Hydroxyzine for the prevention of pruritus and nausea vomiting from spinal morphine in patients having transabdominal hysterectomy under combined spinal-general anesthesia: A randomized control trial.

Background: Pruritus and nausea vomiting are common side effects of spinal morphine and general anesthesia. Hydroxyzine is one of the antihistamines that are used for treating pruritic and nauseous patients. A randomized prospective double-blind study was undertaken in order to identify the preventive effects of hydroxyzine to prevent pruritus and nausea vomiting in patients who have transabdominal hysterectomy under combined spinal-general anesthesia. Methods: 80 patients scheduled for elective transabdominal hysterectomy under combined spinal-general anesthesia were randomized to receive either hydroxyzine 75 mg and oral midazolam 7.5 mg (atarax or ATR group) or placebo and oral midazolam 7.5 mg (control or C group) as premedication at least half an hour before their operation. Clinical data (vital signs, pruritic score, nauseous score, sedation score, etcetera) were recorded at pre-operative, intraoperative and 48-hour post-operative periods. All patients had spinal block with 0.5% heavy bupivacaine 2 ml with 0.3 mg preservative free morphine and general anesthesia with thiopenthal sodium 5 mg/kg as induction, intubated with atracurium 0.6 mg/kg and maintenance with nitrous oxide in 50% oxygen and isoflurane. A conventional reversal technique was done in all patients. Intravenous fentanyl was used for pain as needed, oral chropheniramine syrup 2 tsp (4 mg/10 ml) every 4 hours was used for pruritus and intravenous ondanzetron (8 mg) was used for nausea/vomiting in the post-operative period. Results: Pruritus and nausea vomiting were observed blindly 24 and 48 hours post-operation. At 24 hours post-operation, there were 5 patients in the ATR group (12.5%) and 6 patients in the control group (15%) who had mild pruritus. There was no significant difference between the two groups (p = 0.745). At 48 hours post-operation, all patients were free of pruritus. There were 2 patients who had mild nausea (5%) and 2 patients who had moderate nausea (5%) in the control group within 24 hours post-operation. In the ATR group there was no patient who had mild or moderate nausea. There was no significant difference between the two groups (p = 0.152). At 48 hours post-operation, there was 1 patient in each group who had mild nausea (2.5%), which had no significant difference. At 24 and 48 hours post-operation, all patients were free of vomiting. Conclusion: Hydroxyzine cannot prevent pruritus and nausea/vomiting from spinal morphine in patients having transabdominal hysterectomy under combined spinal-general anesthesia.

Incidence, survival rate and prognostic factors of recurrent/ refractory epithelial ovarian cancer in Siriraj Hospital.

Objective: To assess the incidence, 5-year survival rate and identify the prognostic factors for survival in a cohort of patients with recurrent/ refractory epithelial ovarian cancer in Siriraj Hospital. Methods: We performed a retrospective chart review of 140 patients with primary recurrent / refractory epithelial ovarian cancer who received their treatment at Siriraj Hospital between October 1998 and December 2006. Incidence, 5-year survival rate and potential prognostic factors for survival were identified. Statistical analysis was by SPSS for Windows version 11.5. Kaplan-Meier survival curves were computed and a multivariable proportional hazard model (Cox) was applied to assess the prognostic significance of the different covariates. Results: The incidence of recurrent/refractory epithelial ovarian cancer when compared to total new cases of epithelial ovarian cancer during a 1-year period was 33.62%. The 5-year survival rate for the cohort was 47%, whereas the median overall survival was 4.91 years and the median survival post recurrence was 2.5 years. Of these patients, 64/140 (45.7%) have died of disease. Seventeen factors were evaluated for prognostic significance for survival, on multivariate analysis, only the tumor free interval (TFI) (P = 0.016) and CA 125 at the time of recurrence or refractory (P = 0.02) retained prognostic significance. Conclusion: The incidence of recurrent/ refractory epithelial ovarian cancer when compared to total new cases of epithelial ovarian cancer is about one third. This cohort had a prolonged median overall survival and satisfied a 5-year survival rate. The significant prognostic factors for survival in a cohort of patients are the tumor free interval and CA 125 at time of recurrence or refractory.

