Personal risk factors associated with heat-related illness among new conscripts undergoing basic training in Thailand

Cases of exertional heat stroke have been reported every year during basic training for Royal Thai Army (RTA) conscripts. Prevention is an important strategy to reduce the incidence of heat-related illnesses. We conducted a study to identify potential indicators for the prevention and monitoring of heat-related illnesses among military conscripts undergoing basic training in Thailand. All newly inducted RTA conscripts in 5 basic training units in 5 regions in Thailand were invited to participate in a prospective cohort study from May 1 to July 9, 2013. The incidence rate of heat-related illnesses and the incidence rate ratio (IRR) based on a Poisson regression model were used to identify the independent factors associated with heat-related illnesses, daily tympanic (body) temperatures higher than 37.5°C, >3% decreases in body weight in one day, and the production of dark brown urine. Eight hundred and nine men aged 21.4 (±1.13) years were enrolled in this study. The prevalence of a body mass index (BMI) ≥30 kg/m² was 5.5%. During the study period, 53 subjects (6.6%) representing 3.41/100 person-months (95% confidence interval (CI), 2.55–4.23) developed heat-related illnesses (excluding heat rash), and no subjects experienced heat stroke. The incidence rates of a daily tympanic temperature >37.5°C at least once, body weight loss of >3% per day, and the production of dark brown urine at least once were 8.27/100 person-months (95% CI, 7.69–8.93), 47.91/100 person-months (95% CI, 44.22–51.58), and 682.11/100 person-months (95% CI, 635.49–728.52), respectively. The sole identified independent factor related to the incidence of heat-related illnesses was a BMI ≥30 kg/m² (adjusted IRR = 2.66, 95% CI, 1.01–7.03). In conclusion, a high BMI was associated with heat-related illnesses among conscripts undergoing basic training in Thailand. Daily monitoring of heat-related illnesses, body temperature, body weight and urine color in each new conscript during basic military training was feasible.

Effectiveness of Intraperitoneal Bupivacaine in Reducing Postoperative Morphine Used among Total Abdominal Hysterectomy Patients at Phramongkutklao Hospital

OBJECTIVE

To study the effectiveness of intraperitoneal bupivacaine in reducing 24-hour postoperative morphine used in women underwent total abdominal hysterectomy.

MATERIAL AND METHOD

Sixty-two non-malignant gynecologic patients, aged 25 to 65 years, ASA class I-II, underwent elective total abdominal hysterectomy. On the operative day, patients were allocated simple random sampling. Blinded intraperitoneal solution was prepared and numbered for each patient. In total, 40 ml of 0.25% bupivacaine solution or normal saline was applied in the pelvic cavity after completed the operation. The abdominal muscle and subcutaneous fat were infiltrated with 0.25% bupivacaine 10 ml each layer. Intravenous morphine patient-controlled analgesia (PCA) was started in the recovery room. The assessment of total morphine used, sedative score, numerical rating score (NRS) for pain, postoperative nausea vomiting (PONV), pruritus, and the number of vomiting and antiemetic drugs used were recorded at 1, 2, 4, 8, 12, and 24 hours after intraperitoneal administration. Patients’ satisfactory NRS was evaluated after PCA cessation. Repeated measure ANOVA was used to compare means between two groups. Baseline characteristics were calculated by descriptive statistics, i.e., mean, standard deviation, median, and range. A p-value less than 0.05 was considered statistically significant. Statistical package for the social sciences (SPSS) for Windows version 23 was used.

RESULTS

There were no significant differences were found between the two groups in general patients’ characteristics, intraoperative data, and anesthetic administration. Total morphine consumption at 24 hours after intraperitoneal administration was significantly less in the bupivacaine group than the saline group (25.03 vs. 16.13, p = 0.002). Lower pain score at 1 and 2 hours and significant difference in reduced morphine consumption were observed within the first 4 hours after intraperitoneal bupivacaine administration. Postoperative 24 hours satisfactory score, PONV, pruritic score, overall incidences of vomiting and antiemetic use were similar in both groups. Sedative scores were lower in the bupivacaine group except at 1 and 24 hours postintraperitoneal administration. No evidence of local anesthetic toxicity or operative complication was identified.

CONCLUSION

Administration of intraperitoneal and incisional 0.25% bupivacaine at the completion of total abdominal hysterectomy produced a significant reduction in 24-hour postoperative morphine used without adverse effect.

The Development of Sleep Questionnaires Thai Version (ESS, SA-SDQ, and PSQI): Linguistic Validation, Reliability Analysis and Cut-Off Level to Determine Sleep Related Problems in Thai Population

BACKGROUND

The Epworth Sleepiness Scale (ESS), Sleep Apnea Scale of Sleep Disorders Questionnaire (SA-SDQ), and Pittsburgh Sleep Quality Index (PSQI) are widely used in English speaking countries for sleep problem screening. However, there is no officially validated Thai-version of sleep questionnaires available.

