Retention of chest compression performance of medical students.

Background and objectives: Chest compression (CC) performance is one of the most important parts in saving the lives of victims with cardiac arrest. The primary objective was to determine the retention of CC performance among last-year medical students (externs). Methods: All externs were recorded for their CC performance at the end of their BLS (BLS not yet defined) workshop by the use of a CPR training manikin. The retention of BLS performance was evaluated by CC score (CCS) which is the percentages of correct CC during their internal medicine rotation. Detailed errors of chest compression performance including rate of compression, compression to ventilation ratio, incomplete release, too little, too much, and wrong hand position were also recorded. Results: 223 externs had baseline data for a chest compression score (CCS1) and 118 with follow-up data (CCS2). The interval between CCS1 and CCS2 was 198 (range 119-266) days. CCS during the training course (CCS1) and CCS during the test (CCS2) were 89 (range 84-94) and 81 (range 68- 89) respectively. CCS2 was significantly lower than CCS1 (p < 0.001). The percentages of externs who passed 80% decreased from 90.5% to 51.4% (p <0.001). The independent predictors for a high CCS2 included male gender, grade point average, experience in CPR observation or participation - especially recent experience. The area of errors in CC included compression rate, compression: ventilation ratio, too little and too deep compressions. Conclusion: CC performance significantly decreases after CPR training. Assessment of predictors for retention of CC performance and the area of errors may help to strengthen the CPR training program in the future.

Prevalence incidence and management of anemia in cancer patients treated in the radiation oncology division, Siriraj Hospital.

Objective: This study was designed to find the prevalence of anemia in cancer patients before radiotherapy and the incidence of anemia during radiotherapy treatment. The study also planned to identify factors that affect the incidence and prevalence of anemia and the management of anemia in the radiation oncology division, Siriraj Hospital. Methods: This study is designed prospectively to collect hemoglobin level and factors that might cause anemia in patients whom were treated with radiotherapy at Siriraj Hospital during April - June 2006. The eligible criteria were patients age > 18 years old, had a pathology confirmed to be malignancy, and had never been treated with radiotherapy before. Patients were excluded if they were not treated with radiotherapy, had skin/central nervous system or hematologic malignancies. In this trial, anemia was defined as Hb level < 12 g/dl for both genders. Results: It was found that the prevalence of anemia within 30 days before starting radiotherapy was 54.4% and the incidence of anemia during radiotherapy was 34.3%. The frequency of anemia, defined as the number of patients in the study in whom Hb <12.0 g/dL were found at least once either at enrollment or during the survey, was 66%. Previous chemotherapy was the main predicting factor for anemia before radiotherapy. Concurrent chemo-radiotherapy patients developed a higher incidence of anemia during the survey than patients with radiotherapy alone. The incidence of anemia was highest in gynecologic malignancy patients. Only 25/112 (22.3%) of anemic patients at initial evaluation received treatment for anemia. Most of the patients were treated with a blood transfusion and none was treated with erythropoietin. Our mean trigger hemoglobin level for treatment of anemia was 9.3 g/dl. Conclusion: Anemia is common in the patients who are treated with radiotherapy in our institute with the prevalence of anemia before starting radiotherapy as high as 54.4% especially in patients previously treated with chemotharapy. One-thirds of patients developed anemia during radiotherapy, with a higher incidence in gynecologic malignancy patients and patients who receive combined chemo-radiotherapy. The total frequency of anemia in patients treated in the Division of Radiation Oncology, Siriraj Hospital was as high as 66% before and during radiotherapy.

Accuracy of visual assessment in the detection and quantification of myocardial scar by delayed enhancement magnetic resonance imaging.

