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IJM
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Recent Advances
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ - ¡’π“§¡ 2551
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00 Ayurasat (Intro)
Diagnostic Test for Latent TB Infection
6
Abdominal Pain with Hypertension
11
Original Article
‚√§∫“¥∑–¬—°„π‚√ß欓∫“≈Õÿ¥√∏“π’
Stroke in the Young in Udonthani
Hospital
°“√»÷°…“ “‡Àµÿ¢Õߧ«“¡‰¡à√à«¡¡◊Õ„π°“√„™â¬“
¢ÕߺŸâªÉ«¬‚√§≈¡™—°
Fast Track Acute STEMI
„π‚√ß欓∫“≈¡À“√“™π§√√“™ ’¡“
17
26
37
46
Tetanus
57
EKG Conference
Arrythmia in COPD and Bronchiectasis 61
Patient
Arterial Blood Gas Conference
Dyspnea in Patient with Bronchiectasis 63
Electrolyte Conference
Bone Pain and Hyperchloremic
Metabolic Acidosis
69
Journal Reading
¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å
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æ‘¡æå∑’Ë ‚√ßæ‘¡æå ·Õππ“ ÕÕø‡´µ
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E-mail: [email protected]
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Topic Review
MM Conference
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1
Intersesting Case
§≈—ß∫ÿ≠§√Õß
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√».πæ. ¡»—°¥‘Ï
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Õ.πæ.∏π™—¬
Dermatologic Adverse Effects of
Antiretroviral Therapy
Association between HLA-B* 1502
Allele and Antiepileptic Drug-induced
Cutaneous Reactions in Han Chinese
72
Special Article
How to Success in International
Publication
74
Quiz
Skin Quiz
Hematology Quiz
77
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◊ËÕ°≈“ß√–À«à“ßÕ“¬ÿ√·æ∑¬å ·æ∑¬å‡«™ªÆ‘∫—µ‘∑—Ë«‰ª ·≈–·æ∑¬å‡«™»“ µ√å§√Õ∫§√—«„π¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ
‡º¬·æ√àº≈ß“π∑“ß«‘™“°“√·≈–ß“π«‘®—¬¢Õߧ≥“®“√¬å ·æ∑¬åª√–®”∫â“π ·æ∑¬åºŸâ„Àâ —≠≠“ ·≈–·æ∑¬åµàÕ¬Õ¥ ¿“§«‘™“Õ“¬ÿ√»“ µ√å
§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ ·≈–°≈ÿà¡ß“πÕ“¬ÿ√°√√¡‚√ß欓∫“≈¢Õπ·°àπ √«¡∑—Èß·æ∑¬åºŸâ π„®∑ÿ°∑à“π
æ—≤π“Õߧ姫“¡√Ÿâ·≈– à߇ √‘¡°“√»÷°…“µàÕ‡π◊ËÕß
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‚√ß欓∫“≈¢Õπ·°àπ
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 5 ©∫—∫∑’Ë 1 ¡°√“§¡ - ¡’π“§¡ 2549
1
2/4/08, 11:57
Vol.5 No.1
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Vol.5 No.1
IJM
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∑à“πºŸâÕà“π∑ÿ°∑à“π «“√ “√©∫—∫∑’Ë∑à“πÕà“πÕ¬Ÿàπ’È°â“«¬à“ß
‡¢â“ Ÿàªï∑’Ë 7 ´÷Ë߇ªì𧫓¡¿Ÿ¡‘„®¢Õß¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å
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µ’æ‘¡æåº≈ß“π√–¥—∫π“π“™“µ‘ Õ—π®–°àÕ„À⇰‘¥ª√–‚¬™πåµàÕºŸâÕà“πÕ¬à“߬‘Ëß
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Theme ‡√◊ËÕß Geriatric Medicine ®–®—¥¢÷Èπ√–À«à“ß«—π∑’Ë 6-8 ‘ßÀ“§¡ 2551
®÷ߢՇ™‘≠™«π∑ÿ°∑à“π‡¢â“√à«¡ª√–™ÿ¡·≈–µ‘¥µ“¡√“¬≈–‡Õ’¬¥„π«“√ “√
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ªï∑’Ë 5 ©∫—∫∑’Ë 1 ¡°√“§¡ - ¡’π“§¡ 2549
00 Ayurasat (Intro)
2
2/4/08, 11:58
Recent Advances
Dermatologic Adverse Effects of Antiretroviral Therapy
Õ.æ≠.æ≈Õ¬∑√“¬ ∫ÿ»√“§”
“¢“«‘™“‚√§º‘«Àπ—ß ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
1. Non-nucleoside reverse transcriptase
inhibitors (NNRTIs)
Õÿ∫—µ‘°“√≥å¢Õß°“√‡°‘¥º◊Ëπ„𬓰≈ÿà¡ NNRTIs
æ∫‰¥âª√–¡“≥ √âÕ¬≈– 8.9 - 14
1.1 Nevirapine
ªí®®—¬∑’Ë¡’º≈∑”„À⇰‘¥º◊Ëπ„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“
nevirapine §◊Õ °“√‰¥â√—∫¬“ª√‘¡“≥ Ÿß ºŸâªÉ«¬‡æ»À≠‘ß
√–¥—∫¬“„π plasma Ÿß°«à“ 5.3 ml/L ‰¥â√—∫¬“‡ªìπ
§√—Èß·√° ºŸâªÉ«¬¡’√–¥—∫¢Õß CD4 Ÿß ‚¥¬‡©æ“–
ºŸâªÉ«¬‡æ»À≠‘ß∑’Ë¡’√–¥—∫ CD4 ¡“°°«à“ 200 cells/µL
º◊Ëπ∑’Ëæ∫„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“ nevirapine ¡’À≈“¬™π‘¥
µ—Èß·µà single erythematous lesion without pruritus
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
01-Recent
1
2/4/08, 13:15
¡°√“§¡ › ¡’π“§¡ 2551
1
Vol. 7 No.1
Drug specific skin reaction
®π∂÷ß Stevens-Johnson syndrome/toxic epidermal
necrolysis (ºŸâªÉ«¬∑’ˉ¥â√—∫¬“ nevirapine ¡’Õÿ∫—µ‘°“√≥å
¢Õß°“√‡°‘¥ Stevens-Johnson syndrome Ÿß°«à“
µ—«¬“Õ◊Ëπ„π°≈ÿà¡ NNRTI) ‚¥¬ à«π„À≠ຟâªÉ«¬¡—°¡’
º◊Ëπ„π≈—°…≥– diffuse erythematous maculopapular
eruption
™à«ß‡«≈“∑’Ëæ∫º◊Ëπ ®–‡°‘¥„π™à«ß 6 —ª¥“Àå
·√°¢Õß°“√√—°…“ ‚¥¬‡©æ“–„π 3-4 —ª¥“Àå·√°
Õ¬à“߉√°Áµ“¡ °“√‡ΩÑ“√–«—ß°“√‡°‘¥º◊Ëπ§«√§√Õ∫§≈ÿ¡
‰ª∂÷ß 18 —ª¥“Àå πÕ°®“°π’ȧ«√µ√«® liver function
test „πºŸªâ «É ¬∑’¡Ë º’ π◊Ë ‡æ√“–Õ“®æ∫§«“¡º‘¥ª°µ‘¢Õßµ—∫
√à«¡¥â«¬‰¥â
°“√¥Ÿ·≈√—°…“ nevirapine associated rash ¢÷πÈ
Õ¬Ÿà°—∫§«“¡√ÿπ·√ߢÕߺ◊Ëπ „π°√≥’∑’˺◊Ëπ‰¡à¡“° ¡’
Õ“°“√§—π ºŸâªÉ«¬§«√‰¥â√—∫¬“ antihistamine ·≈–
“¡“√∂„™â¬“µàÕ‰ª‰¥â ·µà„π°√≥’∑º’Ë ªŸâ «É ¬¡’≈°— …≥–¢Õß
hypersensitive À√◊Õ Stevens-Johnson syndrome §«√
À¬ÿ¥¬“‚¥¬∑—π∑’ ‡π◊ËÕß®“° nevirapine ‡ªìπ¬“∑’Ë¡’ long
half-life
°“√ªÑÕß°—π°“√‡°‘¥º◊Ëπ§«√‡√‘Ë¡ nevirapine
200 mg, once daily °àÕπ„π™à«ß 2 —ª¥“Àå·√° À≈—ß
®“°π—Èπ ®÷߇æ‘Ë¡¢÷Èπ‡ªìπ 200 mg, twice daily (2 week
lead in) ·µà„π°√≥’∑’Ë¡’º◊Ëπ„π™à«ß 2 —ª¥“Àå·√°
‰¡à§«√‡æ‘Ë¡ª√‘¡“≥‡ªìπ twice daily Knober ·≈–
§≥–»÷°…“∂÷ߪ√– ‘∑∏‘¿“æ„π°“√ªÑÕß°—πº◊πË ‚¥¬„À⬓
IJM
ªí®®ÿ∫—πºŸâªÉ«¬‚√§‡Õ¥ å®”π«πÀπ÷Ëß∑’Ë¡’‚Õ°“ ‰¥â√—∫¬“µâ“π‰«√— (HAART) ¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’¢÷Èπ
Õ—µ√“°“√µ‘¥‡™◊ÈÕ©«¬‚Õ°“ ·≈–Õ—µ√“°“√‡ ’¬™’«‘µ
≈¥≈ß Õ¬à“߉√°Áµ“¡°“√‰¥â√—∫¬“µâ“π‰«√— Õ“®°àÕ
„Àâ ‡ °‘ ¥ §«“¡º‘ ¥ ª°µ‘ ¢ Õߺ‘ « Àπ— ß ∫“ß™π‘ ¥ ‡æ‘Ë ¡ ¢÷È π
∫∑§«“¡π’È·∫àߧ«“¡º‘¥ª°µ‘∑“ߺ‘«Àπ—ß∑’ˇ°‘¥®“°°“√
√—∫¬“µâ“π‰«√— ‡ªìπ 3 °≈ÿà¡ §◊Õ
1. Drug specific skin reaction
2. The lipodystrophy syndrome
3. Immune reconstitution inflammatory
syndrome
Vol. 7 No.1
IJM
cetirizine §«∫§Ÿà‰ª°—∫ nevirapine º≈§◊Õ cetirizine
‰¡à “¡“√∂ªÑÕß°—π°“√‡°‘¥º◊Ëπ®“° nevirapine √«¡∑—Èß
°“√„Àâ prednisolone „π™à«ß 2 —ª¥“Àå·√° ®–‡æ‘Ë¡
Õ—µ√“°“√‡°‘¥º◊Ëπ®“° nevirapine
1.2 Efavirenz
º◊Ëπ∑’Ëæ∫„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“ efavirenz ¡’
≈—°…≥–‰¥âÀ≈“°À≈“¬ µ—Èß·µà diffuse, erythematous
maculopapular eruption to blistering, moist
desquamation À√◊Õ ulceration √–¬–‡«≈“‡©≈’ˬÀ≈—ß
‰¥â√—∫¬“§◊Õ 11 «—π ·≈–‡ªìπº◊Ëππ“πª√–¡“≥ 16 «—π
„πºŸâªÉ«¬‡¥Á°¡—°‰¡àæ∫«à“‡°‘¥º◊ËπÀ≈—߉¥â√—∫ efavirenz
°“√¥Ÿ·≈√—°…“¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ߢÕߺ◊Ëπ
·≈–Õ“°“√∑’Ëæ∫‡™àπ‡¥’¬«°—∫ nevirapine associated
rash ºŸâªÉ«¬∑’Ë¡’º◊Ëπ®“° efavirenz à«π„À≠à “¡“√∂
„™â¬“µàÕ‰ª‰¥â¬°‡«âπ„π°√≥’∑’Ë¡’‰¢â º◊Ëπ≈—°…≥–‡ªìπ
µÿà¡πÈ”æÕß ¡’ mucosal involvement √à«¡¥â«¬ §«√
À¬ÿ¥¬“∑—π∑’
¢âÕ¡Ÿ≈¢Õß°“√‡°‘¥º◊Ëπ∑’Ë —¡æ—π∏å°—π (crossreactivity) ¿“¬„π°≈ÿà¡ NNRTI ¬—߉¡à‡æ’¬ßæÕ∑’Ë®–‰¥â
¢âÕ √ÿª Õ¬à“߉√°Áµ“¡®“°¢âÕ¡Ÿ≈„π¢≥–π’ȉ¡à·π–π”
„Àâ ‡ ª≈’Ë ¬ πÀ√◊ Õ „™â ¬ “„π°≈ÿà ¡ ‡¥’ ¬ «°— π ¡“∑¥·∑π„π
°√≥’∑’ˇ°‘¥º◊Ëπ®“°¬“„π°≈ÿà¡ NNRTI
Torralba ·≈–§≥– æ∫«à“ √âÕ¬≈– 40 ¢Õß
ºŸâªÉ«¬∑’Ë¡’º◊Ëπ®“° nevirapine ‡°‘¥º◊ËπÀ≈—ß®“°‡ª≈’ˬπ
¬“‡ªìπ efavirenz ·≈–„π∑“ß°≈—∫°—π √âÕ¬≈– 50 ¢Õß
ºŸâªÉ«¬∑’Ë¡’º◊Ëπ®“° efavirenz ‡°‘¥º◊ËπÀ≈—ß®“°‡ª≈’ˬπ¬“
‡ªìπ nevirapine
2. Protease inhibitors
¬“À≈“¬µ—«„π°≈ÿà¡π’ȇ™àπ amprenavir, fosamprenavir, darunavir, tipranavir ¡’Õߧåª√–°Õ∫¢Õß
sulfonamide ®÷ ß §«√À≈’ ° ‡≈’Ë ¬ ß„π°√≥’ ∑’Ë ºŸâ ªÉ « ¬¡’
ª√–«—µ‘·æ⬓°≈ÿà¡ sulfonamide
2.1 Indinavir
2
indinavir ∑”„À⇰‘¥§«“¡º‘¥ª°µ‘¢Õߺ‘«Àπ—߉¥âÀ≈“¬
™π‘ ¥ ‡™à π rash,paronychia, alopecia,ingrown
toe-nails,curling of straight hair º≈µà“ßʇÀ≈à“π’È
§≈⓬§≈÷ß°—∫°“√„™â¬“„π°≈ÿà¡ retinoid (retinoid
effect) ¡’°“√»÷°…“æ∫«à“ √âÕ¬≈– 30 ¢ÕߺŸâªÉ«¬∑’ˉ¥â
√—∫¬“ indinavir ¡’Õ“°“√·≈–Õ“°“√· ¥ß§≈⓬§≈÷ß
°—∫°“√„™â¬“„π°≈ÿà¡ retinoid Õ¬à“ßπâÕ¬ 2 ™π‘¥¢÷Èπ‰ª
πÕ°®“°π’Ⱥ≈¥—ß°≈à“«¬—ß·ª√º—πµ“¡ª√‘¡“≥¢Õ߬“
∑’ˉ¥â√—∫ √«¡∂÷ß°√≥’∑’˺ŸâªÉ«¬‰¥â√—∫¬“ ritonavir ´÷Ëß
‡æ‘Ë¡√–¥—∫¬“¢Õß indinavir ∑”„Àâ¡’‚Õ°“ ‡°‘¥º≈¢â“ß
‡§’¬ß¥—ß°≈à“« Ÿß¢÷Èπ ªí®®—¬Õ◊Ëπʇ™àπ ‡æ» Õ“¬ÿ √–¥—∫
CD4 ‰¡à¡’º≈µàÕ‚Õ°“ °“√‡°‘¥º≈¢â“߇§’¬ß
º◊Ëπ®“° indinavir ¡’≈—°…≥–‰¥âÀ≈“°À≈“¬
µ—È ß ·µà mild erythematous lesions,erythema
multiforme, Stevens-Johnson syndrome ·µàÕ“°“√
· ¥ß∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥§◊Õ º‘«·Àâß ·≈–ºŸâªÉ«¬Õ“®¡’
Õ“°“√· ¥ß§◊Õ scaling, roughness of skin with
excoriation secondary to pruritus-induce scratching
πÕ°®“°π’ÈÕ“®æ∫ chellitis secondary to mucosa
dryness Õ“°“√‡À≈à“π’È “¡“√∂√—°…“‚¥¬„™â topical
emollients ·≈–„™â¬“ indinavir µàÕ‰¥â ·µà„π°√≥’
∑’ˇ°‘¥º◊Ëπ™π‘¥ erythema multiforme ·≈– stevensJohnson syndrome §«√À¬ÿ¥¬“∑—π∑’
Indinavir ∑”„À⇰‘¥§«“¡º‘¥ª°µ‘¢Õ߇≈Á∫‰¥â
‡™àπ paronychia ¡’§«“¡√ÿπ·√߉¥âµ—Èß·µà‡≈Á°πâÕ¬®π∂÷ß
°“√‡°‘¥‡ªìπ granulomatous forming æ∫‰¥â∫àÕ¬∑’Ëπ‘È«
À—«·¡à‡∑â“ „π¢≥–‡¥’¬«°—πÕ“®µ√«®æ∫ retinoid like
effect Õ◊ËπÊ √à«¡¥â«¬ °“√√—°…“ paronychia ∑”‰¥â‚¥¬
topical corticosteroids ·≈– antibacterials
ªí≠À“∑“ߺ‘«Àπ—ß∑’Ë∑”„À⺟âªÉ«¬µâÕß°“√À¬ÿ¥
¬“¡“°∑’Ë ÿ¥§◊Õ alopecia ´÷ËßÕ“®¡’≈—°…≥–‡ªìπ diffuse
alopecia, localized alopecia, alopecia areata „π
°√≥’∑’Ë®”‡ªìπ “¡“√∂À¬ÿ¥„™â indinavir ‚¥¬‡ª≈’ˬπ
‡ªì𬓵—«Õ◊Ëπ„π°≈ÿà¡ protease inhibitors ‰¥â
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
01-Recent
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2.2 Amprenavir and fosamprenavir
Amprenavir ¡’Õ∫ÿ µ— °‘ “√≥å°“√‡°‘¥º◊πË √âÕ¬≈– 27
‡ª√’ ¬ ∫‡∑’ ¬ ∫°— ∫ placebo √â Õ ¬≈– 6 ≈— ° …≥–º◊Ë π
∑’Ëæ∫‰¥â∫àÕ¬§◊Õ maculopapular rash ∑’ˉ¡à√ÿπ·√ß
Õ¬à“߉√°Áµ“¡ ¡’Õÿ∫—µ‘°“√≥å°“√‡°‘¥ Stevens-Johnson
syndrome ®“° amprenavir ‰¥â√âÕ¬≈– 1 à«π„À≠à
º◊Ëπ¡—°‡°‘¥À≈—ß®“°‰¥â√—∫¬“ª√–¡“≥ 11 «—π ·≈–‡ªìπ
º◊Ëππ“πª√–¡“≥ 10 «—π
°“√¥Ÿ·≈√—°…“¢÷ÈπÕ¬Ÿà°—∫§«“¡√ÿπ·√ߢÕߺ◊Ëπ
·≈–Õ“°“√∑’Ëæ∫‡™àπ‡¥’¬«°—∫ nevirapine ¢âÕ·µ°µà“ß
√–À«à“ß amprenavir °—∫ nevirapine §◊ÕºŸâªÉ«¬∑’ˇ§¬¡’
º◊Ë π À≈— ß ®“°‰¥â √— ∫ ¬“ amprenavir ·≈â « à « πÀπ÷Ë ß
“¡“√∂°≈—∫¡“„™â¬“ amprenavir ‰¥â‚¥¬‰¡à¡’º◊Ëπ
‡°‘¥¢÷πÈ Õ’°
Fosamprenavir ‡ªìπ pro-drug ¢Õß amprenavir
‡°‘ ¥ º◊Ë π ‰¥â „ π≈— ° …≥–‡¥’ ¬ «°— ∫ amprenavir ·µà
Õÿ∫—µ‘°“√≥å°“√‡°‘¥º◊ËππâÕ¬°«à“ amprenavir
4. Entry inhibitors
The Lipodystrophy syndrome
The HIV-associated lipodystrophy syndrome
ª√–°Õ∫¥â « ¬°≈ÿà ¡ Õ“°“√∑’Ë ¡’ § «“¡º‘ ¥ ª°µ‘ ¢ Õß°“√
°√–®“¬¢Õß body fat √«¡∑—È ß §«“¡º‘ ¥ ª°µ‘ ∑ “ß
metabolism ‡™àπ insulin resistance, dyslipidemia
°“√°√–®“¬µ—«∑’˺‘¥ª°µ‘¢Õß adipose tissue
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
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Vol. 7 No.1
Enfuvirtide (T-20) ‡ªì𬓄π°≈ÿà¡ fusion
inhibitors ´÷Ëß∫√‘À“√¬“‚¥¬°“√©’¥∑“ß subcutaneous
¡—°‡°‘¥º≈¢â“߇§’¬ß§◊Õ injection-site reactions (ISRs)
‰¥â·°à ‡®Á∫ §—π ·¥ß ‡°‘¥°âÕπ·¢Áß À√◊Õ ∂ÿßπÈ”„π
µ”·Àπàß∑’Ë©’¥ º≈®“°°“√µ—¥™‘Èπ‡π◊ÈÕ∫√‘‡«≥ injectionsite reactions (ISRs) æ∫«à“¡’≈°— …≥–§≈⓬ granuloma
annulare ·≈– interstitial granulomatous
drug reaction ´÷Ë߇°‘¥®“° localized hypersensitivity
Õ¬à“߉√°Áµ“¡§«“¡√ÿπ·√ß∑“ß欓∏‘ ¿“扡à Õ¥§≈âÕß
°—∫≈—°…≥–∑’Ëæ∫∑“ߧ≈‘π‘° ·≈– à«π„À≠à “¡“√∂
«‘π‘®©—¬‰¥â‚¥¬‰¡àµâÕßµ—¥™‘Èπ‡π◊ÈÕ °“√ªÑÕß°—π·≈–
√—°…“∑”‰¥â‚¥¬‡ª≈’Ë¬πµ”·Àπàß∑’Ë©’¥¬“ ‡™àπ µâπ·¢π
Àπâ“∑âÕß À√◊Õ µâπ¢“
Systemic hypersensitivity reaction æ∫‰¥â
πâÕ¬°«à“√âÕ¬≈– 1 Õ“°“√·≈–Õ“°“√· ¥ß∑’Ëæ∫‰¥â·°à
‰¢â º◊Ëπ §≈◊Ëπ‰ â Õ“‡®’¬π µ—∫Õ—°‡ ∫ §«“¡¥—π‚≈À‘µ
µË” „π°√≥’π’ȧ«√À¬ÿ¥¬“∑—π∑’·≈–‰¡à§«√„À⬓„π
°≈ÿà¡π’ÈÕ’°
IJM
3. Nucleoside reverse transcriptase inhibitors
(NRTIs)
3.1 Abacavir
Abacavir ∑”„À⇰‘¥º◊Ëπ™π‘¥ hypersensitivity
reaction‰¥â∫àÕ¬ Õ“°“√∑’Ëæ∫§◊Õ diffuse maculopapular rash ‰¢â ÕàÕπ‡æ≈’¬ Õ“°“√∑“ß√–∫∫∑“߇¥‘πÕ“À“√
·≈– √–∫∫∑“߇¥‘πÀ“¬„® à«π„À≠à hypersensitivity
reaction ¡—°æ∫„π 6 —ª¥“Àå·√°À≈—߉¥â√—∫¬“ ªí®®—¬
‡ ’ˬß∑’Ëæ∫‰¥â·°à ‡æ»À≠‘ß ‡™◊ÈÕ™“µ‘Õ◊ËπÊπÕ°‡Àπ◊Õ
®“° African ·≈– HLA-B5701
°“√¥Ÿ·≈√—°…“„π°√≥’∑º’Ë ªŸâ «É ¬¡’ hypersensitivity
reaction ∑’Ë ‡ À¡“– ¡§◊ Õ À¬ÿ ¥ ¬“∑— π ∑’ ·≈–¥Ÿ · ≈
√—°…“µ“¡Õ“°“√ º◊Ëπ·≈–Õ“°“√∑’Ëæ∫§«√¥’¢÷ÈπÀ≈—ß
®“°À¬ÿ¥¬“ 1-2 «—π
°“√ rechallange abacavir ‡ªìπ¢âÕÀâ“¡∑’Ë
‰¡à§«√∑” ‡æ√“–Õ“®‡°‘¥Õ—πµ√“¬ ·≈–¡’ multiorgan
system failure 䴉
3.2 Zidovudine
Zidovudine ∑”„À⇰‘¥º‘«Àπ—ß·≈–‡≈Á∫¡’ ’§≈È”
¥”¢÷Èπ‰¥â≈—°…≥–‡¥àπ∑’Ëæ∫‰¥â∫àÕ¬ §◊Õ ‡ âπ ’¥”∫“ßÊ
„π·π«¢π“π°—∫ nail bed ¡’√“¬ß“π°“√‡°‘¥º◊Ëπ™π‘¥
√ÿπ·√ß ‡™àπ Stevens-Johnson syndrome ·≈– toxic
epidermal necrolysis
Vol. 7 No.1
IJM
√«¡∂÷ß lipoatrophy,lipohypertrophy À√◊Õ∑—Èß Õß™π‘¥
®“°°“√»÷°…“ cross-sectional study æ∫«à“ lipoatrophy
æ∫‰¥â∫àÕ¬„πºŸâªÉ«¬ HIV ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ control
·µàÕÿ∫—µ‘°“√≥å¢Õß lipohypertrophy ‰¡à·µ°µà“ß®“°
control
Lipoatrophy ∑’Ë —¡æ—π∏å°—∫°“√‰¥â√—∫¬“µâ“π
‰«√— ¡’º≈∑”„Àâ subcutaneous tissue À“¬‰ª‚¥¬
‡©æ“–∑’Ë„∫Àπâ“ ·¢π¢“ ·≈–°âπ °“√∑’ˉ¢¡—π∫√‘‡«≥
„∫Àπâ“≈¥≈ß∑”„À⇰‘¥°“√‡ª≈’ˬπ·ª≈ߢÕß√ŸªÀπâ“
∫√‘‡«≥·°â¡ ·≈–√Õ∫µ“ ´÷ËßÕ“®°àÕ„À⇰‘¥ªí≠À“¥â“π
®‘µ„®·°àºŸâªÉ«¬
°“√ – ¡¢Õ߉¢¡—π∑’˺‘¥ª°µ‘¡—°æ∫∑’Ë∫√‘‡«≥
Àπâ“∑âÕß §Õ À≈—ß ‡µâ“π¡ ·≈–≈”µ—« ¿“«–·∑√°´âÕπ
∑’Ë ”§—≠∑’ËÕ“®æ∫√à«¡¥â«¬‰¥â·°à atherosclerosis ·≈–
diabetes mellitus
°≈‰°°“√‡°‘ ¥ lipoatrophy Õ∏‘ ∫ “¬‚¥¬
mitochondrial toxicity hypothesis §◊Õ NRTIs ¡’
º≈∑”„Àâ mitochondrial DNA polymerase -gamma
À¬ÿ ¥ ∑”ß“π √–¥— ∫ ¢Õß mitochondrial DNA
„π adipocyte ≈¥≈ß °“√ √â“ßæ≈—ßß“π¿“¬„π cell
≈¥≈ß ‡°‘¥ cellular dysfunction ·≈– apoptosis ¢Õß
adipocyte
ªí®®—¬‡ ’ˬߢÕß°“√‡°‘¥ lipoatrophy ‰¥â·°à
ºŸâªÉ«¬∑’ËÕ“¬ÿ¡“° body mass index µË” µ‘¥‡™◊ÈÕ¡“π“π
hypertriglyceride, CD4 µË” tumor necrotic
factor alpha polymorphism °“√„™â¬“ thymidine
analog ‡™àπ stavudine zidovudine ‡ªìπªí®®—¬‡ ’ˬß
∑’Ë∑”„À⇰‘¥ lipoatrophy
°“√√—°…“
1. Switching antiretroviral therapy
®“°°“√»÷°…“¢Õß Carr ·≈–§≥–‚¥¬·∫àß
ºŸâªÉ«¬ moderate-severe lipoatrophy ‡ªìπ 2 °≈ÿà¡‚¥¬
°≈ÿà¡∑’ËÀπ÷Ëß„™â¬“‡¥‘¡ ·≈–°≈ÿà¡∑’Ë Õ߇ª≈’Ë¬π¬“‡ªìπ
4
abacavir º≈°“√»÷°…“æ∫«à“¡’°“√‡æ‘Ë¡¢÷Èπ¢Õß limb fat
„π°≈ÿà¡∑’ˇª≈’Ë¬π¬“‡ªìπ abacavir
2. Thiazolidinedioanes
ªí®®ÿ∫—π°“√„™â¬“„π°≈ÿà¡ thiazolidinedioanes
‡æ◊ËÕ√—°…“ lipoatrophy ¬—߉¡à¡’¢âÕ¡Ÿ≈‡æ’¬ßæÕ∑’Ë®–
‰¥â ¢â Õ √ÿ ª Õ¬à “ ߉√°Á µ “¡„π°√≥’ ∑’Ë ºŸâ ªÉ « ¬¡’ ¿ “«–
lipoatrophy √à«¡°—∫ diabetes mellitus °“√‡≈◊Õ°
„™â¬“„π°≈ÿà¡π’Èπà“®–‡À¡“– ¡ ·µà§«√µ‘¥µ“¡√–¥—∫
transaminase, cholesterol ·≈– triglyceride ´÷ËßÕ“®
Ÿßº‘¥ª°µ‘‡π◊ËÕß®“°¬“„π°≈ÿà¡π’ȉ¥â
3. Uridine
°“√»÷°…“ in vitro ∑’Ëæ∫«à“ uridine ¡’ à«π
™à«¬ªÑÕß°—π°“√‡°‘¥ lipoatrophy ‚¥¬≈¥ mitochondrial
toxicity µàÕ adipocyte
4. Fillers
°“√©’¥ fillers ‡ªìπ∑“߇≈◊Õ°Àπ÷Ëß„π°“√·°â‰¢
¿“«–„∫Àπ⓺‘¥√Ÿª´÷Ë߇°‘¥®“° lipoatrophy ·µàÕ“®¡’
º≈¢â“߇§’¬ß ‡™àπ °“√µ‘¥‡™◊ÈÕ À√◊Õ‡°‘¥ foreign body
reaction ®“° “√∑’Ë„™â
Immune reconstitution inflammatory syndrome
ºŸâ ªÉ « ¬∑’Ë ¡’ ¿ “«– immune reconstitution
inflammatory syndrome Õ“®¡’Õ“°“√·≈–Õ“°“√
· ¥ß¢Õß°“√µ‘ ¥ ‡™◊È Õ ©«¬‚Õ°“ ∑’Ë æ ∫¿“¬À≈— ß °“√
‰¥â√—∫¬“µâ“π‰«√— À√◊Õ°“√·¬à≈ߢÕß°“√µ‘¥‡™◊ÈÕ©«¬
‚Õ°“ ∑’ˉ¥â√—∫°“√√—°…“·≈â«
°≈‰°°“√‡°‘¥¿“«– immune reconstitution
inflammatory syndrome ‡™◊ÕË «à“‡°‘¥®“°°“√‡æ‘¡Ë ¢÷πÈ ¢Õß
antigen-specific CD4 memory T cell ∑’Ë°≈—∫¡“¡’
º≈µàÕ antigen ‡¥‘¡∑’ˇ§¬ recognized ·≈â« πÕ°®“°π’È
°“√‡æ‘Ë¡¢÷Èπ¢Õß proinflammatory cytokines ·≈–
°“√¢“¥ immune regulatory cytokines ∑”„À⇰‘¥
paradoxical inflammatory reaction π’È
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
01-Recent
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„π¬ÿ§¢Õß°“√„™â¬“µâ“π‰«√— (HAART) ¡’
§«“¡º‘¥ª°µ‘∑“ߺ‘«Àπ—ßÀ≈“¬™π‘¥∑’ˇ°‘¥¢÷Èπ∑—Èß∑’ˇ°‘¥
®“°°“√·æ⬓ À√◊Õ‡ªìπº≈¢â“߇§’¬ß®“°¬“ ¡’º◊ËπÀ√◊Õ
§«“¡º‘ ¥ ª°µ‘ ∑ “ߺ‘ « Àπ— ß ∑—È ß ∑’Ë æ ∫√à « ¡°— ∫ Õ“°“√„π
√–∫∫Õ◊ËπÊ À√◊Õ§«“¡º‘¥ª°µ‘∑’˺‘«Àπ—߇∑à“π—Èπ
∫√√≥“πÿ°√¡
1. Crum-Cianflone NF.Immune reconstitution
inflammatory syndromes: whatûs new?.
