Extracardiac conduit versus lateral tunnel for total cavopulmonary connections.

OBJECTIVE: Compare the surgical outcomes of the lateral tunnel and the extracardiac conduit total cavopulmonary connections at a single center during a l0-year period. MATERIAL AND METHOD: From October 1995 through October 2005, 27 total cavopulmonary connections (TCPC) were performed. fourteen patients were the lateral tunnel and thirteen patients were the extracardiac conduit. Prior superior cavopulmonary connective surgery and fenestration surgery were done more often in the group with extracardiac conduit. RESULTS: Operative mortality was 29% in the lateral tunnel and no operative mortality in the extracardiac conduit (p < 0.05). The cause of deaths in three patients was significant AV valve regurgitations and one was small pulmonary artery index. All patients in both groups were in NYHA class 1 and 2 and no patients with supraventricular arrhythmias were detected in the two groups during the follow-up period There was only one patient in the lateral tunnel who developed thromboembolism from irregular warfarin taking. CONCLUSION: The extracardiac conduit had lower mortality than the lateral tunnel. However; there was no difference in early and mid-term complications.

Bladder substitution by ileal neobladder for women with interstitial cystitis

OBJECTIVE: To report our experience with cystectomy and ileal neobladder for women with interstitial cystitis (IC). MATERIALS AND METHODS: Thirty-five female patients treated during 2000-2005 with the mean age of 45.9 ± 4.4 years were included in this study. All of them had experience suprapubic pain with irritative voiding symptoms and were diagnosed as having IC based on NIDDK criteria for at least 2 years. Conservative treatments had failed to relieve their symptoms; and therefore all of them agreed to undergo a bladder removal. For cystectomy, the urethra was cut 0.5 cm below the bladder neck, proximal to the pubourethral ligament, leaving the endopelvic fascia intact. An ileal segment of 65 cm was used to create the neobladder with the Studer's technique. RESULTS: All patients presented good treatment outcome with regard to both diurnal and nocturnal urinary control without any pain. Quality of life using the SF-36 questionnaire showed significant improvement of both physical health and mental health. Spontaneous voiding with minimal residual urine was found in 33 cases (94.3 percent), and the remaining 2 cases (5.7 percent) had spontaneous voiding with residual urine and were placed on clean intermittent catheterization (CIC). Twelve out of 30 cases with sexually active ability had a mild degree of dyspareunia but without disturbance to sexual life. CONCLUSION: Bladder substitution by ileal neobladder for women who suffer from IC can be a satisfactory option after failure of conservative treatment. Resection of the urethra distal to the bladder neck can preserve continence and allow spontaneous voiding in almost all patients.

Incidence and time trend of surgical site infection in Ramathibodi Hospital during the years 2003-2005.

OBJECTIVE: To determine the incidence of surgical site infection (SSI) for high-risk surgical procedures and any changes in the incidence of SSI during the years 2003 to 2005. MATERIAL AND METHOD: SSI surveillance data were obtained from Ramathobodi's Infection Control Committee for analysis. RESULTS: The overall 30-day incidence of SSI for 492 hepato-biliary-pancreas and colon procedures was 7.7% (38 of 492). Of the 38 SSIs, only 35 were analyzed in detail. MosI patients had SSI types I and II, 89% of SSIs were detected within 20 days after operation, and most common organisms isolated were enterococcus species, E.coli, and P. aeruginosa. SSI rate for the year 2005 (11%) was significantly higher than that of the preceding years (4-5%). CONCLUSION: Overall, SSI rates for Ramathibodi Hospital were not significantly different from those of other studies. The increased SSI rate for the year 2005 needed an explanation, but the value of the present report lies in the potential usefulness of the presented results for future prevention of SSIs. years (4-5%). CONCLUSION: Overall, SSI rates for Ramathibodi Hospital were not significantly different from those of other studies. The increased SSI rate for the year 2005 needed an explanation, but the value of the present report lies in the potential usefulness of the presented results for future prevention of SSIs.

Results of D2 gastrectomy for gastric adenocarcinoma: 10-year experience in Thai patients.

