ORs) and
their 95% condence intervals (CIs) were estimated.
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Wichian et al.
Variables at P < 0.1 on univariable analysis, as well as
those considered a priori as possible associated factors
based on previous research, were selected for inclusion
in the nal multivariable model. Variables with more
than 20 per cent missing were excluded from statistical
modelling. All analyses were two-sided with a p-value
< 0.05 as a critical value for statistical signicance.
RESULTS
A total of 76 ACS patients with IABP were enrolled.
Of this number, one patient was excluded due to normal
CAG. Finally, 75 patients were included for analysis. e
patients were predominantly male (70.7%), with the mean
age of 63.9 years (±SD 13.0). During the study period,
31 patients died. e in-hospital mortality of the cohort
was 41.3% (31/75). irty-seven patients (49.3%) were
acute STEMI and 38 patients (50.7%) were NSTEMI/UA.
e cardiogenic shock, Killip class IV at presentation
was found in 44 patients (58.7%) while the 35 patients
(46.7%) had a cardiac arrest at presentation. More than
half of the patients were revascularized by PCI (64%)
and was inserted IABP in peri- or post-revascularization
period (65%). e median duration of IABP use was 3
days (IQR 2-4). Almost all patients (94.7%) received at
least one vasopressor or inotropic agent.
In comparison with survived cases, non-survived
cases were signicantly more likely be the elderly (age
≥65 years) (65% vs. 36%), had Killip class IV (87% vs.
39%), had lower SBP (84.6 mmHg vs. 99.6 mmHg), had
lower DBP (54.7 mmHg vs. 64.3 mmHg), had lower MAP
(64.7 mmHg vs. 76.1 mmHg), presented with cardiac
arrest (84% vs. 20%), had higher serum creatinine (1.3
mg/dL vs. 1.0 mg/dL), were revascularized by PCI (84%
vs. 52%), were performed IABP in the peri- or post-
revascularization period (84% vs. 53%) and had a higher
number of inotropic agents or vasopressors use before
start IABP (Tables 1 and 2). Among the ACS patients
who performed PCI, complete revascularization (PCI all
stenotic vessel), the complete revascularized group had
lower in-hospital mortality (70.8% vs 28%, p = 0.004).
e complications aer IABP insertion was shown
in Table 3. Hemodialysis was the leading complication
followed by sepsis, stroke and limb ischemia.
On the univariable analysis, the following parameters
were considered to be signicantly associated with in-
hospital mortality: elderly (age ≥65 years), Killip class IV,
SBP <90 mmHg, DBP <60 mmHg, MAP <65 mmHg, cardiac
arrest at presentation, revascularization by PCI, IABP
insertion during the peri-/post-revascularization period
and a higher number of inotropic agents or vasopressors
use (Table 4). On multivariable analysis, we identied
3 independent predictors associated with in-hospital
mortality among ACS patients in IABP included cardiac
arrest at presentation (adjusted OR [aOR] 11.18, 95%CI
2.42-51.57, P=0.002), a higher number of inotropes/
vasopressors (aOR 6.10, 95%CI 1.36-27.24, P=0.018) and
Killip class IV (aOR 5.64, 95%CI 1.01-31.39, P=0.048)
(Table 4).
DISCUSSION
In this 4-year retrospective study, patients who
presented with acute myocardial infarction and were
treated with an IABP had high in-hospital mortality
especially in the elderly, cardiogenic shock and cardiac
arrest patients. In the multivariable analysis, we identied
3 independent predictive factors of in-hospital mortality
which included Killip class IV, cardiac arrest, and number
of inotrope or vasopressors use. Furthermore, the adverse
events aer IABP was reported signicantly higher among
the patients who died during the admission.
For identify the predictive factors associated with
poor outcome among patients who received IABP support,
a retrospective study from Japan, enrolled 104 patients
who underwent PCI for treatment the coronary artery
lesion responsible for acute myocardial infarction and
received IABP insertion, showed that shock stage and
low glomerular ltration rate were the predictive factors
for dead, while inserted IABP before start PCI was the
factor associated with survival.
10
However, only 47.1% of
patients in the Japanese cohort were in the shock stage.
Although, we also found that hemodialysis aer IABP
was signicantly higher among non-survived patients
in our study, we did not include this factor into the
nal model due to we aimed to explore the predictor of
in-hospital mortality before IABP insertion. e others
independent predictive factors in the current study for
in-hospital dead, included Killip class IV, presented
with cardiac arrest and high number of inotropic used
were all represent the more severe form of myocardial
infarction.
Comparing to the participants of IABP Shock II trial,
the largest randomized controlled trial which included 600
myocardial infarctions with cardiogenic shock patients
who had planned for early reperfusion therapy, our
participant were relatively younger, lower proportion
of reperfusion therapy with PCI (64.5% vs 96%) but
had similar baseline blood pressure and heart rate.
11
e
higher proportion of our acute myocardial infarction
with cardiogenic patients who received CABG surgery
for reperfusion therapy could be mainly explained by the
higher incidence of le main stenosis which was 51.3%
in our study, compared with only 9.3% in IABP-Shock II
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TABLE 1. Clinical characteristics of non-survived and survived ACS patients with IABP (n=75).
Characteristics Non-survived, (n=31) Survived, (n=44) P-value
Age
years, mean (SD) 66.9 (14.7) 61.8 (11.4) 0.091
≥65 years 20 (65) 16 (36) 0.020
Male sex, n (%) 22 (71) 31 (70) 1.000
Diabetes Mellitus, n (%) 14 (45) 21 (48) 1.000
Hypertension, n (%) 21 (68) 33 (75) 0.600
Previous history of CAD, n (%) 7 (23) 11 (25) 1.000
Previous PCI, n (%) 5 (16) 2 (5) 0.120
STEMI, n (%) 17 (55) 20 (45) 0.490
Anterior wall lesion, n (%) 10 (32) 10 (23) 0.430
Non-STEMI or Unstable angina, n (%) 14 (45) 24 (55) 0.490
Left main coronary artery stenosis 16 (52) 23 (52) 1.000
Killip class at presentation, n (%) <0.001
I 0 (0) 7 (16)
II 1 (3) 7 (16)
III 3 (10) 13 (30)
IV 27 (87) 17 (39)
Systolic BP
mmHg, mean (SD) 84.6 (13.4) 99.6 (25.7) 0.004
<90 mmHg, n (%) 22 (71) 17 (39) 0.009
Diastolic BP
mmHg, mean (SD) 54.7 (11.6) 64.3 (18.8) 0.014
<60 mmHg, n (%) 20 (65) 17 (39) 0.036
Mean arterial BP
mmHg, mean (SD) 64.7 (11.3) 76.1 (20.4) 0.007
<65 mmHg, n (%) 17 (55) 14 (32) 0.059
Heart rate, per minute, mean (SD) 94.1 (25.3) 88.0 (23.2) 0.280
Cardiac arrest at presentation, n (%) 26 (84) 9 (20) <0.001
Serum creatinine, mg/dL, median (IQR) 1.3 (1.1, 1.5) 1.0 (0.9, 1.4) 0.017
Initial hemoglobin level, g/dL, mean (SD) 12.7 (2.1) 11.9 (2.1) 0.140
Current statin use 7 (23) 10 (23) 1.000
DAPT in rst day 30 (96.8) 44 (97.8) 1.000
High potency statin rst day 6 (19.4) 41 (91.1) 0.300
Left ventricular ejection fraction
%, mean (SD) 42.6 (14.3) 44.2 (15.4) 0.670
missing, n (%) 9 (29) 1 (2) 0.004
All proportions (%) and P values calculated based on variables with no missing data.
Abbreviations: ACS, acute coronary syndrome; BP, blood pressure; CAD, coronary artery disease; IABP, intra-aortic balloon pump; IQR,
interquartile range; PCI, percutaneous coronary intervention; SD, standard deviation; STEMI, ST-segment elevation myocardial infarction
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Type of treatment Non-survived, (n=31) Survived, (n=44) P-value
Mode of revascularization 0.015
PCI, n (%) 25 (81) 23 (52)
CABG, n (%) 6 (19) 21 (48)
PCI for STEMI, n (%)
Primary 12 (39) 9 (20) 0.120
Rescue 3 (10) 4 (9) 1.000
PCI for Non-STEMI or Unstable angina, n (%) 10 (32) 10 (23) 0.430
PCI left main, n (%) 9 (29) 9 (20) 0.420
Number of vessel target for CABG 1.000
1 0 (0) 1 (5)
2 1 (17) 4 (19)
3 5 (83) 14 (67)
4 0 (0) 2 (10)
Valve surgery co-committed 2 (6) 2 (5) 1.000
Timing of IABP insertion, n (%) 0.006
Pre- revascularization 5 (16) 21 (48)
Peri- and post revascularization 26 (84) 24 (52)
Duration of IABP, days, median (IQR) 2 (2, 4) 3 (2, 4) 0.140
Inotrope or vasopressor(s) use prior to IABP
Any 31 (100) 41 (91) 0.140
No. of medication use <0.001
1 0 (0) 12 (27)
2 17 (55) 21 (48)
3 14 (45) 7 (16)
Complication Non-survived (n=31) Survived (n=44) P-value
Hemodialysis, n (%) 10 (32) 2 (5) 0.003
Sepsis, n (%) 5 (16) 1 (2) 0.076
Stroke, n (%) 2 (6) 0 (0) 0.170
Limb ischemia, n (%) 1 (3) 1 (2) 1.000
TABLE 2. Comparison of treatment between non-survived and survived ACS patients with IABP (n=76).
Abbreviations: ACS, acute coronary syndrome; CABG, coronary artery bypass gra; IABP, intra-aortic balloon pump; IQR, interquartile
range; PCI, percutaneous coronary intervention; SD, standard deviation; STEMI, ST-segment elevation myocardial infarction
TABLE 3. In-hospital complication aer IABP (n=76).
Abbreviation: IABP, intra-aortic balloon pump
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Predictor Univariable Multivariable
OR (95% CI) P-value aOR (95% CI) P-value
Age, years
<65 1 Reference
≥65 3.18 (1.22-8.30) 0.018 2.45 (0.54-11.03) 0.245
Test for trend (every 1 increased) 1.03 (0.99-1.07) 0.094
Killip class
I 1 Reference
IV 10.72 (3.19-36.05) <0.001 5.64 (1.01-31.39) 0.048
Systolic BP, mmHg
≥90 1 Reference
<90 3.88 (1.45-10.39) 0.007 0.75 (0.09-6.52) 0.799
Test for trend (every 10 decreased) 1.04 (1.01-1.06) 0.008
Diastolic BP, mmHg
≥60 1 Reference
<60 2.89 (1.11-7.49) 0.029 1.50 (0.03-71.13) 0.838
Test for trend (every 10 decreased) 1.04 (1.01-1.07) 0.018
Mean arterial BP, mmHg
≥65 1 Reference
<65 2.60 (1.01-6.73) 0.049 0.92 (0.02-48.21) 0.967
Test for trend (every 10 decreased) 1.04 (1.01-1.07) 0.010
Cardiac arrest at presentation
No 1 Reference
Yes 20.22 (6.06-67.49) <0.001 11.18 (2.42-51.57) 0.002
Serum Creatinine, mg/dL
Test for trend (every 0.1 decreased) 1.00 (0.97-1.03) 0.993
PCI
No 1 Reference
Yes 3.80 (1.31-11.09) 0.014 4.41 (0.29-66.96) 0.285
Timing of IABP
Pre- revascularization 1 Reference
Peri- and post revascularization 4.75 (1.54-14.63) 0.007 1.90 (0.15-23.38) 0.615
No. of inotrope/vasopressor
Test for trend (every 1 agent added) 4.80 (2.02-11.43) <0.001 6.10 (1.36-27.24) 0.018
TABLE 4. Predictor of in-hospital mortality among ACS patients with IABP by univariable and multivariable
logistic regression analysis.
Abbreviations: ACS, acute coronary syndrome; aOR, adjusted OR; BP, blood pressure; CI, condence interval; IABP, intra-aortic balloon
pump; PCI, percutaneous coronary intervention
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Wichian et al.
trial. Furthermore, the incidence of signicant stenosis
in 3 vessels was 70% in our patients, compared with
52.3% in IABP-Shock II trail. For the 30-days mortality
outcome which was reported about 39.7% among IABP
group of IABP-Shock II trail, similar with 42.1% in
our population. Recently, there was a study reported
4-years experience at Hua Hin hospital, a large local
government hospital in the southern part of ailand,
enrolled 57 acute myocardial infarction with cardiogenic
shock and received IABP insertion for hemodynamic
support.
12
Most patients (50.9%) presented with acute
subendocardial myocardial infarction, following with
acute transmural myocardial infarction (45.6%). Only
3.5% of patients had a cardiac arrest at presentation.
e overall in-hospital mortality was 23% which was
lower than 40.8% in our report. However, considering
patients in our study who did not have cardiac arrest,
the in-hospital mortality rate was only 25% which was
comparable with the mentioned study.
Intra-aortic balloon pump, a percutaneously inserted
catheter base mechanical device, had been used for
hemodynamic support among cardiogenic shock patients
since it rst successful clinical application in 1968.
13
Due
to IABP ability to improve patients’ mean arterial blood
pressure, restoration of myocardial perfusion and slight
improve cardiac output, this device became the most
common mechanical support device usage worldwide for
almost 3 decades. Evidence from observational studies and
small-sized randomized controlled trial support the benet
of IABP in cardiogenic shock patients caused by acute
myocardial infarction for timely reperfusion therapy.
14
However, the recent evidence from a large multicenter
randomized controlled trial did not show any benet of
IABP support among acute myocardial infarction with
cardiogenic shock who underwent early reperfusion
therapy thus the European Society of Cardiology 2018
guideline downgraded the routine using of IABP for
hemodynamic support among cardiogenic shock to be
class III recommendation.
15
Our study had some limitations. Firstly, this is a
retrospective observational study conducted at a single
centre. e number of enrolled patients was limited. So
we could unable to identify another potential factor that
might be associated with poor outcome among IABP
inserted patients. Secondly, the application of information
from our study could be considered under the context of
the individual institute, and according to the dierent of
patients’ baseline characters and their receiving standard
of care which may vary from our institute. irdly,
our mortality rate was reported high, which could be
explained by a signicantly high proportion of cardiac
arrest patients that were enrolled in the study.
CONCLUSION
e acute coronary syndrome patients who required
intra-aortic balloon pump support had high mortality.
Cardiac arrest, Killip class IV (cardiogenic shock) at
presentation and requiring a higher number of inotropes
or vasopressors were independent predictive factors of
in-hospital mortality.
REFERENCES
1. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology
of coronary heart disease and acute coronary syndrome. Ann
Transl Med 2016;4:256.
2. Disease Don-c. Individual patient ai database 2018 [Available
from: http://www.thaincd.com/2016/mission/documents-detail.
php?id=13684&tid=32&gid=1-020.
3. Srimahachota S, Boonyaratavej S, Kanjanavanit R, Sritara P,
Krittayaphong R, Kunjara-Na-Ayudhya R, et al. ai Registry
in Acute Coronary Syndrome (TRACS)-an extension of ai
Acute Coronary Syndrome Registry (TACS) group: lower
in-hospital but still high mortality at one-year. J Med Assoc
ai 2012;95:508-18.
4. Sanguanwong S, Srimahachota S, Tungsubutra W, Srichaiveth
B, Kiatchoosakun S. Predictors of in-hospital mortality in ai
STEMI patients: results from TACSR. J Med Assoc Thai
2007;90(Suppl 1):91-97.
5. Members WC, Levine GN, Bates ER, Blankenship JC, Bailey
SR, Bittl JA, et al. 2011 ACCF/AHA/SCAI guideline for
percutaneous coronary intervention: a report of the American
College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines and the Society for Cardiovascular
Angiography and Interventions. Circulation 2011;124:e574-e651.
6. Rihal CS, Naidu SS, Givertz MM, Szeto WY, Burke JA, Kapur NK,
et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement
on the use of percutaneous mechanical circulatory support devices
in cardiovascular care: endorsed by the American Heart Assocation,
the Cardiological Society of India, and Sociedad Latino Americana
de Cardiologia Intervencion; Armation of Value by the Canadian
Association of Interventional Cardiology-Association Canadienne
de Cardiologie d’intervention. J Am Coll Cardiol 2015;65:e7-
e26.
7. Kimura K, Kimura T, Ishihara M, Nakagawa Y, Nakao K,
Miyauchi K, et al. JCS 2018 guideline on diagnosis and treatment
of acute coronary syndrome. Circ J 2019;83:1085-196.
8. ygesen K, Alpert JS, Jae AS, Chaitman BR, Bax JJ, Morrow
DA, et al. Fourth universal denition of myocardial infarction
(2018). J Am Coll Cardiol 2018;72:2231-64.
9. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning
AP, Benedetto U, et al. 2018 ESC/EACTS guidelines on myocardial
revascularization. Eur Heart J 2019;40:87-165.
10. Kasahara T, Sakakura K, Yamamoto K, Taniguchi Y, Tsukui
T, Seguchi M, et al. Clinical Factors Associated with In-Hospital
Mortality in Patients with Acute Myocardial Infarction Who
Required Intra-Aortic Balloon Pumping. Int Heart J 2020;61:209-
14.
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11. iele H, Schuler G, Neumann FJ, Hausleiter J, Olbrich HG,
Schwarz B, et al. Intraaortic balloon counterpulsation in acute
myocardial infarction complicated by cardiogenic shock: design
and rationale of the Intraaortic Balloon Pump in Cardiogenic
Shock II (IABP-SHOCK II) trial. Am Heart J 2012;163:938-45.
12. Euswas P. Results of Intra-aortic Balloon Pump (IABP) erapy
in Cardiogenic Shock Patients: 4Years Experience at Hua Hin
Hospital. Reg 4-5 Med J 2014;33:107-17.
13. Kantrowitz A, Tjonneland S, Freed P, Philipps S, Butner A.
Sherman JL Jr. Initial clinical experience with intraaortic
balloon pumping in cardiogenic shock. JAMA 1968;203:113-
18.
14. Parissis H, Graham V, Lampridis S, Lau M, Hooks G, Mhandu
P. IABP: history-evolution-pathophysiology-indications: what
we need to know. J Cardiothorac Surg 2016;11:122.
15. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning
AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on
myocardial revascularization. Eur Heart J 2018;40:87-165.
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470
ipawan Bowornkitiwong, M.D.*, Wanida Srilarnkhom**, Pawinee Tawatchot**, Teeraporn Paisan**, Suganyapatch
Sirichotpapa***, Sirinya Nanthanangkul**, Teerapol Sommaichaiya, M.D.****
*Department of Palliative Care Unit, Udonthani Cancer Hospital, **Research and Medical Technology Assessment Department, Udonthani Cancer
Hospital, ***Physical erapy Department, Palliative Care Unit, Udonthani Cancer Hospital, ****Anesthesiology Department, Lerdsin Hospital,
Bangkok, ailand.
Short-term Effect of Transcutaneous Electrical
Nerve Stimulation (TENS) on Pain in Patients with
Bone Metastasis: An Uncontrolled Pretest-Posttest
Study
ABSTRACT
Objective: To evaluate the short-term eect of TENS on pain for patients with bone metastasis.
Methods: An experimental descriptive study of 25 eligible advanced cancer patients with bone metastasis. Patients
were enrolled in the study from June 1, 2018 to December 31, 2019. Pain intensity measurements were recorded at
baseline prior to TENS application, then aer 30 minutes and 60 minutes of TENS while the device was switched
on. TENS was applied prior to radiotherapy at the same time every day for 5 days. Pain score was evaluated with
the Visual Analogue Scale (VAS). Symptom assessment was measured by a ai version of the Edmonton symptom
assessment system (ESAS-ai) on the rst day prior to and ve days aer TENS application began. e paired
t-test and Generalized Estimating Equations (GEE) were used analysis.
Results: Mean VAS scores decreased by 1.08 (-1.08; 95% CI; -1.66 to 0.50, p < 0.001) and 1.82 (-1.82; 95 CI; -2.40
to 1.24, p < 0.001) aer 30 and 60 minutes, respectively, compared to the baseline. Lower VAS scores were also
correlated to the number of TENS visits. Mean ESAS scores showed a statistically signicant dierence before and
aer TENS application (before: 4.32 (95% CI: 3.60–5.03); aer: 3.08 (95% CI: 2.61–3.54), p = 0.004). During TENS
application there was a reduction in VAS pain scores over time.
Conclusion: TENS is non-invasive, inexpensive and safe. It may be a useful adjunct to the multimodality treatment
of pain and may reduce the need for morphine.
Keywords: TENS; cancer with bone metastasis (Siriraj Med J 2020; 72: 470-475)
Corresponding author: ipawan Bowornkitiwong
E-mail: mugajung@hotmail.com
Received 30 July 2020 Revised 17 August 2020 Accepted 1 September 2020
ORCID ID: http://orcid.org/0000-0002-7760-6081
http://dx.doi.org/10.33192/Smj.2020.63
INTRODUCTION
Bone is the fourth most common site for metastasis.
1
Bone pain is commonly reported among patients with
metastatic bone disease.
2,3
Bone pain in most cancer
patients initially occurs as intermittent dull aches and
then becomes constant and more severe, especially at
night.
4
Another characteristic of bone pain is breakthrough
(episodic) pain, dened as recurrent episodes of severe
pain breaking through the regimen administered to treat
background pain.
5
It can be spontaneous or precipitated
by some factors especially by movement.
Bowornkitiwong et al.
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Bone cancer pain, which has both a nociceptive
and neuropathic component,
6
is difficult to control
with only one modality, typically requiring the use of
multiple interventions including radiotherapy, surgery,
chemotherapy, bisphosphonate, calcitonin, and analgesics.
7
Patients with pain have decreased quality of life in all
domains, including physical functioning, social relationship
and mental health.
8
Standard analgesic approaches and radiotherapy can
both be used to treat bone cancer pain.
9
Radiotherapy is
estimated to produce complete pain relief at one month
in approximately a quarter of patients.
10
Opioid-based
therapy is the most common analgesic used to treat
cancer bone pain and does not have a ceiling dose until
unmanageable adverse eects occur.
11
However, adverse
eects of sedation, constipation, nausea, and vomiting
are common.
