Relationship between outcome of written and clinical parts in internal medicine board certifying examination.

Objective: To assess the correlation between written and clinical scores of the Thai Board of Internal Medicine certification examination in different academic years. Methods: Data from 585 internal medicine residents who passed both written and clinical parts of the board certifying examination in the first attempt during the academic year 2005-2007 were collected. Correlation between scores from both parts in each year were then examined. Results: Modest positive linear correlation was found between the written and clinical examination scores in overall (r = 0.57, 0.55, and 0.38, p <0.001 in 2005-2007 respectively). When considered for the subpart of clinical examination scores, the correlation with the section of laboratory interpretation was highest (r = 0.52, 0.54, and 0.33, p <0.001 in 2005-2007 respectively). Conclusion: The outcome of written and clinical parts of certification examination for Thai Board of Internal Medicine had a modest relationship.

Pulmonary sarcoidosis: Classic radiographic finding.

We present the classic image findings of pulmonary sarcoidosis which is a rare disease in our country. A 31-year-old woman presents with an abnormal annual check up chest radiograph, which showed bilateral, symmetrical hilar nodes and a right paratracheal node enlargement without abnormal lung parenchyma. The physical examination, complete blood count, and blood chemistry, were unremarkable. Although many diseases can present with this abnormal image finding, but the combination of the nodal group involvement, the presence of intranodal calcification and nodal enhancement pattern, along with other pertinent positive findings on the chest CT scan, the diagnosis could be made.

Factors determining the severity of pulmonary function impairment in silicotic patients.

OBJECTIVE: Silicosis is the most common occupational lung disease in Thailand. Determinants of pulmonary function impairment in Thai silicotic patients have not been mentioned before. MATERIAL AND METHOD: The present study was conducted in silicotic patients who attended the Siriraj Occupational Lung Clinic in the year 2006. Patients were classified according to the forced expiratory volume in one second (FEV1) into the severe impairment group (< 50% predicted) and the non-severe group (FEV1 > 50% predicted) which includes normal FEV1. Comparison between the two groups in terms of demographic characteristics, smoking history, history of pulmonary tuberculosis, and radiographic features were assessed. RESULTS: Thirty-four patients of which 24 were female (70.6%) had an overall mean age of 53.7 years. Seven patients (20.6%) had severe impairment, four were female, three were smokers, and two had a history of pulmonary tuberculosis. All of the severe impairment patients had nodule profusion in category 2 and had large opacity. Only the presence of large opacity was significantly associated with the severity of pulmonary function impairment (p = 0.002). CONCLUSION: Only the presence of large opacity in a chest radiograph can determine the severity of pulmonary function impairment in Thai silicotic patients.

Comparison of clinical and polysomnographic characteristics of non-obese and obese patients with obstructive sleep apnea.

OBJECTIVE: To compare the clinical features, anthropometric indices, and polysomnographic data between different body mass index (BMI) subgroups of obstructive sleep apnea (OSA) patients. MATERIAL AND METHOD: The authors reviewed the data from OSA patients in Siriraj Sleep Clinic from April 2005 to September 2006. Objective measurement for sleepiness (Epworth Sleepiness Scale, ESS), anthropometric measurements [body mass index (BMI), neck circumference, thyromental distance, Mallampati S score, and occlusion pattern] and polysomnographic recordings [apnea/hypopnea index (AHI) during REM and NREM periods, respiratory arousal index, periodic leg movement index, minimal oxygen saturation, total sleep time with oxygen saturation <90%, and desaturation index] were collected. The patients were stratified into the non-obese group and obese group if their BMI was <27 or > or =27 kg/m2 respectively. RESULTS: Of the total 158 patients, 71 were non-obese and 87 were obese, no difference in mean age and sex was observed, but more patients with hypertension and coronary artery disease were noted in the obese group. Mean ESS was not different between the 2 groups. In anthropometric measurements, the obese group had statistically significant large neck circumference (41.6 +/- 3.5 cm vs. 37.0 +/- 2.9 cm, p<0.001), but the nonobese group had a shorter thyromental distance (56.4 +/- 11.7 mm vs. 61.4 +/- 11.2 mm, p=0.006), with no significant difference in Mallampatis score and occlusion pattern. In polysomnographic data, the obese group had statistical significantly more severity of various indices except for AHI during the REM period and the periodic limb movement index. CONCLUSION: Non-obese obstructive sleep apnea patients have more bony structural change than the obese ones as demonstrated by shorter thyromental distance. But degree of abnormalities during sleep was less severe in nearly all aspects.