OBJECTIVE

To provide standard Thai version of three sleep questionnaires and find cut-off level to screening sleep problems in Thai population.

MATERIAL AND METHOD

We used Mapi Research Institute Methods for translation from original language to Thai questionnaire. Then, test-retest reliability analysis was performed. Finally, we collected data from patients who underwent polysomnography in Phramongkutklao Sleep Lab Centre between June and August 2011. Cut-off value to screen population at risk for sleep-related disorder was researched.

RESULTS

The questionnaires were translated with very good inter-rater agreement. Cut-off of ESS, SA-SDQ, and PSQI suggested sleep disorders would be 9, 27, and 6.5 respectively.

CONCLUSION

Sleep disorder questionnaires including ESS, SA-SDQ, and PSQI were translated into Thai with high validity, reliability, and accuracy.

Prevalence and hematological parameters of thalassemia in Tha Kradarn subdistrict Chachoengsao Province, Thailand

OBJECTIVE

To determine the prevalence, molecular characteristics and hematological study of thalassemia in Tha Kradarn Subdistrict Chachoengsao Province.

MATERIAL AND METHOD

The present study population consisted of266 participants from Moo 19 Baan Na-Ngam, Chachoengsao Province, Thailand. After blood collection, all samples were screened for thalassemia by initial screening with the OF and DCIP tests and additional testing by CBC, RBC indices, hemoglobin typing and determination of Hb A2 and Hb E. All common alpha-thalassemia mutations were determined using the PCR with allele specific primers and Gap PCR for common deletions.

RESULTS

The prevalence of alpha-thal 1, alpha-thal 2 and beta-thal were found as 2.72%, 11.26% and 0.97%, respectively. Regarding the abnormal hemoglobins, the prevalence of Hb E, Hb Constant Spring and Hb Pakse was 38.45%, 3.69% and 0.78%, respectively. MCV and MCH were significantly different between P-thalassemia as well as a-thal 1 carriers and normal subjects. In all alpha-thal 1 traits, it was found that the MCV and MCH were less than 75 fL and 25 pg, therefore, these parameters can be used for alpha-thal 1 screening.

CONCLUSION

In the present study, the prevalence of thalassemia was similar to previous studies. Moreover, using the combination of OF and DCIP tests compared with MCV, MCH and DCIP tests for the initial thalassemia screening, it was found that the OF and DCIP tests gave more false positive results, which increased the need for further Hb typing. Hence, the MCV and MCH combined with DCIP tests provide cost minimization and practical for a large population-based screening program.

Comparision of overweight and obesity in medical cadets before and after 6 months studying at Phramongkutklao College

OBJECTIVE

To evaluate prevalence of overweight and obesity in second-year medical cadets and to determine risk behaviors before and after 6 months studying at Phramongkutklao College of Medicine (PCM). MATERIAL AMD METHOD: Data on self-report behavioral questionnaires was collected from 92 medical cadets before and after 6 months studying at PCM in 2008. Body weight, height, waist circumference, blood pressure and body fat were measured according to standard protocols.

RESULTS

Overall, prevalence of overweight and obese medical cadets before studying at PCM was 16.30% and 15.22% according to BMI and 27.17% and 15.22% by percent body fat. After 6 months of study, overall mean of body fat and systolic blood pressure were significantly reduced. For males, the mean of weight, BMI and waist circumference were reduced significantly. In contrast, the mean of body weight and BMI of females were significantly increased. The prevalence of overweight in total participants determined by body fat was significantly reduced from 27.17% to 15.22%. Determination by BMI, obesity was significantly reduced from 34.29% to 14.29% only in males. Behaviors that were found to be significantly increased (p < 0.001) were regular physical activity, night eating, sugar-sweet beverage consumption, amount and frequency of coffee or tea consumption. Significant decrease in time of watching TV or using a computer, and duration of sleep was also determined.

CONCLUSION

The present study indicated that overweight, obesity, waist circumference and body fat of medical cadets were decreased after study at PCM which is possibly due to increasing exercise. Nevertheless, behavioral risks for obesity were also increasing, therefore, it might result in increased the prevalence of obesity in the future.

Associated factors of blood pressure control and complications of hypertension in hypertensive rural Thai populations of Baan Nayao, Chachoengsao Province

OBJECTIVE

To assess associated factors of uncontrolled blood pressure and complications of hypertension in hypertensive rural Thai populations.

MATERIAL AND METHOD

A cross-sectional study was conducted in hypertensive rural Thai people aged > or =35 years-old in Baan Nayao, Chachoengsao Province, Thailand. Blood pressure (BP) was measured and questionnaires were answered. After 12-hr fasting, blood samples were taken for determining plasma glucose, lipid profiles and serum creatinine. Morning urine samples were collected for microalbuminuria testing and electrocardiography (ECG) was performed to detect left ventricular hypertrophy (LVH).