AIDS Read 2006;16:199-206,213-7.
2. Kong HH, Myers SA. Cutaneous effects of
highly active antiretroviral therapy
in HIV-infected patients. Dermatologic
Therapy ;18:58-66.
3. Luther J, Glesby MJ. Dermatologic adverse
effects of antiretroviral therapy. Am J Clin
Dermatol 2007;8:221-33.
4. Ratnam I, Chiu C, Kandala NB, et al.
Incidence and risk factors for immune
reconstitution inflammatory syndrome in
an ethnically diverse HIV type 1-infected
cohort. Clin Infect Dis 2006;42:418-27.
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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Vol. 7 No.1
√ÿª
°“√¥Ÿ · ≈√— ° …“ºŸâ ªÉ « ¬„π°≈ÿà ¡ π’È ®”‡ªì π µâ Õ ß
æ‘®“√≥“∂÷ß ≈—°…≥–∑“ߺ‘«Àπ—ß∑’Ëæ∫ ™à«ß‡«≈“∑’Ëæ∫
§«“¡º‘¥ª°µ‘À≈—߉¥â√—∫¬“ ™π‘¥À√◊Õ Ÿµ√¬“∑’ˉ¥â√—∫
√«¡∑—Èß√–¥—∫ CD4 ¢ÕߺŸâªÉ«¬°àÕπ‰¥â√—∫¬“·≈–¢≥–∑’Ë
µ√«®æ∫§«“¡º‘¥ª°µ‘‡æ◊ËÕª√–°Õ∫°“√«‘π‘®©—¬ °“√
√—°…“ºŸâªÉ«¬§«√æ‘®“√≥“‡ªìπ√“¬Ê‰ª¢÷ÈπÕ¬Ÿà°—∫™π‘¥
¢Õߧ«“¡º‘¥ª°µ‘∑’Ëæ∫ §«“¡√ÿπ·√ß ·≈–™π‘¥¢Õ߬“
∑’Ë∑”„À⇰‘¥§«“¡º‘¥ª°µ‘π—ÈπÊ
IJM
¡’ ° “√»÷ ° …“¬â Õ πÀ≈— ß æ∫«à “ ºŸâ ªÉ « ¬ª√–¡“≥
√â Õ ¬≈– 25 ¡’ ¿ “«– immune reconstitution
inflammatory syndrome Õ“°“√∑’Ëæ∫‰¥â∫àÕ¬§◊Õ ÀŸ¥
∑’ËÕ«—¬«–‡æ» °“√‡°‘¥ herpes genitalis ·≈–¡—°
‡°‘¥¿“¬„π 3 ‡¥◊Õπ·√°À≈—ß°“√‰¥â√—∫¬“µâ“π‰«√— ªí®®—¬‡ ’¬Ë ߢÕß°“√‡°‘¥¿“«– immune reconstitution inflammatory syndrome §◊Õ ºŸâªÉ«¬∑’Ë¡’√–¥—∫
CD4 πâÕ¬°«à“ 200 cell/uL °“√µÕ∫ πÕß∑“ß√–∫∫
¿Ÿ¡‘§ÿâ¡°—π‡√Á« ‡™àπ °“√‡æ‘Ë¡¢÷Èπ¢Õß CD4 Õ¬à“ß√«¥‡√Á«
À≈—߉¥â√—∫¬“µâ“π‰«√— end-staged AIDS °“√¡’
clinical À√◊Õ subclinical opportunistic infections
°àÕπ‰¥â√—∫¬“µâ“π‰«√— ‚¥¬‡©æ“–°“√µ‘¥‡™◊ÈÕ Mycobacterium tuberculosis, M. avium complex, Cryptococcus neoformans
Preliminary diagnostic criteria ‰¥â·°à °“√
≈¥≈ߢÕß HIV RNA level À√◊Õ°“√‡æ‘Ë¡¢÷Èπ¢Õß CD4
Õ¬à“ß√«¥‡√Á«À≈—߉¥â√—∫¬“µâ“π‰«√— √à«¡°—∫Õ“°“√∑’Ë
‡¢â“‰¥â°—∫ infection/inflammatory condition ∑’Ë
‰¡à‰¥â‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ„À¡àÀ√◊Õº≈¢â“߇§’¬ß®“°¬“
∑’ˉ¥â√—∫
Topic Review
Diagnostic Test for Latent TB Infection
æ≠.®‘≥«‘¿“ Õπÿ»√’ 1, √».æ≠.»‘√‘≈—°…≥å Õπ—πµå≥—∞»‘√‘ 2
·æ∑¬åª√–®”∫â“π, 2 “¢“«‘™“‚√§µ‘¥‡™◊ÈÕ·≈–‡«™»“ µ√凢µ√âÕπ
¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
IJM
Vol. 7 No.1
1
‚√§«— ≥ ‚√§¬— ß §ß‡ªì π ªí ≠ À“∑’Ë ”§— ≠ ∑“ߥ⠓ π
“∏“√≥ ÿ¢„πªí®®ÿ∫—π ‚¥¬Õߧ尓√Õπ“¡—¬‚≈° ‰¥â
ª√–¡“≥‡Õ“‰«â «à “ „πªï §».2005 ¡’ ºŸâ ªÉ « ¬ª√–¡“≥
9 ≈â“π§π∑’ˇªìπ«—≥‚√§ ·≈– 2 ≈â“π§π∑’ˇ ’¬™’«‘µ®“°
«—≥‚√§ πÕ°®“°π’Ȭ—ßæ∫«à“ ¡’ºŸâªÉ«¬µ‘¥‡™◊ÈÕ«—≥‚√§
√“¬„À¡à ¡“°°«à“ 40 ≈â“π§πµàÕªï
”À√— ∫ «— ≥ ‚√§„πª√–‡∑»‰∑¬π—È π ¡’ ºŸâ ªÉ « ¬
®”π«π¡“° ·≈–‡ªìπªí≠À“ “∏“√≥ ÿ¢‡™àπ‡¥‘¡ ®“°
∂‘µæ‘ ∫«à“ °≈ÿ¡à Õ“¬ÿ∑ª’Ë «É ¬‡ªìπ«—≥‚√§ ®–Õ¬Ÿ„à π™à«ßÕ“¬ÿ
40-60 ªï ·≈–§«“¡™ÿ°¢ÕߺŸªâ «É ¬∑—ßÈ „π™π∫∑ ‡¢µ‡¡◊Õß
À√◊Õ°√ÿ߇∑æ¡À“π§√°Á¡’®”π«π„°≈⇧’¬ß°—π
¥— ß π—È π °“√‡√à ß §â π À“·≈–√— ° …“ºŸâ ªÉ « ¬∑’Ë µ‘ ¥ ‡™◊È Õ
«—≥‚√§·Ωß (latent TB infection, LTBI) ®÷߇ªìπÕ’°
°≈¬ÿ∑∏åÀπ÷Ëß∑’Ë®–§«∫§ÿ¡°“√√–∫“¥¢Õß‚√§‰¥â
çLTBIé §◊ÕÕ–‰√ ?
§◊Õ °“√∑’Ë√à“ß°“¬‰¥â√—∫‡™◊ÈÕ«—≥‚√§‡¢â“ Ÿà√à“ß°“¬
·µà‰¡à¡’Õ“°“√¢Õß«—≥‚√§À√◊Õ°“√∑’ˉ¡à¡’À≈—°∞“π∑“ß
x-ray ¢Õß‚√§«—≥‚√§
‡ªìπ∑’Ë∑√“∫°—π¥’«à“ diagnostic test ”À√—∫
LTBI §◊Õ tuberculin skin test (TST) ‚¥¬¡’À≈—°°“√
§◊Õ ‡ªìπ°“√µ√«®°“√µÕ∫ πÕߢÕß√–∫∫¿Ÿ¡§‘ ¡ÿâ °—π™π‘¥
cell-mediated immune response µà Õ °“√µ‘ ¥ ‡™◊È Õ
«—≥‚√§∑’‡Ë ªìπ≈—°…≥– çdelayed-type hypersensitivityé
·≈–‡√“∂◊Õ«à“ TST ‡ªìπ gold standard „π°“√µ√«®À“
6
LTBI πÕ°®“°π’È TST ¬—ß√“§“∂Ÿ°·≈– “¡“√∂„™â‰¥â
∑—«Ë ‰ª
Õ¬à“߉√°Áµ“¡ TST °Á¬ß— ¡’¢Õâ ®”°—¥Õ’°À≈“¬Õ¬à“ß
‡™àπ
- °“√·ª≈º≈ TST ∑’ËÕ“®®–·ª√‡ª≈’Ë¬πµ“¡
ºŸâÕà“πº≈ ·≈–ºŸâªÉ«¬µâÕß°≈—∫¡“æ∫∫ÿ§≈“°√∑“ß°“√
·æ∑¬å‡æ◊ËÕÕà“πº≈Õ’°§√—Èß
- º≈¢Õß TST ∑’ËÕ“®®–‡ª≈’Ë¬πµ“¡√–¬–‡«≈“
À≈—ß®“° 48-72 ™¡. À≈—ß®“°∑’Ë¡’°“√µ‘¥‡™◊ÈÕ
- çBooster phenomenoné §◊Õ¬‘Ëß√–¬–‡«≈“
À≈—ß®“° expose µàÕ‡™◊ÈÕπ“π¢÷Èπ°ÁÕ“®∑”„Àâ TST ‰¥âº≈
negative ¥—ßπ—Èπ„πºŸâªÉ«¬∑’Ë„Àâº≈ TST ‡ªìπ≈∫µâÕß∑”
TST ´È”Õ’°§√—È߇æ◊ËÕÕà“πº≈ (2 step TST)
- ¡’ sensitivity ·≈– specificity µË”
- ¢÷Èπ°—∫‡∑§π‘§°“√∑” TST ‡™àπ °“√©’¥µ◊Èπ
À√◊Õ≈÷°®π‡°‘π‰ª®–¡’º≈µàÕ°“√·ª≈º≈ ·µà¢âÕ®”°—¥
∑’Ë ”§— ≠ ∑’Ë ÿ ¥ ¢Õß TST °Á §◊ Õ “¡“√∂‡°‘ ¥ falsepositive1,2 „π°√≥’∑º’Ë ªŸâ «É ¬‡§¬‰¥â√∫— «—§´’π BCG ¡“°àÕπ
À√◊ Õ „π°√≥’ ∑’Ë ºŸâ ªÉ « ¬¡’ ° “√µ‘ ¥ ‡™◊È Õ nontuberculous
mycobacteria (NTM) ‚¥¬¡’¢âÕ —߇°µ«à“À“°‡°‘¥®“°
BCG vaccination ‡¡◊ËÕ∑” TST ·≈â« skin reaction
¡—°®–πâÕ¬°«à“ 15 ¡¡.3 ·≈–∂Ⓡªìπ reaction ®“°
°“√µ‘¥‡™◊ÈÕ NTM æ∫«à“ TST ¡—°®–πâÕ¬°«à“ 10 ¡¡.
‡æ√“–©–π—Èπ ®÷߉¥â¡’§«“¡æ¬“¬“¡∑’Ë®–À“«‘∏’°“√∑’Ë®–¡“
«‘π‘®©—¬ LTBI ‚¥¬ new diagnostic test §«√®–¡’
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
02-Topic
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≈—°…≥– ¥—ßπ’È
- ¡’ sensitivity ·≈– specificity ∑’Ë Ÿß
- Reliable ·≈– stable
- √“§“∂Ÿ°·≈–∑”ßà“¬
·≈–ªí®®ÿ∫π— ¡’°“√µ√«®«‘π®‘ ©—¬™π‘¥„À¡à ‡æ◊ÕË
µ√«®À“ LTBI ´÷Ëß°Á§◊Õ çQuantiFERON (γ)é ‚¥¬
Õ“»— ¬ À≈— ° °“√§◊ Õ „™â specific antigens ¢Õ߇™◊È Õ
M. tuberculosis ´÷Ë߉¡à¡’„π«—§´’π BCG ·≈–„π‡™◊ÈÕ
NTM ·≈– specific antigens ∑’ˇ√“π”¡“„™â¡’Õ¬Ÿà 2 ™π‘¥
§◊Õ
1. Early secreted antigenic target 6 KD
protein (ESAT-6)
2. Culture filtrate protein 10 (CFP 10)
´÷Ëß protein 2 µ—«π’È®–Õ¬Ÿà¿“¬„π region of
difference 1 (RD1) ¢Õß M. tuberculosis genome
‚¥¬„πºŸâªÉ«¬∑’ˇªìπ LTBI °Á®–¡’°“√µÕ∫ πÕß
‚¥¬ memory T cell ®– √â“ß interferon-gamma
ÕÕ°¡“®“°π—Èπ°Á¡’°“√«—¥ IFN-γ ‚¥¬«‘∏’ enzyme-linked
immunoassay À√◊Õ°“√µ√«®¥Ÿ INF-γ -producing cells
‚¥¬«‘∏’ enzyme-linked immunospot assay °Á‰¥âµ“¡
√Ÿª∑’Ë 1
QuantiFERON-Gold
IJM
Vol. 7 No.1
¢âÕ¥’¢Õß QuantiFERON (QFT-TB)
1. Single visit
2. No booster phenomenon
3. Less bias & error
4. ¡’ specificity Ÿß¢÷Èπ (QFT-Gold)
¢âÕ‡ ’¬¢Õß QuantiFERON (QFT-TB)
1. À≈— ß ®“°‡®“–‡≈◊ Õ ¥·≈â « µâ Õ ß𔉪µ√«®
¿“¬„π 12 ™¡.
2. µâÕß°“√ÀâÕß Lab ∑’Ë∑” ELISA technique
3. ¢“¥ª√– ∫°“√≥å„π°“√∑” QFT test
4. µâÕß¡’°“√µ√«®‡æ‘Ë¡‡µ‘¡Õ◊ËπÊ ‡æ◊ËÕ®–∫Õ°«à“
‡ªìπ active TB À√◊Õ LTBI Õ’°∑’
5. √“§“·æß
®–‡ÀÁπ‰¥â«à“„π∑“ß∑ƒ…Æ’π—Èπ QuantiFERON
(QFT) °Á¡’∑—ÈߢâÕ¥’·≈–¢âÕ‡ ’¬ ´÷Ëß°Á‰¥â¡’°“√»÷°…“
‡ª√’¬∫‡∑’¬∫¥Ÿ √–À«à“ß°“√„™â QFT À√◊Õ TST „π
°“√π”¡“‡ªìπ diagnostic test „π LTBI
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
02-Topic
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¡°√“§¡ › ¡’π“§¡ 2551
7
·µà‡π◊ËÕß®“°ªí®®ÿ∫—π gold standard ∑’Ë„™â‡æ◊ËÕ
«‘π‘®©—¬ LTBI ¬—߉¡à¡’ ©–π—Èπ°“√®–À“ new diagnostic
QuantiFERON
IJM
Vol. 7 No.1
ë
ë
ë
ë
1st generation
„™â PPD ‡ªìπ Ag specificity
Specificity similar to TST
May affected by previous BCG
or NTM
”À√—∫ QFT ∑’Ë¡’„™âÕ¬Ÿà ®–¡’ 2 generation
Õ¬à“߉√°Áµ“¡ ·¡â«à“®–‰¡à¡’ gold standard
·µàÀ“°‡√“µâÕß°“√π” QFT ¡“„™â‡ªìπ diagnostic test
·≈â« ‘Ëß∑’˵âÕßπ”¡“æ‘®“√≥“ §◊Õ
1. Sensitivity of test in LTBI ‡ªìπÕ¬à“߉√
2. Environmental mycobacterial infection
¡’º≈°—∫ test À√◊Õ‰¡à
®“°°“√»÷°…“¢Õß Mori T ·≈–§≥–3 ‚¥¬
‰¥â»÷°…“‡√◊ËÕß çSpecific detection of tuberculosis
infection : an INF-γ based assay using new
antigemsé4 ´÷ßË ∑”°“√»÷°…“ºŸªâ «É ¬·≈–π—°»÷°…“欓∫“≈
„π‚√ß欓∫“≈À≈“¬·Àà ß „πª√–‡∑»≠’Ë ªÿÉ π ‚¥¬‰¥â
enrolled case ∑—ÈßÀ¡¥ 369 §π „π™à«ß√–À«à“ß °.§.µ.§. ªï §». 2002 ®“°π—Èπ·∫àߺŸâªÉ«¬‡ªìπ 2 °≈ÿà¡
°≈ÿà¡∑’Ë 1 §◊Õ°≈ÿà¡∑’ˉ¡à¡’§«“¡‡ ’ˬߵàÕ°“√µ‘¥‡™◊ÈÕ«—≥‚√§
·≈–‡§¬‰¥â√∫— «—§´’π BCG ¡“°àÕπÕ¬à“ßπâÕ¬ 1 §√—ßÈ ·≈–
‰¡à¡ª’ √–«—µ ‘ ¡— º— °—∫ºŸªâ «É ¬‚√§«—≥‚√§¡“°àÕπ ·≈–µâÕß
‰¡à‡ªìπ immunocompromised host ‡™àπ HIV, DM,
leukemia, lymphoma ·≈– renal failure ¡’®”π«π
∑—ÈßÀ¡¥ 216 §π à«π°≈ÿà¡∑’Ë 2 §◊Õ°≈ÿà¡∑’Ë¡’Õ“°“√∑’Ë
∑”„Àâπà“ ß —¬«à“®–‡ªìπ«—≥‚√§ ‚¥¬¡’Õ“°“√·≈–Õ“°“√
· ¥ß®”π«π 152 ´÷Ëß°≈ÿà¡π’ȉ¥â√—∫°“√¬◊π¬—π«à“‡ªìπ
8
test ®÷ßÕ“®®–¡’¢âÕ®”°—¥‡æ√“–‰¡à¡’ gold standard ¡“
‡ª√’¬∫‡∑’¬∫„π‡√◊ËÕß sensitivity & specificity
QuantiFERON-Gold
ë 2nd generation
ë Detect 2 Ag proteins in
M.tuberculosis
ë Improved specificity
«—≥‚√§®√‘ߥ⫬º≈‡æ√“–‡™◊ÈÕ (positive culture) ®“°
π—Èπ‰¥âπ”ºŸâªÉ«¬‡À≈à“π’È¡“∑¥ Õ∫¥â«¬ specific antigen
2 µ—«π’È·≈–‡ª√’¬∫‡∑’¬∫°—∫ TST
æ∫«à“ª√‘¡“≥ ESAT-6 ·≈– CFP-10 ®– highly
positive „πºŸâªÉ«¬°≈ÿà¡∑’Ë 2 ·≈–‡¡◊ËÕπ”º≈¢Õß protein
∑—Èß 2 µ—«¡“æ‘®“√≥“√«¡°—π°Á®–∑”„Àâ sensitivity
·≈– specificity ¢Õß test ‡æ‘Ë¡¡“°¢÷Èπ°«à“°“√‡≈◊Õ°
æ‘®“√≥“ protein µ—«„¥µ—«Àπ÷Ëß4,5 ‚¥¬ test π’È®–¡’
sensitivity ‡æ‘¡Ë ¢÷πÈ ‡ªìπ√âÕ¬≈– 89 ·≈– specificity ‡∑à“°—∫
√âÕ¬≈– 98.1 ∑—Èß Ê ∑’ˇ¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ TST ·≈â«
sensitivity ‡∑à“°—∫√âÕ¬≈– 65.8 ·≈– specificity ‡∑à“°—∫
√âÕ¬≈– 35.4 ´÷ËßÕ∏‘∫“¬∂÷ß°“√∑’Ë¡’ specificity µË” Õ“®
‡°‘¥®“° TST ®– positive ‰¥â„π§π∑’ˇ§¬‰¥â«—§´’π
BCG ¡“°àÕπ À√◊ÕÕ“®‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ NTM
·¡â«à“°“√µ√«® ESAT-6 ·≈– CFP-10 ®–„Àâ
º≈ negative µàÕ‡™◊ÈÕ Mycobacterium avium complex
(MAC) ·µà °Á æ ∫«à “ ¡’ ° ≈ÿà ¡ ‡™◊È Õ NTM ∫“ß™π‘ ¥ ∑’Ë ¡’
gene encoding ∑—Èß ESAT-6 ·≈– CFP-10 ´÷Ë߉¥â·°à
M.kansasii, M.marinum, M.szulgai ©–π—È π À“°
µ‘¥‡™◊ÈÕ 3 µ—«π’È°ÁÕ“®∑”„Àâ°“√µ√«® TB specific
antigen protein „Àâº≈∫«°‰¥â
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
02-Topic
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2/4/08, 11:59
πÕ°®“°π’Ȭ—ß¡’°“√»÷°…“¢Õß Kand Ya ·≈–
§≥–‰¥â»°÷ …“‡√◊ÕË ß çDiscrepancy between the TST and
the whole blood IFN-γ assay for the diagnosis of
LTBI in an intermediate tuberculosis-burden countryé6
„ππ—°»÷°…“·æ∑¬å¢Õ߇°“À≈’æ∫«à“ QFT-Gold ¡’§à“
sensitivity √âÕ¬≈– 81 ·≈– specificity √âÕ¬≈– 96
„π¢≥–∑’Ë TST ¡’ sensitivity √âÕ¬≈– 78 ·≈–¡’§à“
specificity √âÕ¬≈– 49 ‡∑à“π—Èπ ®“°¢âÕ¡Ÿ≈∑’Ë°≈à“«¡“
πà“®–™à«¬ π—∫ πÿπ«à“ QuantiFERON Õ“®®–π”¡“
„™â‡ªìπ diagnostic test „π LTBI ‰¥â
CDC recommendation for
QuantiFERON-TB reference
°“√¬◊π¬—πº≈°“√∑¥ Õ∫
1. °“√®–¬◊π¬—πº≈¥â«¬«‘∏’ TST °ÁÕ“®®–∑”‰¥â
(optional) À“°æ∫«à“ QFT „Àâº≈∫«°·≈â«
2. ∂â“ QFT „Àâº≈≈∫ °Á‰¡à®”‡ªìπµâÕß∑¥ Õ∫
¬◊π¬—π ·µà§«√®–¡’°“√∑”∑¥ Õ∫´È” Õ“®®–¥â«¬ QFT
À√◊Õ TST °Á‰¥â
3. ‰¡à§«√¬◊π¬—πº≈¢Õß TST ¥â«¬°“√„™â QFT
¡“∑¥ Õ∫‡æ√“–∑’Ë©’¥ tuberculin ®–∑”„Àâ QFT ·ª≈
º≈º‘ ¥ æ≈“¥‰¥â (¬— ß ‰¡à ¡’ ¢â Õ ¡Ÿ ≈ π’È · πà ™— ¥ „π°√≥’ „ ™â
QFT-Gold ¡“∑¥ Õ∫)
Õ¬à“߉√°Áµ“¡„πÕ𓧵æ∫«à“¡’°“√æ—≤π“ test π’È
‰ª Ÿà third generation ‡√’¬°«à“ çQuantiFERON Gold
in-tubeé ´÷ËßÕ“®®–‡ªìπ test ∑’Ë¥’∑’Ë ÿ¥„π°“√‡ªìπ diagnostic test in LTBI °Á‡ªìπ‰¥â ‡√“§ßµâÕߧլµ‘¥µ“¡
∂÷ߺ≈°“√»÷°…“„πÕ𓧵µàÕ‰ª
‡Õ° “√Õâ“ßÕ‘ß
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
02-Topic
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2/4/08, 11:59
¡°√“§¡ › ¡’π“§¡ 2551
9
Vol. 7 No.1
1. Centers of Disease Control Prevention targeted
tuberculin testing & treatment of LTBI. MMWR
Morb Mortal Wkly Rep 2000;19:1-51.
2. Mazurek GH, Lobue PA, Daley CL, et al.
Comparison of a whole-blood IFN-γ assay
with tuberculin skin test for detecting LTBI. JAMA
2001;286:1740-7.
3. Mori T, Sakatani M, Ramagishi F, et al.
Specific detection of tuberculosis infection : an
interferon-(gamma)-based assay using new
antigens. Am J Respir Crit Care Med 2004;
170:59-64.
IJM
1. ‰¡à·π–π”„Àâ„™â test π’È„πª√–™“°√∑’Ë¡’
§«“¡‡ ’ˬߵàÕ‚√§µË”
2. æ‘®“√≥“∑” test π’È„π°≈ÿࡧπ∑’Ë¡’§«“¡
‡ ’Ë¬ß ŸßµàÕ°“√‡°‘¥ LTBI §◊Õ
2.1 °≈ÿࡧπ∑’Ëæ÷Ëß®–¬â“¬∑’ËÕ¬Ÿà (recent immigrants)
2.2 °≈ÿà ¡ ∑’Ë „ ™â ¬ “‡ 浑 ¥ ™π‘ ¥ ©’ ¥ ‡¢â “ ‡ â π
(IVDU)
2.3 æπ— ° ß“πÀ√◊ Õ ‡®â “ Àπâ “ ∑’Ë ∑’Ë ∑”ß“π„π
‡√◊Õπ®”À√◊Õ∑’Ëæ—°§π‡√à√àÕπ
3. ‰¡à·π–π”„Àâ„™â QuantiFERON-TB ”À√—∫
3.1 „™â screening „π‡¥Á°∑’ËÕ“¬ÿπâÕ¬°«à“
17 ªï À√◊Õ„π°≈ÿà¡∑’Ë¡’§«“¡‡ ’Ë¬ß Ÿß∑’Ë®–¡’ progression
¢Õß LTBI ‰ª‡ªìπ‚√§«—≥‚√§
3.2 °“√ª√–‡¡‘ π °“√ — ¡ º— ‚√§«— ≥ ‚√§
(assessment of contacts of TB disease)
3.3 Evaluating suspected TB disease
”À√—∫°“√·π–π”„Àâ„™â QuantiFERON-TB
Gold ®–¡’§”·π–𔵓¡¡“„π¿“¬À≈—ß
extrapulmonary tuberculosis. J Infect Diasese
2001;183:175-6.
6. Ya K, Lee HW, Yoon HI, et al. Discrepancy
between the TST and the whole blood IFN-γ
assay for the diagnosis of LTBI in an
intermediate tuberculosis-burden country. JAMA
2005;293:2756-61.
IJM
Vol. 7 No.1
4. Arend SM, Anderson P, van Meijgaarden KE,
et al. Detection of active tuberculosis infection
by T cell responses to early-secreted antigenic
target 6-kDa protein and culture filtrate protein
10. J Infect Disease 2000;181:1850-4.
5. Munk ME, Arend SM, Brock I, et al. Use of
ESAT-6 and CPF-10 antigens for diagnosis of
10 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
02-Topic
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2/4/08, 11:59
Interesting Case
Abdominal Pain with Hypertension
æ≠.∑‘æ«√√≥ ∫«√°‘µµ‘«ß»å 1, √».πæ.∏ß™—¬ ª√–Æ‘¿“≥«—µ√ 2
1
·æ∑¬åª√–®”∫â“πÕ“¬ÿ√»“ µ√å, 2 “¢“«‘™“µàÕ¡‰√â∑àÕ·≈–‡¡µ“∫Õ≈‘ ¡
¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
ºŸâªÉ«¬À≠‘߉∑¬ Õ“¬ÿ 28 ªï Õ“™’æ√—∫®â“ß ®—ßÀ«—¥‡≈¬
ª√–«—µ‘Õ¥’µ :
Õ“°“√ ”§—≠ :
ª«¥∑âÕß·≈–§≈◊Ëπ‰ âÕ“‡®’¬π¡“ 3 —ª¥“Àå
ª√–«—µ‘ªí®®ÿ∫—π :
Physical examination :
Neurological examination :
She was fully of consciousness and well
co-operative to examination. She had generalized
motor weakness of all extremities (grade 4/5).
Reflex was hypo-reflexia of all extremities and
Barbinskiûs sign was plantar response both sides.
Sensation was hyperesthesia at lower extremities
and trunk. Cranial nerves and other neurological
examinations were normal.
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
03-Intersesting case
11
2/4/08, 12:02
¡°√“§¡ › ¡’π“§¡ 2551
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Vol. 7 No.1
She looked distress. Her blood pressure and
heart rate were 138/80 mmHg and 110 bpm regular,
respectively. Her abdominal signs showed no
tenderness, no guarding, active bowel sound, and
impalpable liver and spleen. Other systems were
normal except neurological signs.