Maxillomandibular advancement (MMA) for the treatment of severe obstructive sleep apnea syndrome (OSAS): The first case report in Thailand.

Objective: To report the first case experience of maxillomandibular advancement for treatment of severe obstructive sleep apnea syndrome (OSAS) in Thailand. Methods: We present a 65-year-old man patient with severe obstructive sleep apnea syndrome who underwent maxillomandibular advancement in Siriraj Hospital with 4 months follow up. Results: Significant improvement in both subjective symptoms and objective polysomnographic parameters have been demonstrated. There were no serious adverse effects after the operation. Conclusion: Maxillomandibular Advancement procedure may be an excellent alternative treatment for severe OSAS patients who failed CPAP or other interventions and do not need a tracheostomy.

Recovery of heart rate variability in patients with moderate to severe obstructive sleep apnea after 6-month continuous positive airway pressure treatment.

OBJECTIVE: To evaluate the effect of long-term treatment with continuous positive airway pressure (CPAP) on the heart rate variability (HRV) of obstructive sleep apnea (OSA) patients. MATERIAL AND METHOD: Patients with moderate to severe OSA who had never used CPAP treatment were enrolled. Short recording HRV analysis was performed at baseline then at one, three, and six months after CPAP treatment. The measurement included low frequency HRV (LF), high frequency HRV (HF), low frequency to high frequency ratio (LHR), and standard deviation of R-R intervals (SDNN). All domains were measured both during spontaneous and deep breathing. RESULTS: There were 10 patients in the present study, all were men with the mean age of 45 years, mean body mass index 29.3 kg/m2, mean apnea-hypopnea index 60.9 events/hour, and mean average CPAP usage 4.8 hours/night. The HRV showed no significant change after one and three months of CPAP treatment. At 6 months, the only significant change was the SDNN measured after deep breathing (28.80 +/- 9.83 vs. 34.43 +/- 14.23 millisecond, p = 0.032). CONCLUSION: One aspect of heart rate variability in moderate to severe obstructive sleep apnea patients was improved after six month's continuous positive airway pressure treatment.

Rapidly enlarging and asymptomatic abdominal aortic aneurysm in a male patient with chronic obstructive pulmonary disease: A case report of early experience of endovascular aortic aneurysm repair (EVAR).

Objective: to report a case of an incidental large asymptomatic AAA in an ex-smoker with severe COPD successfully treated by EVAR and to delineate the results and complications of EVAR performed in operative theater of Siriraj Hospital. Methods: A retrospective review of selected high-risk patients with asymptomatic AAA treated by EVAR in operative theater of our hospital from August 2003 to December 2005 was performed. Results: All nine cases (100%), including reported case (100%), were successfully treated by EVAR. Merely one of 30-day peri-operative death (11.1%), of post-operative cardiopulmonary arrest (11.1%), of early AAA rupture (11.1%), of early graft limb occlusion (11.1%), of late graft limb occlusion (11.1%), and of early type II endoleak (11.1%) took place in this study. Neither late AAA rupture, AAA sac enlargement, nor graft migration happened. Conclusion: EVAR was achieved as a minimal invasive treatment of an incidental large asymptomatic AAA in an ex-smoker with severe COPD. Although EVAR provides an excellent alternative of AAA in high-risk patients, its high peri-operative mortality rate around 10 % should be taken into account.

HRCT of pulmonary tuberculosis mimics malignancy: a preliminary report.