RESULTS

Of the 289 participants (97 males and 192 females) mean duration of hypertension was 4.29 +/- 4.95 years and 61.5% did not achieve target BP control. Among participants who had ECG performed and urine sample investigation, 15.7% demonstrated LVH and 25.3% had microalbuminuria. In uncontrolled BP participants, 20% had LVH and 24.8% had microalbuminuria whereas in controlled BP participants, 7.8% had LVH and 26.1% had microalbuminuria. Uncontrolled BP was associated with males, dyslipidemia, diabetes, abdominal obesity, metabolic syndrome, always having salty food and salts added for seasoning. The independent risks of uncontrolled BP were hypertensive male (OR = 2.48, 95% CI = 1.07-5.76) and metabolic syndrome (OR = 2.59, 95% CI = 1.24-5.40). Males were also at risk for LVH (OR = 2.86, 95% CI = 1.31-6.23) and history of lipid disorders was a risk of microalbuminuria (OR = 3.13, 95% CI = 1.47-6.67).

CONCLUSION

Males and metabolic syndrome were independently associated with uncontrolled BP in hypertensive participants. Males had more risk than females to develop LVH and having history of lipid disorders lead to microalbuminuria occurrence. Thus, life style modification may prove beneficial to these rural hypertensive participants.

Validate of clinical risk index for osteoporosis in Thai women at Phramongkutklao Hospital

BACKGROUND

Osteoporosis is a common problem found in elderly people and the cost of treatment with its complications is much higher than the cost of diagnosis and prevention. However diagnosis of osteoporosis is hindered by an unavailability of dual energy x-ray absorptiometry (DXA). Many clinical risk index-scoring systems were developed to help prediction of osteoporosis such as Khon Kaen Osteoporosis Study (KKOS). The KKOS is one among those scoring systems based on the Thai population database. The objectives of the present study were to validate KKOS for prediction of osteoporosis in Thai women at Gynecologic Clinic of Phramongkutklao Hospital and to study the prevalence of women with osteoporosis diagnosed with KKOS.

MATERIAL AND METHOD

Four hundred forty six Thai women, aged 40 years or more attending the Gynecologic Clinic of Phramongkutklao Hospital, and had Bone mineral density (BMD) result were enrolled in the present study. The results of BMD were measured at the lumbar spine and femoral neck by DXA and KKOS. The score was evaluated and compared.

RESULTS

Sensitivity and specificity of KKOS for prediction of osteoporosis were 48.6% and 68.1%, respectively. Prevalence of osteoporosis using KKOS was 23% while 32% were diagnosed with DXA.

CONCLUSION

KKOS had low sensitivity and specificity for diagnosed osteoporosis in Thai women at Gynecologic Clinic of Phramongkutklao Hospital.

Current status of the research ethics committees in Thailand

BACKGROUND

Many research ethics committees (RECs) have been established to review biomedical research involving human subjects in many research institutes. The purpose is "To protect rights and welfare of human research participants". It is necessary to determine how many research ethics committees have been established in Thailand and whether they have a high enough standard toprotect the rights and welfare of human research subjects.

OBJECTIVE

To determine the status of research ethics committees in Thailand.

MATERIAL AND METHOD

One hundred thirty survey questionnaires were distributed by mail to medical schools of universities, public hospitals under the Ministry of Public Health, private hospitals, and research institutes.

RESULTS

Seventy-eight questionnaires were returned. Thirty respondents had standard Operating Procedures (SOP). Twenty-two RECs had their own office while 36 had to share the office with other departments or units. Board meeting frequency was once a month. The average number of committee members was 14 and the majority was scientific members. Absence of nonaffiliated members was found in RECs (20.6%). Thirty RECs had never provided training for REC members and investigators, the other 48 provided training at least once a year Decision are made by consensus in 51 and majority vote in 14 RECs. Twenty-two respondents managed conflicts of interest (COI) by asking those members to leave the meeting before a decision was finalized. Thirty-nine RECs required continuous review after approval of the protocols.

CONCLUSION

Strong support from the organization leader is a key factor to efficiency and high standards of REC operation. Developing a network of RECs will be useful for future development. REC members still need knowledge to better protect the rights, safety, and well-being of research participants.

How we teach military medicine to medical cadets at Phramongkutklao College of Medicine

Phramongkutklao College of Medicine has a unique curriculum for "Military Medicine." Military Medicine involves prevention, threat assessment, evacuations and clinical management of diseases and injuries resulting from military occupational exposures. The Military Medicine curriculum covers all the entities of knowledge of Military Sciences, Combat Medical Skills, Military Preventive Medicine, Military Applied Physiology and Military Contingency Medicine. The highlight of the curriculum is "Operation Petcharavut" that represents simulated battlefield operations, involving multidisciplinary clinical integration and military regulation. In this course, medical cadets review all the knowledge that they have learnt and in addition, Medical Platoon leader strategies, Advanced Cardiac Life support and Phramongkutklao Traumatic Life support, crucial medical practices. Medical cadets would experience simulated patients with minimal injuries to critical wounds and complications including combat stress syndromes in various situations, from advancing to retreating units and from Battalion Aid Station to Division Medical Operations Center, whether during day or night. Since the medical cadets experience all Military Medicine courses from the second to the sixth year class and pass all medical knowledge-based examinations, Phramongkutklao College of Medicine expects all graduates to be excellent in not only all standard requirements of the medical professional set forth by the Medical Council of Thailand but also ready to serve the nation effectively in the Royal Thai Armed Forces.