IJM
3 — ª ¥“Àå °à Õ π¡“‚√ß欓∫“≈ ¡’ Õ “°“√
‡Àπ◊ËÕ¬‡æ≈’¬ ª«¥∑âÕß„µâ≈‘Èπªïò §≈◊Ëπ‰ âÕ“‡®’¬π ∑“π
Õ“À“√‰¡à‰¥â ‰¡à¡’‰¢â ®÷߉ª‚√ß欓∫“≈ Õ¬Ÿà√—°…“
ª√–¡“≥ 1 —ª¥“Àå √–À«à“ßÕ¬Ÿà√—°…“ ¡’Õ“°“√™—°‡°√Áß
‰¡à√Ÿâ ÷°µ—« 1 §√—Èß √à«¡°—∫§«“¡¥—π‚≈À‘µ Ÿß°àÕπ∑’Ë®–
¡’Õ“°“√™—°‡°√Áß ‰¡à¡’Õ“°“√ª«¥»’√…– ‰¡à¡’Õ“°“√
·¢π¢“ÕàÕπ·√ßÀ≈—ß™—° ‰¥â√∫— °“√µ√«® CT scan brain
º≈ª°µ‘·≈–‰¥â√—∫°“√«‘π‘®©—¬‡ªìπ hypertensive crisis
‰¥â√—°…“‚¥¬°“√„À⬓≈¥§«“¡¥—π ·≈–„Àâ°≈—∫∫â“π
‡¡◊ËÕ§«“¡¥—π≈¥≈ß
10 «—π°àÕπ¡“‚√ß欓∫“≈ ¡’Õ“°“√ª«¥∑âÕß
¢÷Èπ¡“Õ’°‚¥¬ª«¥∑âÕß∑–≈ÿ‰ªÀ≈—ß ·≈–ª«¥∫√‘‡«≥
°≈“ßÀ≈—ßµ√ß°≈“ß√â“«≈ß¡“¢“∑—Èß 2 ¢â“ß ‰¡à¡’‰¢â
‰¡à¡’Õ“°“√ª«¥»’√…– ªí “«–ª°µ‘ ‰¡à¡’ ’·¥ß ‰¡à¡’
Õ“°“√· ∫¢—¥ Õÿ®®“√–ª°µ‘¥’ ‰ª√—∫°“√√—°…“∑’Ë‚√ß
欓∫“≈ ‰¥âÕ¬Ÿà√—°…“„π‚√ß欓∫“≈ 4 «—π µ√«®æ∫
ª«¥∑âÕß√à«¡°—∫§«“¡¥—π‚≈À‘µ Ÿß 150/110 mmHg
‰¥â√—∫°“√√—°…“‚¥¬„À⬓≈¥§«“¡¥—π‚≈À‘µ atenolol
(50 mg) «—π≈– 1 §√—Èß amlodipine (5 mg) «—π≈– 1
§√—Èß ·≈– enalapril (5mg) «—π≈– 1 §√—Èß ·µàÕ“°“√
ª«¥∑âÕ߉¡à¥’¢÷Èπ ·æ∑¬å®÷ß àßµ—«¡“ª√÷°…“
ªØ‘‡ ∏‚√§ª√–®”µ—«Õ◊Ëπ Ê À√◊Õ∑“𬓄¥Ê
‡ªì π ª√–®” ¬°‡«â 𠇧¬‰¥â √— ∫ °“√«‘ π‘ ® ©— ¬ «à “ ‡ªì π
§«“¡¥—π‚≈À‘µ Ÿß¢≥–µ—ßÈ §√√¿å ‡¡◊ÕË ª√–¡“≥ 1 ªï°Õà π
‰¥â√—∫°“√√—°…“¥â«¬°“√∑“𬓠‚¥¬ “¡“√∂À¬ÿ¥¬“‰¥â
À≈—ߧ≈Õ¥
Laboratory investigation :
CBC : Hb 11.3 g/dL, Hct 33.2%, WBC 5500/
mm3, Plt 373,000/mm3
N 57.9 %, L 29.6%, M 11.3%, E 0.9%,
B 0.3%, MCV 86.4%
Blood chemistry
BUN/Cr 24.4/1.3 mg/dL, Na 120, K 5.2,
HCO3 248, Cl 85 mEq/L
Ca 9.5, PO4 5.6 mg/dL, Chol 246 mg/dL
mg/dL, TP 7.5, Alb 4, Glob 3.5, TB 0.5,
DB 0.2 mg/dL, ALT 23, AST 75,
ALP 87, CK 82 U/L
Serum Osm 252, Urine Osm 364 osmo/L,
Urine Na 10, K 36.6, Cl 22 mEq/L
Other tests were within normal limit including
thyroid funtion tests
1. Pheochromocytoma
2. Lead poisoning
3. Acute pancreatitis
°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡∫◊ÈÕßµâπ ‰¥â·°à
°“√¥Ÿ ’¢Õßªí “«–°àÕπ·≈–À≈—ß°“√µ“°·¥¥ ¥—ß
· ¥ß„π√Ÿª∑’Ë 1 ´â“¬¡◊Õ°àÕ𵓰·¥¥ ¢«“¡◊ÕÀ≈—ß
°“√µ“°·¥¥ æ∫«à“ªí “«–¡’ ‡’ ¢â¡¢÷πÈ Õ¬à“ß™—¥‡®π ‚¥¬
¡’ ’§≈⓬ ’πÈ”Õßÿàπ
(°àÕπ)
(À≈—ß)
√Ÿª∑’Ë 1 ªí “«–¢ÕߺŸªâ «É ¬°àÕπ (´â“¬) ·≈–À≈—ß°“√µ“°·¥¥ (¢«“)
IJM
Vol. 7 No.1
«‘®“√≥å
ºŸâ ªÉ « ¬√“¬π’È ¡’ Õ “°“√ª«¥∑â Õ ß¡“π“π∂÷ ß 3
—ª¥“Àå √—°…“·∫∫‚√§°√–‡æ“–Õ“À“√ Õ“°“√‰¡à¥¢’ π÷È
·≈–®“°°“√´— ° ª√–«— µ‘ · ≈–µ√«®√à “ ß°“¬ ‰¡à æ ∫
≈— ° …≥–‚√§∑’Ë ®”‡ªì π µâ Õ ß‰¥â √— ∫ °“√√— ° …“¥â « ¬°“√
ºà“µ—¥„¥Ê
πÕ°®“°π’È ¬— ß æ∫«à “ ¡’ § «“¡¥— π ‚≈À‘ µ Ÿ ß ´÷Ë ß
‰¡à§«√æ∫„π§πÕ“¬ÿπÕâ ¬ √à«¡°—∫À—«„®‡µâπ‡√Á« ∫àß∫Õ°
«à“√–∫∫ª√– “∑Õ—µ‚π¡—µ‘∑”ß“π‰¡à ¡¥ÿ≈ (sympathetic over activities) √à«¡°—∫æ∫§«“¡º‘¥ª°µ‘∑“ß
√–∫∫ª√– “∑ ´÷Ëßæ∫Õ“°“√ÕàÕπ·√ß∑—Èß·¢π·≈–¢“
∑”„Àâ¡’À≈—°∞“π¬◊π¬—π«à“ ºŸâªÉ«¬πà“®–¡’ autonomic
neuropathy ∑”„À⇰‘¥§«“¡¥—π‚≈À‘µ Ÿß ·≈–Õ“°“√
ª«¥∑âÕß
‚√§∑’˺ŸâªÉ«¬√“¬π’Èπà“®–‡ªìπ¡“°∑’Ë ÿ¥ ‰¥â·°à
acute intermittent porphyria
‚√§∑’˵âÕß«‘π‘®©—¬·¬°‚√§‰¥â·°à
Porphyria
Porphyria ‡ªì𧫓¡º‘¥ª°µ‘∑“ßæ—π∏ÿ°√√¡
∑’ˇ°’ˬ«¢âÕß°—∫‡Õπ‰´¡å„π°“√ —߇§√“–À匒¡ (heme
biosynthesis pathway) ¥—ß· ¥ß„π√Ÿª∑’Ë 2 ‚¥¬®–
·∫à߇ªì𧫓¡º‘¥ª°µ‘¢Õß°≈ÿà¡‚√§π’È ·¬°µ“¡Õ«—¬«–
∑’˺‘¥ª°µ‘ÕÕ°‰¥â‡ªìπ 2 °≈ÿࡧ◊Õ
1. §«“¡º‘¥ª°µ‘¢Õ߇Õπ‰´¡å∑’˵—∫ (hepatic
porphyria)
2. §«“¡º‘¥ª°µ‘¢Õ߇Õπ‰´¡å∑’ˇ¡Á¥‡≈◊Õ¥·¥ß
(erythropoietic porphyria)
≈—°…≥–Õ“°“√· ¥ß∑“ߧ≈‘π‘° ∑’Ë ”§— ≠ ¢Õß
porphyria 䴉ᡈ
1. Õ“°“√∑“ß√–∫∫ª√– “∑ ‰¥â·°à ÕàÕπ·√ß
´÷¡ —∫ π À√◊Õ™—° √à«¡°—∫ Õ“°“√ª«¥∑âÕß®“°
§«“¡º‘¥ª°µ‘¢Õ߇ âπª√– “∑ (neuropathic abdominal pain)
12 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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IJM
Vol. 7 No.1
√Ÿª∑’Ë 2 Heme biosynthesis
„π∑’Ëπ’È®–°≈à“«∂÷߇©æ“– acute intermittent porphyria
2. §«“¡º‘¥ª°µ‘¢Õߺ‘«Àπ—ß´÷Ë߉¥â·°à º◊Ëπ·æâ
· ß (cutaneous photosensitivity)
§«“¡º‘¥ª°µ‘∑“ߧ≈‘π‘°¢Õß hepatic porphyria §◊Õ Õ“°“√∑“ß√–∫∫ª√– “∑ Õ“®®–æ∫§«“¡
º‘¥ª°µ‘∑“ߺ‘«Àπ—ß√à«¡¥â«¬ (µ“√“ß∑’Ë1 )
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
03-Intersesting case
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µ“√“ß∑’Ë 1 §«“¡º‘¥ª°µ‘∑“ߧ≈‘π‘°„πºŸâªÉ«¬ porphyria
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 2 §«“¡º‘¥ª°µ‘∑“ßÀâÕߪƑ∫—µ‘°“√„πºŸâªÉ«¬ porphyria
14 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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Acute intermittent porphyria
≈—°…≥–∑“ߧ≈‘π‘°
Acute intermittent porphyria ‡ªì𧫓¡
º‘¥ª°µ‘∑“ßæ—π∏ÿ°√√¡·∫∫ autosomal dominant ‡ªìπ
º≈®“°§«“¡º‘¥ª°µ‘¢Õß HMB-synthetase activity
µ—Èß·µà°”‡π‘¥ Õ“°“√¢Õß‚√§®–°”‡√‘∫‡¡◊ËÕ∂Ÿ°°√–µÿâπ
¥â«¬ªí®®—¬∑—Èß¿“¬„π·≈–¿“¬πÕ°√à“ß°“¬
à«π„À≠à ®–‰¡à¡’Õ“°“√§«“¡º‘¥ª°µ‘„¥Ê
®π°√–∑—ËßÕ“¬ÿºà“π«—¬√ÿàπ‰ª·≈â« ‚¥¬Õ“°“√®–‡°‘¥¢÷Èπ
‡¡◊Ë Õ ‰¥â √— ∫ µ— « °√–µÿâ π ´÷Ë ß ∑”„Àâ ° “√º≈‘ µ Œ’ ¡ ‡°‘ ¥ °“√
‡ª≈’ˬπ·ª≈ß µ—«°√–µÿâπ¡’∑—Èß®“°¿“¬„π·≈–¿“¬πÕ°
√à“ß°“¬ ‰¥â·°à ŒÕ√å‚¡π‡æ» ¥◊Ë¡Õ—≈°ÕŒÕ≈å Õ¥Õ“À“√
¿“«–µ‘¥‡™◊ÈÕ °“√ºà“µ—¥ ·≈–‰¥â√—∫¬“∑’Ë∑”„À⇡µ“∫Õ≈‘ ¡¢Õߌ’¡‡ª≈’ˬπ·ª≈ß (µ“√“ß∑’Ë 3)
µ“√“ß∑’Ë 3 ¬“∑’Ë “¡“√∂„™â‰¥â·≈–‰¡à‰¥â„πºŸâªÉ«¬ porphyria
IJM
Vol. 7 No.1
Õ“°“√·≈–Õ“°“√· ¥ß∑’Ë ”§— ≠ ∑“ߧ≈‘ π‘ °
‰¥â·°à ª«¥∑âÕß ‡ªìπÕ“°“√∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥ æ∫‰¥â
∑—Èß≈—°…≥– ª«¥∑âÕß ∑âÕßÕ◊¥ ·≈–§≈◊Ëπ‰ âÕ“‡®’¬π ´÷Ëß
¡—°®– —∫ π°—∫‚√§∑“ß»—≈¬°√√¡
§«“¡º‘ ¥ ª°µ‘ ¢ Õ߇ â π ª√– “∑ à « πª≈“¬
(peripheral neuropathy) ‡°‘¥¢÷Èπ ‡π◊ËÕß®“° axonal
degeneration ¡—°®–æ∫°“√ÕàÕπ·√ß„π°≈â“¡‡π◊ÈÕ
à«πµâπ (proximal muscle weakness) ·≈–Õ“®¡’
§«“¡º‘¥ª°µ‘¢Õ߇ âπª√– “∑ ¡Õß (cranial nerve)
√à « ¡¥â « ¬ §«“¡º‘ ¥ ª°µ‘ ∑ “ߥ⠓ π°“√√— ∫ §«“¡√Ÿâ ÷ °
(sensory) ®–æ∫‰¥âπÕâ ¬°«à“ Õ“®®–æ∫ paresthesia À√◊Õ
loss of sensation Õ“°“√ÕàÕπ·√ßÕ“®‡ªìπ¡“°¢÷Èπ
®π∑”„À⇰‘¥°“√ÕàÕπ·√ß„π°≈â“¡‡π◊ÈÕ∑’ˇ°’ˬ«°—∫°“√
À“¬„® ®π∑”„À⇰‘¥¿“«–À“¬„®≈⡇À≈« ·≈–‡ ’¬™’«‘µ
‰¥â πÕ°®“°π’Ȭ—ßÕ“®®–‡ ’¬™’«‘µ®“°°“√∑’ËÀ—«„®‡µâπ
‰¡à ¡Ë”‡ ¡Õ ®“°§«“¡º‘¥ª°µ‘¢Õß√–∫∫ª√– “∑
Õ—µ‚π¡—µ‘
§«“¡º‘¥ª°µ‘¢Õß√–¥—∫§«“¡√Ÿâ ÷°·≈–§«“¡
º‘¥ª°µ‘∑“ß®‘µ (mental symptoms) ‡°‘¥‰¥âÀ≈“¬
≈—°…≥–µ“¡·µà§«“¡√ÿπ·√ß ‰¥â·°à anxiety, insomnia,
depression, disorientation, hallucination, paranoid
πÕ°®“°π’È ¬—ß “¡“√∂∑”„À⇰‘¥°“√™—°∑—Èßµ—«‰¥â ´÷Ëß
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
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¿“«–™—° Õ“®®–‡°‘¥‰¥â®“°º≈¢Õߧ«“¡º‘¥ª°µ‘¢Õß
Œ’¡µàÕ‡´≈ ¡Õß À√◊Õ®“°¿“«–‚´‡¥’ˬ¡„π‡≈◊Õ¥µË”
(hyponatremia) °“√√—°…“Õ“°“√™—°§àÕπ¢â“߬“° ‡π◊ËÕß
®“°¬“°—π™—°∫“ßµ—«Õ“®‡ªìπµ—«°√–µÿâπ∑”„À⇰‘¥§«“¡
º‘¥ª°µ‘¢Õߌ’¡¡“°¬‘ßË ¢÷πÈ ‰¥â ¬“„π°≈ÿ¡à clonazepam ®–
ª≈Õ¥¿—¬°«à“¬“ phenytoin ·≈– barbiturate
¿“«–‚´‡¥’ˬ¡„π‡≈◊Õ¥µË” (hyponatremia) ‡°‘¥
®“°§«“¡º‘¥ª°µ‘¢Õß hypothalamus ∑”„Àâ°“√À≈—Ëß
vasopressin ¡“°¢÷ÈπÕ¬à“߉¡à‡À¡“– ¡ À√◊Õ®“°°“√∑’Ë
√—∫ª√–∑“πÕ“À“√‰¥âπÕâ ¬ √à«¡°—∫§≈◊πË ‰ âÕ“‡®’¬π À√◊Õ
Ÿ≠‡ ’¬ÕÕ°∑“߉µ ®“°§«“¡º‘¥ª°µ‘¢Õ߉µ‚¥¬µ√ß
IJM
Vol. 7 No.1
°“√«‘π‘®©—¬
√–¬–‡«≈“∑’ˇÀ¡“– ¡„π°“√µ√«®√–¥—∫¢Õß
porphyrin ‡æ◊ÕË °“√«‘π®‘ ©—¬‰¥â·°à ¢≥–∑’‚Ë √§°”≈—ß°”‡√‘∫
‚¥¬®–æ∫√–¥—∫ ALA ·≈– PBG ®–‡æ‘Ë¡¢÷Èπ∑—Èß„π
‡≈◊Õ¥ ·≈–ªí “«– ‚¥¬∂⓵√«®„π¢≥–‚√§‰¡à°”‡√‘∫
Õ“°“√°”‡√‘∫ √–¥—∫¢Õß “√¥—ß°≈à“«Õ“®®–Õ¬Ÿ„à π‡°≥±å
ª°µ‘‰¥â
à«π„À≠à„πºŸâªÉ«¬∑’ˇªìπæ“À–¢Õß‚√§ (heterozygotes) ®–‰¡à ¡’ Õ “°“√º‘ ¥ ª°µ‘ „ ¥Ê ¢Õß‚√§
·µàÕ“®®–µ√«®æ∫§«“¡º‘¥ª°µ‘¢Õ߇Õπ‰´¡å HMGsynthetase deficiency ‚¥¬∑’Ë√–¥—∫¢Õß ALA ·≈–
PBG Õ¬Ÿà„π‡°≥±åª°µ‘
°“√√—°…“
°“√√—°…“‡æ◊ËÕ≈¥√–¥—∫Œ’¡„πµ—∫
°“√„Àâ°≈Ÿ‚§ Õ¬à“ßπâÕ¬ 300 °√—¡µàÕ«—π ·≈–
À≈’°‡≈’ˬ߰“√Õ¥Õ“À“√ Õ“®®–®”‡ªìπµâÕß„Àâ°≈Ÿ‚§ ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” „™â„π°√≥’‰¡à “¡“√∂„ÀâÕ“À“√
∑“ߪ“°‰¥â‡ªìπ‡«≈“π“π
°“√„À⌒¡∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‚¥¬√–¥—∫Œ’¡∑’Ë
‡æ‘Ë¡¢÷Èπ®–≈¥√–¥—∫‡Õπ‰´¡å ALA synthase ®–¡’
ª√– ‘∑∏‘¿“楒°«à“°“√„Àâ°≈Ÿ‚§ „π°“√≈¥°“√À≈—Ëß
porphyria precursor ·µà°“√µÕ∫ πÕßµàÕŒ’¡®–≈¥≈ß
∂â“„Àâ°“√√—°…“¥â«¬Œ’¡™â“‡°‘π‰ª
°“√À“¬¢Õߧ«“¡º‘¥ª°µ‘®–‡√Á«À√◊ՙⓢ÷ÈπÕ¬Ÿà
°—∫§«“¡√ÿπ·√ߢÕß°“√‡ ’¬¢Õ߇ âπª√– “∑ ´÷ËßÕ“®
®–¥’¢π÷È Õ¬à“ß√«¥‡√Á«„π 1-2 «—π ‡¡◊ÕË ‰¥â√∫— °“√√—°…“‡√Á«
·µàÕ“®®–À“¬™â“∂â“¡’°“√∑”≈“¬‡ âπª√– “∑Õ¬à“ß√ÿπ·√ß
´÷ËßÕ“®µâÕß„™â‡«≈“‡ªìπ‡¥◊ÕπÀ√◊Õªï
°“√√—°…“‡æ◊ËÕª√–§—∫ª√–§ÕßÕ“°“√
¬“·°âª«¥ ¬“·°âÕ“‡®’¬π ¬“πÕπÀ≈—∫ ·≈–¬“
°— π ™— ° ´÷Ë ß Õ“®®–®”‡ªì π µâ Õ ß„™â §«√‡≈◊ Õ °¬“∑’Ë
ª≈Õ¥¿—¬·≈–‰¡à√∫°«πµàÕ‡¡µ“∫Õ≈‘ ¡¢Õߌ’¡ √ÿª
„πµ“√“ß∑’Ë 3
∫√√≥“πÿ°√¡
1. Desnick R. The porphyrias. Harrisonûs Internal
Medicine. 16th (ed). McGraw-Hill Companies,
USA;2005:2304-5.
16 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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Original Article
‚√§∫“¥∑–¬—°„π‚√ß欓∫“≈Õÿ¥√∏“π’
πæ.∏‘µ‘ Õ÷ÈßÕ“√’
“¢“«‘™“ª√– “∑«‘∑¬“ °≈ÿà¡ß“πÕ“¬ÿ√°√√¡ ‚√ß欓∫“≈Õÿ¥√∏“π’
∫∑§—¥¬àÕ
«—µ∂ÿª√– ߧå
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article
17
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Vol. 7 No.1
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
IJM
‡æ◊ÕË »÷°…“≈—°…≥–∑“ߧ≈‘π°‘ °“√√—°…“ ·≈–
ªí®®—¬∑’Ë —¡æ—π∏å°—∫Õ—µ√“°“√‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬‚√§
∫“¥∑–¬—°„π‚√ß欓∫“≈Õÿ¥√∏“π’ ®—ßÀ«—¥Õÿ¥√∏“π’
√Ÿª·∫∫°“√»÷°…“ : °“√»÷ ° …“·∫∫‡°Á ∫
¢âÕ¡Ÿ≈¬âÕπÀ≈—ß
«‘∏’°“√ : ‡°Á∫¢âÕ¡Ÿ≈‡«™√–‡∫’¬πºŸâªÉ«¬„π∑’Ë
‰¥â√—∫°“√«‘π‘®©—¬ ‚√§∫“¥∑–¬—°„π‚√ß欓∫“≈
Õÿ¥√∏“π’ µ—Èß·µà 1 °√°Æ“§¡ 2538 - 30 ¡‘∂ÿπ“¬π
2549
º≈°“√»÷ ° …“ : ºŸâ ªÉ « ¬‚√§∫“¥∑–¬— °
∑—ÈßÀ¡¥®”π«π 85 √“¬ ·¬°‡ªìπ‡æ»™“¬ √âÕ¬≈–
52.90 ‡æ»À≠‘ß √âÕ¬≈– 47.10 Õ“¬ÿ‡©≈’ˬ 48.88 ªï
‚¥¬æ∫„π™à«ßÕ“¬ÿ 41-50 ªï ¡“°∑’Ë ÿ¥ ºŸâªÉ«¬
à«π„À≠à‰¥â√—∫‡™◊ÈÕ®“°∫“¥·º≈∑’ˇ∑â“√âÕ¬≈– 44.70
æ∫«à“‡ªìπ ∫“¥∑–¬—°™π‘¥‡°√Áß∑—Èßµ—« √âÕ¬≈– 82.35
™π‘¥‡©æ“–∑’Ë√âÕ¬≈– 17.65 √–¬–‡«≈“∑’ˉ¥â√—∫‡™◊ÈÕ
®π‡√‘Ë¡¡’Õ“°“√ ¡“°°«à“ 7 «—πæ∫¡“°∑’Ë ÿ¥ √âÕ¬≈–
41.18 √–¬–‡«≈“∑’ˇ√‘Ë¡¡’Õ“°“√®π¡’Õ“°“√‡°√Áß∑—Èß
µ—«¿“¬„π 1 «—π æ∫¡“°∑’Ë ÿ¥√âÕ¬≈– 56.47 ºŸâªÉ«¬
∑’ˇªìπ‚√§‰µ«“¬·≈–‡∫“À«“π ¡’·π«‚πâ¡∑’Ë®–‡ ’¬
™’«‘µ Ÿß √âÕ¬≈– 100 ·≈– 83.33 µ“¡≈”¥—∫ √–¬–
‡«≈“∑’˺ŸâªÉ«¬Õ¬Ÿà„π‚√ß欓∫“≈„π™à«ß 29 - 35 «—π
¡“°∑’Ë ÿ¥ penicillin ‡ªìπ¬“ªØ‘™’«π–∑’˺ŸâªÉ«¬‰¥â√—∫
¡“°∑’Ë ÿ¥√âÕ¬≈– 84.71 ªÕ¥Õ—°‡ ∫‡ªìπ¿“«–
·∑√°´âÕπ∑’Ëæ∫¡“°∑’Ë ÿ¥ √âÕ¬≈– 59.29 Õ—µ√“
°“√µ“¬¢ÕߺŸâªÉ«¬‚√§∫“¥∑–¬—° √âÕ¬≈– 24.70
ºŸâªÉ«¬∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï ¡’‚Õ°“ ‡ ’¬™’«‘µ 3.3
‡∑à“¢ÕߺŸâªÉ«¬∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ (OR=3.3, 95%
CI=1.07-10.34, p = 0.009) ºŸâªÉ«¬∑’Ë¡’√–¬–‡«≈“
√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√ µË”°«à“À√◊Õ‡∑à“°—∫ 7 «—π ¡’
‚Õ°“ ‡ ’¬™’«‘µ 14.2 ‡∑à“ ¢ÕߺŸâªÉ«¬∑’Ë¡’√–¬–‡«≈“
√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√¡“°°«à“ 7 «—π (OR = 14.2
95% CI = 3.30-69.41, p = 0.001) ºŸâªÉ«¬∑’Ë¡’
‚√§ª√–®”µ—«¡’‚Õ°“ ‡ ’¬™’«‘µ 14.2 ‡∑à“¢ÕߺŸâªÉ«¬
∑’Ë ‰ ¡à ¡’ ‚ √§ª√–®”µ— « (OR = 14.2, 95%
CI = 2.29-147.54, p = 0.001) ºŸâªÉ«¬∑’˵‘¥‡™◊ÈÕ
∑“߇¥‘πªí “«–¡’‚Õ°“ ‡ ’¬™’«‘µ 11.4 ‡∑à“ ¢Õß
ºŸªâ «É ¬∑’‰Ë ¡àµ¥‘ ‡™◊ÕÈ ∑“߇¥‘πªí “«– (OR = 11.4, 95%
CI = 1.76-121.54, p = 0.001)
√ÿª : ºŸâªÉ«¬‚√§∫“¥∑–¬—° à«π„À≠à‰¥â√—∫
‡™◊ÈÕ®“°∫“¥·º≈∑’ˇ∑â“ √âÕ¬≈– 82.35 ‡ªìπ™π‘¥
generalized tetanus ‚¥¬Õ—µ√“°“√‡ ’¬™’«‘µ √âÕ¬≈–
24.70 °“√ªÑÕß°—π‰¡à„À⇰‘¥‚√§¥—ß°≈à“« ‚¥¬°“√
√â“ß¿Ÿ¡‘§ÿâ¡°—π‡ªìπ ‘Ëß∑’Ë¥’∑’Ë ÿ¥
IJM
Vol. 7 No.1
∫∑π”
‚√§∫“¥∑–¬—° ‡ªìπ∑’Ë√Ÿâ®—°°—π¡“π“π 500 ªï
°àÕπ§√‘ µå»—°√“™ ‚¥¬°“√∫—π∑÷°≈—°…≥–Õ“°“√ºŸâªÉ«¬
∑’˵‘¥‡™◊ÈÕ‰«â ‡¡◊ËÕªï 1889 Kitasato ‰¥â·¬°‡™◊ÈÕ®“°ºŸâªÉ«¬
∑’µË ¥‘ ‡™◊ÕÈ ·≈–‡¡◊ÕË ©’¥‡™◊ÕÈ ¥—ß°≈à“«„π —µ«å∑¥≈Õß ∑”„Àâ
¡’Õ“°“√¢Õß‚√§‡°‘¥¢÷πÈ ‚¥¬∑—«Ë ‰ª‚√§‡°‘¥®“°∫“¥·º≈
ªπ‡ªóôÕπ·≈–µ‘¥‡™◊ÈÕ Clostridium tetani1 ´÷Ë߇ªìπ‡™◊ÈÕ
·∫§∑’‡√’¬ anaerobic √Ÿª·∑àß ·°√¡∫«° “¡“√∂ √â“ß
ªÕ√剥â æ∫‰¥â∑—Ë«‰ª„π¥‘π ¡Ÿ≈ —µ«å À√◊Õ·¡â°√–∑—Ëß
∑“߇¥‘πÕ“À“√¢Õß§π ‡™◊ÈÕ®– √â“ß “√æ‘…¢÷Èπ¡“ 2
™π‘¥ §◊Õ tetanolysin ´÷ßË ¬—߉¡àæ∫«à“¡’º≈‡ ’¬µàÕ√à“ß°“¬
¡πÿ…¬å ·≈– tetanospasmin ´÷Ëß¡’ƒ∑∏‘Ï∑”„Àâ°≈â“¡‡π◊ÈÕ
°√–µÿ°∑’Ë·√ß¡“° “¡“√∂ÕÕ°ƒ∑∏‘ω¥â√ÿπ·√ß·¡â®–¡’
ª√‘¡“≥πâÕ¬ ‚¥¬ÕÕ°ƒ∑∏‘Ϭ—∫¬—Èß inhibitor synapse ∑’Ë
∫√‘‡«≥ anterior horn cell ¢Õß spinal cord ∑”„Àâ
°≈â“¡‡π◊ÈÕ‡°√Áß°√–µÿ° ‡™◊ËÕ«à“ “√æ‘…π’È®–°√–®“¬
ºà“π∑“߇ âπª√– “∑·≈⫧àÕ¬°√–®“¬‡¢â“ Ÿàª√– “∑
à«π°≈“ß √–¬–øí°µ—«¢Õß∫“¥∑–¬—°π—∫®“°‰¥â√∫— ‡™◊ÕÈ
À√◊Õ¡’∫“¥·º≈ ®π∂÷߇√‘¡Ë ¡’Õ“°“√‡√‘¡Ë ·√°¢Õß∫“¥∑–¬—°
‚¥¬‡©≈’ˬπ“π 7-8 «—𠬑Ëß√–¬–øí°µ—« —Èπ‡∑à“„¥ Õ“°“√
®–√ÿπ·√ß ·≈–欓°√≥å‚√§®–‡≈«≈߇™àπ‡¥’¬«°—π
Õ“°“√¢Õß‚√§∫“¥∑–¬—°·∫à߇ªìπ 2 ™π‘¥ §◊Õ
1. Local tetanus ‡™àπ cephalic tetanus ∑’Ë
‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ∫√‘‡«≥»’√…– ·≈â«¡’Õ“°“√‡°√ÁߢÕß
°≈â“¡‡π◊ÈÕ„∫Àπâ“ ≈◊¡µ“‰¡à¢÷Èπ (blephalospasm)
2. Generalized tetanus Õ“°“√π”§◊Õ Õ⓪“°
‰¡à¢÷Èπ®“°°“√‡°√ÁߢÕß°≈â“¡‡π◊ÈÕ¢“°√√‰°√ (trismus)
°≈â“¡‡π◊ÕÈ „∫ÀπⓇ°√Á߇À¡◊Õπ· ¬–¬‘¡È (risus sardonicus)
µà Õ ¡“°≈â “ ¡‡π◊È Õ ‡°√Á ß ∑—Ë « √à “ ß°“¬∑”„Àâ æŸ ¥ ·≈–°≈◊ π
≈”∫“° (dysphagia) µ—«‡°√Áß·Õàπ (opisthotonos) √«¡
∑—Èß°≈â“¡‡π◊ÈÕ∑’˧«∫§ÿ¡°“√À“¬∑”„À⺟âªÉ«¬À¬ÿ¥ À“¬„®
‰¥â „π√“¬∑’Ë¡’Õ“°“√√ÿπ·√ß Õ“®æ∫§«“¡º‘¥ª°µ‘¢Õß
√–∫∫ª√– “∑Õ—µ‚π¡—µ‘ ‚¥¬¡’§«“¡¥—π‚≈À‘µ Ÿß-µË”
≈—∫°—π ·≈–™’æ®√‡µâπ‡√Á« ≈—∫™â“‰¥â
·¡â«à“‚√§∫“¥∑–¬—°¡’°“√æ—≤π“«—§´’π ·≈– antitoxin
´÷Ëߙ૬ªÑÕß°—π‚√§‰¥â ·µàºŸâªÉ«¬¥—ß°≈à“«°Á¬—ßæ∫Õ¬Ÿà
Õ¬à“ßµàÕ‡π◊ËÕß ·≈–¡’Õ—µ√“°“√µ“¬ Ÿß2 √âÕ¬≈– 20-50
¥—ßπ—Èπ ®÷ßπ—∫«à“‡ªìπ‚√§∑’Ë¡’§«“¡ ”§—≠ °“√»÷°…“π’È
‡ªìπ°“√√«∫√«¡ºŸâªÉ«¬∫“¥∑–¬—° 11 ªï¬âÕπÀ≈—ß„π
‚√ß欓∫“≈Õÿ¥√∏“π’ ‡æ◊ÕË »÷°…“°≈ÿ¡à ª√–™“°√∑’µË ¥‘ ‡™◊ÕÈ
≈— ° …≥–∑—Ë « ‰ª¢ÕߺŸâ ªÉ « ¬ °“√√— ° …“·≈–ªí ® ®— ¬ ∑’Ë
—¡æ—π∏å°—∫Õ—µ√“°“√‡ ’¬™’«‘µ
«‘∏’°“√»÷°…“
ºŸâ«‘®—¬‰¥â∑”°“√»÷°…“¬âÕπÀ≈—ß ºŸâªÉ«¬∑’ˉ¥â√—∫
°“√«‘π‘®©—¬«à“‡ªìπ‚√§∫“¥∑–¬—°·≈–‰¥â√—∫‡¢â“√—°…“
„π‚√ß欓∫“≈Õÿ¥√∏“π’ ´÷ßË ‡ªìπ‚√ß欓∫“≈»Ÿπ¬å¢π“¥
800 ‡µ’¬ß √—∫ºŸâªÉ«¬∑—Èß„π®—ßÀ«—¥Õÿ¥√∏“π’ ·≈–ºŸâªÉ«¬
∑’ Ë ßà µàÕ¡“®“°µà“ß®—ßÀ«—¥∑’¬Ë ß— ‰¡à¡ª’ √– “∑Õ“¬ÿ√·æ∑¬å
‚¥¬∑”°“√»÷°…“„π™à«ß‡«≈“ µ—ßÈ ·µà 1 °√°°Æ“§¡ 2538