OBJECTIVE: To evaluate potential predictors of high resolution CT (HRCT) findings of pulmonary mass caused by tuberculosis (Tbc). MATERIAL AND METHOD: A retrospective study of chest HRCT was performed in 10 patients diagnosed as pulmonary Tbc. The size, characteristics of lesions, enhancement and mediastinal lymphadenopathy were interpreted. The final diagnosis was reached by laboratory and pathological specimens or clinical improvement from treatment of the Tbc. RESULTS: Of 10 patients, 6 were males and 4 were females. The mean age was 53.5 years old. There were 13 masses analyzed. The mean size of the lesions was 2.3 cm and 53.8% had diameters more than 2 cm. The locations of lesions were right upper lobe (30.8%), right middle lobe (7.7%), right lower lobe (38.5%) and left upper lobe (23.1%). Calcification was found in two lesions. The HRCT findings were spiculated margin (76.9%), lobulated margin (23.1%), smooth margin (7.7%), ground-glass opacity (23.1%), concave border (61.5%), polygonal shape (53.8%), air bronchogram (38.5%), pseudocavity (15.4%), pleural tag (30.8%), distortion of vessels (23.1%), satellite lesions (38.5%), and peripheral subpleural lesion (46.2%). Only 7 cases of enhanced study were available and two cases showed enhancement. Of the 10 cases, mediastinal lymphadenopathy was found in 8(80%) cases. The size of the lymph nodes was less than 2 cm in 6 cases and larger than 2 cm in 2 cases. Other associated findings were pleural thickening or effusion (60%), evidence of volume loss (20%), emphysema (40%), and infiltrations (50%). CONCLUSION: Many characteristics of Tbc lesion on HRCT mimic reported malignant lesions. Re-evaluation of value of HRCT for controversial lesions is needed

The cost-effectiveness of mini peak expiratory flow as a screening test for chronic obstructive pulmonary disease among the Bangkok elderly.

This study aims to explore the cost-effectiveness of Mini Peak Expiratory Flow (miniPEF) as a screening test for Chronic Obstructive Pulmonary Disease (COPD) among the elderly in 124 urban communities around Siriraj Hospital, using the gold standard of diagnosis based on the guidelines of the Thoracic Society of Thailand. There were 3,094 subjects who participated and completed all the tests. The results showed that the cut-off miniPEF percentage of predicted value of highest average accuracy was 62 per cent. The sensitivity was 72.7 per cent (95% CI 67.0-78.6) and the specificity was 81.1 per cent (95% CI 79.7-82.5) The cost of screening 19 elderly to detect one case of COPD is 923 baht, with a false negative rate of 1.9 per cent (95% CI 1.3-2.5%) and a false positive rate of 17.5 per cent (95% CI 15.4-19.6%). It is suggested that measuring a miniPEF is regarded as one of the cost-effective screening tests for COPD in the elderly.

The cost-effectiveness of a questionnaire as a screening test for chronic obstructive pulmonary disease among the Bangkok elderly.

This study aimed to explore the cost-effectiveness of using a questionnaire as a screening test for Chronic Obstructive Pulmonary Disease (COPD) among the Bangkok elderly residing around Siriraj Hospital. The gold standard used for diagnosing COPD followed the guidelines of the Thoracic Society of Thailand. The questionnaire consisted of 10 questions on smoking status, respiratory symptoms and previous history of pulmonary tuberculosis. There were 3,094 elderly who participated, completed the questionnaire, and underwent spirometry as well as chest radiography in the community. The results showed that elderly individuals who are smokers (> 0.5 pack-year) or have ever experienced sudden cough with chest oppression or dyspnea when the weather changes or who have expectorated more than two tablespoons of sputum would be suspected of having COPD with a sensitiviy of 81.4 per cent (95% CI 79.4-83.4), specificity of 62.2 per cent (95% CI 60.4-64.0) false negative rate 1.2 per cent (95% CI 0.7-1.7) and false positive rate 38 per cent (95% CI 35.3-40.7) and subsequently required spirometry and chest X-ray for definitive diagnosis. The test needed to screen 17 elderly individuals to detect one COPD case at a cost of 1,538 baht. This questionnaire is also a self-assessment tool for COPD screening among the elderly in order to encourage them to seek for early medical attention and it is recommended that this should be publicized via the mass media.