Incidence of rickettsial infection in patients with acute fever in provincial Thai army hospitals

Scrub typhus is common among patients with acute fever in rural areas of Thailand. The authors prospectively recruited patients with acute fever from provincial Thai army hospitals. Dot-ELISA test for scrub typhus was done in hospitals and then compared with standard immunofluorescent assay for diagnosis of scrub typhus. Among 178 patients, scrub typhus was diagnosed by immunofluorescent assay in 10 patients (5.61%). The incidence was high in the northeastern and northern regions. Dot-ELISA gave positive results in 4 of 115 patients, while immunofluorescent assay gave positive results in 6 patients (sensitivity = 66.7%). No false positive results of Dot-ELISA were found among 109 patients (specificity = 100%). All patients gave negative results for murine typhus and Thai tick typhus using immunofluorescent assay. Regarding this present study, Dot-ELISA for scrub typhus has a good sensitivity and specificity and can be used in rural hospitals. This test could be useful for diagnosis of scrub typhus in hospitals where immunofluorescent assay is not available.

Prevalence of disease and non-battle injury, anxiety and depression in the Royal Thai Armed Forces during the operation of the United Nations in Burundi

OBJECTIVE

To determine the prevalence and impact of common disease and non-battle injuries (DNBI) among the military personnel deployed to the operations of the United Nations (UN) in Burundi from June to December 2005.

MATERIALS AND METHODS

The study population consisted of 175 Thai military personnel. A pre- and post deployment questionnaire assessing demographic data, general health, dental problems, underlying disease and health risk behaviors was performed. The information of DNBI was collected weekly. Data on initial visits for 27 DNBI categories were complied at the unit and event data on morbidity measures for each DNBI category were aggregated for all reporting units on a weekly basis. Anxiety and depression were assessed using the Hospital Anxiety and Depression (HAD) scale.

RESULTS

The majority of the troops was in good health at pre- and post deployment. The total weekly initial visit DNBI rate was 337.6 visits per 1,000 persons, which was rather high compared to the Joint Chiefs of Staff (JCS) reference rate. The most common DNBI categories were respiratory illnesses (21.9%), medical/surgical injuries (19.8%) and recreational injuries (15.5%).

CONCLUSION

The present data indicated that despite modern preventive medicine measures, illnesses and non-battle injuries were still common, which had a significant impact on military readiness and operational efficiency.

Role of the Student Affairs Division, Phramongkutklao College of Medicine in assessing medical cadets

OBJECTIVE

To evaluate the role of the Student Affairs Division: Phramongkutklao College of Medicine in assessing medical cadets and determine the problems and obstacles in assessing.

MATERIAL AND METHOD

Qualitative study using focus group discussion was conducted in staff and medical cadets to determine functions, problems and obstacles of the Student Affairs Division, Phramongkutklao College of Medicine. Questionnaire was used to determine the agreement to ten domains: main educational programs, aims and missions, teaching methods, organizational culture, key requirements and expectation for programs, related units relationships and communication mechanisms, role of staff for student assessment, discipline, leadership assessment, problems and obstacles for student assessment and related units of student assessment, respectively.

RESULTS

The present study indicated that majority of the subjects agreed with the curriculum of the Student Affairs Division, especially the military subjects. However, a leadership subject should be added. Majority of the subjects supported the organizational culture of the Student Affairs Division.

CONCLUSION

This study showed that most of the subjects supported the vital role of the Student Affairs Division: Phramongkutklao College of Medicine in assessing medical students. However, improving the current assessment system regarding the leadership, is needed.

Perception of medical personnel on informed consent for research participation in Phramongkutklao Hospital and Phramongkutklao College of Medicine

OBJECTIVE

To evaluate the perception of medical personnel and medical cadets toward informed consent obtained from potential research participants.

MATERIAL AND METHOD

The authors conducted a study using self-administered questionnaires which included questions about perception on informed consent regarding its objectives, investigator's role, vulnerable subjects, family involvement and children's assent. The answer for each question was graded into 5 scales.

RESULTS

A selection of 380, 30.5%, 37.6% and 31.8% of 669 were attending staff residents, and medical cadets, respectively. A total of 85.5% agreed that informed consent in therapeutic trials should be obtained by their own doctors. A total of 75.3% agreed that the primary objective of informed consent was to protect investigators from lawsuits. A total of 60.8% agreed that participant spouses had to be involved in the informed consent process. A total of 79.5% agreed that permission from children was necessary in research conducted in children.