∂÷ß 30 ¡‘∂ÿπ“¬π 2549 „πºŸâªÉ«¬∑’Ë¡’Õ“¬ÿ 15 ªï ¢÷Èπ‰ª
®”·π°µ“¡ ‡æ» Õ“¬ÿ ‚√§ª√–®”µ—« √–¬–‡«≈“∑’ˉ¥â
√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√ (incubation period) √–¬–‡«≈“
∑’ˇ√‘Ë¡¡’Õ“°“√®π¡’Õ“°“√‡°√Áß∑—Èßµ—« (onset) ™π‘¥¢Õß
∫“¥∑–¬—° (localized / generalized ) ‚√§ª√–®”µ—«
√–¬–‡«≈“∑’ËÕ¬Ÿà„π‚√ß欓∫“≈ ‚√§·∑√°´âÕπ ·≈–
º≈°“√√—°…“ (√Õ¥™’«‘µ/µ“¬ ) ∂‘µ‘∑’Ë„™â„π°“√«‘®—¬ „™â
∂‘µ‘æ√√≥𓧫“¡∂’Ë√âÕ¬≈– ·≈–À“§à“§«“¡ —¡æ—π∏å
¢Õßªí®®—¬∑’Ë¡’º≈µàÕ°“√‡ ’¬™’«‘µ ‚¥¬„™â ∂‘µ‘ OR
95%CI ¢Õß OR ·≈– ∂‘µ‘ χ2 „π°“√∑¥ Õ∫§«“¡
—¡æ—π∏å
º≈°“√»÷°…“
®“°°“√∑∫∑«π‡«™√–‡∫’¬πµ—ßÈ ·µà 1 °√°Æ“§¡
2538 ∂÷ß 30 ¡‘∂ÿπ“¬π 2549 ¡’®”π«πºŸâ∑’Ë√—∫°“√
«‘π‘®©—¬«à“‡ªìπ‚√§∫“¥∑–¬—° ∑—ÈßÀ¡¥®”π«π 85 √“¬
‡ªìπ‡æ»™“¬ 45 √“¬ (√âÕ¬≈–52.9) ‡æ»À≠‘ß 40 √“¬
(√âÕ¬≈– 47.1) Õ“¬ÿ‡©≈’¬Ë 44.88 ªï ‚¥¬Õ¬Ÿ„à π™à«ß‡«≈“Õ“¬ÿ
41-50 ªï¡“°∑’Ë ÿ¥ ¥—ß√“¬≈–‡Õ’¬¥„𠵓√“ß∑’Ë 1
18 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article
18
2/4/08, 13:16
µ“√“ß∑’Ë 1 · ¥ß§«“¡ —¡æ—π∏å√–À«à“ß‚√§∫“¥∑–¬—°°—∫Õ“¬ÿ·≈–‡æ»
Õ“¬ÿ (ªï)
15-20
21-30
31-40
41-50
51-60
61-70
71-80
> 80
√«¡
‡æ»™“¬
®”π«π(√âÕ¬≈–)
2 (4.44)
3 (6.66)
12 (26.67)
10 (22.22)
6 (13.33)
5 (11.11)
5 (11.11)
2 (4.44)
45 (100)
‡æ»À≠‘ß
®”π«π(√âÕ¬≈–)
0 (0.00)
2 (5.00)
8 (20.00)
12 (30.00)
10 (25.00)
4 (10.00)
3 (7.50)
1 (2.50)
40 (100)
∑—ÈßÀ¡¥
®”π«π(√âÕ¬≈–)
2 (2.35)
5 (5.88)
20 (23.53)
22 (25.89)
16 (18.82)
9 (10.59)
8 (9.41)
3 (3.53)
85 (100)
µ“√“ß∑’Ë 2 · ¥ß∫√‘‡«≥∑’ˉ¥â√—∫‡™◊ÈÕ
®”π«π(√âÕ¬≈–)
‰¡à∑√“∫µ”·Àπàß™—¥‡®π
·º≈∑’‡Ë ∑â“
·º≈∑’Ë»’√…–
·º≈∑’·Ë ¢π·≈–¡◊Õ
®“°°“√∑”·∑âß
·º≈®“°°“√ºà“µ—¥
25 (29.41)
38 (44.70)
7 (8.24)
12 (14.12)
2 (2.35)
1 (1.18)
∫“¥·º≈∑’Ë · ¢π·≈–¡◊ Õ 12 √“¬ (√â Õ ¬≈–14.12)
∫“¥·º≈®“°°“√∑”·∑âß 2 √“¬ (√âÕ¬≈–2.35) ·≈–
∫“¥·º≈®“°°“√ºà“µ—¥ 1 √“¬ (√âÕ¬≈–1.18)
µ“√“ß∑’Ë 3 · ¥ßÕ“°“√·≈–Õ“°“√· ¥ß
Õ“°“√ / Õ“°“√· ¥ß
Localized tetanus (cephalic)
Generalized tetanus
Trismus
Risus sardonicus
Opisthotonos
Dysphagia
®”π«π
15
70
58
66
70
64
√âÕ¬≈–
17.65
82.35
68.24
77.65
82.35
75.29
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article
19
2/4/08, 13:16
¡°√“§¡ › ¡’π“§¡ 2551
19
Vol. 7 No.1
®“°µ“√“ß∑’Ë 2 ºŸâªÉ«¬ 38 √“¬ (√âÕ¬≈– 44.70)
‰¥â√—∫‡™◊ÈÕ®“°·º≈∑’ˇ∑â“ ‰¡àæ∫∫“¥·º≈ 25 √“¬
(√âÕ¬≈– 29.41) ∫“¥·º≈∑’Ë»’√…– 7 √“¬ (√âÕ¬≈– 8.24)
IJM
∫√‘‡«≥∑’ˉ¥â√—∫‡™◊ÈÕ
®“°µ“√“ß∑’Ë 3 æ∫ºŸâªÉ«¬¡’Õ“°“√∫“¥∑–¬—°
‡©æ“–∑’Ë (localized tetanus) 15 √“¬ (√âÕ¬≈– 17.65)
‚¥¬∑—ÈßÀ¡¥‡ªìπ™π‘¥ cephalic Õ’° 70 √“¬ (√âÕ¬≈–
82.35) ‡ªìπ∫“¥∑–¬—°™π‘¥‡°√Áß∑—Èßµ—« (generalized
tetanus) ´÷Ëß®–¡’Õ“°“√µ—«‡°√Áß·Õàπ (opisthotonos)
70 √“¬ (√âÕ¬≈– 82.35) °≈â“¡‡π◊ÈÕ„∫ÀπⓇ°√Á߇À¡◊Õπ
· ¬–¬‘È¡ (risus sardonicus) 66 √“¬ (√âÕ¬≈– 77.65)
°≈◊π≈”∫“° (dysphagia) 64 √“¬ (√âÕ¬≈–75.29)
·≈–Õ⓪“°‰¡à¢÷Èπ (trismus) 58 √“¬ (√âÕ¬≈– 68.24)
µ“√“ß∑’Ë 4 · ¥ß√–¬–‡«≈“∑’ˉ¥â√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√
√–¬–‡«≈“ («—π)
< 3 «—π
3-7 «—π
> 7 «—π
‰¡à∑√“∫√–¬–‡«≈“
‡π◊ËÕß®“°‰¡àæ∫·º≈
µ“√“ß∑’Ë 4 √–¬–‡«≈“∑’ˉ¥â√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’
Õ“°“√ incubation period πâÕ¬°«à“ 3 «—π 7 √“¬
(√âÕ¬≈– 8.24) „π™à«ß 3-7 «—π18 √“¬ (√âÕ¬≈– 21.18)
®”π«π
√âÕ¬≈–
7
18
35
25
8.24
21.18
41.18
29.41
¡“°°«à“ 7 «—π 35 √“¬ (√âÕ¬≈– 41.18) ·≈–‰¡à∑√“∫
‡«≈“‡π◊ËÕß®“°‰¡àæ∫·º≈ 25 √“¬ (√âÕ¬≈– 29.41)
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 5 · ¥ß√–¬–‡«≈“∑’ˇ√‘Ë¡¡’Õ“°“√®π¡’Õ“°“√‡°√Áß∑—Èßµ—«
√–¬–‡«≈“ («—π)
®”π«π
√âÕ¬≈–
1 «—π
2 «—π
3 «—π
>3
48
20
13
4
56.47
23.53
15.29
4.70
µ“√“ß∑’Ë 5 √–¬–‡«≈“∑’ˇ√‘Ë¡¡’Õ“°“√ ®π¡’
Õ“°“√‡°√Áß∑—Èßµ—« (onset) ¿“¬„π 1 «—π æ∫¡“°∑’Ë ÿ¥
48 √“¬ (√âÕ¬≈– 56.47) ¿“¬„π 2 «—π 20 √“¬ (√âÕ¬≈–
23.53) ¿“¬„π 3 «—π 13 √“¬ (√âÕ¬≈– 15.29) ·≈–
¡“°°«à“ 3 «—π 4 √“¬ (√âÕ¬≈– 4.70)
µ“√“ß∑’Ë 6 · ¥ß‚√§ª√–®”µ—«¢ÕߺŸâªÉ«¬
‚√§ª√–®”µ—«
‚√§‡∫“À«“π
‚√§‰µ«“¬‡√◊ÈÕ√—ß
‚√§SLE
‰¡à¡’‚√§ª√–®”µ—«¥—ß°≈à“«
®”π«π(§π)
√âÕ¬≈–
6
2
1
76
7.06
2.35
1.18
89.41
‡ ’¬™’«‘µ(§π) √âÕ¬≈–
5
2
0
14
20 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article
20
2/4/08, 13:16
5.88
2.35
0
16.47
®“°µ“√“ß∑’Ë 6 ‚√§ª√–®”µ—«¢ÕߺŸâªÉ«¬ æ∫
«à“¡’‚√§‡∫“À«“π 6 √“¬ (√âÕ¬≈– 7.06) ·≈–‡ ’¬™’«‘µ
5 √“¬ (√âÕ¬≈– 5.88) ‚√§‰µ«“¬‡√◊ÈÕ√—ß 2 √“¬ (√âÕ¬
≈– 2.35) ·≈–‡ ’¬™’«‘µ∑—Èß 2 √“¬ (√âÕ¬≈– 2.35)
‚√§SLE 1 √“¬ (√âÕ¬≈– 1.18) ·≈–‰¡à‡ ’¬™’«‘µ ‰¡à
æ∫‚√§ª√–®”µ—« 76 √“¬ (√âÕ¬≈– 89.41) ‡ ’¬™’«‘µ
14 √“¬ (√âÕ¬≈– 16.47)
µ“√“ß∑’Ë 7 · ¥ß√–¬–‡«≈“∑’˺ŸâªÉ«¬Õ¬Ÿà„π‚√ß欓∫“≈
√–¬–‡«≈“ («—π)
< 7 «—π
7-14
15-21
22-28
29-35
36-42
43-49
50-56
57-63
64-70
> 70 «—π
5
9
4
16
18
11
4
6
5
3
4
5.89
10.59
4.71
18.82
21.18
12.94
4.71
7.06
5.89
3.53
4.71
‡«≈“π“π∑’Ë ÿ¥¡“°°«à“ 70 «—π 4 √“¬ (√âÕ¬≈– 4.71)
¥—ß√“¬≈–‡Õ’¬¥µ“√“ß∑’Ë 7
Vol. 7 No.1
µ“√“ß∑’Ë 8
√âÕ¬≈–
· ¥ß¬“∑’˺ŸâªÉ«¬‰¥â√—∫
¬“∑’˺ŸâªÉ«¬‰¥â√—∫
TAT (tetanus antitoxin)
DZP
Muscular blocking agent
(atracurium, vacuronium )
Penicillin
Metronidazole
®“°µ“√“ß∑’Ë 8 ºŸâªÉ«¬∑ÿ°√“¬‰¥â‡´√ÿࡵâ“π
∫“¥∑–¬—° (tetanus antitoxin, TAT) ·≈–¬“ ‰¥Õ–´‘
·æ¡ (DZP) ‡æ◊ËÕ≈¥Õ“°“√‡°√Áß ¡’ 64 √“¬ (√âÕ¬≈–
75.29) ∑’ˉ¥â√—∫ muscular blocking agent √à«¡¥â«¬
®”π«π
√âÕ¬≈–
85
85
64
100
100
75.29
72
13
84.71
15.29
ºŸâªÉ«¬ 72 √“¬ (√âÕ¬≈– 84.71) ‰¥â√—∫¬“ªØ‘™’«π–‡ªìπ
penicillin, 13 √“¬ (√âÕ¬≈– 5.29) ‰¥â√—∫ metronidazole
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article
21
IJM
®“°µ“√“ß∑’Ë 7 √–¬–‡«≈“∑’ºË ªŸâ «É ¬Õ¬Ÿ‚à √ß欓∫“≈
æ∫¡“°∑’ Ë ¥ÿ „π™à«ß 29-35 «—π 18 √“¬ (√âÕ¬≈– 21.18)
™à«ß 22-28 «—π 16 √“¬ (√âÕ¬≈– 18.82) ‚¥¬¡’™à«ß
®”π«π
2/4/08, 13:16
¡°√“§¡ › ¡’π“§¡ 2551
21
µ“√“ß∑’Ë 9 · ¥ß¿“«–·∑√°´âÕπ
¿“«–·∑√°´âÕπ
‰¡à¡’¿“«–·∑√°´âÕπ
ªÕ¥Õ—°‡ ∫
µ‘¥‡™◊ÈÕ∑“߇¥‘πªí “«–
‚√§À—«„®¢“¥‡≈◊Õ¥ (HIV)
®“°µ“√“ß∑’Ë 9 Õ“°“√·∑√°´âÕπæ∫ªÕ¥Õ—°‡ ∫
47 √“¬ (√âÕ¬≈– 55.29) µ‘¥‡™◊ÕÈ ∑“߇¥‘πªí “«– 8 √“¬
®”π«π(√âÕ¬≈–)
36 (42.35)
47 (56.29)
8 (9.41)
3 (3.53)
(√âÕ¬≈– 9.41) ‚√§À—«„®¢“¥‡≈◊Õ¥ 3 √“¬ (√âÕ¬≈– 3.53)
·≈–‰¡àæ∫¿“«–·∑√°´âÕπ 36 √“¬ (√âÕ¬≈– 42.35)
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 10 · ¥ßªí®®—¬∑’Ë —¡æ—π∏å°—∫°“√‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬‚√§∫“¥∑–¬—°‚√ß欓∫“≈Õÿ¥√∏“π’
22 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article
22
2/4/08, 13:16
®“°°“√»÷°…“¬âÕπÀ≈—ß 11 ªï µ—ßÈ ·µà 1 °√°Æ“§¡
2538 ∂÷ß 30 ¡‘∂ÿπ“¬π 2549 æ∫ºŸâªÉ«¬∑—ÈßÀ¡¥ 85 √“¬
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article
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Vol. 7 No.1
∫∑«‘®“√≥å
‡©≈’ˬ 7.73 √“¬µàÕªï ‡æ»™“¬ √âÕ¬≈– 52.90 ¡“°°«à“
‡æ»À≠‘ß√âÕ¬≈– 47.10 ´÷Ëßµ√ß°—∫°“√»÷°…“¢Õß Law
IG ·≈–§≥–3 ‡π◊ËÕß®“°ºŸâ™“¬µâÕß∑”ß“ππÕ°∫â“π
¡“°°«à“ºŸÀâ ≠‘ß ‚¥¬‡©æ“–°“√∑”π“ ∑” «π À√◊Õ ß“π
°àÕ √â“ß´÷Ëß¡’‚Õ°“ —¡º— ·≈–‰¥â√—∫‡™◊ÈÕ¡“°°«à“
ºŸâÀ≠‘ß ´÷Ëß¡’°“√∑”ß“π„π∫â“π‡ªìπÀ≈—°
Õ“¬ÿ‡©≈’ˬ¢ÕߺŸâªÉ«¬‡∑à“°—∫ 48.88 ªï ‚¥¬∑’Ë
78 √“¬ „π 85 √“¬ (√âÕ¬≈– 91.76) Õ“¬ÿ¡“°°«à“ 30 ªï
´÷Ëßπà“®–Õ∏‘∫“¬‰¥â®“°∑’˺ŸâªÉ«¬¡’¿Ÿ¡‘§ÿâ¡°—π≈¥≈ßµ“¡
Õ“¬ÿ ‡π◊ËÕß®“°‰¡à‰¥â√—∫°“√©’¥«—§´’π°√–µÿâπ4 ´÷Ëß®“°
°“√»÷°…“¢Õß Gergen PJ ·≈–§≥–5 æ∫«à“¿Ÿ¡‘§ÿâ¡°—π
µàÕ‡™◊ÈÕ∫“¥∑–¬—° ®–‡√‘Ë¡≈¥≈߇¡◊ËÕÕ“¬ÿ 40 ªï „π
ª√–‡∑»‰∑¬ª√–™“°√®–‰¥â√∫— «—§´’π§√—ßÈ ÿ¥∑⓬‡¡◊ÕË Õ“¬ÿ
12-14 ªï ¥—ßπ—Èπ‡¡◊ËÕÕ“¬ÿÀ≈—ß 25 ªï ∂Ⓣ¡à‰¥â√—∫°“√
©’¥«—§´’π°√–µÿâπ ¿Ÿ¡‘§ÿâ¡°—π°Áπà“®–≈¥≈߉ª‰¥â ®“°
°“√»÷°…“§√—Èßπ’Èæ∫«à“ ºŸâªÉ«¬∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï ¡’
‚Õ°“ ‡ ’¬™’«‘µ 3.3 ‡∑à“¢ÕߺŸâªÉ«¬∑’Ë¡’Õ“¬ÿπâÕ¬°«à“
(OR=3.3, 95% CI=1.07-10.34, p=0.019)
ºŸâªÉ«¬ à«π¡“° 38 √“¬ (√âÕ¬≈– 44.70) ‰¥â√—∫
‡™◊ÈÕ®“°·º≈´÷Ë߇°‘¥∫√‘‡«≥‡∑â“ ´÷Ëß¡—°‡°‘¥®“°«— ¥ÿ¡’§¡
‡™àπ µ–ªŸ À√◊Õ‡»…‰¡â À√◊Õ·º≈‡√◊ÈÕ√—ß∑’ˇ∑â“ ´÷Ëßµ√ß
°—∫°“√»÷°…“¢Õß Sanford JP ·≈–§≥–2 ‡π◊ËÕß®“°
‡™◊ÈÕ∫“¥∑–¬—°¡—°Õ“»—¬Õ¬Ÿà„π¥‘π ∑”„À⇢ⓠŸà∫“¥·º≈
‚¥¬ßà“¬
„π°“√»÷°…“§√—Èßπ’Èæ∫ºŸâªÉ«¬∑’ˇªìπ∫“¥∑–¬—°
‡©æ“–∑’Ë (localized tetanus) 15 √“¬ (√âÕ¬≈–17.65)
‚¥¬‡ªìπ cephalic type ∑—ÈßÀ¡¥ ·≈–‰¡à¡’√“¬„¥
‡ ’¬™’«‘µ ºŸâªÉ«¬ 70 √“¬ (√âÕ¬≈– 82.35) ‡ªìπ generalized tetanus ·≈–¡’ºªŸâ «É ¬‡ ’¬™’«µ‘ 21 √“¬ (√âÕ¬≈– 24.70)
´÷Ëßµ√ß°—∫°“√»÷°…“¢Õß Sun Ko ·≈–§≥–6 æ∫«à“
ºŸâ ªÉ « ¬∑’Ë ‡ ’ ¬ ™’ «‘ µ ¡— ° ®–‡ªì π generalized tetanus
‡π◊ËÕß®“°Õ“°“√√ÿπ·√ß°«à“‚¥¬‡©æ“– Õ“°“√µ—«‡°√Áß
·Õàπ (opisthotonos) ´÷Ëßæ∫∑ÿ°√“¬„π generalized
tetanus
IJM
®“°º≈°“√«‘‡§√“–Àåªí®®—¬∑’Ë —¡æ—π∏å°—∫Õ—µ√“
°“√‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬‚√§∫“¥∑–¬—°„π‚√ß欓∫“≈
®—ßÀ«—¥Õÿ¥√∏“π’ ¥â«¬«‘∏’°“√«‘‡§√“–Àå·∫∫µ—«·ª√‡¥’¬«
(univariate analysis) ‚¥¬„™â ∂‘µ‘∑¥ Õ∫‰§ ·§«√å
(χ2) æ∫«à“ ªí®®—¬∑’Ë —¡æ—π∏å°—∫Õ—µ√“°“√‡ ’¬™’«‘µ¢Õß
ºŸâªÉ«¬‚√§∫“¥∑–¬—°Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫
0.05 䴉ᡈ
(1) °≈ÿà¡Õ“¬ÿ¢ÕߺŸâªÉ«¬‚√§∫“¥∑–¬—° ‚¥¬
æ∫«à“ ºŸâªÉ«¬‚√§∫“¥∑–¬—°∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï
¢÷Èπ‰ª¡’‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ §‘¥‡ªìπ 3.3 ‡∑à“
¢ÕߺŸâ ªÉ « ¬‚√§∫“¥∑–¬— ° ∑’Ë ¡’ Õ “¬ÿ µË” °«à “ À√◊ Õ ‡∑à “ °— ∫
50 ªï (OR=3.3, 95%CI=1.07-10.34, p=0.019)
(2) √–¬–‡«≈“∑’ˉ¥â√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√¢Õß
ºŸâªÉ«¬‚√§∫“¥∑–¬—° ‚¥¬æ∫«à“ºŸâªÉ«¬‚√§∫“¥∑–¬—°
∑’Ë¡’√–¬–‡«≈“∑’ˉ¥â√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√µË”°«à“ À√◊Õ
‡∑à“°—∫ 7 «—π ¡’‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ§‘¥‡ªìπ 14.2
‡∑à“¢ÕߺŸâªÉ«¬‚√§∫“¥∑–¬—° ∑’Ë¡’√–¬–‡«≈“‰¥â√—∫‡™◊ÈÕ
®π‡√‘Ë ¡ ¡’ Õ “°“√¡“°°«à “ 7 «— π (OR=14.2, 95%
CI= 3.30-69.41, p=0.001)
(3) °“√¡’‚√§ª√–®”µ—«¢ÕߺŸªâ «É ¬‚√§∫“¥∑–¬—°
‚¥¬æ∫«à“ºŸâªÉ«¬‚√§∫“¥∑–¬—° ∑’Ë¡’‚√§ª√–®”µ—«¡’
‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ§‘¥‡ªìπ14.2 ‡∑à“¢ÕߺŸâªÉ«¬
‚√§∫“¥∑–¬—° ∑’ˉ¡à¡’‚√§ª√–®”µ—« (OR=14.2, 95%
CI=2.29-147.54, p<0.001)
(4) °“√¡’ Õ “°“√·∑√°´â Õ π¢ÕߺŸâ ªÉ « ¬‚√§
∫“¥∑–¬—° ‚¥¬æ∫«à“ºŸâªÉ«¬‚√§∫“¥∑–¬—° ∑’Ë¡’Õ“°“√
µ‘¥‡™◊ÈÕ∑“߇¥‘πªí “«– ¡’‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ
§‘¥‡ªìπ 11.4 ‡∑à“¢ÕߺŸâªÉ«¬‚√§∫“¥∑–¬—°∑’ˉ¡à¡’
Õ“°“√µ‘ ¥ ‡™◊È Õ ∑“߇¥‘ π ªí “«– (OR=11.4, 95%
CI=1.76-121.54, p=0.001)
Vol. 7 No.1
IJM
Õ—µ√“°“√µ“¬¢ÕߺŸâªÉ«¬„π°“√»÷°…“π’È ‡∑à“°—∫ √âÕ¬≈–
24.70 ´÷Ëßµ√ß°—∫°“√»÷°…“¢Õß Sanford JP ·≈–§≥–2
®–æ∫Õ—µ√“°“√µ“¬√–À«à“ß √âÕ¬≈– 20-50 ·≈–„π
°“√»÷°…“π’È Õ—µ√“°“√µ“¬ —¡æ—π∏å°—∫√–¬–‡«≈“∑’ˉ¥â
√—∫‡™◊ÈÕ®π‡√‘Ë¡¡’Õ“°“√ (incubation period) ·≈–√–¬–
‡«≈“∑’ˇ√‘Ë¡¡’Õ“°“√®π¡’Õ“°“√‡°√Áß∑—Èßµ—« ´÷Ëß®–æ∫«à“
¬‘Ëß¡’√–¬– —ÈπÕ“°“√®–√ÿπ·√ß ·≈–欓°√≥å‚√§®–
‡≈«≈߇™àπ‡¥’¬«°—π ®“°°“√»÷°…“§√—Èßπ’Èæ∫«à“ ºŸâªÉ«¬
incubation period πâÕ¬°«à“À√◊Õ‡∑à“°—∫ 7 «—π ¡’
‚Õ°“ ‡ ’¬™’«‘µ 14.2 ‡∑à“ ¢ÕߺŸâªÉ«¬ incubation
period ¡“°°«à“ 7 «—π (OR=14.2, 95% CI=3.30-69.41,
p=0.001)
ºŸâªÉ«¬ 6 √“¬ (√âÕ¬≈– 7.06) ‡ªìπ‚√§‡∫“À«“π
·≈–‡ ’¬™’«‘µ 5 √“¬ ºŸâªÉ«¬‚√§‰µ«“¬‡√◊ÈÕ√—ß 2 √“¬
(√âÕ¬≈– 2.35) ‡ ’¬™’«‘µ∑—Èß 2 √“¬ ´÷Ëß∑ÿ°√“¬„π°“√
»÷ ° …“§√—È ß π’È ∑’Ë ‡ ’ ¬ ™’ «‘ µ ªÉ « ¬‡ªì π ™π‘ ¥ generalized
tetanus §≈⓬°—∫°“√»÷°…“¢Õß Panning CA ·≈–
§≥–7 ∑’Ëæ∫«à“ºŸâªÉ«¬‚√§‡∫“À«“π ‚√§‰µ«“¬ ¡—°®–
‡ªìπ∫“¥∑–¬—°∑’Ë√ÿπ·√ß ·≈–‡ ’¬™’«‘µ Ÿß ‡π◊ËÕß®“°
¿Ÿ ¡‘ §ÿâ ¡ °— π µà Õ ‚√§µË” °«à “ §πª°µ‘ ·≈–‡¡◊Ë Õ ¡’ · º≈
‡√◊ÈÕ√—ß ¡—°À“¬™â“ ∑”„Àâ¡’‚Õ°“ √—∫‡™◊ÈÕ¡“°°«à“ª°µ‘
πÕ°®“°π’ȺŸâªÉ«¬∑’ˇ ’¬™’«‘µ¡—°‡ªìπºŸâªÉ«¬ ŸßÕ“¬ÿ ´÷Ëß¡’
√“¬ß“π«à“¿Ÿ¡§‘ ¡ÿâ °—π∑’≈Ë ¥≈ß®π‡À≈◊ÕπâÕ¬°«à“ √âÕ¬≈– 502
¢Õß√–¥—∫∑’ªË ÕÑ ß°—π‚√§‰¥â„π§πÕ“¬ÿ 60 - 69 ªï ·≈–
‡À≈◊ÕπâÕ¬°«à“ √âÕ¬≈– 30 „πºŸâªÉ«¬Õ“¬ÿ¡“°°«à“ 70 ªï
¥—ßπ—πÈ °“√©’¥«—§´’π„πºŸ â ߟ Õ“¬ÿ8 ·≈– ºŸªâ «É ¬‚√§‡√◊ÕÈ √—ß
‡™àπ ‡∫“À«“𠉵«“¬ Õ“®™à«¬≈¥Õ—µ√“°“√‡°‘¥‚√§
À√◊Õ≈¥§«“¡√ÿπ·√ߢÕß‚√§‰¥â ®“°°“√»÷°…“æ∫«à“
ºŸªâ «É ¬∑’¡Ë ‚’ √§ª√–®”µ—«¡’‚Õ°“ ‡ ’¬™’«µ‘ 14.2 ‡∑à“ ¢Õß
ºŸâªÉ«¬∑’ˉ¡à¡’‚√§ª√–®”µ—« (OR=14.2, 95%CI=2.29147.54, p=0.001)
„π°“√»÷°…“§√—Èßπ’Èæ∫«à“¡“°°«à“ √âÕ¬≈– 80
¢ÕߺŸâªÉ«¬„™â‡«≈“√—°…“µ—«„π‚√ß欓∫“≈¡“°°«à“ 3
—ª¥“Àå ·≈–¡“°°«à“√âÕ¬≈– 80 ¢ÕߺŸâªÉ«¬‰¥â°≈—∫
∫â“π¿“¬„π‡«≈“ 50 «—π ´÷Ë߇ªìπ‚√§∑’Ëæ∫«à“„™â‡«≈“
„π°“√√—°…“µ—«§àÕπ¢â“ßπ“π
ºŸâ ªÉ « ¬∑ÿ ° √“¬„π°“√»÷ ° …“§√—È ß π’È ‰ ¥â √— ∫ ‡´√ÿà ¡
µâ“π∫“¥∑–¬—° (TAT) ‡æ◊ËÕ≈¥ “√æ‘…„π√à“ß°“¬ ·µà
®–¬— ß ‰¡à „ Àâ «— § ´’ π ∫“¥∑–¬— ° (TT) ‡æ√“–«— § ´’ π
∫“¥∑–¬— ° ‰¡à ¡’ à « π™à « ¬≈¥Õ“°“√ºŸâ ªÉ « ¬„π√–¬–π’È
‡π◊ËÕß®“°√à“ß°“¬µâÕß„™â‡«≈“„π°“√ √â“ß¿Ÿ¡‘§ÿâ¡°—π
·µà®“°°“√»÷°…“¢Õß Sanford JP ·≈–§≥–2 æ∫«à“
°“√„Àâ¿Ÿ¡‘§ÿâ¡°—πµàÕ‡™◊ÈÕ∫“¥∑–¬—° (tetanus immunoglobulin) πà“®–™à«¬≈¥ª√‘¡“≥ “√æ‘…‰¥â¥’¬‘Ëߢ÷Èπ
´÷Ë߉¡à‰¥â„Àâ„π°“√»÷°…“§√—Èßπ’È
„π°“√»÷°…“π’ȺŸâªÉ«¬∑ÿ°√“¬‰¥â√—∫¬“ ‰¥Õ–´’
·æ¡ ‡æ◊ËÕ≈¥Õ“°“√‡°√ÁߢÕß°≈â“¡‡π◊ÈÕ ¢π“¥¢Õ߬“
∑’ˇÀ¡“– ¡ §◊Õ 10-30 ¡‘≈≈‘°√—¡ ∑ÿ° 1 ∂÷ß 8 ™—Ë«‚¡ß
À“°„Àâ¡“°°«à“ 402 ¡‘≈≈‘°√—¡µàÕ™—Ë«‚¡ß Õ“®¡’º≈‡ ’¬
‡π◊ËÕß®“°¿“«–‡≈◊Õ¥‡ªìπ°√¥·≈¥µ‘°‰¥â ºŸâªÉ«¬ 64 √“¬
(√âÕ¬≈– 75.29) ‰¥â√—∫ muscular blocking agent
·≈–¡’ 21 √“¬ (√âÕ¬≈– 24.70) ∑’ˇ ’¬™’«‘µ‡π◊ËÕß®“°
ºŸâªÉ«¬∑’ˉ¥â√—∫¬“¥—ß°≈à“«¡—°¡’Õ“°“√√ÿπ·√ß §≈⓬°—∫
°“√»÷°…“¢Õß Sanford JP2 ·≈–§≥–
ºŸâªÉ«¬ à«π¡“° 72 √“¬ (√âÕ¬≈– 84.71) ‰¥â√—∫
¬“ªØ‘™«’ π– ‡ªìπ penicillin ·≈– 13 √“¬ (√âÕ¬≈– 15.29)
‰¥â√—∫¬“ metronidazole ‡π◊ËÕß®“°¬“ penicillin ‡ªìπ
¬“ªØ‘™«’ π–∑’„Ë ™â°π— ∑—«Ë ‰ª„π°“√√—°…“ ‚√§∫“¥∑–¬—°
à « 𬓠metronidazole 1 ¡— ° „Àâ „ π√“¬∑’Ë · æâ ¬ “
penicillin
„π°“√»÷°…“§√—Èßπ’È æ∫«à“ ªÕ¥Õ—°‡ ∫ ‡ªìπ
¿“«–·∑√°´âÕπ∑’æË ∫¡“°∑’ Ë ¥ÿ 47 √“¬ (√âÕ¬≈– 55.29)
´÷Ëß¡—°‡°‘¥®“°°“√ ”≈—° ·≈–µ‘¥‡™◊ÈÕ„π‚√ß欓∫“≈
‚¥¬∑ÿ°√“¬‡ªìπ generalized tetanus ¥—ßπ—Èπ „π√“¬∑’Ë
‡ªìπ generalized tetanus ∑ÿ°√“¬§«√‰¥â√—∫°“√¥Ÿ·≈
„π ICU ∑”°“√‡®“–§Õ (tracheostomy)1,10 ‚¥¬‡√Á«
‡æ◊ËÕ≈¥Õ“°“√ ”≈—°πÈ”≈“¬ (secretion) ·≈–‰¥â√—∫¬“
§≈“¬°≈â“¡‡π◊ÈÕ ¬“ªØ‘™’«π–∑’ˇÀ¡“– ¡
24 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article
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2/4/08, 13:17
4.