BACKGROUND: The therapeutic value of D2 gastrectomy in the curative treatment of gastric adenocarcinoma is controversial outside Japan. MATERIAL AND METHOD: The authors retrospectively reviewed the medical records of 97 patients with gastric adenocarcinoma who underwent curative D2 gastrectomy between October 1995 and September 2005. RESULTS: Subtotal gastrectomy was performed in 42/97 patients (43%) and total gastrectomy in 55/97 patients (57%), with an average number of 38 lymph nodes (range, 22-82) and 48 lymph nodes (range, 24-126) removed, respectively. Overall morbidity rate was 17% (16/97). There was no hospital mortality. The 5-year overall and 5-year disease-free survival rates were 59% and 46%, respectively. The 5-year disease-free survival rate for each TNM stage was 100% for stages IA and IB, 75% for stage II, 78% for stage IIIA, 28% for stage IIIB and 4% for stage IV. Of the 43/97 patients (44%) who had metastasis to the level 2 (N2) lymph nodes, 14/ 43 patients (33%) survived more than 5 years. CONCLUSION: The D2 gastrectomy can be performed with low morbidity and mortality, and may increase the cure rate and survival of Thai gastric adenocarcinoma patients, at least in experienced centers.

Incidence of ventilator-associated pneumonia (VAP) after the institution of an educational program on VAP prevention.

OBJECTIVE: Demonstrate if the institution of an educational program on VAP and its prevention is effective in helping reduce the incidence of VAP in a surgical ICU. MATERIAL AND METHOD: An educational program on VAP and its prevention, which consisted of a 1-hour formal lecture, an educational handout, and a pre-and post-test exam was given to the nursing staff beginning in April 1st, 2003. Reminding posters were posted throughout the ICU. The pre-and post-intervention clinical data that included age, sex, diagnosis, APACHE II, ventilator days, and incidence of VAP were collected. VAP was considered to have occurred only after the patient had been on mechanical ventilation for greater than 48 hours. The primary outcome measure was the incidence of VAP The secondary outcome measures were duration of the ICU and hospital stay, and the ICU and hospital mortality. Values were expressed as mean +/- standard deviation, and median (range). Multiple logistic regression analysis of various variables was used to identify risk factors for the occurrence of the VAP. RESULTS: Eight-five patients in Pre- (July 1st, 2002 to June 30th, 2003) and 89 patients in post- (July 1st, 2003 to June 30th, 2004) intervention met the inclusion criteria. The incidence of VAP decreased from 39.7 per 1000 ventilator-day to 10.5 per 1000 ventilator-day (p-value < 0.001) after the institution of an educational program. The ICU, hospital length of stay, and the mortality rate remained unchanged. Age and the interventional program were found to correlate with the occurrence of VAP. CONCLUSION: An institution of an educational program on VAP and its prevention helps reduce the incidence of the VAP at the study institution but does not affect the ICU, hospital length of stay, and the mortality rate.

Breast pain and service satisfaction during digital mammography.

OBJECTIVES: To determine the frequency and predisposing factors of breast pain felt during digital mammography, and factors associated with service satisfaction. MATERIAL AND METHOD: A questionnaire was distributed to 1250 women immediately after their mammography. The outcomes assessed were a five-point scale of breast pain and rating of the satisfaction with the mammography service. Several factors potentially associated with breast pain and satisfaction were obtained from the questionnaire and analyzed. Multiple cumulative logit regression was used to identify independent, significant factors. RESULTS: Breast pain was found to be absent in 22% of patients, slight in 50%, moderate in 23% and substantial or severe in only 4%. Significant factors associated with breast pain during mammography included higher educational level, having no children, having had prior mammography, impolite and rough radiographer and poorly performed mammography. Factors associated with satisfaction with the mammography service included older age, polite and gentle radiographer and well-performed mammography. CONCLUSION: Radiographer delivery of the mammography service seemed to be the most important, modifiable reason for breast pain during mammography and dissatisfaction with the mammography service.

Positive predictive value of breast cancer in the lesions categorized as BI-RADS category 5.

OBJECTIVE: To determine positive predictive value (PPV) of the breast imaging reporting and data systems (BI-RADS) category 5 mammogram and ultrasound (US) in the diagnosis of breast cancer in the study center and correlation between clinical, mammographic and US findings, and breast cancer. MATERIAL AND METHOD: Four hundred and ninety seven patients with BI-RADS category 5 who underwent mammograms and US at the Breast diagnostic center, Ramathibodi Hospital from January, 1, 2002 to December 31, 2004 were enrolled into the present study. Selected clinical information, mammographic and US findings, and histopathological diagnosis were retrospectively reviewed. RESULTS: Breast cancer was found in 467 of 497 patients, giving a PPV of 94%. Invasive ductal carcinoma was the most common malignancy (89.5%). Fibrocystic change was the most common benign pathology found in the remaining patients. Discrete mass was the most frequently encountered lesion detected on mammography and US, followed by mass containing calcifications. Patients with advanced age, having a clinically palpable breast mass, with mammographic and US evidence of mass containing calcifications showed significant statistical association with breast cancer. CONCLUSION: PPV of BI-RADS category 5 lesions in the present study was comparable to other published studies. Although the probability of malignancy was very high, a small number of patients had benign pathologies. Preoperative histopathologic diagnosis is necessary before definitive treatment.