BACKGROUND: Delayed-enhancement magnetic resonance imaging (DE-MRI) is now a standard for the detection of myocardial scar and viability. Standard analysis needs expensive software. OBJECTIVE: To determine the accuracy of visual assessment in the detection and quantification of myocardial scar by DE-MRI technique. MATERIAL AND METHOD: The authors enrolled 32 patients with coronary artery disease (CAD) as documented by coronary angiography (CAG) and left ventricular dysfunction. All patients underwent cardiac magnetic resonance imaging for the assessment of global and regional myocardial function and DE-MRI. The presence and amount of scar in each myocardial segment was assessed by standard method. Visual assessment was performed by two methods: 1) visual drawing of the boundary of the hyperenhancement region and calculation of percentages of scar in an individual segment; 2) visual estimation of grading of hyperenhancement area from 0 (no scar) to 4 (> 75% scar). The agreement for scar detection and correlation of scar quantification for individual segments were evaluated. RESULTS: Thirty-one of 32 patients in the present study had myocardial scar. One thousand four hundred and thirty two myocardial segments were analyzed. Visual detection of myocardial scar has an excellent level of agreement with standard method of scar (Kappa = 0.963 and 0.952, p<0.001 for visual method I and II). Visual method I and II has an accuracy of 98.2% and 97.6% respectively in the detection of myocardial scar compared to standard method. Percentages of myocardial scar in each myocardial segment by visual method I correlate very well with standard method (Intraclass Correlation Coefficient = 0.885). Visual grading of amount of myocardial scar also has an excellent correlation with standard method (Spearman rank correlation coefficient = 0.934). CONCLUSION: Visual assessment of myocardial scar is accurate for the detection and quantification of scar.

Factors associated with functional improvement at discharge in stroke rehabilitation.

Objective: To study the factors associated with the functional improvement at discharge in stroke patients receiving inpatient rehabilitation. Methods: Retrospective review of the medical records of all the stroke patients admitted to inpatient rehabilitation, Department of Rehabilitation Medicine, Siriraj Hospital from January 2005 to December 2005. Results: There were sixty-one stroke patients, 39 males and 22 females, with a mean age 62.5 years old. Most of them lived with their spouses (61%) and had cerebral infarction (61%). The risk factors of stroke reported were hypertension (86.9%), dyslipidemia (63.9%), diabetes mellitus (34.4%), previous stroke (31.1%), heart disease (18%), smoking (8.2%) and regular alcoholic drinking (3.3%) respectively. The right and left side weakness were equally reported. The median duration of stroke before admission was 62 days. The disabilities at admission were urinary incontinence (39.3%), dysphagia (32.8%), and aphasia (26.2%). During the hospital stay, the complications which occurred were shoulder problems (41%), other musculoskeletal pain (34.4%), depression (26.2%), shoulder hand syndrome (13.1%), urinary tract infection (6.6%), and pneumonia (4.9%) respectively. Forty-seven patients (77%) gained functional improvement at discharge. The Chi-Square and Independent Sample T tests revealed the association between the functional improvement at discharge and urinary continence on admission (p=0.011), and duration of stroke within 3 months before admission to rehabilitation (p=0.011) with the odds ratio 5.9 and 5.3 respectively. Conclusions: The functional improvement after the process of inpatient stroke rehabilitation was associated with the duration of stroke within 3 months before rehabilitation admission and urinary continence on admission.

Delayed hypersensitivity skin testing in the Thai adult population.

OBJECTIVE: The present study was carried out in healthy Thai subjects to determine the types and concentrations of standard antigens used in delayed-type hypersensitivity (DTH) skin testing as an evaluation of cell-mediated immunity. MATERIAL AND METHOD: One hundred subjects were tested with three antigens including tuberculin (purified protein derivative), tetanus toxoid, 1:10 and 1:100 dilutions, and Candida albicans, 1:10 and 1:100 dilutions. RESULTS: We found that 92% of the subjects responded to tuberculin and/or tetanus toxoid at a 1:10 dilution, 77% responded to tetanus toxoid at a 1:10 dilution, and 35% responded to a 1:100 dilution. There was only one subject who responded to Candida albicans at a 1:10 dilution, and none to a 1:100 dilution. The size of tuberculin reactions varied from 5 mm to over 20 mm without any evidence of active tuberculosis. CONCLUSION: Tuberculin and tetanus toxoid at a 1:10 dilution are probably sufficient to be used in DTH skin testing to evaluate T-cell function.