CONCLUSION

The role of investigators in therapeutic clinical trial, primary objectives of informed consent, and role of spouse were misunderstood among medical personnel and medical cadets. Education on research ethics should concentrate on these issues.

Corneal endothelial cell density and morphology in Phramongkutklao Hospital

OBJECTIVE

To describe the corneal endothelial density and morphology in patients of Phramongkutklao Hospital and the relationship between endothelial cell parameters and other factors.

METHODS

Four hundred and four eyes of 202 volunteers were included. Noncontact specular microscopy was performed after taking a history and testing the visual acuity, intraocular pressure measurement, Schirmer's test and routine eye examination by slit lamp microscope. The studied parameters included mean endothelial cell density (MCD), coefficient of variation (CV), and percentage of hexagonality.

RESULTS

The mean age of volunteers was 45.73 years; the range being 20 to 80 years old. Their MCD (SD), mean percentage of CV (SD) and mean (SD) percentage of hexagonality were 2623.49(325) cell/mm(2), 39.43(8.23)% and 51.50(10.99)%, respectively. Statistically, MCD decreased significantly with age (p < 0.01). There was a significant difference in the percentage of CV between genders. There was no statistical significance between parameters and other factors.

CONCLUSION

The normative data of the corneal endothelium of Thai eyes indicated that, statistically, MCD decreased significantly with age. Previous studies have reported no difference in MCD, percentage of CV, and percentage of hexagonality between gender. Nevertheless, significantly different percentages of CV between genders were presented in this study.

Combined clinical risk indices with quantitative ultrasound calcaneus measurement for identifying osteoporosis in Thai postmenopausal women

OBJECTIVE

To examine the diagnostic performance of clinical risk indices combined with quantitative ultrasound calcaneus measurement (QUS) for identifying osteoporosis in Thai postmenopausal women.

MATERIAL AND METHOD

The present study was designed as a cross-sectional investigation in 300 Thai women, aged between 38 and 85 years (mean age: 58). Femoral neck bone mineral density (BMD) was measured by DXA (Hologic QDR-4500; Hologic, Bedford, MA, USA). A BMD T-scores < or = -2.5 was defined as "osteoporosis"; otherwise, "non-osteoporosis". QUS was measured by Achilles+ (GE Lunar, Madison, WI, USA) and converted to T-score. The OSTA and KKOS score was calculated for each woman using her age and weight Women with OSTA/KKOS scores < or = -1 and > -1 were classified as "high risk" and "low risk", respectively.

RESULTS

Using DXA as the gold standard, the sensitivity of QUS to identify osteoporosis was lower than the sensitivity of OSTA/KKOS (60 vs. 71/74%) but the specificity and PPV of QUS were higher than OSTA/KKOS. The sensitivity increased when using OSTA/KKOS combined with QUS to identify osteoporosis (approximately 87-89%) while the specificity, PPV and NPV were comparable with using clinical risk indices alone. The risk (odds ratio; OR) of osteoporosis when QUS T-score < or = -2.5 alone was 9.94 (95%CI: 4.74-20.87), which was higher than high risk by OSTA/KKOS alone (OR: 6.35, 95%CI: 2.99-13.47 for OSTA and 8.15, 95%CI: 3.76-17.66 for KKOS). Furthermore, individuals were classified "high risk" from OSTA/KKOS with QUS T-score < or = -2.5SD, the risk of osteoporosis was increased (OR: 43.68, 95%CI: 13.89-137.36 and OR: 60.92, 95%CI: 17.69-209.76 for OSTA and KKOS, respectively).

CONCLUSION

Using the clinical risk indices combined with QUS could improve the accuracy of osteoporosis identification. This approach could be used in a primary care setting or community-based hospital where a DXA machine is not available.

A nomogram for predicting osteoporosis risk based on age, weight and quantitative ultrasound measurement

INTRODUCTION

Quantitative ultrasound measurement (QUS) or clinical risk index alone are not reliable tools for the identification of women with osteoporosis. This study examined the prognostic value of combined QUS and clinical risk index for predicting osteoporosis risk in Thai women.

METHODS

The study was designed as a cross-sectional investigation with 300 women of Thai background, aged between 38 and 85 years (mean age: 58). Femoral neck bone mineral density (BMD) was measured by DXA (Hologic QDR-4500; Bedford, MA, USA). A femoral neck BMD T-scores <or= -2.5 was defined as "osteoporosis"; otherwise, "non-osteoporosis". QUS was measured by Achilles+ (GE Lunar, Madison, WI, USA) and converted to T-score. Three models for predicting osteoporosis were considered: model I included age, weight and QUS, model II included age and weight, and model III included only QUS. The prognostic performance among the models was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

The prevalence of osteoporosis was 12.7% (n=38/300) by femoral neck BMD. Age, weight and QUS were each significantly associated with osteoporosis risk. The AUC+/-SE value for model I was 0.86 +/- 0.03, which was significantly higher (p=0.02) than that for model II (AUC = 0.80 +/- 0.04) or model III (AUC = 0.79 +/- 0.04). Based on the estimated parameters of model I, a nomogram was constructed for predicting osteoporosis.