Breast cancer in patients initially assigned as BI-RADS category 3.

OBJECTIVES: To determine the Positive Predictive Value (PPV) for malignancy and characteristics of breast cancer found in patients who were initially categorized as having Breast Imaging Reporting and Data System (BI-RADS) 3. MATERIAL AND METHOD: Medical records of patients assigned to BI-RADS 3 from January, 1st to December; 31st 2002 at the Breast diagnostic center, Ramathibodi Hospital who had imaging follow-up for at least 2 years or had biopsy performed were retrospectively reviewed RESULTS: Of 949 patients, 23 were found to have malignancy, i.e., 2.4% PPV. The most common imaging findings of breast cancer were calcifications on mammogram and mass on sonogram. Mean interval from first imaging to biopsy was 13.1 months. Only 78% of malignancies were diagnosed within 2 years. Less than 50% of these were ductal carcinoma in situ or stage I invasive ductal carcinoma. CONCLUSION: PPV for malignancy in the present study was comparable to the previous studies. However, longer time to diagnosis and more advanced stage of breast cancer at diagnosis were found Periodically short-interval mammogram and sonogram, at not less than 2 year-intervals, were recommended

Health research, fair benefits and access to medicines.

Access to medicines within the context of health research is viewed as a negotiation for 'fair benefits" where it is judged by the host country that access to medicines is the most important and desirable benefit. Research ethics committees in the host country, both local and central, are set to be key players in that determination. However, access to medicines, or "reasonable availability" of medicines in research ethics guidelines, may be difficult to achieve in practice. In extreme cases, the problem of access to medicines may need to be viewed as a global problem, beyond the negotiations within the fair benefits framework.

Reliability of a Thai version of King's Health Questionnaire in Thai females with overactive bladder symptoms.

OBJECTIVES: To develop and test the reliability of a Thai version of the King's Health Questionnaire (KHQ). MATERIAL AND METHOD: Three Thai Urologists forward translated the original English KHQ into a Thai version. Back translations were performed by an independent group of physicians. A consensus was reached on a final Thai version after comparing the original KHQ and various translations. Fifty Thai female patients with symptoms of overactive bladder were tested and retested every two weeks using the Thai version (twice) as well as the English version (once) of the KHQ. Test-retest reliability of the Thai questionnaire was measured using the kappa statistic. RESULTS AND CONCLUSION: The Thai version of the KHQ was found to be reasonably reliable for use in Thai female patients with over active bladder symptoms.

Predictors of non-significant endoscopic findings in patients with suspected upper gastrointestinal tract hemorrhage.

OBJECTIVES: The objective of the present study was to determine pre-endoscopic predictive factors of nonsignificant endoscopic findings in patients with suspected upper gastrointestinal tract hemorrhage (UGIH). MATERIAL AND METHOD: Medical records of 187 patients admitted with the primary diagnosis of UGIH were reviewed. Non-significant endoscopic findings were defined as "normal": "mild gastritis" or unspecified gastritis with a hospital stay of two days or less. Possible predictors of non-significant endoscopic findings included pertinent history, physical examination, nasogastric tube aspirate, routine laboratory findings, and units of infused packed red cells (PRC). Multiple logistic regression analysis was used to determine significant predictors. RESULTS: Predictors of non-significant endoscopic findings included the absence of comorbid diseases (OR: 6.4; 95%CI: 3.0-13.6), higher platelet count (OR. 1.7 per 100,000 increase; 95%CI: 1.1-2.5) and less PRC infusion (OR: 1.9 per unit decrease; 95%CI: 1.3-2.7). CONCLUSION: Patients with UGIH who may have a negative EGD can be identified prior to endoscopy.

Breast cancer underestimation rate of atypical ductal hyperplasia diagnosed by core-needle biopsy under imaging guidance.