11
Others are confusion, hallucination,
nightmares, urinary retention, myoclonus, dizziness,
and dysphoria. Other adjunctive medications, such as
NSAIDs and bisphosphonates are also associated with
undesired side eects.
12,13
Transcutaneous electrical nerve stimulation (TENS)
is a non-invasive intervention used to relieve chronic pain,
mostly commonly in non-cancer diseases. Systematic
reviews have shown benets for musculoskeletal and
osteoarthritic pain.
14,15
TENS reduces pain through both
peripheral and central mechanisms.
16
Its purpose is to
selectively activate large diameter non-noxious aerents,
which reduces nociceptor cell activity and sensitization
in the central nervous system.
17
e aerent input is sent
to the central nervous system to activate descending
inhibitory systems to reduce hyperalgesia.
18
e peripheral
blockade of TENS results in the reduction of substance
P in dorsal root ganglia neurons in animals.
18
TENS
may also alter the excitability of peripheral nociceptors
to reduce aerent input to the central nervous system.
18
A few studies have examined the eect of TENS
on bone pain among cancer patients.
18,19
However, the
evidence whether TENS is an eective tool for pain
management among cancer patients is inconclusive.
20
erefore, the objective of this study is to evaluate the
short-term eect of TENS on pain for patients with bone
metastasis.
MATERIALS AND METHODS
Research design
This study was designed as a pre-experimental
pretest-posttest study design without a control group. e
study protocol was reviewed and approved by Udonthani
Cancer Hospital Ethics Committees for Human Research
(reference number UCH–CT 13/2561). Pre-experimental
studies are important for informing future decisions
about sample size and feasibility when information is
limited.
21
Eligibility
e study population comprised patients aged 15
and older receiving palliative radiotherapy treatment at
Udonthani Cancer Hospital for bone metastasis formed
the study population. Participating patients were required
to have advanced cancer with radiologically conrmed
bone metastasis (by plain lm, CT, MRI, or bone scan),
pain rated at least 3 out of 10 on a numerical pain-
intensity scale at rest or on movement, a life expectancy
of more than 4 weeks, and a prescription of regular
analgesic medication. Patients with a pacemaker, history
of seizure, skin infection or abnormal sensation over the
area of bone pain were excluded from the study. Each
patient’s analgesic drug and also non-pharmacological
treatment prior to the intervention were maintained
over the duration of the study. Patients were enrolled
in the study from June 1, 2018 to December 31, 2019.
TENS application protocol
TENS was applied to the site of bone pain by a
physical therapist using a dual channel TENS device.
TENS pads were 61 x 27 x 96 mm in size and were placed
between 5-10 cm apart on the site of skin with a pulse
width of 200 microseconds, and pulse frequency of 80
Hz. e intensity was increased over 60 minutes until
patients indicated maximum tolerance while still feeling
comfortable.
Outcome measures
Pain intensity was assessed by the VAS. Scores were
recorded by marking on a horizontal line (100 mm in
length) that represented a continuum between “no pain”
and “worst pain”.
Pain intensity measurements were recorded at baseline
prior to TENS application, then aer 30 minutes and
60 minutes of TENS while the device was switched on.
TENS was switched o and electrode pads were removed
immediately aer 60 minutes. TENS was applied prior
to radiotherapy at the same time every day for 5 days.
Participants were observed at the end of each TENS
application for adverse reaction.
Symptom assessment was measured by a ai version
of the Edmonton symptom assessment system (ESAS-
ai)
22
on the rst day prior to and ve days aer TENS
application began.
Medical records of all patients were reviewed and
demographic data were recorded including age, histologic
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Bowornkitiwong et al.
types of malignancy, sites of metastasis, performance
status, prescribed treatments and analgesic drugs.
Statistical analysis
Paired t-test and Generalized Estimating Equations
(GEE) were employed to calculate the intensity change
which estimated with ESAS and the correlation between
active TENS and VAS change respectively. Statistical
analysis was carried out in STATA version 15.0 Copyright
by Faculty of Public Health, Khon Kaen University.
(StataCorp. 2017. Stata Statistical Soware: Release 15.
College Station, TX: StataCorp LLC).
RESULTS
Patient characteristics
In total, 25 patients were recruited in this study.
Sixteen of them (64%) were female and 9 (36%) were
male. e average age was 50.7 years old (range 22-78)
Table 1. e most common site of the primary malignancy
was breast (32%), followed by head and neck (12%),
colorectal (12%), lung (12%), bile duct (12%), prostate
(8%), cervix (8%), and ovaries (4%). ECOG performance
status of 1-4 were 13 (52%), 8 (32%), 2 (8%) and 2 (8%),
respectively.
Treatment outcome
e mean VAS score at baseline was 5.90 and
gradually decreased during the rst treatment Table 2.
Aer 30 minutes of TENS treatment the mean VAS
was 3.82, and aer 60 minutes the mean VAS was 2.68
on the rst visit. Similar decreases during treatment
were observed in the second through h treatments.
Additionally, the pre-treatment VAS decreased throughout
the treatment series, decreasing from 5.90 at baseline to
2.31 prior to the h treatment.
Eect analysis
e duration of TENS treatment was related to
VAS pain intensity scores which exhibited statistically
signicant reduction at 30 and 60 minutes Table 3. Mean
VAS pain score decreased by 1.08 at 30 minutes (dierence
-1.08; 95%CI -1.66, -0.50; p<0.001) and decreased by 1.82
at 60 minutes (dierence -1.82; 95%CI -2.40, -1.24; p <
0.001) compared to baseline at 0 minutes when TENS
was initiated. Similarly, the number of applied TENS
visit was correlated to VAS. e mean scores reduced
by 1.63 ( -1.63; 95% CI; -2.07 to -1.19, p < 0.001), 2.04
(-2.04; 95% CI; -2.48 to -1.60, p < 0.001), 2.39 (-2.39;
95% CI; -2.82 to -1.95, p < 0.001), and 2.49 (-2.49; 95%
CI; -2.92 to -2.05, p < 0.001) at the second, third, fourth
and h visit respectively compared to the rst visit.
e mean ESAS score before TENS application was
4.32, compare to a score of 3.08 post TENS application
(p = 0.004) Table 4. ere were no reports of adverse
events related to TENS application.
DISCUSSION
Our study found the benet of TENS for bone cancer
pain and quality of life. VAS scores in patients decreased
relative to the duration and number of visit of the TENS
application. Symptom assessment scores according to
the ESAS decreased aer the TENS application. e
ndings showed a similar ecacy to some previous
studies. Loh and colleagues reported reduction in VAS
scores by 9.8 on a 0-100 mm scale and NRP scores by 0.8
on a 1-10 scale following TENS application.
23
A smaller
study.
24
and case report
18
using TENS for pain reduction
among cancer patients have shown that nearly all patients
reported reductions in perceived pain, which is consistent
with our ndings. Furthermore, a multicenter phase III
trial of TENS in patients with cancer bone pain showed
that TENS relieved pain intensity, particularly during
movement as compared to at rest.
19
However, no large
randomized controlled trials (RCTs) have been conducted
to test improvement in bone pain in cancer patients. A
Cochrane systematic review and meta-analysis found
only three studies which met the eligible criteria as of
2011. e results were inconclusive due to a lack of
suitable RCTs.
20
e limitations of this study included the small sample
size and lack of comparison arm. erefore, the results
may not be generalizable to broader populations, and
the independent eect on pain reduction attributable to
TENS could not be assessed. Another limitation was that
the doctor and patient were not blinded to the treatment.
Finally, the follow-up was short-term. erefore, we could
not assess the long-term eect on pain from TENS.
ere are two potential confounding factors in this
study. First, the intervention of being part of the trial
and the attentions of the physiotherapist could have a
signicant placebo eect each day, and from day-to-day.
Second, radiotherapy would be expected to reduce pain
(although maybe not immediately) and thus inuence
the ESAS and nal intensity rating.
Bone metastasis is a common cause of pain in cancer
patients. e therapeutic goal is not only optimal pain
control but also improvement of quality of life. erefore,
multimodality treatment including pharmacological
and non-pharmacological treatments is important for
patient care.
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TABLE 1. Patient demographics and baseline characteristics.
Patient characteristics No. (N=25) (%)
Gender
Female 16 64
Male 9 36
Age (years)
Mean 50.68 (range 22-78)
Malignancy
Breast cancer 8 32
Head and neck cancer 3 12
Colorectal cancer 3 12
Lung cancer 3 12
Cholangiocarcinoma 3 12
Prostate cancer 2 8
Cervix cancer 2 8
Ovarian cancer 1 4
Site of TENS application*
C spine 1 4
T spine 15 60
L spine 9 36
Pelvis 7 28
Scapula 2 8
Femur 2 8
Performance status**
ECOG 1 13 52
ECOG 2 8 32
ECOG 3 2 8
ECOG 4 2 8
Metastasis site
Bone 18 72
Bone, liver 4 16
Bone, lung 2 8
Bone, liver, lung 1 4
Previous treatment
Chemotherapy and radiotherapy 10 40
Radiotherapy 9 36
Chemotherapy 6 24
Analgesics
Weak opioid 15 60
Strong opioid 10 40
NSAIDs 5 20
Gabapentin 2 8
TCA 3 12
Acetaminophen 7 28
*One person was able to have TENS applied to more than 1 site.
**Eastern Cooperative Oncology Group performance status.
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TABLE 2. Visual analogue scale (VAS); Mean and SD.
TABLE 3. Correlation between active TENS and VAS change.
TABLE 4. ESAS dierence.
Visit Baseline 30 minutes Active TENS 60 minutes Active TENS
Mean SD Mean SD Mean SD
1 5.90 2.36 3.82 2.00 2.68 2.07
2 3.36 1.76 2.48 1.78 1.65 1.65
3 2.74 1.45 1.90 1.12 1.63 1.47
4 2.63 1.69 1.72 1.04 0.87 0.78
5 2.31 1.83 1.54 1.35 1.00 0.87
Correlation Parameter Coefcient Standard Z 95%CI P-value
structure error Upper Lower
Exchange Baseline Reference
correlation 30 minutes -1.08 0.29 -3.65 -1.66 - 0.50 < 0.001
60 minutes -1.82 0.29 -6.16 -2.40 - 1.24 < 0.001
Visit 1 Reference
Visit 2 -1.63 0.22 -7.33 -2.07 -1.19 < 0.001
Visit 3 -2.04 0.22 -9.16 -2.48 -1.60 < 0.001
Visit 4 -2.39 0.22 -10.74 -2.83 -1.95 < 0.001
Visit 5 -2.49 0.22 -11.16 -2.92 -2.05 < 0.001
Variable Mean 95%Condenceinterval t P-value
of the difference
Lower Upper
ESAS (baseline) 4.32 3.60 5.03 3.19 0.004
ESAS (after TENS) 3.08 2.61 3.54
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CONCLUSION
is uncontrolled pre-experimental pretest-posttest
study found reductions in pain among cancer patients,
as reported by visual analog scale. e reductions were
reported immediately following TENS treatment, as well
as proportional to the number of TENS treatments given.
Long-term improvements on pain were not assessed. As
a non-invasive, inexpensive, and safe treatment, TENS
may be a benecial component of multimodal pain
treatment and may reduce the need for morphine. e
results of this study may inform the design of future
RCTs, which are needed to measure the ecacy of TENS
relative to controls or other treatments.
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14. Johnson M., Martinson M. Ecacy of electrical nerve stimulation
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16. Vance CG,Dailey DL,Rakel BA,Sluka KA. Using TENS for
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19. Bennett MI,Johnson MI,Brown SR,Radford H,Brown JM,Searle
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Monton Wongwandee, M.D., M.Sc., Panwara Paritakul, M.D., MMedSci MedEd.
Department of Medicine, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok 26120, ailand.
Pre-class versus In-class Video Lectures for the
Flipped Classroom in Medical Education: A Non-
randomized Controlled Trial
ABSTRACT
Objective: e objective was to test the eectiveness of the two dierent teaching models focusing on pre-class
preparation.
Methods: is study was a single-center, post-test only, non-randomized, controlled trial. e fourth-year medical
students were assigned to attend either ipped classroom (FC) or in-class video classroom (IVC). e FC students
watched a pre-class video lecture individually. In contrast, IVC students viewed the video together during class
time. Both groups had the same in-class interactive activities, including case quizzes and discussion. e primary
outcomes were a post-test score and student satisfaction.
Results: Of 105 students, 53 were assigned to the FC group and 52 to the IVC group. 77% of the FC students reported
video viewing. ere was no signicant dierence in the post-test score between the FC and the IVC groups (p =
.107). However, the subgroup analysis showed that the post-test score of the IVC group was signicantly higher than
the FC subgroup who did not view the video (p = .024). e total satisfaction score was not signicantly dierent
between the FC and the IVC groups (p = .945). 83% of the FC who did not view the video claimed they had too
many out-of-class workloads.
Conclusion: ere were no dierences in the eectiveness between the FC and IVC approach. However, the IVC
students showed better knowledge acquisition over the FC subgroup, who did not watch the video. Hence our study
emphasized an essential role of the knowledge preparation on the successful ipped classroom.
Keywords: Flipped classroom; medical education; nonrandomized controlled trials (Siriraj Med J 2020; 72: 476-482)
Corresponding author: Monton Wongwandee
E-mail: monton@g.swu.ac.th
Received 9 March 2020 Revised 25 May 2020 Accepted 1 September 2020
ORCID ID: http://orcid.org/0000-0002-0747-0174
http://dx.doi.org/10.33192/Smj.2020.64
INTRODUCTION
Medical knowledge is rapidly expanding, diseases are
newly emerged and more complicated, and patient care
is increasingly individualized. In medical education, a
teaching model like a traditional didactic lecture may not
be suitable. In contrast, many believe that an active-learned,
critical thinking-based technique such as ipped classrooms
(FC) is more ecient. Its characteristics promote higher
cognitive learning, not only memorization. e results
of a meta-analysis study supported the eectiveness of
the FC on learning.
1
It concluded that the FC approach
yields a signicant improvement in student learning
compared with traditional teaching methods. However,
its eectiveness in medical education is inconsistent
in the previous systematic review.
2
e key to the FC
approach’s success is that students take responsibility
for their learning and prepare before class.
3
e pre-class
assignment was aimed to master the factual knowledge
Wongwandee et al.
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in preparation for the in-class interactive experiences.
is preparatory work also makes students control their
learning process by dening learning goals and monitoring
their progress in achieving them.
4
Failure to do so leads
to compromise the knowledge acquisition when nishing
the FC. e previous studies, including our teaching
experience, found that many students did not comply
with the pre-class assignment, making the FC fail.
5,6
Our research question was whether the well-prepared
teaching material could be eectively used as a pre-class
self-study for the ipped classroom. We compared the
learning outcome using PowerPoint recording video as
the teaching material between pre-class self-study and
in-class study (FC vs. in-class video classroom (IVC)).
MATERIALS AND METHODS
Study design and participants
is study was a static-group comparison, post-test
only, non-randomized controlled trial. e trial was done
at the Faculty of Medicine, Srinakharinwirot University,
ailand. Its six-year Doctor of Medicine (MD) program is
split into two parts. e rst half is the pre-clinical phase,
and the second is the clinical phase. e population of
interest was medical students, while the study participants
were fourth-year medical students (clerkship). Eligible
criteria included students who registered for the Seizures
and Epilepsy module during the academic year 2018-19.
Students were excluded if they did not attend the class,
did not complete a post-test, or did not give the student
feedback on teaching. Four student groups (A, B, C,
and D) were preexisting formed for medical rotations.
Grade point averages (GPAs) in pre-clinical years were
evenly distributed across the groups. We assigned these
groups to expose two dierent teaching styles. e study
intervention cohort included groups A and C, while
the comparison intervention cohort included groups B
and D. e study was approved by the Human Ethics
Committee of Srinakharinwirot University, Bangkok,
ailand (SWUEC/E-368/2017), and all participants
provided written informed consent.
Interventions
The interventions were two different teaching
methods regarding student pre-class preparation.
e study intervention was an FC approach. Pre-class
30-minute video lecture watching was assigned two
weeks in advance. e students could individually view
the streaming online video lecture on their own devices
via the provided link. We used the PowerPoint slide
presentation as a video format. e content encompassed
basic knowledge of seizures and epilepsy (denition,
etiology, and mechanism), video clips of seizure types,
diagnostic approach, and treatment principle. During
the 40-minute class time, the students participated in
the problem-solving activity and large-group interactive
discussion. ere were 26 to 28 attendees in each class. is
in-class session contained short diagnostic quizzes with
answer choices on ten common epileptic case scenarios.
e students were able to discuss with nearby classmates
and voted via their own devices. e screen in front of the
class showed the voting results. e teacher explained the
answers while students could freely give the comments
or ask the questions.
For the comparison intervention in the IVC, there
was no pre-class assignment. Alternatively, students
were assigned to view the video lecture together at the
beginning of the class. Unlike the FC group, this step
ensured that everyone got preparatory knowledge before
the interactive session. Aer that, they did the same as
the FC group’s in-class activity, including case quizzes
with discussion. e critical dierence between the study
intervention and the comparison intervention was how
students prepared for the interactive class, i.e., out-of-class
or in-class video lecture viewing. e in-class duration
of the FC was 40 minutes, while that of the IVC was 70
minutes (Fig 1). Only one teacher taught all the study
groups.
Fig 1. Class protocols
Pre-class video lecture viewing was assigned for the FC group, while
IVC students watched the video lecture together at the beginning
of the class.
Abbreviations: FC = ipped classroom, IVC = in-class video classroom
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Outcomes
ere were two primary outcomes, including a
post-test score and a total satisfaction score. e students
did the 10-item MCQs post-test at the end of the class.
All questions were application type. ey were told that
it was not an examination and done on the purpose of
research only. ey had to complete the test individually,
and the discussion was not allowed at this stage. Student
feedback on teaching was also anonymously given at
the same time. is feedback included ten aspects of
teaching quality using a ve-point Likert scale as the
point. e total satisfaction score was the sum of these
points. e feedback also included the other three open-
ended questions about what they were satised or not,
and the video watching information.
Statistical analysis
ere was no sample size calculation. All students
who registered for the Seizures and Epilepsy module in
the academic year 2018-19 were enrolled. Quantitative
variables (post-test score, student satisfaction scores,
video watching duration) were reported as mean with
SD or median with IQR. Independent-samples t-test or
one-way ANOVA was used to compare variables with a
normal distribution. Mann-Whitney U test or Kruskal-
Wallis test was chosen to compared variables with non-
normal distribution. A post hoc test was performed using
Bonferroni correction. Spearman’s rho correlation was
selected for the association between the post-test score
and the video watching duration. Categorical variables
(video watching proportion, reasons for not viewing the
video, what students like or dislike about teaching) were
reported as a percentage. All statistical analyses were
done with IBM SPSS Statistics for Windows, Version
25.0. Statistical signicance was set at a two-sided α of
0.05.
RESULTS
Between May 28, 2018, and January 6, 2019, 105
students were assessed for eligibility. All 105 students
were enrolled and nonrandomly assigned to attend either
an FC (n = 53) or IVC (n = 52). No one was excluded.
A total of 105 participants were nally included in the
analysis of outcomes (Fig 2). e student characteristics
were similar between groups at baseline (Table 1).
Fig 2. Trial prole
*Groups (A, B, C, and D) were preexisting
formed with the purpose of medical rotations.
Characteristic Flipped classroom (n=53) In-class video classroom (n=52) p-value
Age, years 18 (17-18) 18 (17-18) 0.576
Female sex, n (%) 29 (54.7) 29 (55.8) 0.912
GPAs* 3.09 (0.50) 3.10 (0.46) 0.882
TABLE 1. Baseline characteristics of the students.
Data are median (IQR) or mean (SD) unless otherwise indicated.
*Grade point averages (GPAs) in the pre-clinical years were presented.
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41 (77%) students, who participated in the FC,
reported watching the pre-class video lecture. e median
viewing duration was 80 (IQR = 40-100) percent of total
video length. Of 12 students who did not watch the
video, 83% claimed that there was not enough time for
viewing, 8% forgot the assignment, and 8% preferred
reading a pre-class handout.
e primary outcomes were demonstrated in Table 2.
We found no signicant dierence in the post-test score
between the FC group (Mdn = 7) and the IVC group
(Mdn = 8), U = 1130.00, p = .107, r = .16, Mann-Whitney
test. e total satisfaction score was not signicantly
dierent between the FC group (M = 43.2, SD = 4.4)
and the IVC group (M = 43.3, SD = 4.9), t(95) = .07,
p = .945, d = .02. Moreover, the satisfaction scores for each
of the ten aspects of teaching qualities did not show the
signicant dierences between the two groups (Table 2).
e subgroup analysis (FC, who did not view the
video; FC, who viewed the video; and IVC) were illustrated
in Fig 3. A Kruskal-Wallis H test showed a statistically
signicant dierence in the post-test score between
the subgroups, χ2(2) = 7.03, p = .030. e post hoc
test using Bonferroni correction showed a signicant
dierence in the post-test score only between the FC
subgroup, who did not view the video (Mdn = 6.5),
and the IVC group (Mdn = 8), p = .024. ere was no
signicant correlation between the duration of pre-class
video viewing and the post-test score, as determined by
Spearman’s rank-order correlation (r
s
= .265, p = .103).
ere was not a signicant dierence in total satisfaction
score between three subgroups (F(2,94) = .004, p = .996,
one-way ANOVA). e reliability index (KR-20) of the
post-test was 0.51.
e students’ favorites, including things that need
improvement in the FC and IVC groups, were illustrated
in Fig 4. Quizzes with discussion were the top favorite
in the FC and IVC group (51% vs. 27%). 42% of the FC
students listed the pre-class video lecture as the favorite.
Of those, the additional positive comments were as
follows:
1. e video watching was self-paced.
2. Students could view the video again later.
3. e video helped them understand in-class time
easily.
19% of IVC students gave the negative vote on the
in-class video lecture. Some said that the video lecture’s
speed was too fast, and the video could not be rerun.
TABLE 2. Primary outcomes.