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Vol. 7 No.1
1. §‡™π∑√å ªîò π ÿ « √√≥ ‡«™»“ µ√å ©ÿ ° ‡©‘ π .
‚§√ß°“√µ”√“«‘∑¬“≈—¬·æ∑¬»“ µ√å æ√–¡ß°ÿÆ
‡°≈â“. 2542;758-64.
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æ√√≥∑‘æ¬å ©“¬“°ÿ≈ ·≈–§≥– ¡“§¡‚√§µ‘¥
‡™◊ÈÕ·Ààߪ√–‡∑»‰∑¬. µ”√“‚√§µ‘¥‡™◊ÈÕ. 2548;
1428.
Bleck TP. Tetanus : pathophysiology, management and prophylaxis. Disease-A-Month
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√Ÿª∑’Ë 1 · ¥ß®”π«πºŸâªÉ«¬·¬°µ“¡‡æ»„π·µà≈–™π‘¥¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß
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µ”·Àπàß
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Venous sinus thrombosis
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√âÕ¬≈–
3.08
32.31
7.69
4.62
21.54
14.62
2.31
13.85
100
∑—ÈßÀ¡¥
®”π«π
√âÕ¬≈–
7
2.94
79
33.19
15
6.30
11
4.62
47
19.75
32
13.45
16
6.72
31
13.03
238
100
34.26 µ“¡¥â«¬ multiple vessels ‡æ»™“¬√âÕ¬≈– 21.54
‡æ»À≠‘ß√âÕ¬≈– 17.60 ·≈– lacunar infarction ‡æ»
™“¬√âÕ¬≈– 14.62 ‡æ»À≠‘ß√âÕ¬≈– 12.04
Vol. 7 No.1
µ“√“ß∑’Ë 3 · ¥ßµ”·ÀπàߢÕ߇≈◊Õ¥ÕÕ°„π ¡Õß ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ° ·¬°µ“¡‡æ»
µ”·Àπàß
™“¬
®”π«π
16
6
2
4
4
3
2
7
44
Basal ganglia
Lobar
Thalamus
Brain stem
Cerebellar
Subarachnoid
Intraventricular
Multiple sites
√«¡
√âÕ¬≈–
36.36
13.64
4.55
9.09
9.09
6.82
4.55
15.91
100
˭ԧ
®”π«π √âÕ¬≈–
8
26.67
4
13.33
1
3.33
4
13.33
2
6.67
3
10.00
2
6.67
6
20.00
30
100
∑—ÈßÀ¡¥
®”π«π
√âÕ¬≈–
24
32.43
10
13.51
3
4.05
8
10.81
6
8.11
6
8.11
4
5.41
13
17.57
74
100
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article(2)
29
2/4/08, 13:17
¡°√“§¡ › ¡’π“§¡ 2551
IJM
®“°µ“√“ß∑’Ë 2 µ”·ÀπàߢÕß‚√§À≈Õ¥‡≈◊Õ¥
¡Õßµ’∫æ∫∑’Ë middle cerebral artery æ∫¡“°∑’Ë ÿ¥
∑—Èß 2 °≈ÿà¡Õ“¬ÿ ‡æ»™“¬√âÕ¬≈– 32.31 ‡æ»À≠‘ß√âÕ¬≈–
˭ԧ
®”π«π √âÕ¬≈–
3
2.78
37
34.26
5
4.63
5
4.63
19
17.60
13
12.04
13
12.04
13
12.04
108
100
29
µ”·Àπà ß ¢Õ߇≈◊ Õ ¥ÕÕ°„π ¡Õß„π‡æ»™“¬
æ∫∑’Ë basal ganglia ¡“°∑’Ë ÿ¥√âÕ¬≈– 36.36 µ“¡¥â«¬
multiple sites √âÕ¬≈– 15.91 ·≈– lobar hemorrhage
√âÕ¬≈– 13.64 „π‡æ»À≠‘ß æ∫‡≈◊Õ¥ÕÕ°„π ¡Õß∑’Ë
basal ganglia ¡“°∑’Ë ÿ¥ √âÕ¬≈– 26.67 µ“¡¥â«¬
multiple sites √âÕ¬≈– 20.00 ·≈– lobar hemorrhage
√âÕ¬≈– 13.33
µ“√“ß∑’Ë 4 · ¥ß “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫ ·¬°µ“¡‡æ»
IJM
Vol. 7 No.1
“‡Àµÿ
Emboli
1. AF (atrial fibrillation)
2. VHD
MS (mitral stenosis)
Prosthetic mitral value
IE
3. Acute MI
4. Thyrotoxicosis
Atherosclerosis
1. HT
2. DM
3. Hyperlipidemia
4. Smoking
Miscellaneous
CNT (SLE œ≈œ)
Pills
Pregnancy
HIV - associated
Unknown
√«¡
™“¬
˭ԧ
®”π«π √âÕ¬≈–
®”π«π
√âÕ¬≈–
54
41.54
42
38.89
96
40.34
42
7
3
2
1
32.31
5.39
2.31
1.54
0.77
32
4
4
3
29.63
3.70
3.70
2.78
74
11
7
2
4
31.09
4.62
2.94
0.84
1.68
14
18
11
7
10.77
13.85
8.46
5.39
11
12
8
4
10.19
11.11
7.41
3.70
25
30
19
11
10.50
12.61
7.98
4.62
4
5
23
130
3.08
3.85
17.69
13
10
3
3
18
108
12.04
9.26
2.78
2.78
16.67
17
10
3
8
41
238
7.14
4.20
1.26
3.36
17.23
À¡“¬‡Àµÿ ºŸâªÉ«¬∫“ߧπÕ“®¡’ “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫À≈“¬™π‘¥
30 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article(2)
30
∑—ÈßÀ¡¥
®”π«π √âÕ¬≈–
2/4/08, 13:17
“‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õßµ’∫ Õ—π¥—∫
·√°§◊Õ AF ‡æ»™“¬√âÕ¬≈– 41.54 ‡æ»À≠‘ß√âÕ¬≈–
38.89 Õ—π¥—∫√Õß≈ß¡“§◊Õ MS ‡æ»™“¬√âÕ¬≈– 32.31
‡æ»À≠‘ß√âÕ¬≈– 29.63 Õ—π¥—∫ “¡§◊Õ ‰¡à∑√“∫ “‡Àµÿ
‡æ»™“¬√âÕ¬≈– 17.69 ‡æ»À≠‘ß√âÕ¬≈– 16.67
µ“√“ß∑’Ë 5 · ¥ß “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ° ·¬°µ“¡‡æ»
“‡Àµÿ
™“¬
®”π«π √âÕ¬≈–
11
25.00
6
13.64
3
6.82
3
6.82
5
11.36
13
29.55
5
11.36
§«“¡¥—π‚≈À‘µ Ÿß
¥◊¡Ë ÿ√“
Ÿ∫∫ÿÀ√’Ë
Aneurysm
AVM
Unknown
Bleeding tendency
‡™àπ coagulation defect,
DHF, thrombocytopenia
À¡“¬‡Àµÿ
˭ԧ
®”π«π √âÕ¬≈–
6
20.00
2
6.67
1
3.33
2
6.67
3
10.00
13
43.33
3
10.00
√«¡
®”π«π √âÕ¬≈–
17
22.97
8
10.81
4
5.41
5
6.76
8
10.81
26
35.14
8
10.81
ºŸâªÉ«¬∫“ߧπÕ“®¡’ “‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ°À≈“¬™π‘¥
Õ—π¥—∫ “¡„π‡æ»™“¬§◊Õ °“√¥◊¡Ë ÿ√“√âÕ¬≈– 13.64 „π
‡æ»À≠‘ß AVM ·≈– bleeding tendency ‡∑à“°—π
√âÕ¬≈– 10
Vol. 7 No.1
µ“√“ß∑’Ë 6 · ¥ß “‡Àµÿ°“√µ“¬ ·¬°µ“¡‡æ»
“‡Àµÿ°“√µ“¬
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
∑—ßÈ À¡¥
™“¬
˭ԧ
™“¬
˭ԧ
®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈–
Brain herniation
ªÕ¥∫«¡/Õ—°‡ ∫
°“√µ‘¥‡™◊ÈÕ
∑“߇¥‘πªí “«–
·º≈°¥∑—∫
¿“«–À—«„®≈⡇À≈«
√«¡
5
1
1
62.50
12.50
12.50
4
2
50.00
25.00
6
5
1
46.15
38.46
7.69
6
3
1
54.54
27.27
9.09
21
11
3
52.50
27.50
7.50
1
1
8
12.50
12.50
100
1
8
12.50
100
1
13
7.69
100
1
11
9.09
100
3
2
40
7.50
5.00
100
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article(2)
31
IJM
“‡Àµÿ¢Õß‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ°∑’Ëæ∫
¡“°∑’Ë ÿ¥§◊Õ ‰¡à∑√“∫ “‡Àµÿ ‡æ»™“¬√âÕ¬≈– 29.55
‡æ»À≠‘ß√âÕ¬≈– 43.33 √Õß≈ß¡“§◊Õ ¿“«–§«“¡¥—π
‚≈À‘µ Ÿß ‡æ»™“¬√âÕ¬≈– 25 ‡æ»À≠‘ß√âÕ¬≈– 20
2/4/08, 13:17
¡°√“§¡ › ¡’π“§¡ 2551
31
Õ—µ√“°“√µ“¬„π°≈ÿà¡‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
Õ—π¥—∫·√°§◊Õ brain herniation „π‡æ»™“¬ 5 √“¬
(√âÕ¬≈– 62.50) „π‡æ»À≠‘ß 4 √“¬ (√âÕ¬≈– 50) Õ—π¥—∫
√Õß≈ß¡“„π‡æ»™“¬§◊Õ °“√µ‘¥‡™◊ÈÕ ªÕ¥∫«¡/ªÕ¥
Õ—°‡ ∫ ·º≈°¥∑—∫ ·≈–¿“«–À—«„®≈⡇À≈« ‡∑à“°—π
§◊Õ 1 √“¬ (√âÕ¬≈– 12.50) „π‡æ»À≠‘ß Õ—π¥—∫ Õߧ◊Õ
¿“«–°“√µ‘ ¥ ‡™◊È Õ ªÕ¥∫«¡/ªÕ¥Õ— ° ‡ ∫ 2 √“¬
(√âÕ¬≈– 25) Õ—π¥—∫ “¡ §◊Õ °“√µ‘¥‡™◊ÈÕ∑“߇¥‘π
ªí “«– ·º≈°¥∑—∫ ·≈–¿“«–À—«„®≈⡇À≈« ‡∑à“°—π
§◊Õ 1 √“¬ (√âÕ¬≈– 12.50)
Õ—µ√“°“√µ“¬„π°≈ÿ¡à ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·µ°
Õ—π¥—∫·√°§◊Õ brain herniation „π‡æ»™“¬ 6 √“¬
(√âÕ¬≈– 46.15) ‡æ»À≠‘ß 6 √“¬ (√âÕ¬≈– 54.54) Õ—π¥—∫
Õß„π‡æ»™“¬ §◊Õ °“√µ‘¥‡™◊ÈÕ ªÕ¥∫«¡/ªÕ¥
Õ—°‡ ∫ 5 √“¬ (√âÕ¬≈– 38.46) Õ—π¥—∫ “¡„π‡æ»™“¬
§◊Õ °“√µ‘¥‡™◊ÈÕ∑“߇¥‘πªí “«– ·º≈°¥∑—∫ ‡∑à“°—π
1 √“¬ (√âÕ¬≈– 7.69) Õ—π¥—∫ Õß „π‡æ»À≠‘ß §◊Õ
°“√µ‘¥‡™◊ÕÈ ªÕ¥∫«¡/ªÕ¥Õ—°‡ ∫ 3 √“¬ (√âÕ¬≈– 27.27)
Õ—π¥—∫ “¡ §◊Õ °“√µ‘¥‡™◊ÈÕ∑“߇¥‘πªí “«– ·≈–·º≈
°¥∑—∫ ‡∑à“°—π 1 √“¬ (√âÕ¬≈– 9.09)
µ“√“ß∑’Ë 7 · ¥ßªí®®—¬∑’Ë —¡æ—π∏å°—∫Õ—µ√“°“√‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π‚√ß欓∫“≈Õÿ¥√∏“π’
Õ—µ√“
°“√‡ ’¬™’«‘µ
(√âÕ¬≈–)
OR (95%CI)
IJM
Vol. 7 No.1
ªí®®—¬
32 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article(2)
32
2/4/08, 13:17
χ2
P-value
ªí®®—¬
Õ—µ√“
°“√‡ ’¬™’«‘µ
(√âÕ¬≈–)
OR (95%CI)
χ2
P-value
IJM
Vol. 7 No.1
* ‰¡à¡’®”π«πºŸâ‡ ’¬™’«‘µ
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article(2)
33
2/4/08, 13:17
¡°√“§¡ › ¡’π“§¡ 2551
33
Vol. 7 No.1
IJM
®“°º≈°“√«‘‡§√“–Àåªí®®—¬∑’Ë —¡æ—π∏å°—∫Õ—µ√“
°“√‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„πºŸâªÉ«¬
Õ“¬ÿπâÕ¬¢Õß‚√ß欓∫“≈®—ßÀ«—¥Õÿ¥√∏“π’ ¥â«¬«‘∏’°“√
«‘‡§√“–Àå·∫∫µ—«·ª√‡¥’¬« (univarate analysis) ‚¥¬
„™â ∂‘ µ‘ ∑ ¥ Õ∫‰§ ·§«√å ( χ2) æ∫«à “ ªí ® ®— ¬ ∑’Ë
— ¡ æ— π ∏å °— ∫ Õ— µ √“°“√‡ ’ ¬ ™’ «‘ µ ¢ÕߺŸâ ªÉ « ¬‚√§À≈Õ¥
‡≈◊Õ¥ ¡Õß„πºŸâªÉ«¬Õ“¬ÿπâÕ¬Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘
∑’Ë√–¥—∫ 0.05 ‰¥â·°à
(1) ‡æ»¢ÕߺŸâªÉ«¬‚¥¬æ∫«à“ ºŸâªÉ«¬‡æ»À≠‘ß
¡’‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ §‘¥‡ªìπ 4.6 ‡∑à“¢ÕߺŸâªÉ«¬
‡æ»™“¬ (OR=4.6, 95%CI=1.76-11.62, P<0.001)
(2) °“√‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ° ‚¥¬
æ∫«à“ ºŸâªÉ«¬∑’ˇªìπ‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ° ¡’
‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ§‘¥‡ªìπ 6.7 ‡∑à“¢ÕߺŸâªÉ«¬
‚√§À≈Õ¥‡≈◊ Õ ¥„π ¡Õßµ’ ∫ (OR=6.7, 95%
CI=3.11-14.38, P<0.001)
(3) µ”·ÀπàߢÕß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫ ‚¥¬
æ∫«à“ ºŸâªÉ«¬∑’ˇªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫∑’˵”·Àπàß
middle cerebral artery ¡’‚Õ°“ ‡ ’ˬß∑’Ë®–‡ ’¬™’«‘µ§‘¥
‡ªìπ 4.1 ‡∑à“¢ÕߺŸâªÉ«¬∑’ˇªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
∑’µË ”·ÀπàßÕ◊πË (OR=4.1, 95%CI=1.25-15.61, P <0.001)
«‘®“√≥å
®“°°“√»÷°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„πºŸâªÉ«¬
Õ“¬ÿπâÕ¬ (stoke in the young) Õ“¬ÿ15-45 ªï ‡°◊Õ∫
∑—ÈßÀ¡¥æ∫«à“ æ∫„π‡æ»™“¬¡“°°«à“‡æ»À≠‘ß2-4 „π
Õ—µ√“ à«π∑’Ë·µ°µà“ß°—𠵓¡¿Ÿ¡‘¿“§ ‡™◊ÈÕ™“µ‘ œ≈œ
´÷Ëß°“√»÷°…“§√—Èßπ’È æ∫«à“‡æ»™“¬¡’ Õ—µ√“°“√ªÉ«¬¡“°
°«à“‡æ»À≠‘ß∂÷ß 1.2 ‡∑à“ ·≈– æ∫‚√§À≈Õ¥‡≈◊Õ¥„π
¡Õßµ’∫¡“°°«à“ ‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ° ∂÷ß 1.92
‡∑à “ ´÷Ë ß æ∫«à “ ¡’ § «“¡·µ°µà “ ß°— ∫ ∑’Ë ‡ §¬»÷ ° …“„π
ª√–™“°√¿“§„µâ6 ∑’Ëæ∫ ‡æ»™“¬ : ‡æ»À≠‘ß 1.5 : 1
·≈–æ∫‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫ : ‚√§À≈Õ¥‡≈◊Õ¥
¡Õß·µ° 1.05 : 1, §«“¡‡ ’ˬߵàÕ‚√§À≈Õ¥‡≈◊Õ¥
¡Õß®–‡æ‘Ë¡¢÷È𠵓¡°≈ÿà¡Õ“¬ÿ∑’Ë¡“°¢÷Èπ ´÷Ëßæ∫µ√ß°—∫
°“√»÷°…“∑’ºË “à π¡“
µ”·ÀπàߢÕß‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õßµ’∫ æ∫
∑’Ë middle cerebral artery ¡“°∑’Ë ÿ¥ √âÕ¬≈– 33.19
µ“¡¡“¥â«¬ multiple vessels √âÕ¬≈– 19.75 ·≈–
lacunar infarction √âÕ¬≈– 13.45 “‡Àµÿ¢Õß‚√§
À≈Õ¥‡≈◊Õ¥„π ¡Õßµ’∫ ¡—°®–¡’ “‡Àµÿ®“°‚√§À—«„®
∑—Èß∑’ˇ°‘¥®“°‚√§À—«„®‡Õß ‡™àπ ¿“«– AF ≈‘ÈπÀ—«„®
µ’∫√—Ë« ¿“«–À—«„®¢“¥‡≈◊Õ¥ ·≈–‚√§∑“ß°“¬∑’Ë∑”„Àâ
°“√‡µâπ¢ÕßÀ—«„®º‘¥ª°µ‘ ‡™àπ¿“«– thyrotoxicosis ´÷ßË
æ∫‡ªìπ√âÕ¬≈– 41.18 ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√»÷°…“
®“°µà“ߪ√–‡∑»3,4,7,8 æ∫„π™à«ß√âÕ¬≈– 4.7-35.4 · ¥ß
«à“„π°≈ÿࡪ√–™“°√∑’ˇ√“»÷°…“¡’‚√§À—«„®¡“°°«à“
°≈ÿà¡°“√»÷°…“Õ◊ËπÊ ‚¥¬‡©æ“–¿“«–≈‘ÈπÀ—«„®√—Ë« ∑’Ë
æ∫ √à«¡°—∫ atrial fibrillation ´÷Ëß®“°°“√»÷°…“¢Õß
Framingham study ∑’Ëæ∫ mitral valve stenosis
√à«¡°—∫ atrial fibrillation ®–‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥
¡Õß9 ‡æ‘Ë¡¢÷Èπ 17 ‡∑à“ ¿“«– prosthetic mitral valve
æ∫√âÕ¬≈– 4.62 ¿“«– infective endocarditis æ∫
√âÕ¬≈– 2.94 ‚¥¬„π°≈ÿà¡ prosthetic mitral valve
æ∫«à“§à“ INR ¡—°®–πâÕ¬°«à“ (2.5-3.5) à«π¿“«–
infective endocarditis æ∫„πºŸâªÉ«¬‰¢â‡√◊ÈÕ√—ß ·≈–‡ªìπ
‚√§À≈Õ¥‡≈◊Õ¥„π ¡Õßµ’∫„π‚√ß欓∫“≈
“‡Àµÿ Õ— π ¥— ∫ ÕߢÕß‚√§À≈Õ¥‡≈◊ Õ ¥„π
¡Õßµ’∫§◊Õ ‚√§À≈Õ¥‡≈◊Õ¥·¢Áßµ—«3,4,7,8 æ∫√âÕ¬≈–
35.71 ´÷Ëß„°≈⇧’¬ß°—∫¢Õßµà“ߪ√–‡∑»∑’Ëæ∫„π™à«ß
√âÕ¬≈– 7.7-31.2 ´÷Ëßæ∫‚√§‡∫“À«“π¡“°∑’Ë ÿ¥ √âÕ¬≈–
12.60 √Õß≈ß¡“§◊Õ§«“¡¥—π‚≈À‘µ Ÿß √âÕ¬≈– 10.50
·≈– ¿“«–‰¢¡—π„π‡≈◊Õ¥ Ÿß √âÕ¬≈– 7.98 ´÷Ëß®“°
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antiprothrombin III, antiphospholipid antibody
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∑’˺à“π¡“ ®–‰¡àæ∫ “‡Àµÿ¢Õß‚√§√âÕ¬≈– 12-343,7,8
„π°≈ÿà ¡ ‚√§À≈Õ¥‡≈◊ Õ ¥ ¡Õß·µ° ∑’Ë æ ∫
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8
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basal ganglia √âÕ¬≈– 32.43, brain stem √âÕ¬≈– 10.81,
cerebellar √âÕ¬≈– 8.11, lobar hemorrhage √âÕ¬≈–
13.51, multiple sites √âÕ¬≈– 17.57 à«π¿“«– AVM
·≈– bleeding tendency ¡—°®–‡ªìπ°≈ÿà¡ non- hypertensive, aneurysm æ∫√âÕ¬≈– 6.76 ‚¥¬®–æ∫‡ªìπ
subarachnoid bleeding Õ¬à“߉√°Áµ“¡¡’√âÕ¬≈– 36.49
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æ∫√â Õ ¬≈– 3.36 ∑—È ß À¡¥‰¥â √— ∫ °“√µ√«® ‰¡à æ ∫
cardiogenic cause à«π¡“°¡—°¡’ opportunistic
infection ¡“·≈â« ‡™àπ pulmonary TB, PCP, cerebral
toxoplasmosis œ≈œ ¡’‡æ’¬ß 2 √“¬ ‡∑à“π—Èπ∑’ˇªìπ
asymptomatic serology positive without opportunistic infection ´÷ßË §ßÕ∏‘∫“¬ “‡Àµÿ§«“¡ —¡æ—π∏å √–À«à“ß
HIV ·≈–13 ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫®“°°“√∑’Ë¡’
immune-mediated vasculitis ‰ª®—∫∑’˺π—ߢÕßÀ≈Õ¥
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À≈Õ¥‡≈◊Õ¥„π ¡Õßµ’∫ ·¡â®–‡ªìπ°“√µ√«®æ‘‡»…
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¢ÕߺŸªâ «É ¬∑’‡Ë ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫∑’µË ”·ÀπàßÕ◊πË
(OR=4.1, 95%CI=1.25-15.61, P< 0.001)
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Vol. 7 No.1
‡Õ° “√Õâ“ßÕ‘ß
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Non-compliance À¡“¬∂÷ ß °“√∑’Ë ºŸâ ªÉ « ¬
‰¡à ª Ø‘ ∫— µ‘ µ “¡§” —Ë ß „™â ¬ “·≈–§”·π–π”¢Õß·æ∑¬å
‡°’ˬ«°—∫°“√„™â¬“
Compliance À¡“¬∂÷ß °“√∑’˺ŸâªÉ«¬ªØ‘∫—µ‘
µ“¡§” —Ëß„™â¬“·≈–§”·π–π”¢Õß·æ∑¬å‡°’ˬ«°—∫°“√
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‚√ß欓∫“≈»√’π§√‘π∑√å ·≈–‰¥â√—∫°“√∫√‘∫“≈∑“ß
‡¿ —™°√√¡®“°‡¿ —™°√ª√–®”§≈‘π‘°‚√§≈¡™—°
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ºŸâ ªÉ « ¬∑’Ë ¡ “√— ∫ °“√√— ° …“„π§≈‘ π‘ ° ‚√§≈¡™— °
‚√ß欓∫“≈»√’π§√‘π∑√å ·≈–‰¥â√—∫°“√∫√‘∫“≈∑“ß
‡¿ — ™ °√√¡®“°‡¿ — ™ °√ª√–®”§≈‘ π‘ ° ‚√§≈¡™— °
√–À«à“ß«—π∑’Ë 15 µÿ≈“§¡ æ.». 2550 - 31 ¡°√“§¡
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µÿ≈“§¡ æ.». 2550 - 31 ¡°√“§¡ æ.».2551 ´÷Ëß
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1. ºŸâªÉ«¬‡¢â“¡“æ∫·æ∑¬å∑’˧≈‘π‘°‚√§≈¡™—°
‚√ß欓∫“≈»√’π§√‘π∑√å ‡æ◊ËÕµ√«®·≈–«‘π‘®©—¬‚√§
·≈–π—¥µ‘¥µ“¡Õ“°“√„π§√—ÈßµàÕ‰ª
2. ‡¿ — ™ °√„Àâ ° “√∫√‘ ∫ “≈∑“߇¿ — ™ °√√¡
°≈à“«§◊Õ §âπÀ“ªí≠À“®“°°“√„™â¬“ ªÑÕß°—π·≈–
·°â‰¢ªí≠À“¥—ß°≈à“« ·≈–§—¥°√ÕߺŸâªÉ«¬∑’ˉ¡à„Àâ
§«“¡√à«¡¡◊Õ„π°“√„™â¬“
3. ºŸâ∑”°“√«‘®—¬∑”°“√ —¡¿“…≥废âªÉ«¬∑’ˉ¡à
√à«¡¡◊Õ„π°“√„™â¬“·∫∫‡®“–≈÷°
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- ‚ª√·°√¡°“√∫— π ∑÷ ° ¢â Õ ¡Ÿ ≈ °“√∫√‘ ∫ “≈
∑“߇¿ —™°√√¡·°àºŸâªÉ«¬ ¢Õ߇¿ —™°√ª√–®”§≈‘π‘°
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≈¡™—°·≈–‰¥â√—∫°“√∫√‘∫“≈∑“߇¿ —™°√√¡ „π™à«ß
‡«≈“¥—ß°≈à“«¡’∑—ÈßÀ¡¥ 103 √“¬ æ∫ªí≠À“®“°°“√
„™â¬“¥—ß· ¥ß„πµ“√“ß∑’Ë 1
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 1 ª√–‡¿∑¢Õߪí≠À“®“°°“√„™â¬“∑’Ëæ∫„π§≈‘π‘°‚√§≈¡™—°
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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39
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¡’ºŸâªÉ«¬®”π«π 29 √“¬ ∑’Ëæ∫ªí≠À“§«“¡‰¡à
√à«¡¡◊Õ„π°“√„™â¬“ ‚¥¬¡’®”π«π§√—ÈߢÕß°“√‡°‘¥
ªí≠À“§«“¡‰¡à√à«¡¡◊Õ„π°“√„™â¬“∑—ÈßÀ¡¥ 41 §√—Èß
®”π«πºŸâªÉ«¬∑’Ë∂Ÿ°§—¥‡≈◊Õ°‡æ◊ËÕ∑”°“√»÷°…“‡™‘߇®“–≈÷°
„π§√—Èßπ’È ¡’®”π«π 29 √“¬ ‚¥¬¡’Õ“¬ÿ√–À«à“ß 19-67
ªï Õ“¬ÿ‡©≈’ˬ 41 ªï ‡ªìπºŸâ™“¬®”π«π 16 §π ºŸâÀ≠‘ß
®”π«π 13 §π ªí≠À“¢Õߧ«“¡‰¡à√à«¡¡◊Õ„π°“√„™â
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¡“°¢÷Èπ (over use) ®”π«π 3 ªí≠À“·≈–„™â¬“≈¥≈ß
(under use) ®”π«π 38 ªí≠À“
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‡Àµÿº≈¡“°°«à“ 1 ‡Àµÿº≈ ´÷Ëß “¡“√∂·∫àß “‡ÀµÿÀ≈—°
·≈–√“¬≈–‡Õ’¬¥¢Õß “‡Àµÿ∑’˺ŸâªÉ«¬‰¡à√à«¡¡◊Õ„π°“√
„™â¬“ ¥—ß· ¥ß„πµ“√“ß∑’Ë 2
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 2 “‡ÀµÿÀ≈—°·≈–√“¬≈–‡Õ’¬¥¢Õß “‡Àµÿ∑’˺ŸâªÉ«¬‰¡à√à«¡¡◊Õ„π°“√„™â¬“
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¢âÕ¡Ÿ≈√“¬≈–‡Õ’¬¥¢Õß “‡Àµÿ∑º’Ë ªŸâ «É ¬‰¡à√«à ¡¡◊Õ
„π°“√„™â¬“
1. “‡Àµÿ®“°µ—«ºŸâªÉ«¬ ‡°‘¥®“°
2.1 §«“¡√Ÿâ‡°’ˬ«°—∫‚√§≈¡™—° (®”π«πºŸâªÉ«¬
2 √“¬) ‚¥¬¡’‡Àµÿº≈¥—ßπ’È
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°—πÕ¬à“ß ¡Ë”‡ ¡Õ ‚¥¬¡’ºŸâªÉ«¬√“¬Àπ÷Ë߉¥â√—∫°“√
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®÷߉¥â¡“√—∫°“√√—°…“∑’˧≈‘π‘°‚√§≈¡™—° ‚√ß欓∫“≈
»√’ π §√‘ π ∑√å ´÷Ë ß ‡¡◊Ë Õ ‰¥â ∑”°“√ — ¡ ¿“…≥å æ ∫«à “
µ≈Õ¥√–¬–‡«≈“∑’˺ŸâªÉ«¬‰¥â√—∫°“√√—°…“‚√§≈¡™—°®“°
∑’ËÕ◊Ëππ—ÈπºŸâªÉ«¬‰¡à∑√“∫«à“®–µâÕß∑”°“√√—∫ª√–∑“π¬“
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Vol. 7 No.1
2. “‡Àµÿ®“°‚√§ ‡°‘¥®“°