OBJECTIVE: To evaluate breast cancer underestimation rate of atypical ductal hyperplasia (ADH) diagnosed by core-needle biopsy (CNB) under imaging guidance in Ramathibodi Hospital and to determine the difference between the malignant and benign groups in terms of clinical and imaging characteristics. MATERIAL AND METHOD: The pathological records of 1521 patients who underwent CNB under imaging guidance were reviewed. Thirty-nine patients diagnosed with ADH were enrolled into the present study. Clinical data, imaging features, biopsy technique and result of excisional biopsy as well as follow-up data were retrospectively reviewed. RESULTS: Of 39 ADH cases, eight (20.5%) were found to have malignancy on subsequent excisional biopsy. The majority of these were ductal carcinoma in situ (DCIS) (62.5%). Lesion categorized as category 5 according to BI-RADS (Breast imaging reporting and data system) was the only feature which was statistically different between the benign and malignant groups. No statistically significant difference was found between the benign and malignant groups in terms of age, personal and family history of breast cancer, clinical finding, mammographic lesion type, size of lesion, image-guided technique and percentage of lesion removal. CONCLUSION: The underestimation rate of ADH in the present study was comparable to other studies. The finding of Bl-RADS category 5 in patients with ADH diagnosed from CNB is a strong indication for subsequent excisional biopsy.

Correlation between symptoms and urodynamic findings in Thai female patients with urinary incontinence.

OBJECTIVE: To determine the accuracy of a urinary incontinence questionnaire in the diagnosis of various types of urinary incontinence classified according to the results of multichannel urodynamic testing. MATERIAL AND METHOD: Between May 2000 and April 2004, 129 women with symptoms of urinary incontinence were interviewed using a urinary incontinence questionnaire consisting of 12 urinary symptoms questions. Various patient demographic and other descriptive data were also collected. All patients underwent multichannel urodynamic testing, and classified using the International Continence Society criteria. Descriptive data and patient symptoms were tested for statistical association with the types of urinary incontinence. Sensitivity and specificity were used to measure the accuracy of the symptoms in distinguishing between the various urodynamic conditions. RESULTS: Of the 12 questions, only three questions (two stress incontinence symptoms and one overactive bladder symptom) were significantly associated with the urodynamic diagnoses of genuine Stress Urinary Incontinence (SUI) and Detrusor Overactivity (DO). The sensitivity and specificity for distinguishing between genuine SUI and DO from other urodynamic diagnoses or between each other were relatively low. CONCLUSION: Symptoms of urinary incontinence were not sufficient to predict types of urinary incontinence. Therefore, the authors suggest that urodynamic testing is still essential in the diagnosis and management of female urinary incontinence.

Waiver of consent in clinical observational research.

In the present article the requirements for waivers of informed consent in clinical research on subjects who are patients in a hospital are reviewed The most important requirements seem to be that the research must pose minimal risk and obtaining informed consent is impracticable. It is suggested that requirements for waivers of consent in research ethics guidelines be modified to exclude the requirement of impracticable consent, but to retain that of minimal risk research, and to add another requirement that restricts modifications of the medical management procedures to those which are minor in some sense. According to these suggestions, waivers of consent for retrospective chart reviews are seen to be coherent and consistent. These suggestions also imply that certain types of prospective observational studies should also be granted waivers of consent. On the other hand, waivers of consent should probably not be granted to any type of randomized clinical trials.

The association between erectile function and severity of lower urinary tract symptoms.

It is unclear whether the erectile dysfunction (ED) that frequently occurs with lower urinary tract symptoms (LUTS) may have a common causative factor: sympathetic overactivity. The aim of this study was to evaluate the association between ED and LUTS. From June 1998 to March 2000, 75 male patients, presenting with LUTS, enrolled into the present study. A total of 63 patients were included into the study, age ranging from 51 - 74 years (mean 61.5). Allpatients completed an American Urological Association (AUA) symptom severity index and IIEF-5 questionnaires. The results from the present study demonstrated that the AUA symptom and IIEF-5 scores do not correlate with increasing age. When the statistical analyses were performed for each age group, there were no significant differences in mean IIEF-5 values between any degree of AUA symptom score in the same age group (p > 0.05). The present results indicate that there is no association between the degree of LUTS and the erectile function. Moreover, the statistical analyses of the association between any degree of erectile function and the mean A UA symptom score either for obstructive or irritative symptoms revealed no significant differences (p > 0.05). The present study demonstrates that there is no association between BPH and erectile function in any age group, inconsistent with the sympathetic overactivity theory.