Flipped In-class video r or mean
Variable classroom classroom difference p-value
(n=53) (n=52) (95% CI)*
Post-test score 7 (6-9) 8 (6.25-9) 0.16 0.107
Total satisfaction score 43.2 (4.4) 43.3 (4.9) 0.07 0.945
(-1.82 to 1.95)
Understanding of subject 4 (4-5) 4 (4-5) 0.11 0.271
Applying to the clinical practice 4 (4-5) 4 (4-5) 0.07 0.490
Teacher’s knowledge of the subject 5 (4-5) 5 (5-5) 0.08 0.423
Opportunity for asking and discussion 5 (4-5) 5 (4-5) 0.14 0.145
The teacher answers the questions clearly 5 (4-5) 5 (4-5) 0.03 0.724
Teacher demonstrates objectives 4 (4-5) 5 (4-5) 0.14 0.140
Video lecture† 4 (4-5) 4 (4-5) 0.14 0.174
Handout 4 (4-4) 4 (3-4) 0.18 0.072
Classroom environment 4 (4-5) 4 (4-5) 0.08 0.402
Class time 4 (4-5) 4 (4-5) 0.04 0.655
e table shows the post-test scores, total satisfaction scores, and satisfaction scores for each aspect of teaching qualities. Data are median
(IQR) or mean (SD) unless otherwise indicated.
*For medians, r is given; for means, the dierence is given with 95% CI. e r-value is calculated from Z/√N, where the Z value is computed
from the Mann–Whitney U test, and N is the total number of the samples.
†Pre-class video lecture for the ipped classroom and in-class video lecture for the in-class video classroom
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Wongwandee et al.
Fig 3. Scores for the subgroups (FC (not view), FC (view),
and IVC)
Boxplots show (A) post-test scores and (B) total satisfaction
scores
*Statistically signicant dierence (Kruskal-Wallis H test,
post hoc test using Bonferroni correction)
FC (not view) = ipped classroom subgroup who did not
view the video lecture, FC (view) = ipped classroom
subgroup who viewed the video lecture, IVC = in-class
video classroom
Fig 4. e number of students that give
feedback on teaching components in the
ipped classroom and in-class video
classroom.
Graph shows numbers of students (with
percentage) who were satised (A) and
unsatised (B) with teaching components
in two teaching groups.
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DISCUSSION
e present study supported the strength of the FC
approach. e pre-class online video lecture remained
the favorite because students were able to study at their
own pace. In other words, they could view the video
as oen as needed, anytime, and anywhere. Pre-class
preparation also helped students understand more easily
in class. In-class activity, i.e., case quizzes with interactive
discussion, was voted the favorite from the FC students.
Its problem-solving style stimulated the learners’ critical
thinking process. Moreover, some students compared
such activity to a game, and they enjoyed it.
Although there were many benefits of the FC,
however, the present study showed no dierences in
post-test scores, including total satisfaction scores between
the FC and IVC groups. One explanation is probably
related to students’ compliance with the FC protocol.
Our subgroup analysis found that the post-test score
for the IVC group was signicantly higher than the FC
students who did not watch the pre-class video. ese
non-compliant students did not master their knowledge
before class, so they might not catch up with others during
the interactive class. Our result showed a signicant
non-compliance (23%), which could compromise the
FC group’s eectiveness.
Several previous studies also found the problems of
non-compliance on the FC protocol, where the incidences
ranged from 20 to 31.3 percent.
5-7
Many students express
concern about time management for the FC. There
may be several out-of-class assignments from dierent
modules in the same period. ey need to balance the
out-of-class assignments and their personal lives, while
some saw the pre-class preparation as a burden.
8
One
study found that half of the students who would not like
to take another FC cited the pre-class work as a reason.
9
As a result, the out-of-class time spent is essential for the
success of the FC model. Some non-health professionals
FC studies demonstrated that most students spent up
to 20 to 25 minutes viewing pre-class video lectures.
10,11
ese results supported our data which the estimated time
of video watching was 24 minutes, i.e., 80% (median) of
30-minute video length. Future research should focus
on the out-of-class workloads and how to improve the
compliance of the FC protocol.
Another possible reason why the FC and IVC
groups did not show signicant dierences in knowledge
and satisfaction is that the IVC was not the same as a
traditional lecture. e in-class activity of the IVC in
our study included case quizzes with the interactive
discussion, which would enhance student engagement
and eectiveness. is explanation is supported by our
study’s result, which the quizzes were the most favorite
for the IVC group.
e present study had several limitations. Firstly,
the study design was post-test only, non-randomized
controlled study. No randomization means that unknown
baseline characteristics between the FC and IVC groups
may not be similar; although, GPAs in pre-clinical years
were evenly distributed across the groups. No pre-test
done indicates that the post-test score only may not reect
the knowledge students gained from the intervention.
Secondly, the eectiveness of teaching, i.e., the satisfaction
and post-test scores were categorized based on Kirkpatrick’s
classication as just level 1 (perceptions of intervention)
and 2b (changes in knowledge and skills), respectively.
12
e post-test done immediately indicates only knowledge
acquisition, which may not correlate with long-term
knowledge retention. e higher level of the eects,
such as changes in behaviors or professional practice, is
more valid and needed in future research. irdly, the
post-test reliability index was relatively low; however,
a small number of the test items (ten) may aect this
value.
Moreover, some components of our FC protocol may
not meet the quality that delivers the highest eectiveness.
e 30-minute duration of the video seemed too long for
the students to concentrate, as discussed above. Moreover,
the video lecture was the only format we provided for
the pre-class assignment. One student who did not view
the video said that reading was a preferred assignment.
erefore, giving various forms of study materials would
be suitable for dierent learning styles. e pre-class
phase also lacked quizzes that students could ensure
their mastery of knowledge before class. Our students’
ratio to teachers (26-28:1) was rather large than the ideal
suggestion, i.e., 4:1 to 25:1.
13
Although there were many advantages of the FC model,
the present study showed no dierences in eectiveness
between the FC and IVC approach. Moreover, the IVC
group was superior to the FC subgroup, who did not view
pre-class video for the knowledge acquisition. erefore,
the present study conrmed the crucial role of compliance
with the FC protocol in successful teaching. Most non-
compliant students were concerned about the out-of-class
assignment. Future research should focus on the FC protocol
concerning student compliance and how to improve it.
ACKNOWLEDGMENTS
e authors thank all the students for their participation
in this study.
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Educ 2017;51:585-97.
3. Kennedy C. Update on the ipped classroom2013 01/12/19.
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Toolkit/ipped classroom. 2013 [cited 2019 Dec 1].
4. Rutherfoord RH, Rutherfoord JK, editors. Flipping the
classroom: Is it for you? Proceedings of the 14
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5. Heitz C, Prusakowski M, Willis G, Franck C. Does the concept
of the “ipped classroom” extend to the emergency medicine
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6. Morgan H, McLean K, Chapman C, Fitzgerald J, Yousuf A,
Hammoud M. e ipped classroom for medical students.
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on Teaching, Assessment, and Learning for Engineering (TALE).
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8. Cotta KI, Shah S, Almgren MM, Macías-Moriarity LZ, Mody
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Wongwandee et al.
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Original Article
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Kasana Raksamani, M.D., Tachawan Jirativanont, M.D., Pavinee Sareenun
Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Correlation of Medical Knowledge and Non-Technical
Skills Assessment in Anesthesia Residents
ABSTRACT
Objective: Non-technical skills training and assessment has been implemented in anesthesia residency training
program to improve quality of patient care but have not been properly assessed. We hypothesized that trainees
with good knowledge correlated with good cognitive parts of non-technical skills.
Methods: Seventy anesthesia residents (24 PGY-1, 24 PGY-2 and 22 PGY-3) were assessed for their knowledge by
180-item MCQs, 5 key-feature essay questions, and 18-station OSCE’s. Subsequently, a perioperative anesthesia
crisis situation was set up in the simulation lab for all residents and was video recorded. Non-technical skills were
assessed by 2 independent trained raters using Anesthetists’ Non-Technical Skills (ANTS) behavioral markers. e
residents’ scores were calculated to nd the correlation within the ANTS rating scale.
Results: e mean scores of knowledge tests were 164.3 ±18.4 out of 300 [165.5 ±18.0, 154.7 ±16.3 and 173.6 ±16.4
for PGY-1, PGY-2 and PGY-3 respectively]. e mean scores of ANTS was divided into 4 categories (rating scale 1
to 4): task management 2.9 (±0.6), teamworking 3.0 (±0.5), situation awareness 2.9 (±0.8) and decision making 2.8
(±0.7). e knowledge test results moderately correlated with ANTS score in task management, situation awareness
and decision making [r=0.382 (p<0.01), r=0.433 (p<0.001) and r=0.350 (p<0.01) respectively] and weakly correlated
with the teamworking category (r=0.166, p=0.16).
Conclusion: Resident’s knowledge scores showed moderate correlation with non-technical skills assessment results
except teamwork. Non-technical skills are required to be trained and assessed together with knowledge to enhance
the patient’s safety and outcome.
Keywords: Non-technical skills; Anesthetists’ non-technical skills; Assessment (Siriraj Med J 2020; 72: 483-487)
Corresponding author: Kasana Raksamani
E-mail: kasana.rak@mahidol.edu
Received 9 March 2020 Revised 25 May 2020 Accepted 26 May 2020
ORCID ID: http://orcid.org/0000-0003-4524-4781
http://dx.doi.org/10.33192/Smj.2020.65
INTRODUCTION
Non-technical skills have been demonstrated to
enhance performance in many medical specialties including
anesthesia.
1,2
Assessment tools of non-technical skills
have been developed and validated in order to facilitate
teaching and learning.
3,4
e Anesthetists’ Non-Technical
Skills (ANTS) system contained the behavioral markers
rating in 4 categories: task management, teamworking,
situation awareness and decision making.
4-5
Non-technical skills training has been implemented
in anesthesia residency curriculum as part of competencies
in order to improve the quality of patient care and safety.
6-8
However, non-technical skills in anesthesia have integrated
with other competencies and has made it dicult to
assess these separately. e assessment of non-technical
skills is still limited to formative assessment along with
knowledge and technical skills.
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When looking closely at non-technical skills, they
are divided into cognitive, analytical thinking, and social
skills such as communication and teamwork.
9
Evidences
suggested non-technical skills enhanced technical
performances in surgical and anesthesia training.
10,11
Moreover, the interprofessional team process training
improved team outcome in crisis situation without
focusing on knowledge.
13,14
However, we hypothesized
that trainees with good knowledge are correlated with
good cognitive parts of non-technical skills.
e aim of this study was to nd the correlations of
knowledge assessment results and non-technical skills
assessment using ANTS behavioral rating system in
anesthesia residents.
MATERIALS AND METHODS
e study protocol was approved by the local ethical
committee Siriraj Institutional Review Board, Bangkok,
ailand (Si 170/2015), and voluntary informed consent
was obtained. Seventy anesthesia residents were assessed
their knowledge at the end of the academic year by 180-
item MCQs, 5 key-features essay questions, and 18-station
OSCEs using the same assessment tools. Subsequently, a
perioperative anesthesia crisis situation was set up in the
simulation lab for all residents and video-recorded. Non-
technical skills were assessed by 2 independent trained
raters using Anesthetists’ Non-Technical Skills (ANTS)
behavioral assessment tool. is tool was translated to
ai version and found to be valid.
14
Consequently, the
residents’ knowledge scores were calculated to nd the
correlation with ANTS rating scale.
A simulation scenario was developed by researchers
focusing on the Anesthetists’ non-technical skills. e
session was established in an operating room setting with
the full-body high delity patient simulator (SimMan 3G;
Laerdal Medical, Stavanger, Norway). e participant
was individually and consecutively assigned a role of
anesthesiologist in the scene of a 45-year-old female
patient, previously healthy, undergoing laparoscopic
myomectomy. e scenario started at the end of the
procedure, aer the reversal agent was given the patient
developed pulseless ventricular tachycardia. e sessions
were video recorded for assessment purposes.
Statistical analysis was performed using PASW
Statistics version 18 (SPSS Inc., Chicago, IL, USA). e
demographic data and mean scores for the knowledge
test and ANTS behavioral markers were analyzed with
descriptive statistics and compared between groups with
one-way ANOVA. e correlations among knowledge
test results and ANTS categories were calculated using
Pearson’s correlation. Pearson’s correlation was dened
as follows: r < 0.3, weak; 0.3 < r < 0.7, moderate; r > 0.7,
strong.Pvalues of less than 0.05 were deemed to be
statistically signicant.
RESULTS
Seventy anesthesia residents participated in this
study (24 PGY-1, 24 PGY-2 and 22 PGY-3), 12 (17.1%)
were male and 58 (82.9%) were female, with mean age
29.3 ±1.6 years. e mean scores of knowledge tests were
161.9 ±20.5 out of 300 [150.7 ±19.1, 159.4 ±17.7 and
177.0 ±15.9 for PGY-1, PGY-2 and PGY-3 respectively]
with signicant dierence between groups. e details
of the scores were reported in Table 1.
The mean scores of ANTS was divided into 4
categories (rating scale 1 to 4): task management 2.9
±0.6, teamworking 3.0 ±0.5, situation awareness 2.9
±0.8 and decision making 2.8 ±0.7 and signicantly
dierent between groups in all categories (Table 2). e
knowledge test results moderately correlated with ANTS
score in all categories; task management, teamworking,
situation awareness and decision making [r=0.48 (p<0.001),
r=0.31 (p=0.01), r=0.54 (p<0.001) and r=0.44 (p<0.001)
respectively]. e correlation of test score in PGY-1 was
moderate in task management, situation awareness and
decision making [r=0.31 (p=0.1), r=47, (p=0.03) and
r=0.50 (p=0.02) respectively) and weakly correlated in
teamwork (r=0.23, p=0.24). ere was poor correlation
between test scores and ANTS score in all categories
for PGY-2 (task management r= -0.03, teamworking
r= -0.17, situation awareness r= -0.02, decision making
r= -0.09). ere was strong correlation for test scores
and task management in PGY-3 (r=0.71, p<0.001) with
moderate correlation in situation awareness (r=0.58,
p<0.01) and decision making (r=0.62, p<0.01), while
there was weak correlation in teamworking (r=0.17). e
details of the correlation coecients were demonstrated
in the Table 3.
DISCUSSION
Non-technical skills are divided into cognitive and
social skill sets.
9
e cognitive skills of Anesthetists’ Non-
Technical Skills (ANTS) behavioral markers are situation
awareness, decision making and task management, while
the social skills are teamworking.
4
e cognitive skills
of ANTS in anesthesia residents moderately correlated
with the knowledge test scores and even had strong
correlation with some categories in PGY-3.
Situation awareness is the rst and most important
step of gathering and interpreting information before
making decision in complex and dynamic anesthesia
clinical work.
15,16
In this study, the level of situation
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Scores Overall PGY-1 PGY-2 PGY-3 P value
MCQ (100) 56.9 ±8.9 53.1 ±9.5 56.9 ±8.5 60.9 ±7.2 0.01
KFQs (100) 49.4 ±6.7 47.2 ±7.0 47.8 ±5.7 53.6 ±5.7 0.001
OSCE (100) 55.6 ±8.0 50.3 ±5.7 54.7 ±7.0 62.5 ±5.9 <0.001
Total scores (300) 161.9 ±20.5 150.7 ±19.1 159.4 ±17.7 177.0 ±15.9 <0.001
ANTS category Overall PGY-1 PGY-2 PGY-3 P value
Task management 2.9 ±0.6 2.5 ±0.5 2.7 ±0.7 3.4 ±0.4 <0.001
Teamworking 3.0 ±0.5 2.7 ±0.5 2.9 ±0.5 3.3 ±0.4 <0.001
Situation awareness 2.9 ±0.8 2.5 ±0.8 2.7 ±0.6 3.6 ±0.5 <0.001
Decision making 2.8 ±0.7 2.4 ± 0.6 2.8 ±0.8 3.2 ±0.6 0.001
TABLE 1. Knowledge test scores of PGY-1, PGY-2 and PGY-3.
Data presented in mean ±SD
Abbreviations: ANTS, Anesthetists’ Non-Technical Skills; PGY, postgraduate year; MCQ, multiple-choice questions; KFQ, Key-features
questions; OSCE, objective structured clinical examination
TABLE 2. Mean score of ANTS.
Data presented in mean ±SD
Abbreviations: ANTS, Anesthetists’ Non-Technical Skills; PGY, postgraduate year
awareness was signicantly improved in each year of
training, and improved most when compared to the other
categories. Also, the situation awareness was moderately
correlated with all test scores. is could be due to the
fact that when the trainees achieved a higher level of
training, they collected more knowledge and broadened
their situation awareness level. is highlighted the
importance of training situation awareness together
with knowledge, which occurred to be the predominant
cause of anesthesia errors in critical incidence reports.
17
e ANTS behavioral markers had 3 levels of situation
awareness of gathering information, recognizing and
understanding, and anticipating, which can be used as
a framework to facilitate teaching, giving feedback and
assessing the learners during both formal training and
clinical learning.
5,6
Decision making consists of 3 elements in the ANTS
behavioral rating system: identifying options, balancing
risks and selecting options, and re-evaluating.
5
e scores
of decision making signicantly improved as the residents
were in a higher level of training, which is in line with
the results of situation awareness because the decision
making process usually happened immediately aer
situation awareness.
18,19
e development of dynamic
decision making in anesthesia needed the collection of
mental models and knowledge for analytical thinking.
19,20
is could explain the results of moderate correlation
of decision making and test scores.
Task management is dened by behaviors such
as planning and preparation, prioritization, providing
and maintaining standards, identifying and utilizing
resources, which are noticeably knowledge based in only
one element, providing and maintaining standards.
20
e
results were in the same direction as situation awareness
and decision making, signicantly increased from PGY-1
to PGY-3 and moderately correlated with the test scores.
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All PGY-1 PGY-2 PGY-3
Task management Overall score 0.48
c
0.31 -0.03 0.71
c
MCQ 0.37
b
0.39 -0.05 0.54
b
KFQ 0.33
b
0.07 -0.11 0.59
b
OSCE 0.54
c
0.30 0.07 0.70
c
Teamworking Overall score 0.31
b
0.23 -0.17 0.17
MCQ 0.016 0.20 -0.23 -0.04
KFQ 0.26
a
0.24 -0.23 0.26
OSCE 0.40
b
0.15 0.03 0.25
Situation awareness Overall score 0.54
c
0.47
a
-0.02 0.58
b
MCQ 0.44
c
0.54
b
-0.05 0.36
KFQ 0.38
b
0.20 -0.15 0.56
b
OSCE 0.58
c
0.41
a
0.13 0.57
b
Decision making Overall score 0.44
c
0.50
a
-0.09 0.62
b
MCQ 0.38
b
0.48
a
0.04 0.43
a
KFQ 0.28
a
0.25 -0.24 0.60
b
OSCE 0.45
c
0.56
b
-0.08 0.56
b
TABLE 3. Pearson’s correlations of the overall scores, MCQ, KFQ, OSCE scores and elements of Anesthetists’ non-
technical skills in PGY-1, PGY-2 and PGY-3 anesthesia residents.
a
p<0.05,
a
p,0.01,
a
p<0.001
e widely used methods for teaching and learning
task management was in simulation settings due to the
controllable tasks to perform.
11,12
e complex tasks can
also be practiced in workplace settings in both routine
and non-routine events.
21
Teamworking is the category that the result had
lowest correlation coecient, dierent from the other
categories, while the teamwork scores were signicant
improved in each level of training, the correlation with
test scores was weak in all types of tests except OSCEs.
is emphasized the importance of additional training
and assessing of teamwork and communication, apart
from knowledge and clinical training.
22
ese social
skills are an important part of anesthesia work in the
operating theater to enhance patient safety.
23
Moreover, the correlation of knowledge scores and
level of situation awareness was dierent between the
levels of training, moderate in PGY-1, poor in PGY-2,
and moderate in PGY-3. This could be due to the
improvement rate of ANTS from increasing clinical
training and experiences, higher than the improvement
rate of knowledge scores.
e limitation of this study was all the tests were
not analyzed according to the learning objectives, which
could be the mixed components of knowledge, skills and
non-technical skills. Further study would be very valuable
to determine the types and components of the tests to
assess non-technical skills together with knowledge
and technical skills. Another limitation was the lack of
evidences of longitudinal development of these knowledge
and skills due to the nature of this cross-sectional study
that assessed at the end of the year. Time-series study
would be answered the development of knowledge and
competency of non-technical skills.
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CONCLUSION
Residents’ knowledge scores have moderate correlation
with the all domain of non-technical skills assessment
results, task management, teamworking, situation awareness
and decision making. e category of non-technical skills
that had lowest correlation coecient was teamwork,
which was poorly correlated with MCQs and KFQs,
but acceptable correlation with OSCEs. Non-technical
skills therefore are required to be trained and assessed
together with knowledge to enhance patient safety and
outcomes and cannot be assumed that residents with
good medical knowledge would have good non-technical
skills in all categories.
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2. Glavin RJ. Excellence in Anesthesiology. e Role of Nontechnical
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3. Flin R, Patey R, Glavin R, Maran N. Anesthetists’ non-technical
skills. Br J Anesth 2010;105:38-44.
4. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R.
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5. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R.
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system for use in Anesthesia.Cognition, Technology & Work
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6. Flin R, Patey R. Non-technical skills for Anesthetists: developing
and applying ANTS.Best Pract Res Clin Anaesthesiol 2011;25:
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7. Engel N, Patey RE, Ross S, Wisely L. Non-technical skills.BMJ
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8. Yule S, Maran N,Tsuburaya A. Training methods for non-technical
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performance. A primer on non-technical skills,CRC Press,London;
2015.
9. Gordon M, Baker P, Catchpole K, Darbyshire D, Schocken D.
Devising a consensus denition and framework for non-technical
skills in healthcare to support educational design: a modied
Delphi study.Med Teach 2015;37:572-7.
10. Mishra A, Catchpole K, Dale T, McCulloch P. e inuence
of non-technical performance on technical outcome in laparoscopic
cholecystectomy.Surg Endosc 2008;22:68-73.
11. Riem N, Boet S, Bould MD, Tavares W, Naik VN. Do technical
skills correlate with non-technical skills in crisis resource
management: a simulation study. Br J Anesth 2012;109:723-8.