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1.1 °“√≈◊¡/®”‰¡à‰¥â (®”π«πºŸâªÉ«¬ 15 √“¬)
‚¥¬¡’‡Àµÿº≈¥—ßπ’È
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∑”ß“π ‰ª —ß √√§å°—∫‡æ◊ËÕπ µâÕßÕÕ°‰ª∏ÿ√–‡√àߥà«π
µâÕߥŸ·≈∫ÿ§§≈„π§√Õ∫§√—«
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- ºŸâªÉ«¬ —∫ π À≈ß≈◊¡«à“√—∫ª√–∑“𬓉ª
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∑“𬓰àÕππÕπ
1.2 °“√®—¥‡°Á∫¬“¢ÕߺŸâªÉ«¬∑’ˉ¡à‡ªìπ√–‡∫’¬∫
(®”π«πºŸâªÉ«¬ 1 √“¬) ‚¥¬¡’‡Àµÿº≈§◊Õ
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Vol. 7 No.1
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
IJM
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Original Article
Fast Track Acute STEMI
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ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article(4)
46
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∑—È ß ¬— ß ¡’ · π«‚πâ ¡ ‡æ‘Ë ¡ Ÿ ß ¢÷È π ∑ÿ ° ªï ·≈–¡’ · π«‚πâ ¡
§à“„™â®à“¬„π°“√√—°…“欓∫“≈„πºŸâªÉ«¬°≈ÿà¡¥—ß°≈à“«
‡æ‘¡Ë Ÿß¢÷πÈ ¥â«¬
„πºŸâªÉ«¬ STEMI ¡’°“√Õÿ¥µ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥
‚§‚√π“√’Ë ∑”„À≡ࡒ‡≈◊Õ¥‰ª‡≈’Ȭ߰≈â“¡‡π◊ÈÕÀ—«„® ∂â“
∑‘È߉«âπ“π®–∑”„Àâ°≈â“¡‡π◊ÈÕÀ—«„®µ“¬„π∑’Ë ÿ¥ „π
°“√»÷°…“ Morrow DA ·≈–§≥– æ∫«à“ºŸâªÉ«¬∑’Ë¡’
TIMI risk score ∑’Ë¡’§à“¡“° —¡æ—π∏å°—∫Õ—µ√“°“√µ“¬
∑’ˇæ‘Ë¡¢÷Èπ
IJM
Vol. 7 No.1
√Ÿª∑’Ë 1 · ¥ß TIMI risk score ·≈–Õ—µ√“°“√‡ ’¬™’«µ‘ ‡ª√’¬∫‡∑’¬∫„πºŸªâ «É ¬∑’‰Ë ¥â·≈–‰¡à‰¥â√∫— reperfusion therapy
®“°°“√»÷°…“¥—ß°≈à“«¬—ßæ∫«à“°“√ reperfusion
therapy ¬—ß¡’ à«π„π°“√≈¥Õ—µ√“°“√‡ ’¬™’«‘µ (√Ÿª∑’Ë 1)
´÷Ëß°“√·°â‰¢¿“«–Õÿ¥µ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥¡’ 2 «‘∏’ §◊Õ
°“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥ À√◊Õ °“√¢¬“¬À≈Õ¥‡≈◊Õ¥
¥â « ¬∫Õ≈≈Ÿ π ·µà ‡ π◊Ë Õ ß®“°‚√ß欓∫“≈¡À“√“™
π§√√“™ ’¡“ °“√¢¬“¬À≈Õ¥‡≈◊Õ¥¥â«¬°“√„™â∫Õ≈≈Ÿπ
‰¡à “¡“√∂∑”‰¥âµ≈Õ¥‡«≈“ ‡π◊ËÕß®“°¢âÕ®”°—¥∑“ß
¥â“π∫ÿ§§≈“°√ ·≈–∑√—欓°√¢Õß‚√ß欓∫“≈ ®÷ß¡’
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article(4)
47
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¡°√“§¡ › ¡’π“§¡ 2551
47
ºŸªâ «É ¬°≈ÿ¡à Àπ÷ßË ∑’‰Ë ¥â√∫— °“√√—°…“¥â«¬¬“≈–≈“¬≈‘¡Ë ‡≈◊Õ¥
´÷Ëß„π‚√ß欓∫“≈„™â¬“ streptokinase
„π°“√»÷°…“π’‡È ªìπ°“√»÷°…“„Àâ∑√“∫∂÷ß Õ—µ√“
°“√‡ ’¬™’«‘µ¢ÕߺŸâªÉ«¬„π°≈ÿà¡ STEMI ∑’ˉ¥â√—∫¬“
streptokinase ·≈–ªí®®—¬‡ ’ˬ߄πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥
‚§‚√π“√’Ë „ π°≈ÿà ¡ ºŸâ ªÉ « ¬∑’Ë ‰ ¥â √— ∫ °“√«‘ π‘ ® ©— ¬ «à “ ‡ªì π
STEMI „π‚√ß欓∫“≈¡À“√“™π§√√“™ ’¡“ µ≈Õ¥®π
»÷°…“∂÷ߪ√–‚¬™πå º≈¢â“߇§’¬ß·≈–§«“¡ª≈Õ¥¿—¬
¢Õß°“√„À⬓ streptokinase Õ’°∑—Èß„π‚√ß欓∫“≈
¡À“√“™π§√√“™ ’¡“¬—߉¡à‡§¬¡’°“√‡°Á∫¢âÕ¡Ÿ≈„πºŸªâ «É ¬
°≈ÿà¡¥—ß°≈à“«¡“°àÕπ °“√»÷°…“π’È®÷߇ªìπ·π«∑“ß°“√
æ—≤π“§ÿ≥¿“æ„π°“√√—°…“ºŸâªÉ«¬°≈ÿà¡ STEMI µàÕ‰ª
„πÕ𓧵
IJM
Vol. 7 No.1
«‘∏’°“√»÷°…“
‡ªì π °“√»÷ ° …“ descriptive prospective
cross-sectional study „πºŸâªÉ«¬∑’ˉ¥â√—∫°“√«‘π‘®©—¬«à“
‡ªì π STEMI ‚¥¬∑”°“√»÷ ° …“ºŸâ ªÉ « ¬„π™à « ߇«≈“
1 情¿“§¡ æ.». 2549 › 31 °√°Æ“§¡ æ.». 2549
ºŸâªÉ«¬∑’ˇ¢â“√à«¡°“√»÷°…“µâÕ߉¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ
STEMI‚¥¬Õ“»—¬Õ“°“√‡®Á∫Àπâ“Õ°∑’ˇ¢â“‰¥â°—∫°≈ÿà¡
‚√§À≈Õ¥‡≈◊Õ¥À—«„®µ’∫‚§‚√π“√’Ë ¡’°“√‡ª≈’ˬπ·ª≈ß
¢Õߧ≈◊Ëπ‰øøÑ“À—«„® §◊Õ ST segment elevation
µ—Èß·µà 0.1 millivolt ¢÷Èπ‰ª„π limb leads À√◊Õ 0.2
millivolt „π chest leads ‚¥¬‡ª≈’¬Ë πµ”·ÀπàßÕ¬à“ßπâÕ¬
2 leads ∑’˵‘¥°—π À√◊Õ left bundle branch block
(LBBB) ∑’ˇ°‘¥¢÷Èπ„À¡àÀ√◊Õ ß —¬®–‡°‘¥¢÷Èπ„À¡à ·≈–
¡’ Õ “°“√‡®Á ∫ ·πà π Àπâ “ Õ°‡°‘ ¥ ¢÷È π ¿“¬„π√–¬–‡«≈“
12 ™—Ë«‚¡ß
à«π exclusion criteria ∑’ Ë ”§—≠„π°“√»÷°…“π’È
§◊Õ active internal bleeding ß —¬ aortic dissection
‰¥â√—∫°“√∫“¥‡®Á∫√ÿπ·√ß ‰¥â√—∫°“√ºà“µ—¥„À≠àÀ√◊Õ
‰¥â√—∫∫“¥‡®Á∫∑’Ë»’√…–¡“¿“¬„π 2 —ª¥“Àå ß —¬
‡π◊ÈÕßÕ°„π ¡Õß ¡’ª√–«—µ‘ cerebral hematoma ¡’
ª√–«—µ‘ cerebrovascular accident À√◊Õ transient
ischemic attack ¿“¬„π√–¬–‡«≈“ 6 ‡¥◊Õπ prolong
cardiopulmonary resuscitation ¡“°°«à“ 10 π“∑’
ß —¬µ—Èߧ√√¿å ‡§¬‰¥â√—∫¬“ streptokinase ¡“°àÕπ
¿“¬„π√–¬–‡«≈“ 2 ªï ·≈–§«“¡¥—π‚≈À‘µ Ÿß‡°‘π 180/
110 À√◊յ˔°«à“ 90/60 mmHg ‚¥¬„™â¬“§«∫§ÿ¡
§«“¡¥—π‚≈À‘µ‰¡à‰¥â
”À√— ∫ ‡°≥±å „ π°“√«‘ π‘ ® ©— ¬ ‚√§‡∫“À«“π
(diabetes mellitus) „™âπÈ”µ“≈°àÕπÕ“À“√ fasting blood
sugar) > 126 mg/dl À√◊Õ‡§¬‰¥â√—∫°“√«‘π‘®©—¬«à“
‡ªìπ‡∫“À«“π¡“°àÕπ À√◊Õ µâÕß„™â¬“„π°“√√—°…“‡∫“
À«“π À√◊Õ§«∫§ÿ¡Õ“À“√
§«“¡¥—π‚≈À‘µ Ÿß (hypertension) „™â‡°≥±å
systolic blood pressure > 140 mmHg ·≈–/À√◊Õ
diastolic blood pressure > 90 mmHg Õ¬à“ßπâÕ¬
2 §√—Èß À√◊Õ ‡§¬‰¥â√—∫°“√«‘π‘®©—¬‡ªì𧫓¡¥—π‚≈À‘µ
Ÿß¡“°àÕπ
‰¢¡—π„π‡≈◊Õ¥ Ÿß „™â‡°≥±å°“√«‘π‘®©—¬µ“¡
National Cholesterol Education Program criteria
§◊Õ total cholesterol > 200 mg/dl, LDL > 130
mg/dl, HDL < 40 mg/dl à«π°“√ Ÿ∫∫ÿÀ√’Ë„™â‡°≥±å
¬—ß¡’°“√ Ÿ∫∫ÿÀ√’ËÀ√◊Õ‡§¬ Ÿ∫∫ÿÀ√’Ë¡“°°«à“ 10 ¡«πªï
ºŸâªÉ«¬∑ÿ°√“¬µâÕß≈ßπ“¡„πÀπ—ß ◊Õ¬‘π¬Õ¡
‡¢â“√à«¡°“√»÷°…“ ‚¥¬ºŸâªÉ«¬‡Õß·≈–≠“µ‘∑’ˇ°’ˬ«¢âÕß
“¬µ√ß ·≈–°“√»÷°…“π’ȉ¥âºà“𧫓¡‡ÀÁπ™Õ∫®“°
§≥–°√√¡°“√®√‘¬∏√√¡¢Õß‚√ß欓∫“≈·≈â«
¢—ÈπµÕπ°“√»÷°…“
ºŸâªÉ«¬∑’ˉ¥â√—∫°“√«‘π‘®©—¬ À√◊ÕÕ“°“√‡¢â“‰¥â°—∫
acute coronary syndrome ·≈–∂Ÿ ° à ß µ— « ¡“®“°
‚√ß欓∫“≈Õ◊Ëπ ®–µâÕß¡’°“√ àߧ≈◊Ëπ‰øøÑ“À—«„®
¡“∑“ß‚∑√ “√°àÕπ ‡¡◊ËÕ¡“∂÷ß‚√ß欓∫“≈¡À“√“™
π§√√“™ ’¡“ ·≈–·æ∑¬å«‘π‘®©—¬«à“‡ªìπ acute STEMI
®–¡’°“√‡√‘Ë¡„À⬓ streptokinase ∑—π∑’∑’ËÀâÕß©ÿ°‡©‘π
48 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article(4)
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ºŸªâ «É ¬∑’‡Ë ¢â“√à«¡°“√»÷°…“ ®–‰¥â√∫— ¬“ streptokinase 1.5 million units √à«¡°—∫¬“ aspirin 300 mg,
enoxaparin 1 mg/kg twice daily ·≈–‰¥â√—∫¬“≈¥
‰¢¡—𠬓≈¥§«“¡¥—π‚≈À‘µ ·≈–¬“Õ◊ËπÊ µ“¡À≈—°
‡°≥±å∑’Ë°”Àπ¥‰«âµ“¡ guideline ACC/AHA
ºŸâªÉ«¬∑ÿ°√“¬®–‰¥â√—∫°“√µ√«®«‘π‘®©—¬·≈–
µ‘¥µ“¡°“√√—°…“‚¥¬·æ∑¬åÕ“¬ÿ√°√√¡ ·≈–·æ∑¬å
Õ“¬ÿ√°√√¡‡©æ“–∑“ß‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ºŸâªÉ«¬
∑ÿ°√“¬®–‰¥â√—∫°“√µ√«®À“ªí®®—¬‡ ’ˬߵà“ßÊ ∑’Ë®–‡°‘¥
‚√§À≈Õ¥‡≈◊Õ¥‚§‚√π“√’Ë ‡™àπ ‡∫“À«“𠧫“¡¥—π
‚≈À‘µ Ÿß √–¥—∫‰¢¡—π„π‡≈◊Õ¥ √«¡∑—Èßªí®®—¬‡ ’ˬߵàÕ
°“√‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥‚§‚√π“√’Ë ‚¥¬µ‘¥µ“¡ºŸâªÉ«¬
®π “¡“√∂ÕÕ°®“°‚√ß欓∫“≈‰¥â
Primary endpoint ¢Õß°“√»÷°…“π’ȧ◊Õ °“√
‡ ’¬™’«‘µ‚¥¬√«¡ (all cause mortality) °“√‡ ’¬™’«‘µ
®“°°≈â“¡‡π◊ÈÕÀ—«„® (fatal myocardial infarction)
º≈¢â“߇§’¬ß º≈ ”‡√Á®®“°°“√„™â¬“ steptokinase ·≈–
√–¬–‡«≈“∑’ˇ√‘Ë¡„À⬓ streptokinase (door to needle
time)
„À≠à‡ªìπºŸâªÉ«¬∑’ˉ¥â√—∫°“√ àßµàÕ¡“®“°‚√ß欓∫“≈
™ÿ¡™π∂÷ß 92 √“¬ àßµàÕ¡“®“°‚√ß欓∫“≈ª√–®”
®—ßÀ«—¥„°≈⇧’¬ß ·≈–‚√ß欓∫“≈‡Õ°™π√«¡ 4 √“¬
ºŸâªÉ«¬¡“®“°∫â“π‡Õß 7 √“¬ ‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ
acute STEMI ·≈–„À⬓ streptokinase 33 √“¬
¥—ß·ºπ¿Ÿ¡‘
IJM
°“√·ª√º≈∑“ß ∂‘µ‘„™â§à“‡©≈’ˬ (means) √à«¡°—∫
§à“‡©≈’ˬ‡∫’ˬ߇∫π¡“µ√∞“π (SD) „π¢âÕ¡Ÿ≈∑’ˇªìπ§à“
·®ßπ—∫„™â §à“°≈“ß (median) °“√«‘‡§√“–Àå∑“ß ∂‘µ‘
„™â‚ª√·°√¡ SPSS version 10 „π°“√‡°Á∫¢âÕ¡Ÿ≈
º≈°“√»÷°…“
„π™à«ß‡«≈“ 1 情¿“§¡ æ.». 2549 - 31
°√°Æ“§¡ æ.». 2549 ¡’ºªŸâ «É ¬¡“ÀâÕß©ÿ°‡©‘π‚√ß欓∫“≈
¡À“√“™π§√√“™ ’¡“¥â«¬Õ“°“√‡®Á∫·πàπÀπâ“Õ°∑’ˇ¢â“
‰¥â°—∫°≈ÿà¡Õ“°“√À≈Õ¥‡≈◊Õ¥‚§‚√π“√’Ë·≈– ß —¬‡ªìπ
acute myocardial infarction √«¡ 103 √“¬ à«π
„πºŸâªÉ«¬∑’ˉ¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ STEMI
·≈–‰¥â√∫— ¬“≈–≈“¬≈‘¡Ë ‡≈◊Õ¥ (streptokinase) √«¡∑—ßÈ ‘πÈ
33 √“¬ ‚¥¬ºŸâªÉ«¬ à«π„À≠à‡ªìπ‡æ»™“¬∂÷ß 20 √“¬
ºŸªâ «É ¬¡’Õ“°“√‡®Á∫Àπâ“Õ°°àÕπ¡“‚√ß欓∫“≈ ‡©≈’¬Ë 5.9
™—Ë«‚¡ß ·≈– à«π„À≠à‰¥â√—∫°“√ àßµ—«°“√√—°…“¡“®“°
‚√ß欓∫“≈™ÿ¡™π„π‡¢µ®—ßÀ«—¥π§√√“™ ’¡“ à«π
ªí®®—¬‡ ’ˬß∑’Ë ”§—≠„πºŸâªÉ«¬°≈ÿà¡∑’Ë»÷°…“§◊Õ §«“¡¥—π
‚≈À‘µ Ÿß 24 √“¬ (√âÕ¬≈– 72.72) ·≈–°“√ Ÿ∫∫ÿÀ√’Ë
À√◊Õ‡§¬ Ÿ∫∫ÿÀ√’Ë¡“°àÕπ 22 √“¬ (√âÕ¬≈– 66.7) ºŸâªÉ«¬
°≈ÿà¡π’È¡’§à“ TIMI score median ‡∑à“°—∫ 5 ¥—ß„π
µ“√“ß∑’Ë 1 ·≈– 2
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article(4)
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¡°√“§¡ › ¡’π“§¡ 2551
49
Vol. 7 No.1
°“√«‘‡§√“–Àå∑“ß ∂‘µ‘
µ“√“ß∑’Ë 1 Baseline characteristics
Baseline characteristics
IJM
Vol. 7 No.1
Age (means + SD) ªï
< 45
45-54
55-64
65-74
>75
Male
DM
Blood sugar (admission) means
Hypertension
History of IHD or stroke
Smoking
Dyslipidemia
LDL (means+ SD)
HDL (means+ SD)
Triglyceride (means+SD)
Number risk factor
0
1
2
>3
BMI : men
Women
Waist : men
Women
Number ( n = 33 )
62.45+8.5
0
4 (12.12%)
14 (42.42%)
12 (36.36%)
3 (9.09%)
20(60.6%)
8 (24.24%)
163.5+ 70.13 mg/dl
24 (72.72%)
8 (17%)
22 ( 66.67%)
10 ( 30.30%)
123.93+40.6 mg/dl
42+12.7 mg/dl
185.78+62.7 mg/dl
4 (12.12%)
7 (21.21%)
14 (42.42%)
8 (24.24%)
22.85+3.21 Kg/m2
23.07+3.69 Kg/m2
84.1+12.07 cm
79.46+9.7 cm
50 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
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µ“√“ß∑’Ë 2 TIMI score
TIMI score
<3
3
4
5
6
7
8
>8
Median 5
Number ( n = 33 ) (%)
4 (12.1%)
6 (18.2%)
6 (18.2%)
6 (18.2%)
7 (21.2%)
2 ( 6.1%)
0
2 ( 6.1%)
”À√—∫§≈◊πË ‰øøÑ“À—«„®„πºŸªâ «É ¬°≈ÿ¡à π’È à«π
„À≠à¡’°“√‡ª≈’ˬπ·ª≈ß„πµ”·Àπàß inferior wall √«¡
∑—Èß ‘Èπ 16 √“¬ (√âÕ¬≈– 48.5) ‚¥¬ºŸâªÉ«¬„π°≈ÿà¡ inferior wall ¡’§≈◊Ëπ‰øøÑ“À—«„® lead V3R ,V4R
‡ª≈’ˬπ·ª≈ß ( right ventricular infarction ) 3 √“¬
À√◊Õ¡’∑—Èß inferior wall infarction √à«¡°—∫ RV infarction ·≈– complete heart block √«¡∑—Èß ‘Èπ 4
√“¬ ¥—ß„πµ“√“ß∑’Ë 3
IJM
µ“√“ß∑’Ë 3 EKG changes
Vol. 7 No.1
EKG ( wall )
Inferior wall
Inferior wall + RV infarction
Inferior wall + RV infarction + heart
block
Anterioseptal wall
Anterior-lateral wall
Lateral wall
Total
Number (n=33) (%)
9 (27.27%)
3 (9.09%)
4 (12.12%)
9 (27.27%)
6 (18.18%)
2 (6.06%)
33
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
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¡°√“§¡ › ¡’π“§¡ 2551
51
ºŸâªÉ«¬°≈ÿà¡π’È “¡“√∂‰¥â√—∫¬“ streptokinase
√–¬–‡«≈“‡©≈’ˬ 24.1 π“∑’ ( door to needle time 24.1
±
11.5 π“∑’ ·≈–¡’√–¬–‡«≈“°“√πÕπ‚√ß欓∫“≈
7.9 ± 2.6 «—π ¥—ßµ“√“ß∑’Ë 4
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 4 Door to needle time and hospital stay
„πºŸâªÉ«¬∑’Ë„À⬓ streptokinase „π°“√»÷°…“π’È
®“°∑—ÈßÀ¡¥ 33 √“¬ ¡’ºŸâªÉ«¬‡ ’¬™’«‘µ„π¢≥–Õ¬Ÿà
‚√ß欓∫“≈√«¡∑—Èß ‘Èπ 4 √“¬ (√âÕ¬≈– 12.1) ‚¥¬
‡ ’¬™’«‘µ√–À«à“ß„À⬓ streptokinase 1 √“¬ ‡π◊ËÕß®“°
cardiogenic shock ºŸâªÉ«¬Õ’° 2 √“¬ ‡ ’¬™’«‘µ®“°
arrhythmia (sudden ventricular tachycardia) „π
«—π·√°¢Õß°“√πÕπ‚√ß欓∫“≈ ·≈–ºŸâªÉ«¬Õ’° 1 √“¬
‡ ’¬™’«‘µ®“°ªÕ¥Õ—°‡ ∫ À≈—ß®“°πÕπ‚√ß欓∫“≈
18 «—π (µ“√“ß∑’Ë 5) ·≈–À≈—ß®“°°“√„À⬓ streptokinase ·≈⫺ŸâªÉ«¬Õ“°“√‰¡à¥’¢÷Èπ ¡’‡®Á∫·πàπÀπâ“Õ°Õ¬Ÿà
¡’§≈◊Ëπ‰øøÑ“À—«„®( EKG )‰¡à¥’¢÷ÈπÀ√◊Õ vital sign
‰¡à stable ®”‡ªìπµâÕ߉ª∑” rescue PCI ®”π«π∑—Èß ‘Èπ
5 √“¬ ‚¥¬ºŸâªÉ«¬ 5 √“¬π’È ¡’‡ ’¬™’«‘µ 1 √“¬ ®“°
arrhythmia
„π°“√»÷°…“π’È ¡’ºŸâªÉ«¬‰¥â√—∫°“√ «πÀ—«„®
·∫∫ early elective PCI (PCI in few day after
thrombolysis ) ®”π«π 16 √“¬ à«πºŸâªÉ«¬Õ’° 6 √“¬
‰¥â√—∫°“√ «πÀ—«„®·∫∫ elective PCI „π¿“¬À≈—ß
º≈¢â“߇§’¬ß®“°°“√„À⬓ streptokinase ¡’
ºŸâªÉ«¬‡≈◊Õ¥ÕÕ° 5 √“¬ ‚¥¬ºŸâªÉ«¬ 4 √“¬ ‡ªìπ‡≈◊Õ¥
ÕÕ°‡≈Á°πâÕ¬·≈–‰¡àµâÕß„Àâ‡≈◊Õ¥„π°“√√—°…“ ‡™àπ
‡≈◊Õ¥ÕÕ°µ“¡√Ÿ‡¢Á¡·∑ßπÈ”‡°≈◊Õ À√◊Õ„ à NG tube ‰¥â
coffee ground à«πºŸâªÉ«¬Õ’° 1 √“¬π—ÈπµâÕß„Àâ‡≈◊Õ¥
„π°“√√—°…“ ‚¥¬ºŸªâ «É ¬‰¥â√∫— °“√«‘π®‘ ©—¬‡ªìπ upper GI
bleeding ¿“¬À≈—߉¥â√—∫°“√∑” esophagogastroscope
º≈‡ªìπ gastric ulcer (µ“√“ß∑’Ë 5)
„π√–À«à“ß°“√„À⬓ streptokinase ¡’ºŸâªÉ«¬
9 √“¬ ¡’§«“¡¥—π‚≈À‘µ≈¥µË”°«à“ 90 /60 mmHg
·≈–¡’Õ“°“√‰¢âÀπ“« —Ëπ §≈◊Ëπ‰ âÕ“‡®’¬π 1 √“¬ ·µà
¿“¬À≈—ß°“√„Àâ “√πÈ”À√◊Õ„À⬓ hydrocortisone À√◊Õ
¬“·°âÕ“‡®’¬π ºŸªâ «É ¬∑ÿ°√“¬ “¡“√∂„À⬓ streptokinase
µàÕ®π§√∫‰¥â∑ÿ°√“¬ ¥—ß„πµ“√“ß∑’Ë 5
52 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article(4)
52
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µ“√“ß∑’Ë 5 Primary outcome
IJM
‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫ baseline characteristics „π
ºŸâªÉ«¬°≈ÿà¡π’È°—∫°“√»÷°…“°àÕπÀπâ“π’È Euro heart
survey ACS, BLITZ study, Grace study ·≈– ºŸâªÉ«¬
STEMI „π‚√ß欓∫“≈»‘ √‘ √ “™ æ∫«à “ ‰¡à ¡’ § «“¡
·µ°µà“ß°—π ‚¥¬ºŸªâ «É ¬¡’Õ“¬ÿ‡©≈’¬Ë ª√–¡“≥ 60 ªï ªí®®—¬
‡ ’ˬß∑’Ë ”§—≠§◊Õ§«“¡¥—π‚≈À‘µ Ÿßæ∫√âÕ¬≈– 50-60
à«π‡∫“À«“πæ∫‡æ’¬ß√âÕ¬≈– 20›30 „π°“√»÷°…“π’È
ºŸâªÉ«¬ à«πÀπ÷Ë߉¡à‡§¬µ√«®√à“ß°“¬À√◊Õµ√«®‡≈◊Õ¥
¡“°àÕπ ·≈–æ∫«à“‡ªì𧫓¡¥—π‚≈À‘µ Ÿß ‡∫“À«“π
À√◊Õ‰¢¡—π„π‡≈◊Õ¥ Ÿß ¿“¬À≈—ß ∂÷ß 8 √“¬ (√âÕ¬≈–
24.24)
„π°“√»÷°…“π’ȺŸâªÉ«¬¡’ TIMI risk score §à“
median 5 ´÷Ë߇¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√»÷°…“°àÕπÀπâ“π’È
Moro DA ·≈–§≥– æ∫«à“∑’Ë TIMI risk score 5 ¡’
Õ—µ√“µ“¬ª√–¡“≥√âÕ¬≈– 19 „π°≈ÿà¡ no reperfusion
·≈–√âÕ¬≈– 10 „π°≈ÿ¡à reperfusion ‚¥¬„π°“√»÷°…“π’È
„™â¬“ streptokinase ¡’Õ—µ√“µ“¬ª√–¡“≥√âÕ¬≈– 12
¥—ß„π√Ÿª∑’Ë 2
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
04-original Article(4)
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¡°√“§¡ › ¡’π“§¡ 2551
53
Vol. 7 No.1
∫∑«‘®“√≥å
√âÕ¬≈–
No
Reperfusio
Maharat
√Ÿª∑’Ë 2 Mortality rate
‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫Õ—µ√“µ“¬°—∫°“√»÷°…“ Euro
heart survey Õ—µ√“µ“¬√âÕ¬≈– 7, BLITZ study Õ—µ√“
µ“¬√âÕ¬≈– 7 , GRACE study Õ—µ√“µ“¬√âÕ¬≈– 7
·≈– STEMI „π‚√ß欓∫“≈»‘√‘√“™ Õ—µ√“µ“¬√âÕ¬≈–
13 ¥—ß √Ÿª∑’Ë 3
IJM
Vol. 7 No.1
√âÕ¬≈–
√Ÿª∑’Ë 3 Mortality rate
µ“¡ ACC/AHA guideline STEMI °“√„À⬓
thrombolytic drugs ‡¡◊ËÕª√–‡¡‘π door to needle
time µâÕßπâÕ¬°«à“ 30 π“∑’ „π°“√»÷°…“π’È door to
needle time ‡©≈’ˬ 24.1 + 11.5 π“∑’ ·≈–„À⬓¿“¬„π
30 π“∑’ ‰¥â√âÕ¬≈– 75.76 ¥—ß„π√Ÿª∑’Ë 4
54 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
04-original Article(4)
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π“∑’
√Ÿª∑’Ë 4 Door to needle time „π·µà≈–°“√»÷°…“
√ÿª
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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04-original Article(4)
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¡°√“§¡ › ¡’π“§¡ 2551
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Vol. 7 No.1
ºŸâªÉ«¬°≈ÿà¡ STEMI ¡’Õ—µ√“°“√‡ ’¬™’«‘µ∑’Ë Ÿß
„π‚√ß欓∫“≈¡À“√“™π§√√“™ ’ ¡ “ ‚¥¬ºŸâ ªÉ « ¬
à«π„À≠à∂Ÿ° àßµàÕ¡“®“°‚√ß欓∫“≈™ÿ¡™π °“√„Àâ
¬“≈–≈“¬≈‘¡Ë ‡≈◊Õ¥∑’√Ë «¥‡√Á«¡’º≈„π°“√≈¥Õ—µ√“°“√µ“¬
º≈°“√»÷ ° …“π’È ®÷ ß π— ∫ πÿ π „Àâ ‚ √ß欓∫“≈§«√¡’
·π«∑“ß°“√√— ° …“∑’Ë ™— ¥ ‡®π ·≈–√–∫∫ à ß µà Õ ∑’Ë ¡’
ª√– ‘∑∏‘¿“æ
IJM
à«π “‡Àµÿ∑’Ë “¡“√∂„À⬓‰¥âÕ¬à“ß√«¥‡√Á«π—Èπ
‡°‘¥®“° ¡’°“√ àߧ≈◊Ëπ‰øøÑ“À—«„®¡“∑“ß‚∑√ “√®“°
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°àÕπ∑’Ë®– àߺŸâªÉ«¬¡“√—°…“µàÕ ·µà∑—Èßπ’Ȭ—߉¡à “¡“√∂
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π§√√“™ ’¡“ ®÷ß∑”„Àâ„πºŸâªÉ«¬∫“ß√“¬‰¡à “¡“√∂„Àâ
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Õ¬à“߬‘Ëß∑’˵âÕß¡’°“√æ—≤π“„π√–∫∫°“√ àßµàÕºŸâªÉ«¬
µàÕ‰ª
IJM
Vol. 7 No.1
∫√√≥“πÿ°√¡
1. Antman EM, Anbe DT, Armstrong PW, et al
.ACC/AHA guidelinesfor the management of
patients with ST-elevation myocardial Infarction- executive summary. A report of the American College of Cardiology/ American Heart
association Task Force on Practice Guidelines
(writing committee to revise the 1999 guidelines for the management of patients with acute
myocardial infarction). J Am Coll Cardiol
2004;44:671-719.