Endoscopic extraperitoneal radical prostatectomy (EERPE): a new approach for treatment of localized prostate cancer.

Laparoscopic radical prostatectomy is usually performed by transperitoneal approach. Patients may encounter; intraperitoneal organs injury, and prolonged ileus during recovery period. The authors firstly performed endoscopic extraperitoneal radical prostatectomy (EERPE) in Thailand, which is mimicking open radical prostatectomy, the gold standard for treatment of localized prostate cancer. OBJECTIVE: Assess and evaluate the feasibility and early outcomes of the authors' experience in endoscopic extraperitoneal laparoscopic radical prostatectomy (EERPE). MATERIAL AND METHOD: From December 2005 to May 2006, 27 cases of EERPE were performed at the authors' institute for clinically localized prostate cancer by one surgeon (group I). Operative data was compared to those 55 patients who underwent open radical prostatectomy from February 2001 to August 2005 for early prostate cancer by the same surgeon (group II). Early postoperative results, clinical outcomes and complication were analyzed between the two groups using Chi-Square, student unpaired t-test and Mann-Whitney U tests. RESULTS: Patients' age and clinical staging were not different between the two groups. Mean operative time was longer in the EERPE group (268 minutes vs 157 minutes; p < 0.01). Median blood loss was 500 mls and 1000 mls in the EERPE and open groups, respectively (p < 0.001). The likelihood of transfusion rate in the open group was higher than the EERPE group, with odd ratio of 8.75 (95%CI = 2.09-39.86), p = 0.001. Hospitalization time and pathological stage were not different between the two groups. In the EERPE group, there were two rectal complications, including rectal injury and rectal necrosis, which were treated laparoscopically and conservatively without long-term problems. CONCLUSION: The authors' early experience has shown that EERPE is feasible. Although operative time was longer; the patients may gain benefit of minimally invasive surgery and decreased operative blood loss. In EERPE group, oncological outcomes are equal to open surgery, however more cases and long-term follow up are required to evaluate the efficacy of such an approach.

Prevalence of prostate cancer in aging males receiving PSA (prostate specific antigen) screening test (A campaign for celebration of Siriraj Established Day).

Prostate cancer is a potential men's health problem. The prevalence of prostate cancer continues to rise. Serum PSA (Prostate Specific Antigen) can be used as a screening tool for detection of early prostate cancer However, a screening program for prostate cancer has not yet been accepted as cost-effective and long term survival benefits have not been shown. Nevertheless, some doctors request PSA testing in men who present with lower urinary tract symptoms (LUTS) to detect prostate cancer OBJECTIVE: To study for prevalence of prostate cancer in healthy men seeking medical check-up for prostate cancer. MATERIAL AND METHOD: During the anniversary celebration of Siriraj established day (26/07/1888), a cohort study of Prevalence of prostate cancer in aging males using PSA Screening Test was carried out, 200 men over 45 years of age were invited to PSA testing and prostate glands check-up including, IPSS (international prostatic symptoms score), QOL (quality of life score) and DRE (digital rectal examination). Patients with elevated PSA were advised to undergo transrectal-ultrasound-guided-biopsy of the prostate (TRUS-biopsy). Cancer detection rate was calculated according to symptoms described by patients, IPSS and age groups. Data was compared using Chi-Square test. RESULTS: Median values from data of men's ages, IPSS, QOL and PSA were 63 years, 11, 2, and 1.23 ng/ml, respectively. 9 of 200 patients (4.5%) were found to have prostate adenocarcinoma on biopsy. Most of the cancer cases showed a localized lesion. Prostate cancer was found more common in patients who described themselves as having abnormal urination. There was no prostate cancer found in patients with a mild degree of LUTS (IPSS less than 8). Prostate cancer tended to be more common in men with high IPSS. CONCLUSION: Screening prostate cancer by PSA testing detected the cancer in 4.5%. Most cancers were found on symptomatic patients. Patients with LUTS should be made aware of prostate cancer and PSA testing may be offered in such patients. However screening of prostate cancer in all men regardless of symptoms must wait for a larger study looking at long term survival benefit, cost-effectiveness of screening, and lastly, quality of life of patients on a screening program.