12. Doumouras AG, Hamidi M, Lung K, Tarola CL, Tsao MW,
Scott JW, et al. Non‐technical skills of surgeons and Anesthetists
in simulated operating theatre crises.Br J Surg 2017;104:1028-
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13. Gjeraa K, Jepsen RMHG, Rewers M, Østergaard D, Dieckmann
P. Exploring the relationship between anaesthesiologists’ non‐
technical and technical skills.Acta Anaesthesiol Scand 2016;60:
36-47.
14. Jirativanont T, Raksamani K, Aroonpruksakul N, Apidechakul P,
Suraseranivongse S. Validity evidence of non-technical skills
assessment instruments in simulated Anesthesia crisis
management.Anesth Intensive Care 2017;45:469-75.
15. Gaba DM, Howard SK, Small SD. Situation awareness in
anesthesiology.Hum Factors 1995;37:20-31.
16. Schulz CM, Endsley MR, Kochs EF, Gelb AW, Wagner KJ.
Situation awareness in anesthesia: concept and research.
Anesthesiology 2013;118:729-42.
17. Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF,
Wagner KJ. Situation awareness errors in anesthesia and
critical care in 200 cases of a critical incident reporting system.BMC
Anesthesiol 2015;16:4.
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19. Stiegler MP, Tung A. Cognitive processes in anesthesiology
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Assoc 2002;9(6 Suppl 1): S58-S63.
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PL, et al. Nontechnical skills in anesthesia crisis management
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22. Wacker J, Kolbe M. Leadership and teamwork in anesthesia–
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Sumanas Bunyaratavej, M.D., Rungsima Kiratiwongwan, M.D., Pichaya Limphoka, M.D., Kamonpan Lertrujiwanit,
B.Sc., Charussri Leeyaphan, M.D.
Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Pattern Recognition using Morphologies of
AnthropophilicandZoophilicDermatophytosis
Lesions: Comparison between Final-Year Medical
Students and Dermatology Residents
ABSTRACT
Objective: To compared pattern recognition abilities of nal-year medical students and dermatology residents to
distinguish and classify supercial fungal infections and resembling lesions.
Methods: e study was conducted at the Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol
University, Bangkok, ailand, in 2019. e participants had to make diagnosis from 78 images including typical
and atypical lesions within 50 seconds. No history or any description was given. e answer sheets were reviewed.
Results: Medical students (n = 18) and dermatology residents (n = 19) showed no signicant dierences in the
means of overall accuracy scores. Residents demonstrated a statistically higher mean score than the medical
students in diagnoses of anthropophilic infection with mostly presented with typical lesion. However, there were
no signicant dierences in the mean scores for their diagnoses of zoophilic dermatophytosis as atypical lesions
and other skin lesions.
Conclusion: Pattern recognition was helpful for the diagnosis of cutaneous dermatophytosis, especially in cases of
typical lesions. Nonetheless, pattern recognition alone is insucient for the diagnosis of atypical dermatophytosis
lesions; analytical diagnostic skills should also be enhanced to an increase in the accuracies of atypical-lesion diagnoses.
Keywords: Morphological diagnosis; anthropophilic dermatophytosis; zoophilic dermatophytosis, accuracy; medical
students; dermatology residents (Siriraj Med J 2020; 72: 488-491)
Corresponding author: Charussri Leeyaphan
E-mail: charussrilee@gmail.com
Received 10 June 2020 Revised 20 July 2020 Accepted 19 August 2020
ORCID ID: http://orcid.org/0000-0001-8430-376X
http://dx.doi.org/10.33192/Smj.2020.66
INTRODUCTION
Pattern recognition is an important clinical skill in
dermatology.
1
Cutaneous dermatophytosis, a common skin
infectious disease, is mainly caused by anthropophilic and
zoophilic dermatophytes.
2
e recognition and classication
of cutaneous dermatophytoses are based on clinical
characteristics and lead to appropriate investigations.
3
e typical presentation of cutaneous dermatophytosis
is a scaly, red, and slightly elevated lesion with an active
border.
3
However, zoophilic infections frequently cause
more inammatory lesions
4
and may resemble other
skin diseases, such as eczema and psoriasis, leading to a
misdiagnosed pattern.
5
is study therefore compared the
abilities of nal-year medical students and dermatology
residents to distinguish and classify skin lesions for
supercial fungal infections and resembling lesions, as
well as the participants’ condence levels.
Bunyaratavej et al.
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MATERIALS AND METHODS
e investigation was conducted at the Department
of Dermatology, Faculty of Medicine Siriraj Hospital,
Mahidol University, Bangkok, ailand, in 2019. e study
protocol had been approved by the Siriraj Institutional
Review Board (Si 197/2020). High-quality, representative,
clinical images with proper exposure were selected by
two clinical instructors. e 78 clinical images comprised
anthropophilic cutaneous lesions (37 cases), zoophilic
cutaneous dermatophytosis lesions (33 cases), and other
skin lesions resembling cutaneous dermatophytosis (8
cases). Sample pictures that were used as questions were
demonstrated in Fig 1. No history or any description was
given. e participants had to state whether each image
was a dermatophytosis, and they needed to provide a
condence-level score for each decision (1, low condence;
2, moderate condence; 3, high condence). e decision
for each image needed to be made within 50 seconds. All
cases of anthropophilic and zoophilic dermatophytosis were
conrmed with positive branching septate hyphae from
potassium hydroxide examination, and with fungal culture
results in Sabouraud’s dextrose agar with cyclohexamide.
e data from the response sheets were consolidated, and
a retrospective review was undertaken of the accuracy
scores and condence scores of the nal-year medical
students and dermatology residents.
Data were analyzed using SPSS Statistics for Windows,
version 18.0 (SPSS Inc., Chicago, IL, USA). e unpaired
t-test was applied to compare the correct results and
condence scores of the nal-year medical students
and dermatology residents. A p-value of less than 0.05
indicated statistical signicance.
RESULTS
A total of 37 participants consisting of 18 nal-year
medical students (48.6%) and 19 dermatology residents
(51.4%) were enrolled. eir accuracy and condence
scores are detailed in Table 1. e nal-year medical
students and dermatology residents showed no signicant
dierences in the means of their overall accuracy scores
(41 ± 8.2 vs. 43.5 ± 10.5, respectively; p = 0.421). As to the
diagnoses of the anthropophilic lesions, the dermatology
residents demonstrated a statistically higher mean score
(23 ± 5.9) than the nal-year medical students (18.6 ±
5.3; p = 0.014). In contrast, there were no signicant
dierences in the mean scores for their diagnoses of
zoophilic dermatophytosis and other skin lesions. e
dermatology residents had signicantly higher condence
scores than the nal-year medical students (p < 0.05)
for the evaluations of the overall, anthropophilic, and
zoophilic dermatophytosis images. On the other hand,
the condence scores of the 2 groups for the diagnoses
of other dermatological conditions were not statistically
dierent.
DISCUSSION
Pattern recognition is a necessary skill for dermatologic
diagnosis.
1
is study revealed that the dermatology
residents had a higher accuracy rate and greater condence
than the nal-year medical students for the diagnosis of
anthropophilic dermatophytosis. “Pattern recognition” refers
to the process of matching a present case with examples
from previous patients or prototypes of a disease stored
in the diagnostician’s memory. e process is normally
very useful for diagnoses, especially in instances of typical
lesions.
6,7
In the current study, the higher correct scores
and condence scores of the dermatology residents for the
diagnoses of typical lesions may stem from their having
more experience and the use of typical presentations of
cutaneous anthropophilic dermatophytosis.
For both groups, the ability to diagnose zoophilic
dermatophytosis, which usually presents with atypical
Fig 1. Sample pictures that were used as questions for (A) anthropophilic dermatophytosis and (B) zoophilic dermatophytosis
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TABLE 1. Accuracy and condence scores of nal-year medical students and dermatology residents.
Mean score ± SD
Total Final-year Dermatology P-value
score medical students residents
(n = 18) (n = 19)
Accuracy scores
Overall 78 41.0 ± 8.2 43.5 ± 10.5 0.421
Anthropophilic dermatophytosis 37 18.2 ± 5.3 23.0 ± 5.9 0.014*
Zoophilic dermatophytosis 33 15.6 ± 5.6 12.8 ± 5.2 0.098
Other dermatological conditions 8 7.2 ± 0.9 7.7 ± 0.7 0.093
Condencescores
Overall 234 138.8 ± 27.0 157.4 ± 15.0 0.022*
Anthropophilic dermatophytosis 111 66.8 ± 14.5 75.5 ± 7.3 0.030*
Zoophilic dermatophytosis 99 59.3 ± 11.8 66.5 ± 7.3 0.036*
Other dermatological conditions 24 15.5 ± 6.2 15.4 ± 7.1 0.964
* p < 0.05
Abbreviation: SD, standard deviation
lesions, was lower than that for anthropophilic lesions.
Although there was no signicant dierent in accuracy
scores for the recognition of zoophilic dermatophytosis
between nal-year medical students and dermatology
resident, nal-year medical students intended to have a
higher mean score. However, the dermatology resident
had higher condence scores than the nal-year medical
students. is result is similar to that reported by a
previous investigation, which revealed that there was
no correlation between confidence levels and the
accuracy of diagnoses.
8
e misdiagnoses of zoophilic
dermatophytosis by both groups may due to atypical
presentations of zoophilic dermatophytosis having been
used. is condition frequently results in highly inamed
lesions
4
that may resemble other skin diseases, such as
eczema and psoriasis.
5
Other research reported that
diagnostic errors for atypical dermatology conditions
resulted from the ambiguities of atypical clinical lesions;
moreover, only a little improvement in accuracy was
gained with higher levels of clinician expertise.
7
at study
suggested that atypical lesions may contain inadequate
information for diagnostic purposes. To increase the
diagnostic accuracy of medical students and dermatology
residents, we suggest that more instruction with atypical
lesions should be given, and with a greater frequency
than typical lesions. Nevertheless, pattern recognition
alone may not be enough to make diagnoses for atypical
lesions. e development of analytical and diagnostic
skills within a framework utilizing patients’ histories and
physical examinations should also be enhanced in order
to improve clinicians’ abilities to discriminate between
atypical skin-lesion types.
e limitation of this study is its small sample size.
In addition, cutaneous dermatophytosis was the sole,
representative skin disease used in this study. Further
study with a larger sample size and a wider variety of
skin lesion types is recommended.
In conclusion, pattern recognition was found to
be a helpful clinical skill for the diagnosis of cutaneous
dermatophytosis, especially in cases of typical lesions.
Given that dermatology residents encounter typical skin
lesions more frequently than medical students, they can
develop a higher degree of pattern recognition skills
and, in turn, expertise in the diagnosis of typical skin
lesions. As to atypical skin lesions, it is recommended that
training in pattern recognition for such lesions should be
provided with more frequency than for typical lesions.
Nonetheless, pattern recognition alone is insucient for
the diagnosis of atypical lesions: analytical diagnostic
skills should also be enhanced. Collectively, such actions
should contribute to an increase in the accuracies of
atypical-lesion diagnoses.
Bunyaratavej et al.
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ACKNOWLEDGMENTS
e authors thank Assist. Prof. Chulaluk Komoltri,
DrPH, for her invaluable support with the statistical
analyses.
REFERENCES
1. Rimoin L, Altieri L, Cra N, Krasne S, Kellman PJ. Training
pattern recognition of skin lesion morphology, conguration,
and distribution. J Am Acad Dermatol 2015;72:489-95.
2. Hassanzadeh Rad B, Hashemi SJ, Farasatinasab M, Atighi J.
Epidemiological Survey of Human Dermatophytosis due to
Zoophilic Species in Tehran, Iran. Iran J Public Health 2018;
47:1930-6.
3. Kaushik N, Pujalte GG, Reese ST. Supercial Fungal Infections.
Prim Care 2015;42:501-16.
4. Weitzman I, Summerbell RC. e dermatophytes. Clin Microbiol
Rev 1995;8:240-59.
5. Hainer BL. Dermatophyte infections. Am Fam Physician
2003;67:101-8.
6. Costa Filho GB, Moura AS, Brandao PR, Schmidt HG, Mamede
S. Effects of deliberate reflection on diagnostic accuracy,
condence and diagnostic calibration in dermatology. Perspect
Med Educ 2019;8:230-6.
7. Norman GR, Rosenthal D, Brooks LR, Allen SW, Muzzin LJ.
e development of expertise in dermatology. Arch Dermatol
1989;125:1063-8.
8. Landefeld CS, Chren MM, Myers A, Geller R, Robbins S,
Goldman L. Diagnostic yield of the autopsy in a university
hospital and a community hospital. N Engl J Med 1988;318:
1249-54.
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Sadudee Rojanapirom, D.N.S. Candidate*, Siriorn Sindhu, Ph.D.**, Ketsarin Utriyaprasit, Ph.D. **, Peera
Buranakitjaroen, Ph.D. ***, Chukiat Viwatwongkasem, Ph.D. ****
*Doctor of Nursing Science Program, Faculty of Nursing, **Department of Surgical Nursing, Faculty of Nursing, Mahidol University, ***Department
of Medicine, Faculty of Medicine, Mahidol University, ****Department of Biostatistics, Faculty of Public Health, Mahidol University, Bangkok 10700,
ailand.
Effects of Four Noble Truths Practice on
Hypertension Control
ABSTRACT
Objective: To examine the eects of Four Noble Truths practice in controlling blood pressure with three-group
comparison, involving a Mobile Web group, Guidebook group and usual care group in patients with stage 1
hypertension.
Methods: is randomized controlled trial was conducted in one university hospital setting. 145 participants
were recruited into the study by randomized selection and were randomly assigning to the three groups. Of these,
45 participated as Mobile Web users, 50 as Guidebook users and 50 in the control group. e Mobile Web and
Guidebook were developed using the guidance of the Four Noble Truths and received a phone call every two weeks
for three times while control received a usual care. en, the outcomes were measured including blood pressure
and satisfaction at two-month aer recruitment. e average blood pressure and satisfaction were compared by
comparative descriptive statistic. Finally, analysis of covariance (ANCOVA) was used to analyze the covariate that
may inuence the outcomes with the post hoc analysis by Bonferroni.
Results: Participants who received Mobile Web or Guidebook had reduced their blood pressure more than those
receiving usual care, with statistical signicance (P < 0.05). It was found that blood pressures could be lowered
to a maximum level of 15.09 ± 9.62 mmHg within 8 weeks of treatment. Participants who attended participated
in Mobile Web or Guidebook were satised with healthcare services more than those receiving usual care, with
statistical signicance (P < 0.05).
Conclusion: e program could be applied to control high blood pressure in patients with stage 1 hypertension.
e outstanding of this program could support overall dierence in healthcare of each patient with fast ecacy.
Keywords: Blood pressure control; four noble truths; mobile web (Siriraj Med J 2020; 72: 492-501)
Corresponding author: Siriorn Sindhu
E-mail: siriorn.sin@mahidol.ac.th
Received 18 May 2020 Revised 23 June 2020 Accepted 24 June 2020
ORCID ID: http://orcid.org/0000-0001-9326-757X
http://dx.doi.org/10.33192/Smj.2020.67
INTRODUCTION
One billion of the current world population suers
from high blood pressure,
1
and half of this population has
uncontrolled hypertension.
2
ailand has also found the same
trend among people aged 18 years and older who are likely to
have high blood pressure with 53.2% reporting uncontrolled
hypertension.
3
Untreated hypertension is notorious for
increasing the risk of mortality and is oen described as
a silent killer. Prehypertension and stage 1 hypertension
are also associated with a high risk of atherosclerotic
disease by 30% and organ damage by 50% in patients with
uncontrolled hypertension within 8-10 years aer onset.
4
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In its general practice guidelines in 2012, the ai
Hypertension Society focused on behavioral change
along with treatment to control blood pressure, but the
outcome was not optimal. e numbers of people with
uncontrolled hypertension continued to rise nationwide.
Over the past decade, previous studies have suggested
that uncontrolled hypertension is inuenced by three
main components including personal factors, health
care provider factors, and health service system factors.
Interventions for alleviating uncontrolled hypertension
by development of these three factors have continued
to the present.
5
In recent studies, eorts have been made to control
both blood pressure and behavioral modication in
patients with hypertension. In the last 20 years, self-
management and self-management support have been
addressed in terms of raising awareness about creating
self-care, systems and environments. Self-management
intervention consisted of health education, self-regulation
and support group in order to improve the outcomes
of care.
6
Moreover, nowadays, there were an increasing
number of self-management intervention using the
mobile application.
7
However, those interventions were
implemented without considering the social determinants
of health in ai patients with hypertension, so patients
remained unable to control blood pressure.
Several interventions used Buddhism as a guidance to
develop the intervention in order to control blood pressure
level such as meditation. Meditation interventions were
eectively reducing blood pressure level when compared
with control.
8-9
All uncontrolled hypertension is based
on the patient’s own behavior
10
and the intervention
should focus on the seeking for the truth of problem and
develop an intervention related to the cause of problem
using of the Four Noble truths guidance. erefore,
interventions aimed at changing the behaviors of patients
to reduce blood pressure with the guidance of the Four
Noble truths include the following: 1) Dukkha - the
truth of suering; 2) Samudaya - the truth of the cause of
suering; 3) Nirodha - the truth of the end of suering;
and 4) Magga - the truth of the path that frees us from
suering.
11
Eective methods are important and require
the inclusion of modern communication technology that
is suitable for long-distance patients and large groups
of the population.
In this study, an intervention was developed to
control blood pressure in people with stage 1 hypertension
with a combination of the principles of Buddhism and
modern technology such as mobile health technology.
Mobile health or mHealth technology enables platform
exibility and improves patients’ mHealth application
performance, which is suitable for patients in terms of
schedule and treatment planning. e popularity of
mHealth studies in hypertension and other chronic diseases
such as improving self-management,
12
and medication
adherence
13
is demonstrated in the improvements in
health status made possible by the mHealth application,
which is an eective intervention to improve the blood
pressure controlling.
e Four Noble Truths are a rational way to understand
the realities of suering and nding a way out of suering.
is will solve the problem of failure to modify behavior
that causes uncontrolled hypertension by combining
with Mobile Web, which is easy to access, inexpensive,
aordable to many people and features a process for
eectively reducing the blood pressure of patients. e
objective of this study was to determine the eects of
practicing the Four Noble Truths in controlling blood
pressure. e hypothesis postulated that patients with
hypertension in both groups (Mobile Web and Guidebook
groups) who attended the Four-Noble Truths Practice
on Hypertension Control program would have lower
blood pressure and more health service satisfaction than
those who received the usual care program only.
MATERIALS AND METHODS
is study was a randomized control trial (RCT)
with a three-group pre-test and post-test design. e
study was conducted at a university hospital in ailand.
e study protocol was reviewed and approved by the
Research Ethical Committee of the Faculty of Medicine
Siriraj Hospital, Mahidol University (Si 296/2018). e
study participants were male or female patients diagnosed
with stage 1 hypertension by a physician and recorded in
medical folders by using the international classication
of disease codes-9 (ICD-9)* (systolic blood pressure:
SBP = 140-159 mmHg or diastolic blood pressure: DBP
= 90-99 mmHg.),
14
aged 18 years and over with regular
doctor’s appointments in the out-patient department of
the university hospital where the study was conducted.
e sample size was calculated by performing power
analysis with the G*Power program.
15
e dierences
in the mean scores were compared among the three
groups with repeated measure analysis (pre-intervention,
rst month, and post intervention) with ANCOVA.
us, the sample size calculation set alpha at 0.05 and
assigned power of test at 0.80. According to Cohen’s
guideline, the medium eect size for ANCOVA was set
at 0.25. is study obtained 158 patients (53 subjects per
group) and added 10% (16 subjects) to prevent attrition
from the sample group, thereby bringing the number of
participants in this study to a total of 174 (58 subjects/
group).
16
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494
The inclusion criteria for the participants
was as follows: 1) diagnosis with uncontrolled stage 1
hypertension and treatment with antihypertensive drugs
for at least six months and 2) SBP ranging between 140-
159 mmHg. e exclusion criteria consisted of: 1) 1)
diagnosed with diseases in the critical stage in the past 3
months; 2) history of diagnosis with psychiatric problems
such as depression and schizophrenia; 3) Pregnancy.
e participants who met the criteria were selected for
enrollment in the study by the minimizer technique
version 1.0
17
for improving external validity as follows:
1) Minimization of covariates related to blood pressure
level for controlling confounding factors. e covariates
should not exceed three variables. In this study, one
covariate, gender, was included; 2) Random assignment
into the following three groups: usual care (Usual Care
Group), learning by interactive program (Mobile Web
Group) and learning by Guidebook (Guidebook Group).
e intervention packages were categorized into
the following three types: 1) e guidebook contained
parts of self-directed records (i.e. self-evaluation related
blood pressure level, self-perception related cause of
hypertension, setting up targeted blood pressure level,
nding a way to lower blood pressure, and recording
activities); 2) e Mobile Web contained mobile phone
information including an animation to present how to
control blood pressure. e information for the guidebook
and Mobile Web were developed based on the Four Noble
Truths which aimed to support hypertension control
by understanding the truth of suering (dukkha), the
truth of the cause of suering (samudaya), the truth
of the end of suering (nirhodha) and the truth of the
path that frees us from suering (magga). erefore, the
interventions included self-evaluation related to blood
pressure levels, self-perception related to the causes of
hypertension, setting up targeted blood pressure levels,
nding ways to lower blood pressure and recording
activities. e information was implemented into the
program following the recommendations of the JNC
8; 3) Usual care received general care from the nurses
at the hypertension clinics, including recording blood
pressure and weight in addition to following-up with
physicians.
SBP and DBP blood pressure were measured by
the average value of two separate measures by using a
mercury sphygmomanometer
18
aer minutes of relaxation.
e measurements were taken on the le arms of the
participants. All clothing was removed from the arm and
the center of the bladder was placed over the brachial
artery. e measurement was taken by a trained nurse.
Next, health service evaluation was used to measure
patients’ satisfaction regarding health service delivery.
e instrument was developed by Sindhu, et al. (2004)
with a questionnaire containing 20 items on patient
perception of health services received from healthcare
providers. e overall satisfaction rate was 0-100. In
terms of interpretation of the overall items and the overall
satisfaction scores, higher scores indicated higher health
service satisfaction. e internal consistency (Cronbach’s
alpha) was 0.89.