CONCLUSION

These data suggest that the combination of QUS and age and weight could significantly improve the prognosis of osteoporosis in Asian women, and that the nomogram can assist primary care physicians in the identification of high-risk women.

The association between meconium-stained amniotic fluid and chorioamnionitis or endometritis

OBJECTIVE

Assess the association between meconium-stained amniotic fluid and chorioamnionitis or endometritis in term pregnant women.

MATERIAL AND METHOD

A five-year retrospective study was undertaken between January 1, 1999 and December 31, 2003. One thousand seventy-nine pregnant women who delivered at the Department of Obstetrics & Gynecology, Phramongkutklao Hospital were included in the present study.

RESULTS

Five hundred andfifty-three pregnant women (51.25%) had meconium-stained amniotic fluid (group 1) and 526 (48.75%) pregnant women were clear of amniotic fluid (group 2). Two pregnant woman in group 1 (0.36%) and eight pregnant women in group 2 (1.52%) were found to have chorioamnionitis (OR = 0.235). Postpartum endometritis was detected in only one (0.18%) pregnant women in group 1 and nine (1.71%) pregnant women in group 2 (OR = 0.104).

CONCLUSION

No association was found between meconium-stained amniotic fluids and chorioamnionitis or endometritis.

Cost-Effectiveness Analysis of Various Screening Methods for Osteoporosis in Perimenopausal Thai Women

OBJECTIVE

To perform a health economics analysis of 5 screening programs for osteoporosis in perimenopausal Thai women comparing two alternatives; without intervention and universal treatment without screening.

DESIGN

A decision analysis was performed to evaluate five screening strategies: Dual energy X-ray absorptiometry (DXA), Quantitative ultrasound sonography (QUS), risk index (clinical risk factors), two-step screening with QUS followed by DXA, and screening with risk index followed by DXA, comparing outcomes without intervention and universal treatment without screening.

RESULTS

The costs for universal treatment, screening by DXA with treatment, screening by QUS with treatment, screening by Risk index with treatment, screening by QUS and DXA with treatment, and screening by Risk index and DXA with treatment strategies to prevent one fracture were 207.82, 88.42, 147.05, 127.67, 71.33, and 60.30 USD, respectively. The cost for no intervention to prevent one fracture is 8.49 USD (1 USD = 40 Thai baht).

CONCLUSION

At present, no intervention is the most cost effective strategy. However, screening with risk index and DXA with treatment became the most cost effective when the patients reached the postmenopausal period and had a high risk index, for which the prevalence of osteoporosis will increase. Cost effective screening guidelines still cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk, are available.

BVBLUE test for diagnosis of bacterial vaginosis in pregnant women attending antenatal care at Phramongkutklao Hospital

BACKGROUND

Bacterial vaginosis (BV) is a disorder of the vaginal ecosystem characterized by a shift in the vaginal flora form the normally predominated lactobacillus to one dominated by sialidase enzyme-producing mixed flora.

OBJECTIVES

To compare the sensitivity of BVBLUE test for diagnosis of bacterial vaginosis with Gram stain by using Nugent score as a gold standard.

MATERIAL AND METHOD

From April to June, 2004, a total of 173 pregnant women who received antenatal care at Phramongkutklao Hospital had reached the study criteria. The speculum for this exam, used in the process of collecting vaginal secretions, must not be lubricated with any lubricants. The vaginal discharge was collected from the lower 1/3 of the vaginal wall. Gram stain score and BVBLUE test were conducted and compared.

RESULTS

173 patients were enrolled in the present study. BVBLUE test was compared to the standard method for the diagnosis of BV by Gram stain using Nugent score as a gold standard. The sensitivity, specificity, accuracy, positive and negative predictive value of BVBLUE test versus the Gram stain score for diagnosis of bacterial vaginosis were 94%, 96%, 96% 86%, and 98%, respectively.

CONCLUSION

BVBLUE test for diagnosis of bacterial vaginosis had high sensitivity, specificity, accuracy, positive and negative predictive value (94%, 96%, 96%, 86%, and 98%, respectively).

Teaching medical ethics: Phramongkutklao College of Medicine's model

BACKGROUND

Third-year (first preclinical year) Royal Thai Army (RTA) medical cadets were exposed to a rural community in a community medicine field activity. The poor, kind rural people gave good conditions for student's professional development and empathy.

OBJECTIVES

To report a community medicine field work activity for professional development of the RTA medical school.