Cystography helps Shorten urethral catheterization time after radical retropubic prostatectomy.

Objective: Post operative urethral drainage after radical retropubic prostatectomy is bothersome to patients. We assessed the possibility of using cystography to determine the feasibility and safety of early removal of urinary catheter. Methods: 56 patients who underwent radical retropubic prostatectomy from February 2001- December 2004 by one surgeon using one operative technique were reviewed. Cystography was performed on post-operative day 7 in the last 14 consecutive cases (group 1). The control group included 42 patients who had the urinary catheter removed 14 days postoperatively without cystography (group 2). In group 1, the urinary catheter was removed if cystogram showed no contrast media leakage. Data of the operations, pathological reports, complications and incontinence rate were compared between the two groups. Results: In group 1, the urinary catheter was removed on post-operative day 7 in 71% of the patients. The median catheterization time was 7 days and 14 days in group 1 and group 2, respectively (p<0.001). The incontinence rate was not significantly different in the two groups. There was no voiding difficulty or urinary retention reported in group 1. Conclusion: Cystography alleviates urethral discomfort after radical retropubic prostatectomy by shortening urinary catheterization time. Cystography should be considered in all patients who undergo radical retropubic prostatectomy on post-operative day 7. A meticulous urethrovesical anastomosis is required to reduce urinary catheterization time.

Validation of clinical scoring system in the primary care of children with suspected acute appendicitis.

Objective: To establish a scoring system for the diagnosis of acute appendicitis in children in order to decrease the rate of negative and delayed appendectomies and delayed. Methods: Record charts of pediatric patients admitted with suspected appendicitis at the Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital during July 2000 - September 2001 were retrospectively reviewed. Clinical predictors were listed out and weighed as coefficients, which were later formed into a score equation. The score was then prospectively studied in the following year from October 2001-September 2002. The score was used to aid decision making in the management of cases suspected of appendicitis. The out come was compared to the conventional management based on histologically confirmed diagnosis. Results: The retrospectively collected data listed out 14 significant variables. Using logistic regression, the parameters were weighed as coefficients, which became scores to each parameter. The score was applied to a consecutive series in the following year. By using the score, the patients were categorized into three groups: discharged, observed and operated. The accuracy of the score is 85.83% with a positive predictive value of 96.55% and negative predictive value of 75.81%. From this study group, the negative appendectomy rate is 4.17% and the perforation rate is 6.67%. Compared to the previous year during which 133 children were treated under the conventional management, the negative appendectomy rate was 4.51% and the perforation rate was 21.8% Conclusion: The scoring system is an accurate diagnostic tool, which proves the importance of history taking, physical examination in coordination with laboratory investigations and close observation. Altogether these parameters can reduce the rate of misdiagnosis and delayed diagnosis of pediatric appendicitis.

Is radical prostatectomy after transurethral resection of prostate (TUR-P) feasible.

Objective: Radical prostatectomy (RP) is usually difficult after TUR-P. We assessed the possibility and studied the outcomes of RP in patients who had previously received TUR-P. Methods: From August 2001 to April 2005, we performed 11 cases (group 2) of RP in localized cancer patients who had previously received TUR-P. The patients’ operative data and outcomes of the operation were compared to another 47 cases (group 1) of RP without earlier TUR-P. The operation was performed by one surgeon using the bladder-neck sparing technique. Results: The patients in group 2 had median operative time of 180 minutes, which was 30 minutes longer than that of group 1. Median operative blood losses were 1,100 ml and 1,000 ml in group 1 and 2, respectively. Median catheterization time was 14 days in both groups. Using Mann Whitney U-test, there were no differences among the two groups in terms of operative time, blood loss, catheterization time, hospital stay and serum PSA after the operation. The likelihood of bladder neck involvement and anastomosis stricture rate were higher in the patients who had received TUR-P with odd ratios of 3.06 and 3.15 respectively; nevertheless, these had no statistically significant difference. Conclusion: Radical prostatectomy after TUR-P is therefore feasible; however, meticulous surgical technique is needed to prevent complication.