19
e research assistants were trained in following
protocol, approaching patients, giving questions and
answers every two weeks by phone with the same questions
and controlling times for accurate treatment between
researcher and research assistants. In the intervention
group, the participants met the researcher at the rst
appointment and received usual care with instructions
on how to use the Guidebook or Mobile Web. Every two
weeks for three sessions aer recruitment, the intervention
group received phone calls for empowerment, advice and
answers to patients’ questions. Finally, in the two-month
follow-up phase, the participants had data collected on
clinical characteristics, SBP and patients’ service satisfaction.
On the other hand, the control group received usual care
detailing hypertension information and measuring the
outcome at the end of the study at two months. e ow
chart of the data collection process is presented in Fig 1.
Statistical analysis
e comparison of the demographic data among the
three groups used the Kruskal Wallis Test. en the post
hoc analysis employed Dunn’s test to perform pairwise
comparison of variables. In this case, the expected value
was < 5 more than 20%, and chi-square or Fisher’s exact
testing was used. e average pre- and post- SBP of each
intervention were compared by using the Wilcoxon Signed
Ranks Test. en the comparison of each part of satisfaction
on healthcare services was compared by Kruskal Wallis
Test and followed by pairwise comparison using Dunn’s
test. Finally, analysis of covariance (ANCOVA) was used
to analyze the covariate potentially inuencing blood
pressure reduction aer the program with dependent
variables (SBP and patient satisfaction) Aer adjusting
the covariate, if at least one pair of the dependent variables
and covariate had statistically signicant dierences, post
hoc analysis by Bonferroni was performed to identify
those pairs. e variance among the three groups was
analyzed by Levene’s Test in which a 2-sided p value of
<0.05 was considered statistically signicant.
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Patients with Hypertension Stage I
Meeting No
.
1
- Notifying objectives of this
experiment
- Measuring body weight &
blood pressure
- Questioning and answering
by nurses
Control Group 1 (45 Cases)
Mobile Web
Control Group 2 (50 Cases)
Guide book
11
Control Group (50 Cases)
Usual Care
Personal Meeting
- Process of applying 4 Noble Truth into
action for Hypertension management
- Assessing severity of disease and health
risk behavior status in patients’ view
- Scanning QR-code for linking to website
address
- Learning to use the website content and
program activities Homework: analyzing
and determining their cause of illness
Personal Meeting
- Process of applying 4 Noble Truth into
action for Hypertension management
- Assessment of patients’ perception in
health behavior status
- Learning to use Manual guide book
content and program activity
Homework: analyzing and determining
their cause of illness
Telephone Meeting
Analyze cause suffering, set goal and
choose the activities.
- Discussing about their conclusion relates
to their cause of illness
- Set up their goal of disease management
from their causes of illness
- Integrating 8 Magga
2 Days
-
Calling patients and answering questions
by nurses about suffering, origin of
suffering, cessation of suffering.
- Asking interview questions and answers
by nurses
- L
etting patients try out about 2 weeks
.
1 Day
Revision
- Calling Patients and answering questions
by nurses
2 Weeks
- Calling Patients and answering
questions by nurses
2 Weeks
- A telephone reminder 1 day before the
scheduled appointment.
-
Recording body weight, blood pressure,
BMI and patient satisfaction for health
care service in follow up day
.
1 Day
Telephone Meeting
Analyze cause suffering, set goal and
choose the activities.
- Discussing about their conclusion relates
to their cause of illness
- Set up their goal of disease management
from their causes of illness
- Integrating 8 Magga
2 Days
- Calling patients and answering questions
by nurses about suffering, origin of
suffering, cessation of suffering.
- Asking interview questions and answers
by nurses
- Letting patients try out about 2 weeks.
1 Day
Revision
- Calling Patients and answering questions
by nurses
- Calling Patients and answering questions
by nurses
-
A telephone reminder 1 day before the
scheduled appointment.
-
Recording body weight, blood pressure,
BMI and patient satisfaction for health
care service in follow up day
.
1 Day
- A telephone reminder 1
day before the scheduled
appointments.
Recording body weight,
blood pressure, BMI and
patient satisfaction for
health care service in
follow up day.
1 Day
8 Weeks
2 Weeks
2 Weeks
2 Weeks
2 Weeks
Fig 1. Flow of Data Collection Process.
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RESULTS
One hundred and seventy-four patients with stage 1
hypertension who were eligible based on the inclusion
and exclusion criteria were recruited into this study.
During data collection, 29 patients withdrew from the
study due to the diculty in getting to the hospital and
inconvenience in completing the 2-month study program.
us, a total of 145 participants remained in the study
including 45 Mobile Web users, 50 Guidebook users
and 50 participants in the control group.
Demographic characteristics
e mean ages in each group were 57.6 ± 11.75 years
for the Mobile Web group, 68.04 ± 8.86 years for the
guidebook group and 63.70 ± 13.40 for the control group.
Most of the participants were females. e percentage
of females in each group was 75.6 in the Mobile Web
group, 76 in the guidebook group and 66 in the control
group. When comparing the personal characteristics of
the experimental Mobile Web, Guidebook, and control
groups, it was found that gender and type of hypertension
medication showed no statistically signicant dierence.
However, there were statistically signicant dierences
in body mass index (BMI), blood pressure before the
program, duration aer hypertension diagnosis, educational
attainment, healthcare coverage, income, employment
and comorbidities (Table 1).
Systolic blood pressure
The comparison of mean SBP following the
intervention found that the Mobile Web group had an
average decrease at the end of the program (2 months),
with a mean dierence SBP of 15.09 ± 9.62 mmHg, while
the Guidebook group had a mean dierence in SBP of
13.02 ± 12.19 mmHg and the control group had a mean
dierence of 9.18 ± 12.95 mmHg. e comparisons of
mean SBP at pre- and post-intervention were statistically
and signicantly dierent in all three groups as shown
in Table 2.
Comparison of SBP among three groups aer adjusting
for covariates
Analysis of covariance (ANCOVA) was used to
analyze the covariates potentially inuencing blood
pressure reduction aer the program, including age,
comorbidities, SBP before the program, duration aer
hypertension diagnosis, educational attainment, healthcare
coverage, income, employment and BMI. Aer adjusting
the covariate, it was found that at least one pair of the
mean SBP had a statistically signicant dierence. e
post hoc analysis by the Bonferroni method found that
the mean SBP of the Mobile Web group was lower than
the control group, while the Guidebook group was also
lower than the control group with statistical signicance
as shown in Tables 3 and 4.
Satisfaction scores
e satisfaction score with the selected program
found the Mobile Web group to have the highest mean
satisfaction score of 93.78 ± 4.97, followed by the control
group (93.36 ± 7.26) and the Guidebook group (90.4 ±
5.26).
Comparison of satisfaction scores among the three
groups aer adjusting for covariates
Analysis of covariance (ANCOVA) was used to
analyze the covariate with potential influence over
satisfaction scores, including age, comorbidities, SBP
before the program, duration aer hypertension diagnosis,
educational attainment, healthcare coverage, income,
employment and BMI. Aer adjusting the covariate, at
least one pair of satisfaction scores was found to have
statistically signicant dierences as shown in Tables 5
and 6.
DISCUSSION
e mobile web and Guidebook groups had lower
SBP than the control group aer participating in the
Practice of Four Noble Truths for Controlling High
Blood Pressure program with statistical signicance. At
the same time, there were dierences in diastolic blood
pressure in the Mobile Web and Guidebook groups
with no statistical signicance. us, the program was
able to have remarkable effects on lowering SBP in
both groups. e program introduced the Four Noble
Truths of Buddhism combined with the Mobile Web
and the Guidebook technology under the management
of specialized nurses in high blood pressure.
Both of the experimental groups with Mobile Web
and Guidebook users were encouraged to lower their
blood pressure accurately, continuously and appropriately
according to individual cases. e Four Noble Truths
of Buddhism comprise the four truths of suering and
cessation of suering, which briey refer to the cessation
of suering from the causes with correct processes. In
patients with high blood pressure, the causal eects
were from high blood pressure. Hence, the design of this
program had to focus on the elimination of those causes
in each patient according to the Four Noble Truths,
including Dukkha, Samudaya, Nirodha, and Magga
20
as described below:
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TABLE 1. Demographic of participants.
Characteristic Mobile web Guide book Control P-value
(n=45) (n=50) (n=50)
Age (years) 57.60±11.75 68.04±8.86 63.70±13.40 <0.001
1
Sex 0.455
2
Male 11 (24.4) 12 (24.0) 17 (34.0)
Female 34 (75.6) 38 (76.0) 33 (66.0)
BMI 27.92±6.21 24.58±3.60 26.09±5.02 0.040
1
SBP before participating in the study (mmHg) 144.18±8.26 147.24±7.28 148.40±5.69 0.050
1
Duration after hypertension diagnosis (years) 6.57±5.33 10.12±6.98 13.62±7.81 <0.001
1
Educational attainment <0.001
2
Uneducated or elementary school 6 (13.3) 28 (56.0) 13 (26.0)
High school or vocational school 9 (20.0) 7 (14.0) 17 (34.0)
Bachelor degree or higher 30 (66.7) 15 (30.0) 20 (40.0)
Healthcare coverage 0.002
3
UHC 1 (2.2) 2 (4.0) 11 (22.0)
SSS 4 (8.9) 2 (4.0) 8 (16.0)
CSMBS 28 (62.2) 39 (78.0) 27 (54.0)
Self-employed 10 (22.2) 6 (12.0) 3 (6.0)
Other 2 (4.4) 1 (2.0) 1 (2.0)
Income 19,328.89±11,565.26 12,164±11,807.21 13,840±17,289 0.004
1
20,000 (0-50000) 8,000 (0-50,000) 5,000 (0-70,000)
Employment 0.004
3
Marchant 2 (4.4) 7 (14.0) 3 (6.0)
Government ofcer 13 (28.9) 2 (4.0) 4 (8.0)
Employer 9 (20.0) 4 (8.0) 9 (18.0)
Unemployed 21 (46.7) 37 (74.0) 34 (68.0)
Types of hypertension medication 0.595
3
Never received 0 (0.0) 2 (4.0) 1 (2.0)
1 type 26 (57.8) 26 (52.0) 23 (46.0)
2 types 19 (42.2) 22 (44.0) 26 (52.0)
Comorbidities 0.023
2
None 26 (57.8) 15 (30.0) 23 (46.0)
Have 19 (42.2) 35 (70.0) 27 (54.0)
Diabetes 9 (20.0) 22 (44.0) 13 (26.0)
Hyperlipidemia 10 (22.2) 19 (38.0) 17 (34.0)
AR 1 (2.2) 1 (2.0) 0 (0.0)
CKD 1 (2.2) 3 (6.0) 5 (10.0)
Other 3 (6.7) 4 (8.0) 6 (12.0)
1
Kruskal Wallis Test,
2
Chi-square test,
3
Fisher’s exact test
Results: mean±SD, median (min-max), n (%)
Abbreviations: BMI = Body Mass Index, SBP = Systolic Blood Pressure, UHC = Universal health coverage, SSS = Social Security Scheme,
CSMBS = Civil Servant Medical Benet Scheme, AR = Allergic Rhinitis, CKD = Chronic Kidney Disease
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TABLE 2. e average of SBP before and aer intervention with the mean dierence of SBP.
TABLE 3. e ANCOVA of mean SBP dierence and mean satisfaction dierence among groups aer adjusting
for age, comorbidities, SBP before the program, duration aer hypertension diagnosis, educational attainment,
healthcare coverage, income, employment and BMI.
Groups Before SBP After SBP P-value Mean SBP
difference
Mobile web 144.20±8.27 129.09±7.85 <0.001 15.09±9.62
Guide book 147.24±7.29 134.22±10.10 <0.001 13.02±12.19
Control 148.40±5.69 139.22±12.85 <0.001 9.18±12.95
Wilcoxon signed ranks test
Abbreviation: SBP = Systolic Blood Pressure
Variables SS df MS F P-value
SBP
a
Groups 1464.3549 2 732.1775 6.94 0.001
Age 168.2553 1 168.2553 1.59 0.209
Comorbidities 343.2014 1 343.2014 3.25 0.074
SBP before the program 255.1927 1 255.1927 2.42 0.123
Duration after hypertension diagnosis 228.5107 1 288.5107 2.16 0.144
Educational attainment 30.6850 2 15.3425 0.15 0.865
Healthcare coverage 335.7861 4 83.9465 0.80 0.530
Income 245.8787 1 245.8787 2.33 0.129
Employment 348.2690 3 116.0897 1.10 0.352
BMI 115.8679 1 115.8679 1.10 0.297
Satisfaction
b
Groups 287.1816 2 143.5908 3.87 0.023
Age 0.4960 1 0.4960 0.01 0.908
Comorbidities 12.2170 1 12.2170 0.33 0.567
SBP before the program 26.5270 1 26.5270 0.71 0.400
Duration after hypertension diagnosis 137.3572 1 137.3572 3.70 0.057
Educational attainment 36.9258 2 18.4629 0.50 0.609
Healthcare coverage 54.9481 4 13.7370 0.37 0.830
Income 14.7046 1 14.7046 0.40 0.530
Employment 46.2282 3 15.4094 0.41 0.743
BMI 0.4826 1 0.4826 0.01 0.909
a
Levene's Test of Equality of Error Variances: F=0.647 P-value=0.966
b
Levene's Test of Equality of Error Variances: F=1.098 P-value=0.346
Abbreviations: SBP = Systolic Blood Pressure, BMI = Body Mass Index
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TABLE 4. e mean dierence of mean SBP aer the program in the mobile-web, the guide-book and the control
groups.
TABLE 5. e ANCOVA of mean satisfaction score among groups aer adjusting for age, comorbidities, SBP
before the program, duration aer hypertension diagnosis, educational attainment, healthcare coverage, income,
employment and BMI.
Group Mean Difference P-value
SBP
a
Mobile web Guide book -3.09 0.711
Mobile web Control -9.15 0.001
Guide book Control -6.06 0.045
Satisfaction
b
Mobile web Guide book 2.92 0.183
Mobile web Control -1.02 1.000
Guide book Control -3.94 0.023
a
Adjustment for multiple comparisons: Bonferroni
b
Post hoc analysis of satisfaction score
Variables SS df MS F P-value
Groups 287.1816 2 143.5908 3.87 0.023
Age 0.4960 1 0.4960 0.01 0.908
Comorbidities 12.2170 1 12.2170 0.33 0.567
SBP before the program 26.5270 1 26.5270 0.71 0.400
Duration after hypertension diagnosis 137.3572 1 137.3572 3.70 0.057
Educational attainment 36.9258 2 18.4629 0.50 0.609
Healthcare coverage 54.9481 4 13.7370 0.37 0.830
Income 14.7046 1 14.7046 0.40 0.530
Employment 46.2282 3 15.4094 0.41 0.743
BMI 0.4826 1 0.4826 0.01 0.909
Levene's Test of Equality of Error Variances: F=1.098 P-value=0.346
TABLE 6. Comparison of overall satisfaction on health services.
Characteristics Mobile-web group Guide-book group Control group P-value
(n=38) (n=38) (n=42)
Overall satisfaction on health services 95.33±6.94 87±11.11 89.80±12.86 0.001
3
3
Kruskal Wallis test
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Dukkha (knowing symptoms) - Patients understood
their own symptoms when they had physical examinations
by taking measurements for blood pressure, weight and
height in addition to receiving immediate information
from the staff. Blood pressure measurement could
inform the patients that they had asymptomatic stage 1
hypertension.
21
us, they became careless. However,
this program would stimulate patients to know and
understand, so they had greater awareness and self-care.
Samudaya (knowing causes) - e patients received
knowledge, considered, and determined the causes of their
own hypertension, particularly the causes by incorrect
lifestyles
22
that could be solved and prevented on their
own. e causes of each patient were dierent. Patients
reviewed those causes with nurses in this program, thereby
allowing patients to understand the causes based on
their behaviors and the eects to their blood vessels and
systems in the body. e program empowered patients
to strengthen their well-being as a source of awareness
about the importance of healthcare with true beliefs and
knowledge based on health science. e patients could
make their decisions to change or maintain the behaviors
that support controlling hypertension as advised by
nurses and other people involved. Ultimately, there was
a development of health with clear outcomes.
19
is was the reason why the researcher used the
Mobile Web or Guidebook, which were designed to
allow patients to understand the pathophysiology of fatty
tissues that could narrow blood vessels. e patients could
then imagine the changes in their bodies as motivation
to solve all causes. e pictures in Guidebook or the
animation in Mobile Web described the mechanisms
of high blood pressure in the body with deep and clear
understanding rather than practice by usual care of
simply using words to describe and explain. According
to the ndings, the general introduction of tablet devices
could entail a shi in the way students learnt, because
the devices provided interactive, media-rich and exciting
new environments.
23
When understanding the self-led
causes, patients could come up with the idea that they
were able to correct themselves and design or choose a
lifestyle that would suit them. For instance, they chose
to exercise by cycling or walking fast at home, at work,
with friends, and at convenient times to do so. us, they
were able to adopt these activities into real-life practice.
24
Nirodha - Once the patients understood the root
causes of their behaviors, they accepted the idea that
they were able to x those problems themselves. ey
were the ones who set the right goals and chose the right
lifestyles. For example, they chose to exercise by cycling
or walking fast at home, at work, or with friends. Setting
the right times for themselves could actually be helpful
in everyday life. e nurses provided information. ere
was goal-setting between patients and nurses, which was
also a means of empowerment. e study of Anuruang
found that participants in the program were healthier
and more satised with their healthcare services than
in the past and better than the control group receiving
usual care only with statistical signicance (p <0.05).
19
ese clear goals led patients to practice continuously
until they reached their goals.
Magga (practice) - Implementation could be the key
to success. Buddhist concepts tend to focus on practice
rather than prayer. e main focuses are on the present
time, concentration of mind and conscious actions at
all times. It should be important to encourage patients
to order and remind themselves constantly. e two
experimental groups (100%) were composed of Buddhists
who understood these contexts when they were encouraged
to do so. In particular, all of the participants were ai
Buddhists and used the principles of Buddhism in their
daily lives. erefore, they could correct their own causes
based on the Noble Eightfold Path toward successful
achievement of goals.
In terms of overall satisfaction in health care
services, it was found that the average satisfaction of
the Mobile Web group was statistically and signicantly
higher than that of the Guidebook group. According
to the ndings, the patients’ satisfaction with Mobile
Internet-based Health Services (MIHS) was positively
inuenced by perceived usefulness and conrmation of
MIHS performance expectations.
25
When comparing the
satisfaction with the health services of the three groups,
the Mobile Web group had the highest satisfaction,
followed by the Guidebook group and the control group,
respectively.
Limitation
ere was some limitation in this study. First, the
adherence to antihypertensive drugs may inuence the
blood pressure level of participants however we did not
measure the adherence of participants and control for this
extraneous variable. Second, there was the statistically
significant differences among groups for baseline
characteristics (e.g. age, BMI, education) however we
used the random assignment to assign participants into
three groups so the dierence may happen by change.
ird, our study lacked of controlling for changes in
anti-hypertensive regimens during the study period
so the medication adjustment may inuence the blood
pressure level.
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CONCLUSION
e program, “Practice of Four Noble Truths in
Controlling High Blood Pressure” could be applied to
controlling high blood pressure in patients with stage 1
hypertension in nursing and health care practice at both
public and private public health centers, hospitals and
others. e outstanding features of this program were
able to support the overall dierences in the healthcare of
each patient with rapid ecacy with a variety of choices
such as interventions (Mobile Web or Guidebook) for
patients to choose based on their needs. ey could select
their own activities that t their reasons, convenience and
preferences. e program could potentially develop nursing
roles in providing care for patients with hypertension
nationwide. In particular, the project team could collaborate
with other healthcare providers to improve the health of
the entire population. It could be helpful to use the Four
Noble Truths in health service delivery as a reasonable
and conceptual practice leading to optimal success.
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16. Dreher ML. Dietary Patterns and Hypertension. Dietary Patterns
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17. Montrieux H, Vanderlinde R, Schellens T, De Marez L. Teaching
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502
Kanokrat Suvarnsit, M.D.*, ansamorn Chantarawiwat, M.D.*, Sarun Prakairungthong, M.D.*, Siriporn
Limviriyakul, M.D.*, Suvajana Atipas, M.D.*, Pittayapon Pitathawatchai, M.D.**
*Department of Oto-Rhino-Laryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, **Department of Otolaryngology Head
and Neck Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, ailand.
Granular Myringitis Treatment at Siriraj Hospital
ABSTRACT
Objective: To review the clinical features and management of patients diagnosed with granular myringitis at Siriraj
Hospital, during 2014–2016, and their applications in clinical practice.
Methods: e clinical data of 115 patients diagnosed with myringitis at the Department of Otorhinolaryngology,
Faculty of Medicine Siriraj Hospital, between September 1, 2014, and September 30, 2016, were retrospectively
reviewed. Patients who were lost to follow-up aer the rst visit or patients who were diagnosed with other diseases,
such as bullous myringitis, were excluded, leaving 96 patients included in the study. Patient information and data,
including age, gender, underlying disease, history of ear disease and surgery, symptoms, duration, type of treatment,
outcome, total follow-up time, complications, and recurrence rate were recorded.
Results: In total, 96 patients (27 men (28.10%) and 69 women (71.90%)) were included in the study. eir ages
ranged from 3 to 90 years old (mean, 52.88). Sixty-two patients (64.60%) were diagnosed by otologic sta. e
average duration of symptoms from onset was 5.6 months (range, 0.03–60.80 months). e most frequent symptom
was otorrhea (55.3%). ere were 38 treatment regimens applied. e most common medications used were topical
antibiotics with steroids (28.11%), topical antibiotics (24.91%), and diluted vinegar (17.08%). ere was no signicant
dierence in the curative rate between these regimens (p = 0.261).
Conclusion: Granular myringitis is a poorly understood condition and there is no standard treatment regimen.
While there is a great variation in the treatment of granular myringitis at Siriraj Hospital, this retrospective review
showed there was no statistical signicant dierence among the dierent regimens. Further high-value research is
needed to further assess the management strategies.