2. Antonio DC, Francesco C, Stefano S, et al.
Epidemiology of acute myocardial infarction
in Italian CCU network. The BLITZ Study.
Euro Heart J 2003 ;24 ; 1616-29.
3. Hasdai D, Behar S, Wallentin L, et al. The
Euro Heart Survey of Acute Coronary
Syndromes (Euro Heart Survey ACS). Eur
Heart J 2002; 23; 1190-201.
4. Morrow DA, Antman EM, Charlesworth A, et
al. TIMI risk score for ST-elevation myocardial
infarction: A convenient, bedside, clinical
score for risk assessment at presentation:
5.
6.
7.
8.
An intravenous rt-PA for treatment of infarcting
myocardium early II trial substudy. Circulation
2000;102:2031-37.
Philippe GS, Robert JG, Joel MG, et al. Baseline
characteristics, management practices, and
in-hospital outcome of patients hospitalzed with
acute coronary syndromes in Global Registry
of Acute Coronary Events (GRACE). Am J
Cardio 2002 : 90:358-63
Roger WJ, Bowlby LJ, Chandra NC, et al.
United States [1990 to1993] Observations from
the National Registry of Myocardial Infarction. Circulation 1994;90:2103-14.
Sittivarakul P, Phankingthongkum R. Clinical
characteristic management strategies, inhospital outcome, and predictors of death in
patients STEMI in Siriraj Hospital. Thai
Heart Journal. 2549;19:15-23.
World Health Organization. World Health
Report 1999: Making a difference. Geneva :
World Organization, 1999.
56 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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2/4/08, 13:20
Morbidity - Mortality Conference
Tetanus
æ≠.«—π«√ÿ≥ æÿà¡™ÿ¡æ≈ 1, √».πæ. ¡»—°¥‘Ï ‡∑’¬¡‡°à“ 2, º».πæ.™≈∏‘ª æß»å °ÿ≈ 3, √».πæ.¿‘√ÿ≠ ¡ÿµ ‘°æ—π∏å 4,
√».æ≠.𑵬“ ©¡“¥≈ 5, º».æ≠.‡Õ◊ÈÕ¡·¢ ÿ¢ª√–‡ √‘∞ 6
1
5
·æ∑¬åª√–®”∫â“π, 2 “¢“«‘™“ª√– “∑«‘∑¬“, 3 “¢“«‘™“‚√§‰µ·≈–‰µ‡∑’¬¡, 4 “¢“«‘™“‚√§µ‘¥‡™◊ÈÕ·≈–‡«™»“ µ√凢µ√âÕπ ¿“§«‘™“Õ“¬ÿ√»“ µ√å,
¿“§«‘™“√—ß ’«‘∑¬“, 6 “¢“‚√§¡–‡√Áß«‘∑¬“∑“ßÕ“¬ÿ√»“ µ√å ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
ºŸâªÉ«¬™“¬ Õ“¬ÿ 70 ªï ∑’ËÕ¬Ÿà Õ”‡¿Õ∫â“π‰ºà ®—ßÀ«—¥¢Õπ·°àπ
Admission date 26 ‡¡…“¬π æ.».2550
Õ“°“√ ”§—≠ :
‡®Á∫§Õ °≈◊πÕ“À“√≈”∫“° ÀÕ∫‡Àπ◊ËÕ¬¡“
3 «—π
ª√–«—µ‘ªí®®ÿ∫—π :
OPD GP note : ª√–«—µ‘‰Õ·Àâß Ê ¡“ 1 ªï
·≈–‰Õ¡’‡ ¡À– 3 «—π ‰¡à¡‰’ ¢â PE: BP 130/70 mmHg,
PR 72 /min , increase AP diameter, lung: poor air
entry, generalized rhonchi & expiratory wheezing,
normal heart sound §‘¥∂÷ß COPD àß∑” pulmonary
function test À≈—ß∑” BP 130/60 mmHg,O2sat
96%, PR 85/min (irregular), RR 20/min àߪ√÷°…“
·æ∑¬å‡«√Õ“¬ÿ√°√√¡∑’Ë OPD AE ¥â«¬‡√◊ËÕß dyspnea
·≈– irregular HR
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
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Vol. 7 No.1
ª√–«—µ‘‡æ‘Ë¡‡µ‘¡
IJM
3 «—π°àÕπ¡“‚√ß欓∫“≈ ‰¢âµË”Ê ‰Õ ‡Àπ◊ËÕ¬
ÀÕ∫ πÕπ√“∫‰¥â ‰¡à‡®Á∫Àπâ“Õ°
2 «—π°àÕπ¡“‚√ß欓∫“≈ ¡’Õ“°“√‡®Á∫§Õ
§“ß∫«¡ ª«¥ °≈◊πÕ“À“√≈”∫“° Õ⓪“°‰¡à‰¥â πÈ”≈“¬
‰À≈µ≈Õ¥‡«≈“ À“¬„®‰¡à –¥«° ‡Àπ◊ËÕ¬ÀÕ∫¡“°¢÷Èπ
¡◊Õ®’∫‡°√Áß 2 ¢â“ß
OPD AE note : dyspnea, BP 172/72 mmHg,
BT 36.7 ÌC, PR 48/min (irregular), RR 24/min,
O2 sat 92%, lung: poor air entry, generalize expiratory rhonchi both lungs & expiratory wheezing
both lower lungs, heart : irregular heart rate, no
murmur, no neck vein engorgement, no murmur,
diagnosis : COPD with exacerbation with PVC „Àâ°“√
√—°…“ O2 canular 3 LPM, æà𬓠beradual 1 nebule
·≈– ventolin 2 nebule, Õ“°“√‰¡à¥’¢÷Èπ ®÷ߪ√÷°…“
·æ∑¬å‡«√·ºπ°Õ“¬ÿ√°√√¡
Medicine AE note : PE : trismus, no
Chovstek sign, lung : wheezing & fine crepitation
both lungs, heart : normal S1S2, no murmur, right
hand spasm
Relevant history : ‚¥π≈«¥Àπ“¡¡’ π‘¡
∫“¥¡◊Õ¢«“ ‡¡◊ËÕµâπ‡¥◊Õπ‡¡…“¬π æ.». 2550 ‰ª
∂“π’ Õ π“¡— ¬ ‰¥â ≈â “ ß·º≈·≈–©’ ¥ «— § ´’ π ªÑ Õ ß°— π
∫“¥∑–¬—° 1 ‡¢Á¡ ªØ‘‡ ∏‚√§ª√–®”µ—«Õ◊ËπÊ
Diagnosis : 1. Upper airway obstruction
®÷ߪ√÷°…“·æ∑¬å ENT
2. Tetanus
ENT note : PE : marked swelling of floor
of mouth, submandibular & submental area, soft
consistency, drooling of saliva, marked poor oral
hygiene, lower dental caries, inter-incisor distance
1.5 cm
Diagnosis : Ludwigûs angina cause upper
airway obstruction
°“√√—°…“„π‚√ß欓∫“≈
Admit ward 5ß : √— ° …“¥â « ¬°“√ºà “ µ— ¥
©ÿ°‡©‘π‚¥¬°“√∑” incision and drainage ∑—π∑’ º≈
°“√ºà“µ—¥æ∫¡’ marked swelling of floor of mouth,
reddish mucosa, submental & submandibular area
swelling & necrosis of subcutaneous À≈—ßºà“µ—¥
„À⬓µâ“π®ÿ≈™’懪ìπ augmentin 1.2 °√—¡©’¥∑“ß
À≈Õ¥‡≈◊Õ¥¥”∑ÿ° 8 ™—Ë«‚¡ß
Investigation ·√°√—∫∑’Ë ”§—≠
IJM
Vol. 7 No.1
CBC
: Hb 13.6 g/dl, Hct 40%, Wbc 13000
cells/mm3 (N 89.7%, L 5.7%, M 4%),
Plt 257,000 cells/mm3
Blood chemistry: BS 133 mg/dl , Bun/Cr 12.8/
1.2 mg/dl
Electrolyte : Na 137, K 3.8, HCO3 26.3, Cl 103
mEq/L, Ca 8.2, PO4 2.8, Mg 2.4 mg/dl
LFT
: Chol 216 mg/dl, Alb 3.7, Glo 2.9
g/dl, TB 0.6, DB 0.1 mg/dl, ALT 34,
AST 40, ALP 78 U/L
CXR
: no pulmonary infiltration
ABG (canula 3 LPM) : pH 7.43 , PaO2 79, PaCO2
34, HCO3 24, Sat O2 96%
Anti HIV : non-reactive
°“√¥”‡π‘π‚√§„π‚√ß欓∫“≈
Post operation day 1 : on ET tube & Birdûs
respirator Õ⓪“°‰¥âπâÕ¬ ·º≈´÷¡¡“° ÀÕ∫‡Àπ◊ËÕ¬
‰¢â Ÿß PE: BT 38.7 ÌC, wheezing both lungs,
floor of mouth : minimal bleeding, swelling and
necrotic tissue ‡Õ°´å ‡ √¬å ª Õ¥‡π◊Ë Õ ß®“°ºŸâ ªÉ « ¬¡’
bronchospasm µ≈Õ¥ ®÷ߪ√÷°…“·æ∑¬å√–∫∫∑“߇¥‘π
À“¬„®µ√«®æ∫¡’ loss of right dome diaphragm
with sign of volume loss
Diagnosis : RLL atelectasis „Àâ continue
augmentin ‡Àµÿ º ≈‡æ√“–§√Õ∫§≈ÿ ¡ community
acquired pneumonia ∑—Èß anaerobe, gram positive
·≈– H. influenzae ‰¥â¥’
Day 4
¡’ªí≠À“ septic shock ·≈– acute renal
failure, BP 80/50 mmHg, BT 40.9 ÌC , BUN/Cr
26.8/2.8 mg/dl, cut down CVP = 5 cmH2O „Àâ
°“√√—°…“‚¥¬ load 0.9% NSS, ‡ª≈’ˬπ antibiotic
‡ªìπ tazocin 4.5 °√—¡ ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑ÿ°
8 ™—Ë«‚¡ß ·≈–ª√÷°…“·æ∑¬å‡«√Õ“¬ÿ√»“ µ√å „Àâ°“√
√—°…“‡æ‘Ë¡‡µ‘¡ ‚¥¬„Àâ levophed titrate dose keep
BP > 90/60 mmHg ¬â“¬≈ß SICU, on volume
respirator : TV 450 cc, FiO21.0 , RR 16/min
22:00 π. ¡’ AF with rapid ventricular
response, rate160/min, BP 64/34 mmHg §‘¥∂÷ß
secondary AF ®“° infection ·≈– levophed ‰¥â
„Àâ°“√√—°…“‚¥¬ defibrillation synconized 100j
·≈– 150 j , cordarone 150 mg iv drip in 30 min ,
then 300 mg iv drip in 5 hr, then 600 mg iv
drip in 20 hr
ºŸâ ªÉ « ¬‰¥â √— ∫ °“√ª√–‡¡‘ π „À¡à ® “°À— « Àπâ “
·æ∑¬å‡«√Õ“¬ÿ√°√√¡‡π◊ÕË ß®“°¡’ª√–«—µ‰‘ ¢â ‡®Á∫§Õ °≈◊π
Õ“À“√≈”∫“° §“ß∫«¡ Õ⓪“°‰¡à‰¥â πÈ”≈“¬‰À≈
µ≈Õ¥‡«≈“ ≈”µ—«·≈–¡◊Õ‡°√Áß poor dental hygiene
µ√«®√à“ß°“¬ : æ∫ trismus ·≈– spasticity §‘¥∂÷ß
58 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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58
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tetanus ¡“°∑’Ë ÿ¥ ‰¥â„Àâ°“√√—°…“‚¥¬ TAT (human)
4,000 IU IM, valium ¢π“¥ 10 ¡‘≈≈‘°√—¡∑“ߪ“°
∑ÿ° 4 ™—Ë«‚¡ß ·≈– PGS 3 ≈â“π¬Ÿπ‘µ©’¥∑“ßÀ≈Õ¥
‡≈◊Õ¥¥”∑ÿ° 4 ™—Ë«‚¡ß
Day 5
ª√— ∫ ¢π“¥ valium ·≈– trachium µ“¡
Õ“°“√‡°√Áß ‰¢â≈¥≈ß BP stable, wean off dopamine
·≈– levophed ‰¥â·µà APD √—Ë«´÷¡µ≈Õ¥®÷ß„ÀâÀ¬ÿ¥
°“√∑” APD ‡æ◊ËÕªÑÕß°—π°“√µ‘¥‡™◊ÈÕ·≈–«“ß·ºπ∑”
CVVH ·∑π
Day 12-14
Day 15
Õ“°“√‰¡à¥’¢÷Èπ ≠“µ‘¢Õ°≈—∫∫â“π‡«≈“ 8:00 π.
Day 7
¡’ªí≠À“ APD ¢“¥∑ÿπµ≈Õ¥ ‡√‘Ë¡¡’ volume
overload ·≈– hyperkalemia BUN/Cr 70.2/8.0 mg/
dl, K 5.3 mEq/L, CVP 17 cmH2O·≈–∑” APD §√∫
3 «—π ®÷ߪ√÷°…“»—≈¬°√√¡ ‡æ◊ËÕ«“ß “¬ CAPD ‚¥¬
‡ªî¥ run ·∫∫ APD ·≈–„Àâ kalimate ‡æ◊ËÕ√—°…“
hyperkalemia ºŸâªÉ«¬¡’Õ“°“√‡°√Áß¡“°¢÷Èπ®÷߉¥â„Àâ
trachium 25 ¡‘≈≈‘°√—¡©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑ÿ° 6 ™—«Ë ‚¡ß
·≈–‡æ‘Ë¡¢π“¥ valium ‡ªìπ 30 ¡‘≈≈‘°√—¡µàÕ™—Ë«‚¡ß
«‘®“√≥å
ª√– “∑·æ∑¬å
„πºŸªâ «É ¬√“¬π’¡È °’ “√«‘π®‘ ©—¬·¬°‚√§ 2 ‚√§ §◊Õ
Ludwigûs angina ·≈– tetanus Õ¬à“߉√°Áµ“¡‡¡◊ËÕ
¥Ÿ®“°ª√–«—µ‘ tetanus ‡ªìπ‚√§∑’˵âÕߧ‘¥∂÷ß¡“°∑’Ë ÿ¥
‡æ√“–Õ“°“√·≈–Õ“°“√· ¥ßµà“ß Ê ∑’ˉ¥â®“°°“√´—°
ª√–«—µ·‘ ≈–µ√«®√à“ß°“¬‰¥â§Õà π¢â“ß™—¥‡®π ‡™àπ Õ⓪“°
‰¡à‰¥â πÈ”≈“¬‰À≈ ·≈– trismus
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
05-MM
59
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¡°√“§¡ › ¡’π“§¡ 2551
59
Vol. 7 No.1
¡’ªí≠À“ septic shock ‰¢â Ÿß BT 38.4 ÌC,
BP 80/50 mmHg, CVP 11 cmH2O, septic work up
„À¡à ‰¡àæ∫ source of infection sputum culture
(30/4/50): Pseudomonas aeruginosa ·≈– Enterobacter,
‰«µàÕ¬“ ceftazidime, tazocin ®÷߇ª≈’Ë¬π¬“µâ“π®ÿ≈™’æ
®“° meropenem ‡ªìπ ceftazidime „Àâ dopamine,
levophed, ·≈– adrenaline, titrate dose µ“¡ BP ¡’
ªí≠À“‰µ«“¬¡“°¢÷Èπ BUN/Cr 125.8/13.2 mg/dl
¡’ uremic symptom, volume overload ·≈– K 6.1
mEq/L, EKG ¡’ tall peak T √—°…“‚¥¬„Àâ 10%
Ca gluconate, 7.5% NaHCO3, RI ·≈– glucose
·≈– kalimate ª√÷°…“Õ“¬ÿ√·æ∑¬å “¢“‚√§‰µ §‘¥«à“
‰¡à “¡“√∂∑” CVVH ‰¥â ‡π◊ËÕß®“°§«“¡¥—π¢Õß
ºŸªâ «É ¬‰¡à§ß∑’Ë ®÷ß„Àâ°“√√—°…“‚¥¬æ¬“¬“¡∑” APD µàÕ
IJM
‰¥â ª √÷ ° …“ª√– “∑·æ∑¬å µ √«®√à “ ß°“¬æ∫
¡’ risus sardonicus, generalized muscle rigidity,
abdominal guarding with spasm ‡¢â“‰¥â°—∫ tetanus
„Àâ°“√√—°…“‚¥¬°“√‡æ‘Ë¡¢π“¥ valium ‡ªìπ 180
¡‘≈≈‘°√—¡µàÕ«—π ·≈–ª√—∫¢π“¥¬“µ“¡Õ“°“√‡°√Áß ¡’
ªí≠À“ septic shock BP 80/40 mmHg, BT 39 ÌC
‰¥âª√÷°…“·æ∑¬å “¢“‚√§µ‘¥‡™◊ÈÕ‰¥â septic work up
„À¡à CXR æ∫ infiltration ∫√‘‡«≥ RLL, diagnosis
pneumonia RLL with septic shock ®÷߇ª≈’ˬπ
¬“µâ“π®ÿ≈™’懪ìπ meropenem 1 °√—¡©’¥∑“ßÀ≈Õ¥
‡≈◊Õ¥¥”∑ÿ° 12 ™—Ë«‚¡ß ·≈–‡ª≈’Ë¬π¬“µâ“π®ÿ≈™’æ„π
°“√√—°…“ tetanus ‡ªìπ metronidazole 500 ¡‘≈≈‘°√—¡
©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑ÿ° 12 ™—Ë«‚¡ß „Àâ IV fluid,
dopamine ·≈– levophed µàÕ¡“¡’¿“«– rhabdomyolysis
with acute renal failure ¡“°¢÷Èπ BUN/Cr 46.9/6.5
mg/dl, CK 20,933 U/L ‰¥âª√÷°…“·æ∑¬å “¢“‚√§
‰µ„Àâ°“√√—°…“‚¥¬∑” acute peritorenal dalysis (APD)
·µà¢“¥∑ÿπ 1,300 ´’´’µàÕ«—π
Day 8-11
Vol. 7 No.1
IJM
„πºŸâªÉ«¬√“¬π’È ·æ∑¬å‡«√Õ“¬ÿ√»“ µ√å ∑’Ë ER
§‘¥∂÷ß‚√§π’ȵ—Èß·µàµâπ ·µà‰¡à‰¥â„Àâ°“√√—°…“ ‡π◊ËÕß®“°
ºŸâªÉ«¬‰¥â admit ‰ª·ºπ° ENT §«“¡®√‘ߧ«√„Àâ°“√
√—°…“‰ªæ√âÕ¡°—π∑—Èß 2 ‚√§
„π·ßà°“√√—°…“ tetanus πÕ°®“° TAT ·≈–
¬“µâ“π®ÿ≈™’æ·≈â« °“√„Àâ valium ‡ªìπ°“√√—°…“∑’Ë
”§—≠‡æ◊ÕË ªÑÕß°—π°“√‡°‘¥ rhabdomyolysis ·≈– ARF
´÷Ëß√“¬π’ȉ¥â¢π“¥πâÕ¬„π™à«ß·√°
”À√—∫ trachium ´÷Ë߇ªìπ muscle relaxant
§«√À≈’°‡≈’Ë¬ß ∂â“ “¡“√∂„Àâ valium high dose ·≈â«
§«∫§ÿ¡Õ“°“√‡°√Á߉¥â ‡π◊ËÕß®“°°“√ª√–‡¡‘π°“√
√—°…“ºŸâªÉ«¬®”‡ªìπµâÕßÕ“»—¬§«“¡√à«¡¡◊Õ¢ÕߺŸâªÉ«¬
·≈–√–¥—∫°“√√Ÿâ ÷°µ—«∑’Ë¥’ ·µà∂Ⓣ¡à “¡“√∂§«∫§ÿ¡
°“√‡°√Áߥ⫬ valium‰¥â °Á “¡“√∂„Àâ trachium ‰¥â
·µà‡¡◊ËÕÕ“°“√¥’¢÷Èπ§«√√’∫ tape off trachium ‡æ◊ËÕ
ª√–‚¬™πåª√–‡¡‘π°“√√—°…“ºŸâªÉ«¬ °“√ª√–‡¡‘π°“√
‡°√Á ß π—È π µâ Õ ßª√–‡¡‘ π „π¢≥–πÕπæ— ° ·≈–‡¡◊Ë Õ ∂Ÿ °
°√–µÿâπ ´÷Ëß®”‡ªìπµâÕߧ«∫§ÿ¡Õ“°“√‡°√Áß„À≥â∑—Èß 2
¿“«–
ARF „πºŸâªÉ«¬√“¬π’ȇ°‘¥®“° rhabdomyolysis
·≈–¿“«– prerenal ®“°°“√∑’Ë loss volume ‰ª„π
extravascular compartment ‡™àπ„π°≈â“¡‡π◊ÕÈ ∑’∫Ë «¡ ·≈–
soft tissue Õ◊Ëπ Ê ®“°¿“«– septic shock ÿ¥∑⓬
àߺ≈„Àâ¡’¿“«– volume overload ·≈– hyperkalemia
°“√√—°…“ rhabdomyolysis ‡πâπ∑’Ë°“√·°â‰¢ “‡Àµÿ
§«√§«∫§ÿ¡°“√‡°‘¥ muscle spasm „À≥â√«¥‡√Á«
°“√√—°…“ hyperkalemia «‘∏’°“√∑’ˇÀ¡“– ¡
∑’Ë ÿ ¥ „πºŸâ ªÉ « ¬√“¬π’È §◊ Õ °“√∑” hemodialysis ·µà
‡π◊ËÕß®“°ºŸâªÉ«¬§«“¡¥—π‚≈À‘µµ°‰¥â√—∫ high dose
vasopressor ‰¡à “¡“√∂∑” hemodialysis À√◊Õ CVVH
‰¥â ®÷ß∑”‡ªìπ peritoneal dialysis ·µà‡ªìπ«‘∏’∑’Ë≈¥
potassium ‰¥â‰¡à¥‡’ ∑à“°“√∑” hemodialysis À√◊Õ CVVH
Õ“¬ÿ√·æ∑¬å “¢“‚√§µ‘¥‡™◊ÈÕ
√ÿª
¬“µâ“π®ÿ≈™’æ„π°“√√—°…“ tetanus π—Èπªí®®ÿ∫—π
∑’ˇÀ¡“– ¡∑’Ë ÿ¥§«√‡ªìπ metronidazole ‡π◊ËÕß®“°
PGS ´÷Ë߇ªìπ beta-lactam group ®–¡’º≈„π°“√≈¥
GABA activity ´÷Ë߉ª≈¥ threshold ¢Õß neuron
àߺ≈„À⇰‘¥°“√™—°‰¥âßà“¬¢÷Èπ ‡π◊ËÕß®“°‚√§ tetanus
‡ªìπ‚√§∑’ˬ—ßæ∫‰¥âÕ¬Ÿà‡√◊ËÕ¬Ê ·≈–∑”„À⺟âªÉ«¬‡ ’¬™’«‘µ
‰¥â ¥—ßπ—Èπ®÷ߧ«√‡πâπ„π‡√◊ËÕß°“√ªÑÕß°—π °“√¥Ÿ·≈
∫“¥·º≈ ·≈–∑∫∑«π¢âÕ∫àß™’„È π°“√„Àâ TT ·≈– TAT
à«π°“√ª√—∫¬“µâ“π®ÿ≈™’æ„π°“√√—°…“ pneumonia
°“√«‘ π‘ ® ©— ¬ tetanus ‡ªì π °“√«‘ π‘ ® ©— ¬ ‚¥¬
æ‘®“√≥“®“°≈—°…≥–∑“ߧ≈‘π‘°‡ªìπÀ≈—° ¥—ßπ—Èπ∂â“
ºŸâªÉ«¬¡’Õ“°“√‡¢â“‰¥â°—∫ tetanus §«√‡√‘Ë¡„Àâ°“√√—°…“
∑—π∑’ °“√√—°…“µâÕߪ√–‡¡‘π¢π“¥¢Õ߬“∑’Ë„™â‡æ◊ËÕ
≈¥°“√‡°√ÁߢÕß°≈â“¡‡π◊ÈÕ°—∫º≈·∑√°´âÕπ¢Õ߬“∑’Ë
®–‡°‘¥¢÷È𠇙àπ °¥°“√À“¬„® ∑’Ë ”§—≠µâÕߪÑÕß°—π
·≈–√—°…“º≈·∑√°´âÕπ®“° tetanus ‡Õß ‡™àπ ¿“«–
rhabdomyolysis ·≈– acute renal failure
®”‡ªìπµâÕßÕ“»—¬º≈°“√‡æ“–‡™◊ÈÕ‡ ¡À–‡ªìπµ—«™à«¬
„π°“√µ—¥ ‘π„®‡ª≈’Ë¬π¬“ ·≈–‡¡◊ËÕ√“¬ß“πº≈°“√
‡æ“–‡™◊ÈÕ‡ ¡À–°Á§«√ de-escalate antibiotic µ“¡
º≈‡æ“–‡™◊ÈÕ ‡æ◊ËÕ≈¥‚Õ°“ ‡™◊ÈÕ¥◊ÈÕ¬“
Õ“¬ÿ√·æ∑¬å “¢“‚√§‰µ
60 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
05-MM
60
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EKG Conference
Arrythmia in COPD and Bronchiectasis Patient
√».πæ. «‘√—µπå §≈—ß∫ÿ≠§√Õß
“¢“«‘™“À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
™“¬‰∑¬ Õ“¬ÿ 70 ªï √—∫√—°…“‰«â „π‚√ß欓∫“≈
Complaint of fever, cough and dyspnea
Question : What is the most likely EKG diagnosis?