Determination of fecal occult blood in primary schoolchildren infected with Trichuris trichiura.

A correlation of Trichuris trichiura infection and fecal occult blood detection was conducted in 146 primary schoolchildren in Narathiwat Province, Thailand. The Kato-Katz thick smear method was used for determining egg counts and stated as eggs per gram of feces (epg). The number of T. trichiura eggs was categorized as class I (1-499 epg), class 11 (500-4,999 epg), and class III (> 5,000 epg), according to the relation between infection intensity and reduced hemoglobin concentration. Each fecal sample was processed to detect occult blood using a guaiac-based test (Hema-Screen, USA) and an immunochromatographic-based test (HEXAGON OBTI test, Germany). There were 50 schoolchildren without parasitic infection in the control group. Of 96 cases with T. trichiura infection, 85 and 11 children were classified in the class I and class II groups, respectively, but no subjects were in the class III group. Positive occult blood detection results in the control, class I, and class II groups using the guaiac and the immunochemical tests were 0, 3.5, and 9.1% (p=0.19), and 0, 2.4, and 36.4%, (p<0.0001) respectively. This study suggests that T. trichiura infection with an intensity of 500 epg or greater may be associated with intestinal bleeding.

Management pattern and hospital charge of repairing cleft palate at Siriraj Hospital.

Management pattern and hospital charge for repairing cleft palate at Siriraj Hospital during 1996-1999 were studied retrospectively. From the examination of 100 patient records, four cases were excluded since no surgical correction was performed during hospitalization. Fifty-nine percent were female and the average age was 5.54 years old. Fever and otitis media were associated with two and three cases respectively. Other underlying diseases included hypothyroidism, patent ductus arteriosus and ventricular septal defect were found one in each case. The cleft palate was successfully repaired in all cases. Surgical correction was done in 84 percent of cases within the first five days of hospitalization. The average length of stay was 5.89 + 2.85 days and ranged from 2-20 days. The hospital charge for cleft palate repair was 7,031.22 + 1,365.33 Baht per case. This study illustrate that a small variation is practiced in the management of a reasonably straight forward condition and better preparation of the patients before hospitalization could reduce the hospital stay or avoid unnecessary hospitalization.

Applicability of the Thai nasality test.

The aim of this study was to investigate the applicability of a speech stimuli, the Thai Nasality Test, to identify the presence of hypernasality and hyponasality speech. The Thai Nasality Test was evaluated by a comparison study between the perceptual assessment rated by the investigators and the acoustic assessment by using a Nasometer. The study was conducted to 69 normal speakers, 36 dysarthric speakers, and 32 clients with cleft palate. The perceptual assessment was preceded acoustic assessment. Each subject was asked to read or repeat the Thai Nasality Test. Results indicate the reliability and validity of the Thai Nasality Test by a) a positive correlation between perceptual assessment and the instrumental assessment, b) a significant correlation between age and the Tuk Tuk passage and significant correlations between gender and the Manee as well as the Sai Yok water fall passages of the normal group, and c) the discriminating power between disordered speech from normal speech. This study indicated the Thai Nasality Test as a perfect speech stimuli to elicit speech sample for acoustic assessment, particularly the TukTuk and the Sai Yok water fall passages in assessing for hypernasality problems. While an applicability of nasal sentences the Manee to detect the hyponasality could not be confirmed definitely because there was no significant difference among studied groups.

Brief conners’ teacher rating scale for assessing attention deficit hyperactivity disorder in Thai children.

As the modified Brief Conners’ Teacher Rating Scale in the Thai version possessed high reliability and validity, we can expect it to be a useful assessing tool for ADHD in Thai children. Because the diagnosis of ADHD is usually based on clinical interview and observation that are time-consuming it might be impossible for the physician to make a decision in the clinical setting. The behavioral problems in ADHD are normally prominent in the classroom setting. Therefore if this rating scale can be apply to Thai children, it will be helpful for the physicians to use it as an adjuvant tool for assessing ADHD.