Medical research ethics in Thailand: what should be the most appropriate approach? An analysis based on Western ethical principles.

An approach to the ethical consideration of medical research in Thailand is presented in terms of Western principles. It is argued that at the present time the principle of therapeutic beneficence is to be considered a priority over respect for autonomy, expressed as informed consent. This approach is especially recommended for therapeutic research in an inpatient hospital setting in Thailand. Only when valid and effective informed consent processes have been developed should respect for autonomy be given more weight in research ethics considerations. The discussion is presented within the context of recent developments in the field of bioethics and in light of some recent findings in informed consent research both in and outside of Thailand.

Comparative study of renal function between standard and modified anatrophic nephrolithotomy by radionuclide renal scans.

OBJECTIVE: To compare the changes in renal function after surgery between standard and modified anatrophic nephrolithotomy using the technetium 99m-DTPA renal scan in patients with complex staghorn calculi. MATERIAL AND METHOD: From July 2001 to March 2002, standard anatrophic nephrolithotomy (sANL) was performed in 7 patients with complex staghorn calculi and modified anatrophic nephrolithotomy (mANL) was performed in another group of 8 patients with the same condition. Preoperative and postoperative renal function were assessed by technetium 99m-DTPA renal scan. RESULTS: Mean patient age was 41 years in the sANL group and 45 years in the mANL group. Male to female ratio was 4:3 in the sANL group and 5:3 in the mANL group. Median operative time was 205 minutes in the sANL group compare with 180 minutes in the mANL group (P = 0.03). Median estimated blood loss was 300 ml. in the sANL group and 275 ml. in the mANL group (P = 0.17). Median percent reduction of GFR on the operated kidney was 9.13 (-30.03 to -3.15) in the sANL group and 27.25 (-41.81 to -1.55) in the mANL group (P = 0.13). Residual small stone was seen in one patient of the sANL group and ESWL was performed for stone fragmentation. There were no serious short-term complications. CONCLUSION: The average operative time of sANL was longer than mANL however, sANL preserved more renal function than mANL. This study suggested that sANL should be the procedure of choice in patients who have compromised renal function.

A comparison of nutritional screening tools in the prediction of post-operative infectious and wound complications in the elderly patients undergoing abdominal operations.

OBJECTIVE: To compare four nutritional screening tools--the Short Form Mini Nutritional Assessment (MNA-SF), the Nutrition Risk Classification (NRC), the Malnutrition Screening Tool (MST), and the Nutrition Risk Score (NRS)--in the prediction of post-operative infectious and wound complications in elderly patients undergoing abdominal surgery. PATIENTS AND METHOD: During the nine-month period from April 2002 to December 2002 nutritional screening was performed on 190 patients aged 60 years or over who underwent major abdominal surgery. Each patient was classified as either at risk or not at risk of malnutrition. This classification, for each screening tool, was tested for association with the occurrence of post-operative infectious and wound complications. Each screening tool was calculated and compared under the area of Receiver Operating Characteristic (ROC) curve. RESULT AND CONCLUSION: The NRC classification was the best prediction for the occurrence of post-operative infectious and wound complications in elderly surgical patients.

Clinical study of the Ginko biloba--Troxerutin-Heptaminol Hce in the treatment of acute hemorrhoidal attacks.

OBJECTIVE: The aim of this study was to assess the clinical efficacy, compliance and safety of Ginko biloba--Troxerutin-Heptaminol Hce in the treatment of patients with acute hemorrhoidal attacks in Thailand. MATERIAL AND METHOD: In a prospective clinical study on hospital outpatients, the authors studied the effect of Ginko biloba--Troxerutin-Heptaminol Hce for a week in adults (18-70 years old) with acute hemorrhoidal attacks. RESULT: Twenty-two patients, with a mean age of 41.7 years were included in the study. The male to female ratio was 1 : 1.2. Most patients (77%) had grade 1 and 2 hemorrhoids with an average duration of attacks of 3 days. On intention to treat analysis, bleeding, pain, tenesmus and discharge were significantly improved. Treatment was well accepted and safe. CONCLUSION: In the short-term, Ginko biloba--Troxerutin-Heptaminol Hce is effective, acceptable and safe in the treatment of patients with acute hemorrhoidal attacks.