Keywords: Granular myringitis; chronic myringitis (Siriraj Med J 2020; 72: 502-507)
Corresponding author: Suvajana Atipas
E-mail: grsat2@gmail.com
Received 20 October 2017 Revised 14 August 2020 Accepted 15 August 2020
ORCID ID: http://orcid.org/0000-0002-5760-1339
http://dx.doi.org/10.33192/Smj.2020.68
INTRODUCTION
Granular myringitis is characterized by a chronic
inammation of the tympanic membrane leading to the
replacement of its epithelial surface and, occasionally,
adjacent deep meatal skin with proliferating granulation
tissue
1
(Fig 1). It is possible that this condition may
have been underdiagnosed in the past due to the low
magnication power available under physical examination
by using an otoscope instead of a microscope. Moreover,
it may have been misdiagnosed as otitis externa or
chronic otitis media, in which case the same treatment
would help to improve myringitis as well. Although
granular myringitis is a minor illness, it can lead to several
complications, such as tympanic membrane perforation,
post-inammatory canal brosis, or atresia.
2,3
Patients
usually seek treatment because of their annoying symptoms;
for example, malodorous otorrhea, intrameatal itching,
feeling aural fullness, and earache.
4
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At present, the etiology of this condition is unclear.
It may be an infectious process, inammation, or local
trauma. Clinicians can treat this condition with topical
ear drops, which are topical antibiotics with/or without
steroid drops, or diluted vinegar solution.
5
Some also
use a LASER or other chemical substances, and surgical
intervention has even been reported in the previous
literature.
6
Recently, the medication of choice has normally
depended on the causative organism identied by tissue/
uid cultures, which typically are bacteria or fungi.
4,7
ese organisms grow best in a narrow pH range, i.e.,
from pH 6.5 to 7.5.
8
So, the management of various types
of external otitis is to maintain the acidity of the external
canal to prevent their growth. In order to acidify the ear
canal for treatment involving draining the ear, acetic
acid and Burow’s solution have long been successfully
used.
9,10
As in folk medicine, vinegar can be used to
manage external otitis with good eect.
11
It is possible
that the acidication of the external ear has a good
eect on granular diseases of the tympanic membrane
by preventing bacterial growth and the stimulation of
squamous re-epithelialization. However, a standard
eective regimen for granular myringitis is lacking and
remains in need.
In this study, we reviewed the records of patients
diagnosed with myringitis at Siriraj Hospital, as a
supertertiary care hospital, during 2014-2016. The
objective of this review was to determine the optimal
management for the treatment and prevention of the
recurrence of granular myringitis that could later be
applied in clinical practice.
MATERIALS AND METHODS
e research was approved by the Institutional
Review Board of the Faculty of Medicine Siriraj Hospital,
Mahidol University (Si 728/2559).
e clinical data of 115 patients (34 males and 81
females) diagnosed with myringitis based on ICD-10
code (H73) at the Department of Otorhinolaryngology,
Faculty of Medicine Siriraj Hospital, Mahidol University,
ailand, between September 1, 2014, and September
30, 2016, were retrospectively reviewed.
e exclusion criteria were patients who were lost
to follow-up aer the rst visit and patients who were
diagnosed with other diseases, such as bullous myringitis.
Patient information and data, including age, gender,
underlying diseases, history of ear diseases and surgeries,
aected side, symptoms, duration, investigations, type of
treatment, outcome, total follow-up time, complications,
and recurrence rate, were recorded.
e follow-up outcomes were categorized into 4 grades:
“Resolved,” when an intact completely epithelialized TM
without otorrhea, moistness, or subjective complaints
was documented; “Improved,” when there was a marked
improvement in both the physical signs and subjective
symptoms; “Unchanged,” when there was little or no
improvement of the TM appearance or symptoms; or
“Worse,” when the subjective symptoms had an exaggerated
or increased otorrhea, or the myringitis or granulation
tissue occupied a larger area of the TM. We classied
resolved and improved as “good outcomes” and unchanged
and worse as “poor outcomes.”
Statistical analysis
PASW Statistics (SPSS) version 18.0 (SPSS Inc.,
Chicago, IL., USA) was used for the statistical analysis.
Quantitative data are reported herein as the mean +/-
SD and qualitative data are reported as the number of
patients and as percentages. e Chi-square test was used
to compare categorical data. A probability (p) value of
less than 0.05 was considered statistically signicant.
RESULTS
Demographic data
Between September 1, 2014, and September 30,
2016, 115 patients were identied with a diagnosis of
myringitis based on ICD10 (H73) and considered for
inclusion in the study; however, 19 patients were excluded
as they were also diagnosed with other diseases too, such
as bullous myringitis, acute otitis media, or mastoiditis,
leaving 96 patients included in the study.
e 96 patients included in the study comprised
27 men (28.10%) and 69 women (71.90%), aged from
Fig 1. Le granular myringitis - the granulation tissue presents on
the surface of the tympanic membrane with associated inammatory
changes to the external auditory canal epithelium.
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3 to 90 years old (mean, 52.88 years old). e right
ear was aected in 50 patients (52.10%), the le in 36
(37.50%), and both in 10 (10.40%). Sixty-two patients
(64.60%) were diagnosed by otologic sta, while 34
patients (35.40%) were diagnosed by non-otologic sta
and residents. e average total follow-up time was 31.2
weeks (range, 0.86–160.86 weeks). e average duration
of symptoms was 5.6 months (range, 0.03–60.8 months).
e presenting symptoms varied, including otorrhea
in 47 patients (55.30%), aural fullness in 40 patients
(47.10%), itching in 17 patients (20.00%), earache in 22
patients (25.90%), and tinnitus in 12 patients (14.10%).
Recurrence was noted in 12.5% of patients. None of the
patients had any complications, such as ear canal stenosis
post treatment.
Many patients had associated medical illness; for
example, allergic and/or chronic rhinitis (25.00%),
hypertension (25.00%), dyslipidemia (18.80%), diabetes
mellitus (15.60%), and chronic kidney disease (4.20%).
Also, 43 patients (44.79%) had a history of other ear
diseases, such as closed TM perforation (13.54%), TM
perforation (12.50%), otitis externa (9.38%), otomycosis
(6.25%), otitis media (1.04%), impact cerumen (1.04%),
and bilateral superior canal dehiscence (1.04%). e
patient who had bilateral superior canal dehiscence
developed granular myringitis aer myringotomy with
a pressure equalization tube (PE tube) placement.
Fieen patients (15.63%) had a previous TM perforation
prior to the diagnosis of granular myringitis. irteen
patients (13.54%) underwent tympanoplasty and 2 patients
(2.08%) underwent a paper patch. Two patients (2.08%)
had myringotomy and a PE tube placement and 1 patient
(1.04%) had a history of ear wax removal. e duration
between otologic procedures and the onset of granular
myringitis ranged from 0.53 to 361.33 months. (median,
68.90 months)
Outcome
e total number of visits was 397 visits, involving
96 patients. However, 116 of those visits involved patients
ultimately lost to follow-up. us, the outcomes of only
281 visits were evaluated. In this review, there were 38
treatment regimens. We categorized these into 4 groups:
no treatment (7.47%), single topical ear drop treatment
(40.57%) or adjuvant treatment (11.74%), topical ear
drop with adjuvant treatment (37.37%), and surgery
(2.85%). Adjuvant treatments noted in the literature
included antiseptic solutions, chemical cauterization, oral
antifungal, oral antibiotics, and intravenous antibiotics.
(Tables 2 and 3)
TABLE 1. Demographic data and clinical characteristics of the 96 patients reviewed in detail in the study.
Number (%) or Mean (Min, Max)
Sex
Female 69 (71.90)
Male 27 (28.10)
Age (year) 52.88 ± 19.24 (3,90)
Affected side
Bilateral 10 (10.40)
Right 50 (52.10)
Left 36 (37.50)
Duration of symptoms (month) 5.6 ± 13.69 (0.03 - 60.8)
Total follow-up time (month) 3.18 ± 9.93 (0.22 - 40.22)
Clinician
Staff
Otologist 62 (64.60)
Non-otologist 20 (20.80)
Resident 14 (14.60)
Recurrence
Yes 12 (12.50)
No 55 (57.30)
Could not be evaluated 29 (30.20)
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TABLE 2. Topical ear drops.
Visit Outcome
(n = 218) Poor (%) Good (%)
(n = 67) (n=151)
Antibiotic 70 24 (34.28) 46 (65.71)
Alone 38 15 (39.47) 23 (60.52)
With adjuvant treatment 32 9 (28.13) 23 (71.87)
Antibiotic with steroid 79 25 (31.65) 54 (68.35)
Alone 48 16 (33.33) 32 (66.67)
With adjuvant treatment 31 9 (29.03) 22 (70.97)
Diluted vinegar 48 11 (22.92) 37 (77.08)
Alone 18 5 (27.78) 13 (72.22)
With adjuvant treatment 30 6 (20.00) 24 (80.00)
Antifungal 18 5 (27.78) 13 (72.22)
Alone 7 1 (14.29) 6 (85.71)
With adjuvant treatment 11 4 (36.36) 7 (63.63)
2.5% NaHCO3 in glycerine 3 2 (66.67) 1 (33.33)
Alone 3 2 (66.67) 1 (33.33)
With adjuvant treatment 0 0 (0.00) 0 (0.00)
TABLE 3. Adjuvant treatments.
Visit Outcome
(n = 154) Poor (%) Good (%)
(n = 43) (n=111)
Topical antiseptic 65 15 (23.08) 50 (76.92)
Alone 23 5 (21.74) 18 (78.26)
With adjuvant treatment 42 10 (23.81) 32 (76.19)
Cauterization 30 7 (23.33) 23 (76.67)
Alone 5 2 (40.00) 3 (60.00)
With adjuvant treatment 25 5 (20.00) 20 (80.00)
Oral antibiotic 51 18 (35.29) 33 (64.71)
Alone 5 2 (40.00) 3 (60.00)
With adjuvant treatment 46 16 (34.78) 30 (65.22)
Oral antifungal 7 3 (42.86) 4 (57.14)
Alone 0 0 (0.00) 0 (0.00)
With adjuvant treatment 7 3 (42.86) 4 (57.14)
IV antibiotic 1 0 (0.00) 1 (100.00)
Alone 0 0 (0.00) 0 (0.00)
With adjuvant treatment 1 0 (0.00) 1 (100.00)
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e most common topical ear drops used to treat
granular myringitis included topical antibiotics with steroids
(28.11%), topical antibiotics (24.91%), and diluted vinegar
(17.08%). e adjuvant treatments most frequently used
were antiseptics (23.13%), oral antibiotics (18.15%), and
cauterization (10.68%). Diluted vinegar was only used
by otologists in 48 visits: 37.50% as a single treatment
and 62.50% combined with another treatment.
The outcomes of each treatment regimen were
compared using Chi-square test. e result showed
no statistical signicant dierence between outcomes
among these regimens (p = 0.261).
DISCUSSION
Between 2014 and 2016, 115 patients were
diagnosed with granular myringitis at the Department
of Otorhinolaryngology, Faculty of Medicine, Siriraj
Hospital, of whom 96 were included in the present
study. e prevalence of granular myringitis was higher
in women (71.90%) than in men (28.10%), with a 2.6-
fold greater prevalence in women. e most frequent
presenting symptom was an otorrhea. Other symptoms
recorded include a sensation of fullness, mild pain, or
itching in the ear. Recurrence was noted in 12.50% of
patients and some were aected bilaterally.
A predisposing health condition may not be associated
with granular myringitis according to the small percentage
of each underlying condition demonstrated in this study.
Generally, injury to the epithelial layer and exposure of the
brous middle layer causes the formation of granulation
tissue in an attempt to heal the defect.
4
Schuknecht
described the focal or diuse replacement of the dermis
of the tympanic membrane and adjacent canal wall
with granulation tissue as a characteristic of granular
myringitis.
12
Blevins and Karmody reported that 60%
of patients, both adults and children, had undergone
previous otologic procedures.
13
In this study, only 18.75%
of patients had undergone an otologic procedure prior
to the development of granular myringitis, in which the
duration between the otologic procedure and the onset
of symptoms ranged from 0.53 to 361.33 months (mean,
68.90 months). is percentage was lower than in previous
studies. is was possibly because the average duration
was longer than the healing process of the tympanic
membrane, so it seems like the healed surgical site was
similar to being in a normal condition.
To date, granular myringitis remains a poorly
understood condition and the proposed treatments
are quite variable. A 2008 systemic review of the
management of granular myringitis concluded that
there was insucient high-quality evidence to support
any particular management plan or treatment protocol
for patients with granular myringitis.
14
In this review,
there were many dierent treatment regimens for granular
myringitis at Siriraj Hospital. Aer meticulous aural
toilet, topical antibiotics with steroid drops and topical
antibiotic drops were the most frequently used in this
study, oen combined with another adjuvant treatment,
such as a topical antiseptic, oral antibiotic, and chemical
cauterization. Diluted vinegar was also used but only by
otologists and the results showed a good outcome in
77.10% of cases. Surgical interventions were limited in
use, and involved only 2.85% of cases that had failed to
respond to medical treatment, but led to a high success
rate (87.5%). All the surgical interventions in this study
were myringoplasty. However, there was no signicant
dierence in the success rate between each treatment
group.
e limitation in this study was due to a small number
of patients. A further study of longer data collecting period
could yield signicant outcome. A study of randomized
controlled trial utilizing a larger population is suggested.
CONCLUSION
Granular myringitis is a poorly understood condition
and there is no standard eective treatment regimen.
Regarding our results, topical ear drops, such as antibiotic
ear drops with or without a steroid, or diluted vinegar,
showed fair outcomes in the treatment with an about
60–80% success rate, without any statistical signicant
dierence among these regimens. Hence, diluted vinegar
solution might be considered as another option for
patients with granular myringitis because it is less likely
to cause bacterial resistance and also as it is safe, low-
cost, and has high availability despite the unfamiliarity
with its use among many general practitioners. However,
further high-value research (i.e., randomized controlled
trials) is needed to further assess and identify the most
appropriate management strategies that could both
resolve granular myringitis and prevent its recurrence.
ACKNOWLEDGMENTS
We gratefully appreciate the kind contributions of
the consulting statistician Miss Julaporn Pooliam as well
as the research assistants (Ms. Jeerapa Kerdnoppakhun,
Miss Ngamrat Treerassapanich) and all the patients who
were involved in this project.
Disclosure of the presence of nancial support
is study was funded by the Faculty of Medicine
Siriraj Hospital, Mahidol University.
Suvarnsit et al.
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Conicts of interest
e authors declare that they have no conict of
interest.
REFERENCES
1. Gulya AJ, Minor LB, Glasscock ME, Poe D. Glasscock-Shambaugh
Surgery of the Ear: People’s Medical Publishing House-USA;
2010.
2. Lavy J, Fagan P. Chronic stenosing external otitis/postinammatory
acquired atresia: a review. Clin Otolaryngol Allied Sci2000;25:
435-9.
3. Slattery WH 3
rd
, Saadat P. Postinammatory medial canal
brosis. Am J Otol 1997;18:294-7.
4. Stoney P, Kwok P, Hawke M. Granular myringitis: a review.
J Otolaryngol 1992;21:129-35.
5. Jung HH, Cho SD, Yoo CK, Lim HH, Chae SW. Vinegar
treatment in the management of granular myringitis. J Laryngol
Otol 2002;116:176-80.
6. El-Sei A, Fouad B. Granular myringitis: is it a surgical problem?
Am J Otol 2000;21:462-7.
7. Kunachak S. Intractable granular myringitis: possible etiology
and management. J Otolaryngol 1992;21:297-8.
8. Aminifarshidmehr N. e management of chronic suppurative
otitis media with acid media solution. Am J Otol 1996;17:24-5.
9. Smathers CR. Chemical treatment of external otitis. South
Med J 1977;70:543-5.
10. orp MA, Kruger J, Oliver S, Nilssen EL, Prescott CA. e
antibacterial activity of acetic acid and Burow’s solution as
topical otological preparations. J Laryngol Otol 1998;112:925-8.
11. Flint PW, Haughey BH, Niparko JK, Richardson MA, Lund
VJ, Robbins KT, et al. Cummings Otolaryngology - Head
and Neck Surgery: Head and Neck Surgery, 3-Volume Set:
Elsevier Health Sciences; 2010.
12. Schuknecht HF. Infections. In: Schuknecht HF, ed. Pathology
of the ear, 2
nd
eds. Cambridge, MA: Harvard University Press;
1974.
13. Blevins NH, Karmody CS. Chronic myringitis: prevalence,
presentation, and natural history. Otol Neurotol 2001;22:3-10.
14. Neilson LJ, Hussain SS. Management of granular myringitis:
a systemic review. J Laryngol Otol 2008;122:3-10.
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508
Angurbala Mishra, MBA.*, Subhasmita Biswal, Ph.D.*, Somadatta Das, MA.**, Rabindra Nath Padhy, Ph.D.**,
Bibhuti Bhusan Pradhan, Ph.D.***
*Department of Humanities and Social Sciences, Institute of Technical Education and Research, Siksha ‘O’ Anusandhan Deemed to be University,
Bhubaneswar-751030, Odisha, India. **Central Research Laboratory, IMS and SUM hospital, Siksha ‘O’ Anusandhan Deemed to be University,
Bhubaneswar-751003, Odisha, India. ***Siksha ‘O’ Anusandhan Deemed to be University, Bhubaneswar-751003, Odisha, India.
Social Transmission of Corona Virus: An Overview
ABSTRACT
Corona virus (COVID-19) causes an infectious disease of the upper respiratory tract, with terminating illness of
failure of lungs. Being a viral disease, no ensconced drug for control is known and it is picked up by a new host the man
as droplets in air released by a patient. e virus has been detected in 215 countries and World Health Organization
(WHO) declared as an epidemic and pandemic. e common structures of social contact critically determine the
spread of the infection from a patient; in the dearth of vaccines, the control of the virus has been its prevention of
spread through systematic ‘social distancing measures’. Furthermore, the use of cotton facemask in public places and
while dealing with one has been the robust method of prevention of spread of the virus from sneezing or talking with
anyone. It was seen from January to April 2020 counties followed social distancing procedures without touching;
hand-shaking or hugging with any one had least number of COVID-19 aected persons. Hand washing with soap-
water frequently to ward o any viral contamination obtained from touches of fomite or furniture etc., is rigorously
followed, city disinfection with bleaching water has been additional practice in societies to abate infection from spits
from patients in the common spaces. Moreover, the described types of social distancing framework adopted by some
countries without additional measures prevented super-infection of the virus in societies. Finally, the ndings have
important implications for the policy making to be adopted globally as well as, individual-scale preventive methods.
Keywords: COVID-19; social distancing; social transmission; pandemic (Siriraj Med J 2020; 72: 508-511)
Corresponding author: Rabindra Nath Padhy
E-mail: rnpadhy54@gmail.com
Received 17 July 2020 Revised 2 September 2020 Accepted 3 September 2020
ORCID ID: http://orcid.org/0000-0002-2522-9843
http://dx.doi.org/10.33192/Smj.2020.69
INTRODUCTION
e present situation with human corona virus
COVID-19 all over, as an emerging infectious virus,
causes a major staggering respiratory morbidity for
8-10 days with eventual mortality, worldwide.
1
e virus
constantly demonstrates a rising patterns of society-
transmission at several Indian cities, despitean eective
social isolation (lockdown) through the country. WHO has
not recommended any particular drug against COVID-19;
in the absence of any emulative drug, social distancing and
self-isolation in homes have the most eective steps for
the control of the COVID-19 pandemic.
2
Prevention of
social contacts in schools/colleges, workplaces and public
spheres are the means of control measures. Droplets from
nose and mouth serve as the vehicles of transmission
of the virus from an infected individual to one and all
nearby, within proximity of one to two meters; social
interactions within a set of empirical variables including
the most basic human behaviour patterns, as, coughing,
sneezing, hand-haking, touching and sharing of objects
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with some individual any object and fomite.
3-6
Other
previous fatal viral infections of upper respiratory tract
leading to the fatal lungs infections were due to Severe
Acute Respiratory Syndrome (SARS) virus and Middle East
Respiratory Syndrome (MERS) virus. ese two human
viral pathogens had not been seen in India. However,
COVID-19 is another fatal virus belonging to “Corona”
group of viruses, identied in China in 2019 causing
respiratory infections ranging from the common cold
to severe disease of lungs, contaminated through air.
7,8
e most common symptoms of COVID-19 are fever,
tiredness, shivering, headache, muscle pains, dry cough
and gastrointestinal disorders.
8
Sometimes, infection
remains cryptic without any kind of visible symptoms,
which would be manifested in immune-compromised
individuals. Any individual with chronic comorbidities
stemming from inherent diabetes or problems of some
innards such as, heart, brain liver or kidney, blood pressure,
coronary artery disease and a few more other serious
illness under some active medication with any mainstream
drug(s) develop expression of the fatal lungs infection.
ose individuals need hospitalization of uninterrupted
supply of oxygen in ICUs even. us COVID-19 aects
much the elderly senior citizens mush more aect older
people, who suffer from medical comorbidities like
diabetes, chronic kidney disease or inammatory lung
disease, etc.
eoretical Framework
The COVID-19 wave influences all sections of
the community and is especially harmful to the elderly
people who are in the most vulnerable section for virus
spread; people of any age group with comorbidities,
such as, hearth diseases diabetes, hypercholesterolemia,
blood pressure problems, renal of liver problems, and
a few more are too vulnerable to infection. us, inter-
personal or social distance is to be maintained everywhere;
consequently. Social gathering for ceremonies, market
places, railway stations and bus-stands, etc. to cite for
example, are prohibited by government. Maintenance of
social distance at workplaces, industries, construction-
sites being prevented adversely inuence the individual
and national economy
7
, with concomitant community
preservations from viral infections at work place, help
men serving as automated moderators. Social distancing
is obligatory to minimize the spread of the disease; if not
executed accurately, spread would be fast. e expanded
social isolation leads to lack of communication with senior
citizens who may need support.
8
Government have called
on the youth to cuddle the attempt to preserve themselves
and overall citizens. By the by, youths help those, who are
most vulnerable and enhance social awareness on health
in societies. erefore, youths are critical to limiting
the virus spread; consequently, youths inuence public
health, society and the economy at large.
e rst point of precaution is the spreading of
virus controlling information in local languages, thus
ensuring that services and facilities are appropriate to
the specic situation of local people. e large number of
local peoples disobeying the specic standard procedure of
social precautionary system remains vulnerable, especially
if they are dependent on the income from the broader
economy-produces, tourism, handicras and similar
employments in urban areas. Social and physical distancing
helps low down of virus spread by causing moratorium
in infection chain growths.