MATERIAL AND METHOD

Descriptive analysis on two occasions to evaluate the third-year RTA medical cadets' impressions immediately after the community medicine field activity in a rural area in central Thailand and one year later using baseline scores of cadets' impressions against our institute's objectives.

RESULTS

At the end of the field work, 90.9% of the cadets reported they achieved several institute objectives. The four most frequent mentioned were ethical development (70.6%), professionalism (84.3%), human relationship & communication skills (92.2%), and capability to work in the cmmunity (64.7%). Furthermore, RTA medical cadets rated the staff as good role models (51%).

CONCLUSION

The community field work course provided a good environment for the third year medical cadets in building morality and professional development to be good doctors.

Prevalence of the metabolic syndrome, and its association factors between percentage body fat and body mass index in rural Thai population aged 35 years and older

OBJECTIVES

To obtain the prevalence of metabolic syndrome (MS) and its associated socioeconomic factors, and also to evaluate the association between percentage body fat (BF) and body mass index (BMI) in a rural Thai population.

MATERIAL AND METHOD

MS defined by the National Cholesterol Education Program Adult Treatment Panel III criteria. The prevalence of the MS was then determined using the NCEP III criteria with and without the modified waist circumference criteria. BMI indicating normal weight, overweight and obesity as re-defined for the Asian by International Association for the Study of Obesity (IASO), WHO. Four-hundred and four rural Thai men and women aged 35 years and older were evaluated. Data on anthropometry, blood pressure, socioeconomic status, lifestyle-related information, blood studies, and bioelectrical impedance (BIA) values had been collected.

RESULTS

The prevalence of the MS in the rural Thai people was 18%, but increased to 23% with the modified Asian criteria. High BMI, female gender, and older age were associated with increased odds of the MS. Household income, dietary composition, smoking and drinking status were not associated with increased odds of the MS. There was significant association between percent BF and BMI in men and women in rural Thai population.

CONCLUSION

The MS was present in about 18% of the rural Thai population and was significantly influenced by body mass index, gender and age. Metabolic syndrome becomes an important problem in rural Thai populations who even live basic lifestyle in the non-urbanized and non-industrialized areas. Identification and clinical management of this high-risk group is an important strategy for coronary heart disease prevention.

Prevalence and an analysis of noise--induced hearing loss in army helicopter pilots and aircraft mechanics

BACKGROUND AND OBJECTIVE

Hearing impairment from noise exposure has been reported in fix-wing pilots, especially in civilized countries. However, there are few studies on rotary wing aviators and aircraft mechanics, especially in developing countries whose hearing conservative program is not well established. The present study, therefore, was done to evaluate the prevalence of noise induced hearing loss and the contributing factors that may effect both groups of noise-exposed population.

MATERIAL AND METHOD

Report questionnaires were reviewed and physical examination combined with audiometric records of 34 pilots and 42 mechanics in the Royal Thai Army Aviation Center, Lobburi, were examined. Hearing loss was studied using four categories of significant threshold shift (STS). Amplitude of noise radiated by aircraft was also measured at different distances.

RESULTS

No significant difference was found in prevalence of hearing loss in aviators (32.4%) and aircraft mechanics (47.6%), but in the aircraft mechanics group there were more damage of frequency involvement including speech frequency and high frequency and more decibels loss than aviators. The type of hearing protection and smoking index were strongly correlated with hearing loss. Age, flight time and alcohol habit had no significant effect and ninety percent of the subjects had no self awareness of hearing loss.

CONCLUSION

Aircraft mechanics had more severity on hearing loss than aviators. Types of noise protector and cigarette smoking had significant association with hearing loss.

Screening for thalassemia and hemoglobinopathy in a rural area of Thailand: a preliminary study

The present study aimed to screen thalassemia and hemoglobinopathy in Baan Na-Ngam, Chachoengsao Province, Thailand. Blood samples were obtained from 266 volunteers; 105 males and 161 females aged 7 to 49 years. Blood samples screened for thalassemia combining the OF and modified DCIP precipitation tests. CBC, RBC indices, hemoglobin typing, HbA2 and Hb E were determined. Combined OF and DCIP tests found that in normal subjects, 128 out of 155 were negative for both, 3 were -/+ pattern, 22 were +/- pattern and 2 was positive for both. Interestingly, one sample showed an abnormal hemoglobin pattern, which could not be determined by automated LPLC. Three beta-thalassemia trait subjects were positive for only the OF test. For the Hb E trait, 57 out of 94 were -/+ pattern; 37 were positive for both tests. Moreover, 14 homozygous Hb E subjects were positive for both tests. The prevalence of beta-thalassemia trait was 1.1%, Hb E trait was 35.3% and homozygous Hb E was 5.3%. Since DNA analysis was not performed, alpha-thalassemia1 and alpha-thalassemia2 traits cannot be excluded. In conclusion, a combination of the OF and DCIP tests is suitable for preliminary screening for thalassemia and hemoglobinopathy. However, RBC parameters, hemoglobin typing and PCR analysis will provide more specific diagnosis, especially in alpha-thalassemias.