Gestational trophoblastic disease in 2005.

Gestational trophoblastic diseases are still problematic in our practice. Event the incidence is in generally decreasing. And the development of Medicine in this decade can elucidate some parts of pathophysiology at cellular and molecular levels. However, malignant changes still can not be prevented. Approximately 20% of patients will develop malignant sequelae requiring administration of chemotherapy after evacuation of hydatidiform moles. Most patients with postmolar gestational trophoblastic disease will have non-metastatic molar proliferation or invasive moles, but gestational choriocarcinomas and metastatic disease can develop in this setting. Gestational choriocarcinoma occurs approximately 50% after term pregnancies, 25% after molar pregnancies, and the remainder after other gestational events. Although much rarer than hydatidiform moles or gestational choriocarcinomas, placental site trophoblastic tumors can develop after any type of pregnancy. For optimal management, practicing obstetrician-gynecologists should be able to diagnose and manage primary molar pregnancies, diagnose and stage malignant gestational trophoblastic neoplasia, and assess risk in women with malignant gestational trophoblastic neoplasia. This chapter views some points which may be useful for evidence-based practice in modern Medicine.

Cervical cancer in elderly Thais.

BACKGROUND : Neoplasm is the second most common cause of death in Thai women and cervical cancer is the most common. The prevalence of cervical cancer in Thai elderly women is unknown. What is the optimum time for a regular Papanicolaou smear check up. METHOD: A cross-sectional study of healthy elderly women (age >60 years) who lived within a 10-kilometer radius of Siriraj Hospital was carried out. All had their history taken and were examined by vaginal examination and Papanicolaou smear for cancer screening three times; on the day of enrollment, at one-year and two-years. RESULTS: Six hundred and eighty two women aged 60-88 years were recruited. There were 7 cases (1.0%) who had a positive Papanicolaou smear on the day of enrollment. Six cases (0.9%) had complete investigations: 2 cases (33.3%) had invasive cervical cancer stage III b, 4 cases had CIN III. There was one case out of 268 (0.4%) at one-year and one case out of 342 (0.3%) at two-years who had a positive Papanicolaou smear and the final diagnosis was CIN III. CONCLUSION : The prevalence of cervical cancer in Thai elderly women in this study was 1 per cent. Thai elderly women need a yearly Papanicolaou smear check up.

Integrated health research program for the Thai elderly: prevalence of genital prolapse and effectiveness of pelvic floor exercise to prevent worsening of genital prolapse in elderly women.

BACKGROUND: Genital prolapse is a common health problem in elderly women. It is prevalent among elderly females and affects their quality of life. Those with a severe degree of genital prolapse may need operative treatment which may be risky due to co-morbid conditions such as hypertension, respiratory disease, cardiovascular disease and diabetes mellitus. The aim of this study was to determine the prevalence of genital prolapse and the effectiveness of pelvic floor exercise to prevent worsening of genital prolapse in elderly females. METHOD: The authors conducted a cross sectional study to determine the prevalence of genital prolapse in 682 elderly women (aged > or = 60 years) who lived within a 10-kilometer radius of Siriraj Hospital. 654 subjects were eligible for the controlled trial to determine the effectiveness of pelvic floor exercise to prevent worsening of genital prolapse. There were 324 subjects in the control group and 330 subjects in the experimental group. The experimental group received training in pelvic floor exercise and were asked to perform the exercise 30 times after one meal, every day for 24 months. The subjects were followed-up every 6 months for 24 months to assess worsening of genital prolapse. RESULTS: The prevalence of genital prolapse was 70 per cent. There were 324 subjects in the control group and 330 subjects in the experimental group. After 24 months of pelvic floor exercise, the rate of worsening of genital prolapse was 72.2 per cent in the control group and 27.3 per cent in the experimental group (p = 0.005). The rate of worsening of genital prolapse was not significantly different between the control group and the study group in those who had a mild degree of genital prolapse. CONCLUSION: The prevalence of genital prolapse in elderly Thai women was 70 per cent. A 24 months pelvic floor exercise program was effective to prevent worsening of genital prolapse in the women who had severe genital prolapse.