7
Physical distance between
people, and hand washes with soap minimize contact
with contaminated fomite/ furniture/ surfaces, and help
escape from infection.
7
Maneuvers for the common people
comprise initiating easy going work arrangements like,
work at home, e-learning, minimizing and preventing
crowdedness, shut down of non-essential facilities and
services, which safe guard and prevent virus spread. e
adopted government procedure of prevention of going
out for some trivial purposes and avoiding crowds for
obtaining essential home requirements is restricted. e
measures are used in with individual protective methods
against COVID-19, such asfrequent hand-washing and
the gentle-manly cough-etiquette or using cotton face
mask.
All public health maneuvers to cease the spread
of disease can be stabilized with easily moulded plan
of actions to inspire endurance by society and social
connection, governmental protection of incomes and
secured the food supply. Countries should stabilize the
possible benets and help eliminate negative outcomes of
each obstruction, and dispose plan of actions to stimulate
petty community-engagements, acquire mutual trust and
limit social harm in the economic sphere. Many action
plans can be implemented for community endurance
stimulating mental health, by with physical access to
essential and non-essential goods and semi-technical
services, and limit the economic damage of stay at home
maneuvers, where these are considered inevitable. Work
at home and distance learning plan of actions in divergent
situations exhibit transformation and the role of technology
in supporting business continuity and sustaining social
connections within ‘authority and individuals’, ‘teachers
and students’, as well as, ‘families and communities’. In
a broader sense, enforcement of distancing maneuvers
intent to prot from personal and professional community
connections by widely accessible means with mobile
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510
phones and computers. E-conferences are and to be
conducted across international platforms on medical
and technological themes.
In parallel, there were suspected cases of COVID-19
that were to be tested and cases were promptly isolated
to newly organised COVID-hospitals; and the particular
zones were declared as ‘containment zones’with imposed
restrictions of movements into or from it. Previous
contact tracing is done, and home-quarantication of
contact peopleis seriously advised in containment zones
for the duration of the incubation period of 14 to 21 days.
is is almost universal in counties where prevention
is taken as the main task than treatment of COVID-19
patients. Isolation manoeuvre in a society makes the task
of contact-tracing of identied easier since the number
of infected people rapidly in ceases, by the by, infection
case numbers sharply declines. As social measures would
be lied, case-nding, isolation for COVID-19 cases and
quarantine of contacts, to respond categorically to resurgent
or imported cases shall be emphasised. Reorganization
of health and social services should continue to work
in coordination to assess and test patient by rapid tests
for sue treatments, to minimise least virus spread. WHO
describes four levels of COVID-19 transmission (1) no
reported case (2) sporadic cases (3) clusters of cases, and
(4) community transmission.
COVID-19 spreads through droplets and mucus
from a patient, who might not have been hospitalised;
thus, droplets and mucus are released. Droplets are very
small and remain suspended in air for a while. With a
deep breath A typical cough begins during which, lungs
eject air in a compressed form with thrust with crackles.
A person blows out around one-and-a-half-litre of air
in one cough. Moreover, when one coughs or sneezes,
saliva contaminated with viruses comes out. Around
3,000 droplets of saliva come out in a single cough;
droplets of saliva travel at the speed of up to 80 kmph.
At such a speed, one should not be in the range when
COVID-19 is pandemic everywhere. Each droplet of
saliva contains around 20lakh virus particles. Even if a
few of those reach a healthy person’s respiratory tract,
the particles colonise the person’s body and multiply to
billions in 6-7 days. e infected individual would start
showing symptoms of Covid-19 at end of a week aer
infection.
Preventive Measures
Some protective advice followed by the local public
health agency for protect oneself and others around,
knowing the facts and taking proper precautions to
avoid the infections of COVID-19:
1. If one is going outside home use of mask is
mandatory.
2. Reaching home hands must be cleaned using
soap/ hand wash liquid or alcohol-based hand
rub.
3. Maintain a safe distance of one to 1.5 m as
interpersonal distance mandatory and coughing
or sneezing must be done with etiquette.
4. Don’t touch your Eyes, nose or mouth need be
was he oen beforehand.
5. Cover your nose and mouth with your bent
elbow or a tissue when you cough or sneeze.
6. Stay home if you feel unwell.
7. Medical attention if showing any kind symptoms
such as fever, a cough and diculty in breathing,
8. Follow the directions of your local health authority.
Avoiding unneeded visits to medical facilities allows
healthcare systems to operate more eectively, therefore
protecting you and others.
CONCLUSION
In this study, COVID-19 preventive measures were
theoretically and empirically taken into account. It is
evident that the reproductive patterns of the virus are
tightly linked with human social behaviour. erefore,
preventive policies, measures and individual behaviour
need be suiting to virus spread. Social isolation and
availability of COVID-19 conrmation test facility are
mandatory for any country, since those are the most
reliable and convergent forms of obtaining solutions to
reduce community transmission of virus. Concerning
transmission check observed in China and South Korea
the other super-spreading patterns observed were the full
convergence of nonlinear variables with the adoption of
social isolation, COVID-19 conrmation tests availability
and the social distancing methods of 1 to 2 meters
physical distance with the additional use of masks use and
sanitization (city disinfection). Other important points for
use of masks were religiously followed; social distancing
measures with the use of masks and city disinfection
helped preventing dissemination. e isolation of the
undetected infected hosts (asymptomatic cases) and
prevention of airborne transmission were done. us,
policy actions are needed to include strategic measures
to minimise the natural community transmission to
achieve eciency are, social distancing measures, the
use of masks and disinfection measures at public spaces.
Dearth of masks and nancial costs for disinfection of
vulnerable areas, might be limiting factors. e individual
dimension of prevention (citizen collaboration and
Mishra et al.
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support) is mandatory for governmental actions to result
in community prevention stability. Global eorts from
all countries are necessary to help control community
infections everywhere by disallowing air travels.
Conict of interest
Each of the authors has contributed to read and
approved this manuscript. None of the authors has any
conict of interest, nancial or otherwise.
REFERENCES
1. Sun P, Lu X, Xu C, Sun W, Pan B. Understanding of COVID-19
based on current evidence. J Med Virol 2020;92:548-51.
2. Ferguson NM, Laydon D, Nedjati-Gilani G, Imai N, Ainslie K,
Baguelin M, et al. Impact of non-pharmaceutical interventions
(NPIs) to reduce COVID-19 mortality and healthcare demand.
Imperial College COVID-19 Response Team; 19 March 2020.
Available from: https://doi.org/10.25561/77482.
3. Global Surveillance for human infection with novel coronavirus
(2019-nCoV): interim guidance, 31 January 2020. World
Health Organization; 2020.
4. Rational use of personal protective equipment for coronavirus
disease (COVID-19) and considerations during severe shortages.
Interim guidance; 6 April 2020. World Health Organization;
2020.
5. Coronavirus disease 2019 (COVID-19) Situation Report – 68.
WHO situation report; 28 March 2020. Available from: https://
www.who.int/emergencies/diseases/novel-coronavirus-2019/
situation-reports
6. Isolation Precautions: Personal Protective Equipment. Elsevier
Clinical Skills. GN_08_2. Available from: https://www.elsevier.
com/_data/assets/pdf_le/0004/974623/Isolation-Precautions_
Personal-Protective-Equipment.pdf
7. Centers for Disease Control and Prevention (CDCP) (2020).
www.cdc.gov
8. World Health Organization (2020). www.who.int. 20 April
2020.
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Pairoa Praihirunkit, Ph.D.
Department of Forensic Science, Faculty of Allied Health Sciences, ammasat University, Prathumthani 12121, ailand.
miRNAs: Perspective Towards the Use for Body
FluidIdentication
ABSTRACT
Identication of body uids provides an important lead for crime investigation by which it can give a clue
about the nature of the case and assist crime reconstruction. In the last decade, miRNAs have emerged as promising
markers for body uid identication due to their cell- /tissue-specicities. miRNAs are a class of small noncoding
RNAs with ~ 22 nucleotides in length and their small sizes enable them to be resistant to degradation. e possibility
to adopt miRNA markers for body uid identication has been studied in various forensically relevant body uids.
is review aims to give a comprehensive summary of proposed miRNA markers for identifying ve body uids
(venous blood, menstrual blood, semen, vaginal secretion and saliva). Based on numerous evaluations of miRNA
markers and the development of model analysis using a single panel of miRNAs to identify unknown samples,
proposed panels and analysis strategies were gathered and discussed.
Keywords: miRNA; forensically relevant body uids; body uid identication; crime; forensic casework (Siriraj
Med J 2020; 72: 512-526)
Corresponding author: Pairoa Praihirunkit
E-mail: pairoa.prai@gmail.com
Received 10 June 2020 Revised 22 July 2020 Accepted 8 August 2020
ORCID ID: http://orcid.org/0000-0002-3202-5240
http://dx.doi.org/10.33192/Smj.2020.70
INTRODUCTION
miRNAs are a class of small non-coding RNAs with ~
22 nucleotides in length that have been found in organisms
ranging from viruses, plants, invertebrates, vertebrates to
humans as demonstrated in the latest release of miRBase
(v22), the online database of miRNA sequences which
contains 48,860 miRNA sequences from 271 organisms.
1
It is known that miRNAs regulate gene expression within
cells they are generated and they can be secreted into the
extracellular space for regulating other cells or for cell-to-
cell communication.
2,3
Following physiological activities
of the cells and cell death, miRNAs are non-specically
released from cells.
4,5
ese extracellular miRNAs have
been found in vesicle-like molecules such as exosomes,
microvesicles and apoptotic bodies
2,6
, whereas some are
associated with proteins, particularly AGO2.
4,6,7
is
allows miRNAs to be shielded from RNAase degradation
and to increase their stability in biological uids.
4
Studies on expression proles of miRNAs revealed
that they are dierentially expressed in each cell type.
In human cells, the Functional Annotation of the
Mammalian Genome (FANTOM5) consortium has
recently demonstrated that miRNAs are dierentially
expressed in 121 distinct cell types with the top ve
expressed miRNAs accounting for ~50% of the overall
miRNA in each cell type.
8
ese expression patterns
of miRNAs suggest that miRNAs could be promising
markers for cell type and tissue identication. For body
uid identication, miRNAs have been extensively studied
in ve forensically relevant body uids: venous blood,
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menstrual blood, semen, vaginal secretion and saliva as
previously reviewed in.
9-13
e rst review by Courts C.
et al. mentioned panels of miRNAs specic for the ve
body uids from two publications that opened up the
view of applying miRNAs for body uid identication.
12
Subsequent reviews added more recent miRNA markers
and covered issues of miRNA proling methodologies,
factors inuencing miRNA expression
9
, standardisation
of analysis procedures (methods to isolate and quantify
miRNAs)
10
and the potential use of miRNA in clinical
conditions.
11
e present review aims to provide up-
to-date work focusing on the ve body uids: venous
blood, menstrual blood, semen, vaginal secretion and
saliva that are relevant to violent and sexual assaults.
e presence of venous blood is generally related to
injuries and can be an indicator of oensive scenarios.
Signicant evidence in sexual assaults includes semen,
vaginal secretion, menstrual blood and saliva. is review
summarises and discusses model analyses consisting of
proposed panels of miRNA to distinguish one kind of
body uids from other forensically relevant body uids.
miRNA markers in venous and menstrual blood
Discrimination between venous blood and menstrual
blood could give a clue about the nature of the case and
assist crime reconstruction whether it associates with
violent and/or sexual assaults. e presence of venous
blood is related to violent assaults causing injury or death.
Menstrual blood could be involved in sexual assaults in
a certain case. For instance, a woman who is sexually
assaulted by a man during her menstruation can transfer
the menstrual blood on the suspect’s penis. Hanson E.K.
et al. were the rst to propose certain miRNA markers for
identifying the forensically relevant body uids including
venous and menstrual blood. Using quantitative real-
time polymerase chain reaction (qRT-PCR) as a miRNA
proling and validation method, they demonstrated
that miR-451 and miR-16 were dierentially expressed
in venous blood compared to menstrual blood, semen,
vaginal secretion and saliva. In line with this, several studies
have shown that miR-451 and miR-16 were specic to
venous blood and could be potential markers for venous
blood identication
14-21
(Table 1). Based on a number
of independent studies using qRT-PCR or microarray
for miRNA proling followed by validation of miRNA
expression, an array of potential markers was proposed
and repeatedly identied in several studies.
15,17,22-25
With
the advance of technologies, more recent studies have
conducted massively parallel sequencing (MPS) or next-
generation sequencing (NGS) for screening miRNAs at
the genome-wide level which allows determination of
miRNA quantity and expression patterns. Hence, this
enables the discovery of novel miRNAs in biological
samples. Wang Z. et al. investigated the expression of
miRNAs in venous blood using the Ion Personal Genome
Machine
TM
(PGM
TM
) System with the capacity to detect
2,588 annotated mature miRNAs in the human genome
(miRBase v21).
18
e authors obtained a miRNA prole
and ranked the most abundant miRNAs to search for
potential miRNA markers. ey showed the top six
miRNAs in the blood samples to be miR-486-5p, miR-
16-5p, miR-451a, miR-144-3p, miR-126-5p and miR-
144-5p. e rst four of which had been reported in
previous studies as summarised in Table 1. In addition, a
study used Illumina HiSeq 4000 to examine the miRNA
expression in venous blood.
19
Following analyses of the
data, the study identied the top 20 highly expressed
miRNAs in which four of them were consistent with
previous reports: miR-486-5p, miR-451a, miR-182-
5p and miR-16-5p. More recently, a study on miRNA
proling in the venous blood using MPS and validation
of miRNA expression via qRT-PCR has shown miR-451a,
miR-486-5p, let-7i-5p, let-7b-5p and miR-92a-3p as the
ve most abundant miRNAs.
21
Strikingly, these miRNAs
overlapped with the highly-expressed miRNAs reported
by Wang Z. et al.
18
and El-Mogy M. et al.
19
Altogether,
the accumulating data highlight a panel of miRNAs
repeatedly found in venous blood and the analysis of such
a panel, instead of individual miRNAs, could increase the
specicity of venous blood identication. However, it is
worth noting that some venous blood-specic miRNAs:
miR-451, miR-185-3p and miR-144-3p have also been
detected at an equivalent level in menstrual blood. is
suggests that the application of miRNA markers for
discrimination between venous blood and menstrual
blood requires an analysis model in which a threshold
or cuto value is set up to assist the result interpretation.
miRNA proling in menstrual blood is less extensively
studied compared to studies on venous blood. Based
on the relevant studies in Table 1, it was suggested that
miR-144-3p could be a potential marker for menstrual
blood; however, this miRNA was also highly expressed
in venous blood.
22,23,25
Particularly, miRNA proling in
venous blood in healthy women during the menstrual
cycle revealed that miR-144-3p was the second most
abundant miRNA.
15
is underscores that miR-144-
3p is commonly found in blood-type samples and its
expression is independent of physiological changes during
the menstrual cycle. us, the appropriate approach to
dierentiate menstrual blood from venous blood could
be the establishment of a decision algorithm comprising
miR-144-3p and additional miRNAs, yielding a score to
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TABLE 2. Proposed panels of miRNA and model analyses to distinguish body uids.
Groups miRNAs in the panel Types of model analysis Model analyses Accuracy/testing Experimental
of the model methods/reference
RNA
1. Hanson E.K. - Venous blood: miR-451 and miR-16 2D scatter plots consisting Identify unknown samples by 100% accuracy for SYBR Green
et al., 2009
32
- Menstrual blood: miR-451 and miR- of dCt of two markers in positioning dCt on 2D scatter venous blood, semen qRT-PCR/U6b
412 eachtypeofbodyuid containingclustersofknown andsaliva;~90%
- Semen: miR-135b and miR-10b samples accuracy for vaginal
- Vaginalsecretion:miR-124aand secretion;~80%
miR-372 accuracy for
- Saliva:miR-658andmiR-205 menstrualblood
2. HansonE.K. - Menstrualblood:miR-185-5p, Logisticmodel Logit=-(0.005*dCt(miR-185-5p)*dCt 100%accuracy SYBRGreenqRT-
et al., 2014
23
miR-144-3pandmiR-144-5p (miR-144-3p)*dCt(miR-144-5p))+ (12blindedsamples PCR/miR-940
(3.718*dCt(miR-185-5p))–32.017 tested)
Menstrual blood if p>0.5
(Chi-square)
3. Wang Z. - Menstrual blood vaginal secretion Stepwise strategy to Identify saliva using a combination N/A TaqMan qRT-PCR/
et al., 2015
34
and saliva: miR-205-5p identify saliva of miRNAs to distinguish saliva U6
- Menstrualblood:miR-214-3p fromotherbodyuids
- Saliva and menstrual blood: miR-203a
- Semen:miR-891a
4. SauerE. - Semen:miR-891a Decisionalgorithm Startedwithquanticationof 90%accuracy TaqManqRT-PCR/
et al.,2015
33
- Venousandmenstrualblood: miR-891atodifferentiatesemen. (9outof10blinded SNORD24,
miR-144-3pandmiR-203a-3p Non-semensampleswere sampleswere SNORD38Band
5. SauerE. - Vaginalsecretionandsaliva: subsequentlyanalysedusing correctlyidentied.) SNORD43
et al.,2016
25
miR-124-3pandmiR-203a-3p D=-1.504-0.127*dCt(miR-144-3p)
+0.454*dCt(miR-203a-3p)
Venous blood if D>0 and menstrual
blood if D<0
D=-3.305-0.743*dCt(miR-203a-3p)
+0.582*dCt(miR-124-3p)
Saliva if D>0 and vaginal secretion
if D<0
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TABLE 1. Summary of reported miRNAs in forensically relevant body uids, analysed by miRNA proling and/or validation. (continue)
Groups Venous blood Menstrual Semen Vaginal Saliva Screening Validation Evaluation of miRNA
blood secretion platforms methods/reference stability in stain
RNA samples
6. Rekker K. et al., miR-451a* N/A N/A N/A N/A qRT-PCR N/A N/A
2013
15
miR-144-3p* (Exiqon
miR-16-5p* miRCURY
miR-15a-5p* LNAmicroRNA)
miR-19b-3p HumanpanelI)
miR-142-3p
miR-486-5p
miR-92a-3p*
miR-20a-5p
miR-223-3p
miR-103a-3p
miR-93-5p
miR-106a-5p
let-7g-5p*
let-7b-5p*
7. Wang Z. et al., miR-486* miR-214 miR-888 N/A N/A Microarray TaqMan -Bloodstainsstoredat
2013
17
miR-16* miR-891a* qRT-PCR/U6 RT,1month:No
signicantchangein
miR-486andmiR-16
expressioncompared
to fresh samples
- Menstrual bloodstains
stored at RT, 1 month:
Nosignicantchange
inmiR-214expression
compared to fresh
samples
- Semen stains stored
at RT, 1 month: No
signicantchangein
miR-888andmiR-891
expressioncompared
to fresh samples
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TABLE 1. Summary of reported miRNAs in forensically relevant body uids, analysed by miRNA proling and/or validation. (continue)
Groups Venous blood Menstrual Semen Vaginal Saliva Screening Validation Evaluation of miRNA
blood secretion platforms methods/reference stability in stain
RNA samples
8. HansonE.K.et al., miR-185-5p* miR-185-5p* N/A N/A N/A qRT-PCR SYBRGreen N/A
2014
23
miR-144-3p* miR-144-3p* qRT-PCR/miR-940
miR-144-5p*
9. ParkJ.L.et al., miR-484 N/A miR-2392 miR-1260b miR-223 Microarray SYBRGreen N/A
2014
24
miR-182* miR-3197 miR-654-5p miR-145 qRT-PCR/U6
10. Sauer E. et al., miR-144-3p* miR-203a-3p* miR-891a* miR-124-3p miR-203a* N/A TaqManqRT- N/A
2015
33
PCR/SNORD24,
SNORD38Band
SNORD43
11. Tong D. et al., N/A N/A miR-10b N/A N/A N/A TaqMan qRT- - Semen stains stored at
2015
38
miR-135b PCR/U6b 25°C, 1 year: No
signicantchangein
miR-10b and miR-135b
expressioncompared
to stains at day 1
12. Wang Z. et al., N/A N/A N/A N/A miR-200c-3p* N/A TaqManqRT- N/A
2015
34
miR-203a* PCR/U6
miR-205-5p*
13. Sauer E. et al., miR-144-3p* miR-144-3p* miR-891a* N/A N/A Microarray TaqManqRT- -Bloodstainsstoredat
2016
25
miR-10a PCR/SNORD24, RT,1to36years:
miR-10b SNORD38B miR-144-3pwas
miR-135b andSNORD43 detectableatthelevel
that yielded the correct
uididenticationusing
the decision algorithm.
- Semen stains stored at
RT,1year:miR-891a
was detectable at the
level that yielded the
correctuididentication
using the decision
algorithm.