The comparative study of bone mineral density between premenopausal women receiving long term suppressive doses of levothyroxine for well-differentiated thyroid cancer with healthy premenopausal women

OBJECTIVE

To compare bone mineral density (BMD) of lumbar spines (LS) and femoral neck (FN) by Dual energy X-ray absorptiometry (DEXA) in premenopausal well-differentiated thyroid carcinoma women S/P total or near total thyroidectomy with a control group and the effect of Levothyroxine (LT4) to BMD between short term and long term treatment.

MATERIAL AND METHOD

DEXA were performed at LS (L1-L4) and FN in 22 premenopausal thyroid carcinoma women S/P total or near total thyroidectomy followed by 1-131 ablation and long term suppressive dose LT4 and 22 healthy premenopausal women.

RESULTS

Mean BMD of LS and FN were not significantly different between thyroid cancer group and control (LS 1.023 +/- 0.088 VS 0.980 +/- 0.075 g/cm2, p > 0.05, FN 0.800 +/- 0.068 VS 0.770 +/ - 0.061 g/cm2, p > 0.05). Period of time taking suppressive doses LT4 was divided into 3 groups (2-5 6-10 yrs and 11-14 yrs). Mean LS BMD +/- S.D of 2-5 yrs, 6-10 yrs and 11-14 yrs therapy are 1.042 +/- 0.135, 1.004 +/- 0.044 and 1.042 +/- 0.055 respectively (p > 0.05). Mean FN BMD +/- S.D of 2-5 yrs, 6-10 yrs and 11-14 yrs therapy are 0.808 +/- 0.084, 0.781 +/- 0.067 and 0.816 +/- 0.013 respectively (p > 0.05).

CONCLUSION

The suppressive doses LT was not the risk factor of osteoporosis. Although, there was no 4 statistically significant difference of BMD between short and long-term suppressive doses LT groups, the present sample size was not enough to conclude that long-term suppressive doses LT did not decrease BMD.

Dyslipidemia in Thai rural adults

The present study aimed to determine the prevalence of dyslipidemia in adults in a rural area of Thailand. Random sampling was conducted in 443 volunteers, 187 males and 256 females, aged > or = 35 years in Chachoengsao Province. After a 12-hour fast, the blood was drawn for the analysis of total cholesterol, triglycerides, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol. Mean serum lipids of cholesterol, LDL cholesterol, HDL cholesterol and triglycerides were 207.79 +/- 46.98, 117.26 +/- 36.59, 50.53 +/- 2.14 and 201.21 +/- 131.07 mg/dL, respectively. Nineteen percent of them had cholesterol > or = 240 mg/dL and 10% had LDL cholesterol > or = 160 mg/dL. Seven percent had HDL cholesterol < or = 35 mg/dL. However, LDL/HDL cholesterol ratios > 5, were found in only 0.9%. In conclusion, the prevalence of dyslipidemia was high in rural Thai adults. Further surveillance in this population is essential in verifying the impact of dyslipidemia as a risk of cardiovascular disease in rural Thai adults.

Diagnostic performance of quantitative ultrasound calcaneus measurement in case finding for osteoporosis in Thai postmenopausal women

AIM

Dual-energy X-ray absorptiometry (DXA) is currently considered the gold standard for the diagnosis of osteoporosis. Quantitative ultrasound (QUS) can be an alternative method that is less expensive, portable, and can be used at a primary care level to indicate osteoporosis in women. The present study aimed to assess the diagnostic performance of QUS calcaneus measurement in a case finding for osteoporosis in Thai postmenopausal women using DXA as a gold standard.

METHODS

Three hundred postmenopausal women, who had not menstruated normally for at least 1 year, were included in the study. To determine the accuracy and reliability of QUS of the calcaneus, calcaneus bone density measurement was carried out using the QUS and left femoral neck bone density was measured using DXA. Bone mass density (BMD) was interpreted as osteoporotic or normal using WHO criteria for determining the performance of QUS. Optimal cut-off values were determined using a receiver operating characteristic (ROC) curve for diagnosing the osteoporosis cases.

RESULTS

The number of osteoporosis cases in this study was 107 (35.67%). The sensitivity, specificity, positive and negative predictive values were 39.25%, 91.71%, 72.41%, 73.14%, respectively, when using the T-score of the WHO criteria as a reference. The positive and negative likelihood ratios were 4.73 and 0.66. When using the ROC curve to determine the optimal cut-off values, using the stiffness index of the QUS and categorizing age (<65 years and >or=65 years) before conducting the test, sensitivity and specificity were 77.6% and 59.6%, respectively.

CONCLUSIONS

Bone mass density measurement for predicting osteoporosis using QUS had a very low sensitivity and was not good enough to replace the standard tool (DXA).