The cost-effectiveness of chest radiography as a screening test for chronic obstructive pulmonary disease among the Bangkok elderly.

Regular screening with chest radiography (CXR) in an annual physical check up of the elderly is most frequently practiced. This study aimed to identify the CXR indices and the cost-effectiveness of CXR as a screening test for Chronic Obstructive Pulmonary Disease (COPD) among the elderly in 124 urban communities of Bangkok around Siriraj Hospital. The gold standard for diagnosing COPD followed the guidelines of the Thoracic Society of Thailand. There were 3,094 subjects who participated, completed spirometry and a CXR. The selected nine indices from PA and lateral CXR for diagnosing COPD were based on the presence of hyperinflation. The positive criteria of each index were reported. The cut-off point of best average accuracy ie, Z score of the CXR was 0.07 with a sensitivity of 75.9 per cent (95% CI 70.2-81.6%), specificity of 72.4 per cent (95% CI 70.8-74.0%) and the best average accuracy of 74.1 per cent (95% CI 72.5-75.7%) whereas the cost-effective cut-off point of a Z score of CXR as a screening test for COPD was 0.04 at the lowest grand total cost. The cost to detect one case of COPD was 2,008 baht and needed to screen 17 elderly. It is suggested that CXR is probably not a suitable screening test for COPD in the elderly due to the complicated derivation of the CXR indices. However, its efficacy may be of some value in in-office diagnosis of COPD.

Pharmacokinetics of ofloxacin in drug-resistant tuberculosis.

The pharmacokinetics of ofloxacin were investigated in 11 drug-resistant pulmonary tuberculosis (TB) patients with a mean age (SD) of 38.09 (11.97) years. All patients received ofloxacin 10 mg/kg once daily combined with other active anti-TB drugs. Following an 8-h overnight fast, serum samples were drawn prior to and from 0.25 up to 24 hours after dosing. Serum ofloxacin concentrations were determined by high performance liquid chromatography (HPLC) assay. Pharmacokinetics of ofloxacin were well described by a linear, 2-compartment open model with first-order absorption and first-order elimination. Mean +/- SD of Cmax was 9.61 +/- 2.17 microg/ml occurred at 1.68 +/- 1.21 hours. Means +/- SD of AUC(0-24) and AUC(0-infinity) were 70.57 +/- 26.40 and 82.45 +/- 43.64 microg x h/ml, respectively. Ofloxacin distributed widely with a mean +/- SD of Vss/F of 1.37 +/- 0.24 L/kg. Mean +/- SD of CL/F was 8.19 +/- 2.53 L/h, whereas mean +/- SD of T(1/2beta) and mean residence time were 8.03 +/- 3.37 and 10.77 +/- 4.55 hours, respectively. The free Cmax/MIC of Mycobacterium tuberculosis of 7.7-15.4:1 was estimated. These suggested that ofloxacin 10 mg/kg once daily combined with other active anti-TB drugs provides sufficient Cmax/MIC ratio and long T(1/2beta) which supported its use in drug-resistant TB.

An unexpected complication of traditional Thai massage.

Traditional massage is one of the art of the Thai people, but its application in an inappropriate situation or with incorrect technique may contribute to severe complications. we report a 46-year-old man who was massaged by his nephew in oreder to relieve an aching right leg. Unfortunately, he developed a deep venous thrombosis with subsequent acute pulmonary embolism. Emergency embolectomy was performed because the thrombus engaged into the left heart through the foramen ovale.

The prevalence and incidence of COPD among urban older persons of Bangkok Metropolis.