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TABLE 1. Summary of reported miRNAs in forensically relevant body uids, analysed by miRNA proling and/or validation. (continue)
Groups Venous blood Menstrual Semen Vaginal Saliva Screening Validation Evaluation of miRNA
blood secretion platforms methods/reference stability in stain
RNA samples
14.Seashols-WilliamsS. N/A N/A miR-891a* N/A miR-26b Massively SYBRGreenqRT- N/A
et al.,2016
28
parallel PCR/Let7iand
sequencing Let-7g
(IlluminaHiseq)
15. Wang Z.et al., miR-486-5p* N/A N/A N/A miR-203a-3p* Massively N/A N/A
2016
18
miR-16-5p* miR-205-5p* parallel
miR-451a* miR-223-3p sequencing
miR-144-3p* miR-200c-3p* (IonPersonal
miR-126-5p miR-141-3p Genome
miR-144-5p miR-375* Machine1
miR-34a-5p system)
let-7c-5p
miR-27b-3p*
miR-125b-5p
miR-23b-3p
miR-99a-5p*
miR-29a-3p
miR-23a-3p
miR-27a-3p
miR-210-3p
miR-24-3p*
miR-29b-3p
miR-22-3p
16.LiZ.et al., N/A miR-141-3p N/A N/A N/A Microarray SYBR Green N/A
2017
39
miR-497-5p and TaqMan
miR-143-5p qRT-PCR/U6
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Groups Venous blood Menstrual Semen Vaginal Saliva Screening Validation Evaluation of miRNA
blood secretion platforms methods/reference stability in stain
RNA samples
17. Wang Z. et al., N/A N/A miR-891a* N/A N/A Massively N/A N/A
2017
40
miR-888* parallel
miR-429 sequencing
miR-449a
miR-34b
miR-2392
miR-3197
miR-30a
miR-196b
18. El-Mogy M. et al., miR-486-5p* N/A N/A N/A miR-143-3p Massively N/A N/A
2018
19
let-7f-5p miR-203a-3p* parallel
miR-451a* miR191-5p sequencing
miR-92a-3p* miR-26a-5p
miR-191-5p let-7f-5p
let-7a-5p miR-486-5p
let-7i-5p* miR-378a-3p
let-7g-5p miR-27b-3p*
miR-182-5p* let-7g-5p
let-7b-5p* miR-24-3p*
miR-185-5p* let-7a-5p
miR-16-5p* miR-375*
miR-26a-5p miR-148a-3p
miR-25-3p miR-21-5p
miR-183-5p miR-205-5p*
miR-181a-5p miR-320a
miR-151a-5p miR-99a-5p*
miR-151b let-7i-5p
miR-101-3p miR-92a-3p
miR-30d-5p let-7b-5p
miR-30e-5p
TABLE 1. Summary of reported miRNAs in forensically relevant body uids, analysed by miRNA proling and/or validation. (continue)
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N/A: Not applicable
RT: Room temperature
Asterisks indicate miRNAs that were repeatedly found in more than one study.
miR-451 is also known as miR-451a.
miR-16 is also known as miR-16-5p.
miR-182 is also known as miR-182-5p.
miR-205 is also known as miR-205-5p.
miR-124a is also known as miR-124-3p.
TABLE 1. Summary of reported miRNAs in forensically relevant body uids, analysed by miRNA proling and/or validation. (continue)
Groups Venous blood Menstrual Semen Vaginal Saliva Screening Validation Evaluation of miRNA
blood secretion platforms methods/reference stability in stain
RNA samples
19.OLearyK.R. et al., miR-451* N/A miR-891a* N/A N/A N/A TaqManqRT- N/A
2018
20
PCR/miR-16
20. Tian H. et al.,
0
N/A N/A miR-891a* N/A N/A N/A TaqManqRT- N/A
2018
3
miR-888* PCR/U6
miR-10a
miR-10b
miR-135b
21. Fang C. et al., miR-451a* N/A N/A N/A N/A Massively SYBRGreen -Bloodstainsstored
2019
21
miR-486-5p* parallel qRT-PCR/ atRT,3weeksand
let-7i-5p* sequencing Cel-miR-39 37°C,1day:No
let-7b-5p* signicantchange
miR-92a-3p* inmiR-451aand
miR-486-5p
expressioncompared
to fresh samples
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classify the type of the blood. Indeed, Hanson E.K. et al.
have generated a probability algorithm using miR-144-
3p, miR-144-5p and miR-185-5p and the validation
of this model showed 100% accuracy in a set of test
samples, which are independent of samples used in the
model development.
23
To allow the use of the model in
practical work, the authors determined the expression of
the miRNAs throughout 28 days of the menstrual cycle.
e results from two donors showed that the developed
model successfully identied menstrual blood between
day 1 through 4 of menstruations. Sauer E. et al. also
proposed an algorithm using miR-144-3p and miR-
203a-3p to distinguish menstrual blood from venous
blood with 100% accuracy.
25
Analysis of miRNA stability
in aged samples, approximately one to four years old,
demonstrated that the menstrual blood samples were
successfully classied from venous blood, suggesting
the exible implementation of the algorithm in aged
menstrual blood. Because both algorithms were validated
in a small sample size: 12 and 2 samples, respectively,
further studies may be conducted in a larger sample size
prior to application for casework.
To be able to adopt miRNAs as markers for body
uid identication, their stability within the samples
is one of the most important concerns. In bloodstains,
it was shown that potential markers for venous blood
including miR-16, miR-144-3p, miR-486, miR-451a were
relatively stable in samples stored at room temperature.
17,21,25
Particularly, miR-144-3p abundance was not signicantly
altered in bloodstains kept for one year
22
and 36 years.
25
Quantication of miR-451a in bloodstains exposed to
natural heat (8.9-61°C), humidity (10-99%) and sunlight
for 180 days revealed that miR-451a was detected, though
its level was signicantly decreased as compared to the
control samples kept at room temperature, low humidity
and darkness.
26
In line with this, bloodstains treated with
1% sodium hypochlorite solutions showed a signicant
downregulation of six blood markers (miR-16, miR-
486, miR-451a, miR-20a, miR-151a and miR-148a)
compared to untreated controls.
21
Based on the studies
of miRNA stability in various circumstances, it seems
that miRNAs tend to be degraded in the samples under
environmental challenges and harsh chemical exposure.
Taken together, this suggests that samples for miRNA
analysis should be stored in an appropriate condition and
be protected from exposure to chemicals. In menstrual
bloodstains, expression of miR-214 in samples stored at
room temperature for one month was not signicantly
altered compared to the fresh sample.
17
In contrast,
miRNAs in liquid whole blood appeared to be decreased
following sample storage at room temperature for 72
hours and at -80°C for nine months.
27
is suggests
that sample storage in dehydrated form is preferable to
liquid form to protect miRNAs from degradation, and
the specimen collection using a dry swab and stains of
biological uids gathered at a crime scene are applicable
for miRNA analyses.
miRNA markers in semen
Semen is crucial evidence in sexual assault cases
that can be present in the form of stains on objects or
fabrics and it can be recovered from a victim’s body,
e.g. skin and vagina. Semen comprises spermatozoa and
uids from the seminal vesicles, the prostate and the
bulbourethral glands. Although spermatozoa are ultimate
markers of semen, they do not always exist especially in
sterile seminal uid. To search for alternative markers
for identifying semen, miRNA proling was conducted
by the abovementioned studies (Table 1). Among the
proposed miRNAs, it was clear that miR-891a was highly
and exclusively expressed in semen compared to other
forensically relevant body uids: venous blood, menstrual
blood, vaginal secretion and saliva.
17,20,22,25,28
Due to its
distinctive expression in semen, miR-891a was suggested
to be solely used for semen identication without the
necessity of a statistical algorithm.
Evaluation of time-wise miRNA stability of miR-
891a using qRT-PCR revealed that semen stains stored
at room temperature for one month
17
, one year
22
and
three years
25
had a similar miRNA expression compared
to fresh samples. Furthermore, a study has determined
the eects of heat, humidity and sunlight on the stability
of miR-891a by which semen stains were kept in an
environmental chamber mimicking dry 24 hours in a
Virginia summer with a temperature between 45-52°C
and humidity of 50% for 14 days.
29
roughout the
experiment, it was observed that expression of miR-
891a was not signicantly changed in the stain kept
in the chamber compared to the control samples kept
at room temperature.
29
Whereas, samples treated with
dish detergents showed amplication failures of let-
7g, a highly expressed reference miRNA that could be
because the detergent disrupts the cell membrane lipid
composition of miRNA-containing microvesicles.
29
Another
study has treated semen stains at a higher temperature
and humidity (a temperature between 8.9-61.0°C and
humidity ranged from 10-99%) for 180 days. It was
revealed that expression of miR-891a was dramatically
decreased from day 120, compared to control samples
kept at room temperature, low humidity and darkness
(a temperature between 19.0-23.7 °C and humidity ranged
from 38-52%).
26
is provides examples of environmental
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factors and chemical exposure aecting the analysis of
miRNA expression in semen. Further studies on other
factors are required to understand the limitation of
miRNA analysis which would be a great consideration
for implementation into casework.
It is likely that miR-891a can be used to identify
infertile semen. Although miR-891a was signicantly down-
regulated in four types of infertile semen (asthenospermia,
oligospermia, azoospermia and oligospermia combined
with asthenospermia) compared to normal semen, its
expression was still higher in the infertile semen when
compared to non-semen body uids (venous blood,
menstrual blood, vaginal secretion and saliva).
30
is
suggests that miR-891a could be used to discriminate
semen from other forensic-related body uids. Conversely,
a subsequent study showed that the expression of miR-
891a in azoospermia and asthenospermia was comparable
to that in normal semen.
31
e discrepancy between the
two studies can be derived from dierences in reference
RNAs used in the miRNA quantication in which the
former study used SNORD24 and SNORD38B, whereas
the latter study used 5s-rRNA. Taken together, the ndings
point out the potential of miR-891a for identifying both
normal and infertile semen from other forensically relevant
body uids.
miRNA markers in vaginal secretion and saliva
Vaginal secretion is one of the most important
forensically relevant body uids, particularly in sexual
assault cases. It can be present on penile swabs, male
underpants and objects with alleged vaginal penetration.
Among several studies, it has been shown by two groups
that miR-124a (also known as miR-124-3p) was strongly
associated with vaginal secretion.
32,33
A miRNA assay
combining miR-124a with miR-372 revealed that the
assay correctly dierentiated ten of a total of eleven
vaginal secretion samples from venous blood, menstrual
blood, semen and saliva, suggesting that these miRNA
markers could be used for an initial screening of unknown
samples.
32
Likewise, miR-124a was selected together
with miR-203a-3p to develop a decision tree facilitating
the determination of vaginal secretion from venous
blood, menstrual blood, semen and saliva. rough the
validation of the decision tree using blind samples, it was
demonstrated that nine out of a total of ten samples were
correctly identied.
33
e overlap of miR-124a in these
studies suggests that miR-124a could be a promising
marker for vaginal secretion.
e identication of saliva can be proof that an assault
occurred, especially in sexual assault cases. For example,
saliva may be deposited on female underpants or bodies
in a disputed licking event. Several independent lines of
evidence suggested that the three miRNAs: miR-200c-
3p, miR-203a and miR-205-5p were potential markers
for saliva.
14,18,19,33,34
Quantication of the three miRNAs
in saliva, vaginal secretion, semen, venous blood and
menstrual blood revealed that they were also detected in
vaginal secretion and menstrual blood at a comparable
level to that in saliva, whereas their expression was low
in semen and venous blood.
34
is is possible due to
the fact that both saliva and vaginal secretion contain
mucous membranes and menstrual blood consists of
vaginal epithelial cells.
35
us, these body uids share a
similar pattern of miRNA expression. Although miR-
200c-3p, miR-203a and miR-205-5p were not exclusively
expressed in saliva, they tended to be potential markers
for saliva identication when they were combined with
other body uid-specic miRNAs to establish a stepwise
approach for body uid identication.
33,34
Proposed miRNA panels and analysis strategies to
identify forensically relevant body uids
To eectively identify forensically relevant body uids,
an ideal strategy would be the analysis of a panel, which
consists of dierentially expressed miRNAs. As shown in
Table 2, the rst panel was proposed by Hanson E.K. et al.
who quantied two specic markers for each type of body
uid and plotted dCt values in two-dimensional (2D)
scatter plot.
32
In this model, the unknown samples could
be categorised against the cluster of dCt values on the 2D
scatter plot of known samples, allowing identication of
the body uid origin. e authors tested the specicity
of the model and showed that the accuracy was in the
range of 80-100% for the ve body uids. Although the
accuracy was close to 100%, the model may not be able
to identify body uids of which do not clearly belong
to a particular cluster. is suggests the requirement of
statistical approaches to establish a threshold for the
probability of identication. Subsequent studies have
addressed this issue and developed statistical models to
determine the source of body uids.
23,25,30,33,41
A signicant
model was reported by the group of Sauer E. et al. who
suggested to initially distinguish semen from other body
uids using miR-891a, a truly semen-specic marker.
25,33
If the sample was non-semen, further statistical analysis
was applied to dierentiate venous blood from menstrual
blood and vaginal secretion from saliva. e expression of
semen-specic markers (miR-891a, miR-135a and miR-
10a) was extended in infertile semen and it was shown
that their expression was signicantly down-regulated in
infertile semen compared to normal semen.
30
However,
the reduction in miRNA expression did not aect the
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Praihirunkit et al.
TABLE 2. Proposed panels of miRNA and model analyses to distinguish body uids.
Groups miRNAs in the panel Types of model analysis Model analyses Accuracy/testing Experimental
of the model methods/reference
RNA
1. Hanson E.K. - Venous blood: miR-451 and miR-16 2D scatter plots consisting Identify unknown samples by 100% accuracy for SYBR Green
et al., 2009
32
- Menstrual blood: miR-451 and miR- of dCt of two markers in positioning dCt on 2D scatter venous blood, semen qRT-PCR/U6b
412 eachtypeofbodyuid containingclustersofknown andsaliva;~90%
- Semen: miR-135b and miR-10b samples accuracy for vaginal
- Vaginalsecretion:miR-124aand secretion;~80%
miR-372 accuracy for
- Saliva:miR-658andmiR-205 menstrualblood
2. HansonE.K. - Menstrualblood:miR-185-5p, Logisticmodel Logit=-(0.005*dCt(miR-185-5p)*dCt 100%accuracy SYBRGreenqRT-
et al., 2014
23
miR-144-3pandmiR-144-5p (miR-144-3p)*dCt(miR-144-5p))+ (12blindedsamples PCR/miR-940
(3.718*dCt(miR-185-5p))–32.017 tested)
Menstrual blood if p>0.5
(Chi-square)
3. Wang Z. - Menstrual blood vaginal secretion Stepwise strategy to Identify saliva using a combination N/A TaqMan qRT-PCR/
et al., 2015
34
and saliva: miR-205-5p identify saliva of miRNAs to distinguish saliva U6
- Menstrualblood:miR-214-3p fromotherbodyuids
- Saliva and menstrual blood: miR-203a
- Semen:miR-891a
4. SauerE. - Semen:miR-891a Decisionalgorithm Startedwithquanticationof 90%accuracy TaqManqRT-PCR/
et al.,2015
33
- Venousandmenstrualblood: miR-891atodifferentiatesemen. (9outof10blinded SNORD24,
miR-144-3pandmiR-203a-3p Non-semensampleswere sampleswere SNORD38Band
5. SauerE. - Vaginalsecretionandsaliva: subsequentlyanalysedusing correctlyidentied.) SNORD43
et al.,2016
25
miR-124-3pandmiR-203a-3p D=-1.504-0.127*dCt(miR-144-3p)
+0.454*dCt(miR-203a-3p)
Venous blood if D>0 and menstrual
blood if D<0
D=-3.305-0.743*dCt(miR-203a-3p)
+0.582*dCt(miR-124-3p)
Saliva if D>0 and vaginal secretion
if D<0
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TABLE 2. Proposed panels of miRNA and model analyses to distinguish body uids. (continue)
Groups miRNAs in the panel Types of model analysis Model analyses Accuracy/testing Experimental
of the model methods/reference
RNA
6. SirkerM. - Venousandmenstrualblood: Receiveroperator CalculatingtheareaundertheROC N/A TaqManqRT-PCR/
et al.,2017
42
miR-451 characteristic(ROC) curve(AUC)todiscriminate miR-26b,miR-92,
- Semen:miR-10bandmiR-374 betweenpairsofbodyuids miR-484,miR-144
- Vaginal secretion: miR-203
- Saliva: miR-943
7. TianH. - Semen:miR-891a,miR-135a Discriminationfunction Y2=-1.152*dCt(miR-10a)+ 97.5%accuracy TaqManqRT-PCR/
et al.,2018
30
andmiR-10a analysis 0.910*dCt(miR-135a)+1.092*dCt U6
(miR-891a)-0.639
Semen if Y2 < 0 and non-semen
if Y2 > 0.
8. DorumG. - Venousblood:miR-126-3p, Partialleastsquares(PLS) - 65%accuracy Massivelyparallel
et al., 2019
41
miR-486-3pandmiR-486-5p andlineardiscriminant (13outof20blinded sequencing
- Menstrualblood:miR-200a-3p analysis(LDA) sampleswerecorrectly
andmiR-451a identied.)
- Semen: miR-375
- Vaginal secretion: miR-203b-5p
and miR-205-5p
- Saliva and skin: miR-1246
9. Fujimoto S. - Venous blood: miR-144-3p Partial least squares- - >90 % posterior SYBR Green qRT-
et al.,2019
31
andmiR-451a-5p discriminantanalysis probability PCR/miR-484,
- Semen:miR-888-5pand (PLS-DA) (13outof14blinded miR-92a-3pand
miR-891a-5p sampleswere 5S-rRNA
- Vaginalsecretion:miR-1260b correctlyidentied.)
- Saliva: miR-203a-3p and
miR-223-3p
2D: two-dimensional
N/A: Not applicable
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discrimination function analysis to dierentiate semen
from non-semen as follows: Y2 = -1.152*dCt (miR-10a)
+ 0.910*dCt (miR-135a) +1.092*dCt (miR-891a)-0.639,
semen if Y2 < 0 and non-semen if Y2 > 0. us, this
underscores the potential of miR-891a for identifying
semen and suggests possible implementation in casework.
Based on miRNA expression using MPS, a recent
study proposed a panel of nine miRNAs for identication
of six body uids/tissues: venous blood, menstrual blood,
semen, vaginal secretion, saliva and skin.
41
Notably, three
miRNAs (miR-126-3p, miR-486-3p and miR-486-5p)
were selected as venous blood-specic markers which is
in accordance with previous studies.
14,15,17-19, 21
While the
panel included miR-205-5p as a vaginal secretion marker,
the miRNA has been also shown to be highly expressed
in saliva.
14,18,19,32,34
Possibly, both vaginal secretion and
saliva are generated from mucosa-like environments,
allowing them to share a similar pattern of miRNA
expression. e overlap pattern of miRNA expression
adds an extra layer of complexity to the development
of a miRNA panel. is problem could be overcome by
exploring more specic miRNAs and/or generating a
statistical algorithm to analyse a dierential expression
that would permit the prediction of body uid origins.
To date, the existing data provide a good starting point
for further work, showing the potential of a miRNA panel
to simultaneously analyse several forensically important
body uids. Prior to the implementation of a miRNA
panel in forensic casework, it is necessary to validate such
a panel in a larger sample size. Besides, the analysis of
miRNA via qRT-PCR requires the standardisation of the
procedure using robust reference genes for normalisation
that would decrease inter-laboratory variations and take
miRNAs a step closer from research to casework for
body uid identication.
Conclusions and future directions towards applications
of miRNA markers in forensic casework
During the last decade, miRNAs have emerged
as promising markers for body uid identication and
several independent lines of evidence have reported
a range of potential miRNAs specic to venous blood,
menstrual blood, semen, vaginal secretion and saliva,
which are commonly signicant evidence for crime
reconstruction. A great eort has been made to transfer
these miRNAs from laboratory benches to applications in
forensic casework through an evaluation of the markers
in uid stains and development of model analysis to
accurately dierentiate a certain body uid from the
others. An ideal strategy involves the establishment of
a miRNA panel consisting of dierentially expressed
miRNAs in forensically relevant body uids that will
allow identication of unknown stains. To achieve this,
several studies have developed various model analyses
and some of them used overlapped miRNA markers
from previous studies. Based on the previous studies,
it appears that all panels allow distinct identication
of blood in general and semen, whereas the candidate
miRNAs showed less association with vaginal secretion
and saliva. is suggests that the initial implementation of
miRNA markers for routine casework could be applicable
for the identication of blood and semen.
To apply a miRNA analysis into routine procedures,
it is necessary to establish standardised protocols starting
from miRNA extraction, determination of miRNA
expression, validation of reference RNAs for qRT-PCR
normalisation, result analysis and result interpretation.
At the step of miRNA quantication using qRT-PCR,
the protocol largely requires a solid normalisation of
reference genes, which are non-biological variances to
deliver reliable and reproducible results. To address this
point, the MIQE-guidelines (Minimum Information for
Publication of Quantitative Real-Time PCR Experiments)
is recommended to be adopted in forensic genetics
for method standardization.
43
e MIQE-guidelines
suggest a qRT-PCR checklist covering details of samples
and sample processing, assay optimisation/validation,
experiment setup and data analysis that should be
included into the submitted manuscript along with the
full disclosure of oligonucleotide sequences, aiming to
increase experimental transparency and reliability of the
result.
44,45
is would also help researchers to reproduce
the published protocol and unequivocally interpret the
result. Besides, the standardised protocols can be conducted
in workgroup trials at which a selected miRNA panel
is validated in a large sample size. e accumulation of
the result from laboratory members would also allow
determination of inter-laboratory variances that would
be useful for protocol optimisation or development of the
assay guideline. At present, identication of forensically
relevant body uids usually relies on mRNA-based analysis.
is is likely due to the existence of several collaborative
exercises on DNA/mRNA co-analysis which provides
guidelines for DNA/mRNA co-extraction, mRNA proling,
data interpretation as well as awareness throughout the
technique.
46-49
If inter-laboratory trials of miRNA markers
were established, it would be worthwhile to include
miRNA/mRNA co-analysis. is would maximise the
capacity of the approach in body uid identication. At the
step of the extraction, several studies have demonstrated
that miRNAs in forensically relevant body uids can be
co-extracted with DNA using standard DNA extraction
Praihirunkit et al.
Volume 72, No.6: 2020 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
525
Review Article
SMJ
methods.
50-52
More recently, it has been shown that a co-
extraction kit, the AllPrep DNA/RNA/miRNA Universal
Kit (APU), had comparable eciency to standard kits
for mRNA/DNA or miRNA/DNA co-extraction.
53
e
successful co-extraction provides good support for
the development of the protocol to analyse miRNAs,
mRNAs and DNA, especially when amounts of sample
are limited and DNA typing is more preferable. is
would allow the method to be exible and eective in
sample consumption.
ACKNOWLEDGMENTS
I would like to thank Dr. Hans Rudi Grams under
the program of Research Clinic, the Faculty of Allied
Health Sciences, ammasat University, for language
help of the manuscript.
Formatting of funding sources: is review article did
not receive any specic grant from funding agencies in
the public, commercial, or not-for-prot sectors.
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