COPD substantially affects the national healthcare resource and healthcare cost especially among the older persons. Identifying the accurate prevalence and incidence reflects the scale of problem posed by COPD. This epidemiological study using the criteria for diagnosing COPD based on ratio of FEV1.0/FVC less than 70 per cent and the reversibility of less than 15 per cent increase of post bronchodilator FEV1.0 in the absence of parenchymal lesions and cardiomegaly in CXR (PA and lateral view) revealed the prevalence (1998) of COPD among the 3094 older persons aged 60 years and over in the communities of Bangkok Metropolis 10 km around Siriraj Hospital was 7.11 per cent (95% CI: 6.21-8.01), whereas the incidence (1999) of COPD was 3.63 per cent (95% CI: 2.83-4.43). Both the prevalence and the incidence were increased with increasing age.The disease occurred predominantly among male smokers. The distribution of mild : moderate : severe COPD in the prevalence study was 5.6:2.2:1. The current findings also suggest that tobacco smoking is the prime important cause of COPD and the indoor pollution especially cooking smoke is not significant. In particular, the unexpectedly high incidence compared with prevalence in this population probably represents the warning message to the national policy maker for prompt and effective health promotion and disease prevention to prevent further social and economic loss.

Comparison of the efficacy of the weight-based heparin dosing nomogram and standard method.

Nowadays, heparin is extensively used in patients with various medical diseases without standardized dose adjustment. Previous studies revealed that delayed therapeutic level achievement led to suboptimal outcome. Objective: To determine the most effective method of heparin dose adjustment and factors affecting appropriate heparin dose. Methods: All patients requiring heparin treatment were monitored for APTT ratio in phase 1 (conventional method), then randomized into Standard and Weight-based method in phase 2 with the same manner of APTT ratio monitoring. Results: Student t-test for primary outcome favored the Standard dosing heparin nomogram in comparison with conventional method at 18 h ( p-value = .0006) and 24 h ( p-value = .03) and the Weight-based nomogram at 18 h ( p-value = .02). At 24 h, 21 of 28 patients ( 75%) of the Standard nomogram group achieved the therapeutic range, comparing with 14 of 28 patients (50%) in the Weight-based nomogram group and 15 of 39 patients ( 38%) in conventional group. Only age and body weight may affect the appropriate heparin dose. Conclusion: The Standard heparin nomogram was more effective and practical in heparin dose adjustment. Factors affecting appropriate heparin dose were age and body weight.

Evaluation of cholesterol and albumin gradient in the differentiation of pleural effusion.

Prospective comparison of pleural cholesterol and serum-pleural albumin gradient to Light’s traditional criteria were evaluated in 73 patients to differentiate exudative from transudative pleural effusions. The criteria of Light et al remain the most accurate method for distinguishing exudates from transudates even though misclassified 5 of 20 transudates (25%) to be exudates. All of those 5 patients can be correctly diagnosed to have transudative pleural effusions using either pleural cholesterol or serum-pleumin albumin gradient criteria.

Thymolipoma simulating cardiomegaly: A case report.

A routine chest radiograph of a 27-year-old woman who presented with chronic cough for four weeks disclosed an anterior mediastinal mass simulating cardiomegaly. The computed tomography revealed a mass with diffuse fat density intermingled with soft tissue density. At thoracotomy a thymolipoma weighing 750 g was completely resected and typical histological findings were demonstrated. She made a good recovery and remained in good health at her most recent follow-up visit.

Clinical utility of bronchoalveolar lavage and transbronchial biopsy.

A retrospective study is reported of the efficacy of 167 cases of bronchoalveolar lavage (BAL) and 212 cases of transbronchial biopsy (TBB) between August 1991 and August 1992. BAL & TBB gave diagnostic yields of 38.7% in smear negative pulmonary tuberculosis, 33% in primary or metastatic lung cancer and 55% in immunocompromised patients with pulmonary infiltrates. Overall diagnostic yield for BAL, TBB, BAL and TBB were 33, 35.8 and 39.8%. With future development, BAL and TBB will enhance the strengths of diagnostic competency for an increasing array of pulmonary diseases.