IJM
Vol. 7 No.1
‡©≈¬ EKG findings
1. æ∫¡’ narrow QRS complex rate ª√–¡“≥
105-110 §√—ÈßµàÕπ“∑’ ¡’ variable ¢Õß R-R interval
·≈–¡’ irregular rhythm
2. æ∫¡’ P wave π”Àπâ“ QRS complex
∑ÿ°µ—« √Ÿª√à“ß≈—°…≥–¢Õß P wave ·µ°µà“ß°—π 3
≈—°…≥– ·≈–¡’ variable ¢Õß PR interval
3. ¡’ LVH by voltage criteria ·≈– nonspecific ST-T abnormalities
®“°≈—°…≥– EKG µ“¡¢â“ß∫ππ’È (¢âÕ 1 ·≈–
2) Õ“®∫Õ°‰¥â«à“‡ªìπ arrhythmia ∑’ˇ¢â“‰¥â°—∫≈—°…≥–
¢Õß multifocal atrial tachycardia (MAT)
®“°ª√–«—µ‘ ºŸâª«¬™“¬Õ“¬ÿ 70 ªï ‡¢â“¡“¥â«¬
Õ“°“√‰¢â ‰Õ ÀÕ∫ ≈—°…≥–Õ“°“√‰Õ¡’‡ ¡À–¢âπ‡À𒬫
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
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61
À√◊Õ adrenergic drugs MAT ¡’ high incidence ∑’ˇ°‘¥
AF ‰¥âª√–¡“≥ √âÕ¬≈– 50-70
À≈— ° °“√√— ° …“∑’Ë ”§— ≠ §◊ Õ „Àâ ° “√√— ° …“
underlying disease À√◊Õ conditions ∑’Ë∑”„À⇰‘¥
arrhythmia ‡™àπ °“√√—°…“ COPD, bronchiectasis ∑’Ë¡’
infection, hypoxemia ‡ªìπµâπ
√ÿª§”µÕ∫ §◊Õ :
1. Multifocal atrial tachycardia
2. LVH by voltage criteria and non specific ST-T abnormalities
3. COPD and infected bronchiectasis
IJM
Vol. 7 No.1
’‡À≈◊Õß ª√‘¡“≥¡“° ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ
COPD √à«¡°—∫¡’ infected bronchiectasis
≈—°…≥–¢Õß EKG finding „π multifocal
(chaotic) atrial tachycardia (MAT) ¡’¥—ßπ’È
1. ¡’Õ—µ√“°“√‡µâπ¡“°°«à“ 100 §√—ÈßµàÕπ“∑’,
irregular ventricular rate ·≈– rhythm
2. ¡’ morphology ¢Õß consecutive P wave
·µ°µà“ß°—π µ—Èß·µà 3 ≈—°…≥–¢÷Èπ‰ª ·≈–¡’ variable
¢Õß PR interval
MAT ¡—°‡°‘¥®“° COPD ¿“«– hypoxia ·µà
¡’∫“ߧ√—ÈßÕ“®‡°‘¥®“° digitalis intoxication, chronic
heart disease, hypokalemia ·≈–®“°¬“ theophylline
62 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
06-EKG
62
2/4/08, 13:21
Arterial Blood Gas Conference
Dyspnea in Patient with Bronchiectasis
æ≠.æ√æ‘¡≈ ‡À≈à“«™‘√– ÿ«√√≥1, √».æ≠.«‘¿“ √’™—¬æ‘™‘µ°ÿ≈2
1
·æ∑¬åª√–®”∫â“π, 2 “¢“«‘™“‚√§√–∫∫∑“߇¥‘πÀ“¬„®·≈–‡«™∫”∫—¥«‘°ƒµ ¿“§«‘™“Õ“¬ÿ√»“ µ√å
§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
ºŸâªÉ«¬À≠‘߉∑¬§Ÿà Õ“¬ÿ 78 ªï ®—ßÀ«—¥¢Õπ·°àπ
Õ“°“√ ”§—≠
Heart
‰¢â ‰Õ ÀÕ∫ 2 «—π°àÕπ¡“‚√ß欓∫“≈
ª√–«—µ‘ªí®®ÿ∫—π
2 «—π°àÕπ¡“‚√ß欓∫“≈ ºŸªâ «É ¬¡’‰¢â ‰Õ À“¬„®
‰¡à –¥«° ‡ ¡À–¢“«ªπ‡À≈◊Õß ‡Àπ◊ËÕ¬‡æ≈’¬‰ª
‚√ß欓∫“≈ ‘ √‘ π ∏√ ‰¥â ¬ “ªØ‘ ™’ « 𖇪ì π tazocin
Õ“°“√‰¡à∑ÿ‡≈“
: audible S1, S2, pansystolic murmur at
apex
Lungs
: equal lung expansion, coarse
crepitating both lungs
Abdomen : soft, not tender,
liver and spleen were impalpable
Extremities : clubbing of fingers
Problem list
1. Bronchiectasis
2. Acute fever with dyspnea
Laboratory investigation
CBC
Physical examination
General appearance : An elderly woman, looked
dyspnea, fully conscious
Vital signs : BT 39oC, PR 98/min, RR 28/min,
BP 130/60 mmHg
HEENT : pink conjunctivae, anicteric sclerae,
cervical lymph nodes were impalpable,
trachea in midline
LFT
CXR
: Hb 11.8 g/dL, Hct 36.8%, WBC
4,900 cell/mm3 (N 68.2%, L 19%,
M 12.4%), plt 251,000 cell/mm3
BS 116, BUN 7.7, Cr 0.8 mg/dL,
Na 137, K 4, HCO3 34.6, Cl 90
mEq/L, Ca 8.3 mg/dL
: Chol 140 mg/dL, alb 2.8, glob 3.7
g/dL, TB 1.7, DB 0.5 mg/dL,
AST 11, ALT 24, ALP 74 U/L
: reticulonodular infiltration both
lungs
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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63
Vol. 7 No.1
‰¥â√—∫°“√«‘π‘®©—¬‡ªìπ bronchiectasis ‡¡◊ËÕ
æ.». 2547 √—°…“∑’Ë‚√ß欓∫“≈»√’π§√‘π∑√å ‰¥â¬“
¢¬“¬À≈Õ¥≈¡‡™â“-‡¬Áπ „π™à«ß 1 ‡¥◊Õπ∑’˺à“π¡“
¡’Õ“°“√ÀÕ∫µâÕß¡“æàπ¬“∑’‚Ë √ß欓∫“≈ —ª¥“Àå≈–§√—ßÈ
‰¡à Ÿ∫∫ÿÀ√’Ë
IJM
ª√–«—µ‘Õ¥’µ
2/4/08, 13:22
¡°√“§¡ › ¡’π“§¡ 2551
63
°“√¥”‡π‘π‚√§
Day 1
23.00 π. À≈—ߺ≈ ABG °≈—∫¡“º≈ O2 sat 41%
·µà®“°‡§√◊ËÕß monitor O2 sat ‰¥â 89-90%
®÷ß„Àâ
- Oxygen canula 3 L/min
- Beradual 1NB æàπ∑ÿ° 4 ™¡.
- Start antibiotic: tazocin 4.5 gm ©’¥
∑ÿ° 8 ™¡.
- Observe clinical
Day 2
08.00 π. ºŸªâ «É ¬√Ÿ â °÷ µ—«·µà¬ß— ¡’Õ“°“√ÀÕ∫ (RR 32/min)
‰¥â‡®“– ABG ´È”¢≥– on O2 canula 3 L/min
- º≈ ABG: pH 7.30, PaCO2 74, PaO2 75,
HCO3 38.1, O2 sat 94%
17.00 π. ºŸâªÉ«¬´÷¡ª≈ÿ°µ◊Ë𬓰‰¡à∑”µ“¡§” —Ëß O2 sat
ª≈“¬π‘È« 75%
- ET tube intubation on Bird respirator
(air mix) VT 400, RR 24/min ·≈–‡®“–
ABG À≈—ß®“°π—ÈπÕ’° 30 π“∑’‰¥âº≈ : pH
7.18, PaCO2 60, PaO2 24, HCO3 22.4,
O2 sat 49%
21.00 π. ¬â“¬ºŸâªÉ«¬‰ª on setting CMV (FiO2 0.4,
VT 450, RR 16/min, PEEP 2)
- ‡®“– ABG (22.47 π.) : pH 7.59, PaCO2
40.3, PaO2 90, HCO3 38.1, O2 sat 98%
- ºŸâªÉ«¬À“¬„®µ“¡‡§√◊ËÕߥ’·µà pressure Ÿß®÷ß
‡ª≈’ˬπ setting ‡ªìπ PCV (FiO2 0.4, IP 24,
RR 14, I:E 1:3 (VT 370) º≈ ABG
(01.30 π.): pH 7.56, PaCO2 43, PaO2 93,
HCO3 38.5, O2 sat 98%
IJM
Vol. 7 No.1
µ“√“ß∑’Ë 1 º≈°“√µ√«® arterial blood gas
64 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
07-Arterial blood
64
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07-Arterial blood
65
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¡°√“§¡ › ¡’π“§¡ 2551
65
Vol. 7 No.1
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
IJM
ºŸâªÉ«¬ bronchiectasis ¡“¥â«¬Õ“°“√‰¢â Ÿß ‰Õ
·≈–ÀÕ∫¡“°¡“ 2 «—𠓇Àµÿ∑’˧‘¥∂÷ß¡“°∑’Ë ÿ¥§◊Õ
‚√§µ‘¥‡™◊ÈÕ∑’˪ե®“°‡™◊ÈÕ·∫§∑’‡√’¬ ‚¥¬‡©æ“–‡™◊ÈÕ
gram-negative rod À√◊Õ‡™◊ÈÕ P. aeruginosa ºŸâªÉ«¬‰¥â
√—∫¬“ªØ‘™«’ π–·≈⫉¡à¥¢’ π÷È ¬—ß¡’Õ“°“√‰Õ·≈–ÀÕ∫¡“°
®÷߉¥â bronchodilator ·≈– oxygen therapy ‘Ëß∑’Ë
∑”„À⺟âªÉ«¬Õ“°“√∑“ߧ≈‘π‘°·¬à≈ß Õ“®®–‡°‘¥®“°‚√§
æ◊Èπ∞“π‡¥‘¡´÷Ëß¡’°“√·≈°‡ª≈’ˬπ°ä“´‰¡à¥’ ‡¡◊ËÕ¡’°“√
µ‘¥‡™◊ÈÕ®÷ß∑”„Àâ°“√·≈°‡ª≈’ˬπ°ä“´·¬à≈ßÕ’° À√◊ÕÕ“®
‡°‘¥®“°°“√µ‘¥‡™◊ÕÈ ∑’√Ë πÿ ·√ßÀ√◊Õ°“√µ‘¥‡™◊ÕÈ ∑’¬Ë “ªØ‘™«’ π–
∑’Ë„ÀâÕ¬Ÿà‰¡à§√Õ∫§≈ÿ¡ ‡™à𠇙◊ÈÕ gram-negative rod
∑’Ë¥◊ÈÕ¬“ À√◊Õ‡™◊ÈÕ«—≥‚√§ ‡π◊ËÕß®“°ºŸâªÉ«¬À“¬„®ÀÕ∫
‰¥â„Àâ oxygen canula ·≈–‡®“– arterial blood gas
º≈ arterial blood gas ¢≥– on oxygen canula
3 L/min À“¬„®¥â«¬Õ—µ√“°“√À“¬„® 34 §√—Èß/π“∑’ ‰¥â
pH 7.31, PaCO2 77, PaO2 66, HCO3 38.8, O2 sat
41% ·æ∑¬å ß —¬«à“®–‡®“–‡¢â“ vein ®÷ß«—¥ pulse
oxygen saturation ª≈“¬π‘È««—¥‰¥â 89-90% ‚¥¬
∑—Ë«‰ª∂Ⓡªìπ®“°°“√‡®“– arterial blood gas ‡¢â“ vein
º≈ venous blood gas „πºŸªâ «É ¬∑’¡Ë ’ normal respiratory
·≈– cardiac function ®–‰¥âº≈ PCO2 46, PO2 40
·≈– O2 sat 75% ´÷Ë߇¡◊ËÕ‡∑’¬∫°—∫º≈∑’˵√«®‰¥â„π
ºŸâªÉ«¬√“¬π’È®÷ߧ‘¥«à“πà“®–‡®“–‡¢â“ arterial blood ®√‘ß
·µàºŸâªÉ«¬¡’ severe arterial hypoxemia, acute ontop
chronic respiratory acidosis ·≈– compensated
metabolic alkalosis à«π°“√∑’Ë oxygen saturation ®“°
arterial blood gas µË”°«à“ pulse oxygen saturation
ª≈“¬π‘È« ‡π◊ËÕß®“°ºŸâªÉ«¬À“¬„®ÀÕ∫¡’ severe V/Q
misthatch ·≈–æ÷Ëß®–‰¥â oxygen therapy ‰¡àπ“π
æÕ∑’Ë®–‡°‘¥ equilibrium ·æ∑¬å°Á√’∫µ√«® arterial
blood gas ·≈â« à«π°“√®—∫«—¥ pulse oxygen saturation
¡“µ√«®«—¥¿“¬À≈—ß ‡¡◊ËÕ‡ÀÁπº≈ arterial blood gas
‡æ√“–‚¥¬∑—Ë«‰ª §à“ oxygen saturation ∑’ˉ¥â®“°
°“√µ√«® arterial blood gas ®–‡ªìπ§à“∑’Ë·¡à𬔰«à“
°√≥’∑’˵√«®·≈⫵˔°«à“ pulse oxygen saturation
ª≈“¬π‘È« Õ“®‡ªìπ‰ª‰¥â 2 °√≥’§◊Õ ·æ∑¬å‡®“– arterial
blood gas ·≈â« àßµ√«®™â“ ∑”„À⇡Á¥‡≈◊Õ¥¢“«„™â oxygen
∑’Ë¡’Õ¬Ÿà ‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë¡’®”π«π‡¡Á¥‡≈◊Õ¥¢“« Ÿß
„π‡≈◊Õ¥ ®–∑”„Àâ°“√µ√«® oxygen saturation µË”≈߉¥â
À√◊ÕÕ’°°√≥’Àπ÷Ë߇°‘¥®“°·æ∑¬å‡®“–µ√«® arterial
blood gas ‡√Á«‡°‘π‰ª À≈—ß„Àâ°“√√—°…“¥â«¬ oxygen
therapy ‰¡àπ“π ‚¥¬‡©æ“–ºŸªâ «É ¬∑’¡Ë æ’ ¬“∏‘ ¿“æ∑’ªË Õ¥
Õ¬Ÿ‡à ¥‘¡ Õ“®µâÕß√Õª√–¡“≥ 20-30 π“∑’ À≈—ß„Àâ oxygen
therapy ®÷ß®–ª√–‡¡‘πº≈°“√√—°…“ ´÷ËߺŸâªÉ«¬√“¬π’È
§‘¥«à“Õ¬Ÿà„π°√≥’π’È
°“√¥”‡π‘π‚√§„π«—π∑’Ë 2 À≈—ß„Àâ°“√√—°…“
æ∫«à “ ‡¡◊Ë Õ „Àâ ¬ “ªØ‘ ™’ « π– ·≈–¬“¢¬“¬À≈Õ¥≈¡
®–‡ÀÁπ«à“°“√·≈°‡ª≈’ˬπ°ä“´¥’¢÷Èπ ·µà‡°‘¥ªí≠À“¢Õß
°“√√—°…“§◊Õ ºŸâªÉ«¬‰¥â oxygen therapy ¡“°‡°‘π‰ª®π
shut-off hypoxic drive ®–‡ÀÁπ‰¥â«à“ on O2 canula 3
L/min ‰¥â PaO2 75 ·≈– O2 sat 94% ºŸâªÉ«¬®÷ß´÷¡
ª≈ÿ°µ◊Ë𬓰 ·≈–À“¬„®™â“≈ß ®π‡°‘¥ PaCO2 §—Ëß ·≈–
µ“¡¡“¥â«¬ O2 sat ª≈“¬π‘È« drop ≈ß ∂â“À“°·æ∑¬å
§”π÷ß∂÷ß¿“«–π’È ‚¥¬‡©æ“–ºŸâªÉ«¬ bronchiectasis ∑’Ë¡’
chronic hypoxemia Õ¬Ÿà‡¥‘¡ §«√®–µâÕß≈¥ O2 canula
®“° 3 L/min ‡ªìπ 1-2 L/min ‚¥¬ keep PaO2 60
·≈– O2 sat 90% „π‡¬Áπ«—π∑’Ë 2 ºŸâªÉ«¬µâÕß„ à∑àÕ
™à«¬À“¬„® ·≈–„™â‡§√◊ÕË ß™à«¬À“¬„® ‡æ√“–¡’¿“«– CO2
narcosis ‡¡◊ËÕ„™â Bird respirator ‡«≈“ 17.00 π.
®–‡ÀÁπ«à“ arterial blood gas ∑’µË √«®‰¥â ¡’ severe arterial
hypoxemia √à«¡°—∫ combined acute ontop chronic
respiratory acidosis and metabolic acidosis °“√∑’Ë
µ√«®‰¥âº≈ arterial blood gas ¥—ß°≈à“« ‘Ëß∑’Ë·æ∑¬å
µâÕߧ”π÷ß∂÷ßπÕ°®“°°“√‡®“– arterial blood gas
‡√Á«‡°‘π‰ª·≈â« §◊Õ°“√∑’˺ŸâªÉ«¬À“¬„®‰¡à‡¢â“‡§√◊ËÕß
´÷Ëß„πºŸâªÉ«¬√“¬π’È·æ∑¬å√–∫ÿ«à“‡®“–µ√«®À≈—ß®“°„ à
‡§√◊ËÕߙ૬À“¬„®·≈â« 30 π“∑’ ¥—ßπ—ÈπºŸâªÉ«¬Õ“®®–
Vol. 7 No.1
IJM
À“¬„®‰¡à‡¢â“‡§√◊ËÕß ´÷ËßµâÕß¡“¥Ÿ«à“µ—È߇§√◊ËÕߙ૬À“¬„®
‡À¡“– ¡À√◊Õ¬—ß À√◊Õ®”‡ªìπµâÕß„Àâ sedative drug
°—∫ºŸâªÉ«¬ ºŸâªÉ«¬‰¥â√—∫°“√‡ª≈’Ë¬π®“° Bird respirator
‡ªìπ volume respirator ‡¡◊ËÕµ—Èß CMV mode ·≈–
„À⺟âªÉ«¬À“¬„®‡¢â“°—∫‡§√◊ËÕߥ’ ®–‡ÀÁπ«à“ºŸâªÉ«¬µâÕß°“√
FiO2 0.4 °Á‰¥â PaO2 ∂÷ß 90 · ¥ß«à“欓∏‘ ¿“æ
∑’˪ե‡ªìπ V/Q mismatch ºŸâªÉ«¬∂Ÿ° ventilate
®π PaCO2 ∂Ÿ° wash out ®π pH ‡ªìπ alkalosis
·æ∑¬å‡ª≈’ˬπ mode ®“° CMV ‡ªìπ PCV ‡æ√“–
pressure Ÿß ·µà‰¡à∑√“∫«à“‡∑à“‰À√à ‡æ√“–‡¡◊ËÕµ—Èß
PCV mode „™â IP ‡æ’¬ß 24 °Á‰¥â VT 370 ·≈– PaCO2
43 · ¥ß«à “ pressure ®“°°“√µ—È ß CMV mode
‰¡àπà“®– Ÿß¡“° ®“°º≈ arterial blood gas „π«—π∑’Ë 2
®–‡ÀÁπ«à“°“√√—°…“ºŸªâ «É ¬∑’¡Ë ª’ ≠
í À“ chronic hypoxemia
Õ¬Ÿ‡à ¥‘¡ °“√„Àâ oxygen therapy §«√„Àâ·∫∫ controlled
oxygen therapy §◊Õ §«∫§ÿ¡„Àâ O2 sat ‰¥âª√–¡“≥
90% À√◊Õ PaO2 ª√–¡“≥ 60 ´÷Ë߇¡◊ËÕºŸâªÉ«¬‰¥â√—∫¬“
ªØ‘™«’ π– ·≈–¬“¢¬“¬À≈Õ¥≈¡·≈â«®–¡’º≈∑”„Àâ V/Q
mismatch ¥’¢÷Èπ “¡“√∂≈¥ O2 canula ≈߉¥â ‚¥¬„Àâ
O2 saturation ª≈“¬π‘È«ª√–¡“≥ 90% à«π‡¡◊ËÕ
ºŸâªÉ«¬„ à∑àՙ૬À“¬„®·≈â« ªí≠À“¢Õß°“√√—°…“
°≈—∫°≈“¬‡ªìπ PaCO2 ‰¡à„™à PaO2 ‡π◊ËÕß®“°ºŸâªÉ«¬
‰¡à‰¥âÀ“¬„®‡Õß·≈â« ‰¡àµâÕß√–«—ߪí≠À“ shut-off
hypoxic drive ·µàªí≠À“∑’ˇ°‘¥¢÷Èπ§◊Õ‡¡◊ËÕ·æ∑¬å„ à∑àÕ
™à«¬À“¬„®‰¥â·≈â« ¡—°®–∫’∫ ambu ¥â«¬ tidal volume
∑’ˇ¬Õ–‡°‘π‰ª·≈–∫’∫‡√Á«‡°‘π‰ª ®π PaCO2 ∂Ÿ°¢—∫
ÕÕ°‡√Á«¡“°‡°‘¥ acute respiratory alkalosis ´÷Ëß
∫“ߧ√—ßÈ Õ“®®–∑”„À⺪Ÿâ «É ¬™—°‰¥â°“√µ—ßÈ ‡§√◊ÕË ß™à«¬À“¬„®
„πºŸªâ «É ¬∑’¡Ë ’ chronic CO2 retension Õ¬Ÿ‡à ¥‘¡§◊Õ µ—ßÈ tidal
volume ·≈– respiratory rate „À≥â minute ventilation
∑’Ë∑”„Àâ§à“ PaCO2 ‡∑à“°—∫ resting PaCO2 ´÷Ëß°Á§◊Õ
§à“ª°µ‘‡¥‘¡¢ÕߺŸâªÉ«¬ ´÷Ëß∂â“À“°·æ∑¬å‰¡à‡§¬µ√«®
arterial blood gas ºŸâªÉ«¬¡“°àÕπÀπâ“π’È∑’˺ŸâªÉ«¬ ∫“¬¥’
‡√“°Á®–ª√–¡“≥«à“ resting PaCO2 §◊Õ §à“ PaCO2
∑’Ë∑”„Àâ pH Õ¬Ÿà„π‡°≥±åª°µ‘ §◊Õ 7.40 ‡æ√“–©–π—Èπ
‡√“®–‰¡à wash out PaCO2 ®π‰¥â 40 ·≈â« ∑”„Àâ pH
‡ªìπ alkalosis
°“√¥”‡π‘π‚√§ (µàÕ)
Day 3
07.00 π. on setting ‡¥‘¡ À“¬„®µ“¡‡§√◊ËÕß (RR 14/
min) F/U ABG
- ‰¥âº≈: pH 7.62, PaCO2 39, PaO2 99, HCO3
40.1, O2 sat 99%
- ª√—∫ setting „À¡à‚¥¬‡æ‘Ë¡ I:E ‡ªìπ 1:4
13.51 π. ‡®“– ABG À≈—ß on setting „À¡à
- ‰¥âº≈: pH 7.48, PaCO2 59, PaO2 86, HCO3
43.9, O2 sat 97%
Day 4
08.00 π. ºŸâªÉ«¬√Ÿâ ÷°µ—«¥’‰¢âµË” Ê ‰¡àÀÕ∫
10.00 π. try wean CPAP 5, PS 10 ºŸâªÉ«¬À“¬„®
20-24/min, ‰¡à´÷¡
15.00 π. wean T-piece 10 L/min as tolerate
Day 5
- off ET tube‰¥â ‰¡à´÷¡ ‰¡àÀÕ∫ ‰Õ‡ ¡À–
„π≈”§Õ º≈ sputum AFB 2+ ®÷ß start INH,
rifampicin, and ethambutal ·≈– æàπ
beradual µàÕ
Day 6-9
- ‰¢â‡√‘Ë¡≈¥≈ß Õ“°“√§ß∑’Ë, I/O balance
- on O2 canula 1 L/min ---> O2 sat 94-95%
Day 10-11
- check up routine lab æ∫ hyponatremia
(Na 122) ‰¡à¡’ clinical „Àâ°“√√—°…“¥â«¬
0.9% NaCl
Day 12
09.50 π. ∫àπ‡Àπ◊ËÕ¬ ÀÕ∫ RR 36/min wheezing
both lungs
66 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
07-Arterial blood
66
2/4/08, 13:22
- on ventilator setting ‡¥‘¡
Day 15
«‘®“√≥å
®–‡ÀÁπ‰¥â«“à ‡¡◊ÕË on respirator ·æ∑¬å§«√√–«—ß
°“√ over ventilation ‚¥¬µ—Èß setting „À≥â PaCO2
∑’Ë∑”„Àâ pH ª√–¡“≥ 7.40 ´÷Ëß baseline PaCO2 „π
ºŸâªÉ«¬√“¬π’ÈÕ“®®–Õ¬Ÿàª√–¡“≥ 55 mmHg ‡π◊ËÕß®“°
ºŸâªÉ«¬¡’‰¢âµË”Ê µ≈Õ¥À≈—ß on antibiotic ·≈– CBC
‰¡àæ∫ leukocytosis ‚¥¬ CXR æ∫ reticulonodular
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
07-Arterial blood
67
2/4/08, 13:22
¡°√“§¡ › ¡’π“§¡ 2551
67
Vol. 7 No.1
Wean off dopamine 䴉, clinical stable
- off cut down
- ‡√‘Ë¡ enteral feeding
Day 16-18
‰¡àÀÕ∫ ‰¡à¡’‰¢â
- EKG ‰¡à¡’ inverted-T ·≈â«
- wean CPAP 5 PS 8 ≈—∫ CMV ‡æ‘Ë¡
™—Ë«‚¡ß¢÷Èπ‡√◊ËÕ¬Ê
Day 19-29
- wean T-piece 10 L/min ≈—∫ CMV ‡æ‘Ë¡
™—Ë«‚¡ß¢÷Èπ‡√◊ËÕ¬Ê
- ‡®“– ABG °àÕπ off wean T-piece (RR
24/min) º≈: pH 7.45, PaCO2 54, PaO2
229, HCO3 37.5, O2 sat 100%
Day 30
- wean L-piece keep O2 sat ª≈“¬π’È 90%
as tolerate 䴉
Day 31
- off ET-tube 䴉
- on O2 canula 2 L/min (RR 20 /min) º≈
ABG: pH 7.43, PaCO2 56, PaO2 70,
HCO3 37.2, O2 sat 95%
Day 32
D/C °≈—∫∫â“π„Àâ antiTB drugs ‰ª°‘πµàÕ
IJM
- ventolin æàπ·≈–‡æ‘Ë¡ flow O2 canula ‡ªìπ
3 L/min
- ‡®“– ABG ‰¥âº≈ : pH 7.21, PaCO2 72,
PaO2 90, HCO3 28.8, O2 sat 95%
11.00 π. ´÷¡≈ߪ≈ÿ°‰¡àµ◊Ëπ
- ET tube intubation (secretion ‰¡à¡“°)
on Bird ventilator (air mix) VT 400, RR
24 /min ·≈–‡®“– ABG º≈ : pH 7.09,
PaCO2 103, PaO2 254, HCO3 31.2, O2
sat 99%
13.00 π. ¬â“¬ºŸâªÉ«¬‰ª on setting CMV (FiO2 0.4,
VT 350, RR 22 /min, PEEP 0)
- F/U electrolyte ¡’ hyponatremia (Na 122)
- CXR: progression of interstitial infiltration both lungs
- EKG: inverted-T II, III, AVF, V4-6
- elevate of troponin-T
18.00 π. BP drop 60/40 mmHg cut down CVP 10
cm 䴉 0.9% NaCl 500 ml BP 90/60 mmHg
- ‡®“– ABG º≈ : pH 7.47, PaCO2 37, PaO2
216, HCO3 26.9 ,O2 sat 100%
- correct hyponatremia ¥â«¬ 3% NaCl
- start enoxaparin, plavix, ASA
Day 13
À≈— ß ‰¥â enoxaparin ¡’ bleed ®“°·º≈
cutdown, gum, hematuria BP 80/50 mmHg, PR 90/
min, CVP 9 cm, Hct 41---> 33%
- off enoxaparin, plavix, ASA
- start dopamine
- cryoprecipitate, FFP transfusion
Day 14
ºŸªâ «É ¬√Ÿ â °÷ µ—«¡“°¢÷πÈ ‰¡à¡‰’ ¢â À“¬„®µ“¡‡§√◊ÕË ß
‰¥â ‰¡à¡’‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘
- Na 132 mEq/L, Hct 35%
blood gas ¢≥– on O2 canula 2 L/min °àÕπ®–
discharge ®–‡ÀÁπ«à“ºŸªâ «É ¬πà“®–¡’ PaO2 ‡¥‘¡Õ¬Ÿªà √–¡“≥
60 ·≈– PaCO2 ª√–¡“≥ 55 ´÷Ë߇¡◊ËÕ∂Ÿ° precipitation
¥â«¬ infection ∑’˪ե °Á∑”„Àâ gas exchange ·¬à≈ß
·≈–‡¡◊ËÕ·æ∑¬å‰¡à√–¡—¥√–«—ß°“√„™â oxygen ∑’Ë∂Ÿ°µâÕß
°Á∑”„À⇰‘¥¿“«–·∑√°´âÕπµà“ßÊ µ“¡¡“
∫√√≥“πÿ°√¡
1. «‘¿“ √’™—¬æ‘™‘µ°ÿ≈. °“√«‘‡§√“–Àå°ä“´®“°À≈Õ¥
‡≈◊Õ¥·¥ß (arterial blood gas interpretation).
»√’π§√‘π∑√凫™ “√ 2543; 15: 107-14.
2. «‘ ¿ “ √’ ™— ¬ æ‘ ™‘ µ °ÿ ≈ . °“√√— ° …“¥â « ¬ÕÕ°´‘ ‡ ®π
(oxygen therapy). „π «‘¿“ √’™—¬æ‘™‘µ°ÿ≈. ªí≠À“
‚√§√–∫∫∑“߇¥‘πÀ“¬„®∑’æË ∫∫àÕ¬„π¿“«–©ÿ°‡©‘π
(common pulmonary problems in emergency
medicine). ¢Õπ·°àπ : ¿“§«‘™“Õ“¬ÿ√»“ µ√å
§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ, 2545:
169-90.
IJM
Vol. 7 No.1
infiltration ®÷ßµ√«® sputum AFB º≈ positive ®÷ß
‰¥â√—∫ anti TB drugs ºŸâªÉ«¬√“¬π’È ‰¥â√—∫°“√ weaning
‡√Á«¡“° ®π off ET-tube ¿“¬„π 2 «—π Õ¬à“߉√°Áµ“¡
¢≥– weaning „πºŸâªÉ«¬∑’Ë¡’ chronic hypoxemia
Õ¬Ÿà ‡ ¥‘ ¡ °Á µâ Õ ß°≈— ∫ ¡“√–¡— ¥ √–«— ß °“√„™â oxygen
‡π◊ËÕß®“°ºŸâªÉ«¬µâÕßÀ“¬„®‡Õß ¥—ßπ—ÈπºŸâªÉ«¬√“¬π’ȧ«√
weaning ¥â«¬ L-piece ·≈– monitor O2 saturation
ª≈“¬π‘È«„À≥âª√–¡“≥ 90% ·≈–‡¡◊ËÕ off ET-tube
°Á§«√ on O2 canula 1-2 L/min keep O2 saturation
ª≈“¬π‘È«ª√–¡“≥ 90% ºŸâªÉ«¬√“¬π’ȵâÕß intubation
Õ’°√Õ∫ ‡æ√“– CO2 narcosis ®“°°“√„Àâ oxygen
therapy ¡“°‡°‘π‰ª ‡°‘¥ blood pressure drop ®“°
positive pressure ventilation ·≈–¢≥– weaning
‡°‘¥ coronary heart attack ‰¥â√—∫°“√√—°…“®π‡°‘¥
complication bleeding ÿ¥∑⓬ºŸâªÉ«¬√“¬π’ȉ¥â monitor
O2 saturation ª≈“¬π‘È« ¢≥– weaning ¥â«¬ L-piece
·≈– O2 canula 1-2 L/min ·≈– “¡“√∂°≈—∫∫â“π
‰¥â¥â«¬ room air ·≈– anti-TB drugs ´÷Ëß®“° arterial
68 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
07-Arterial blood
68
2/4/08, 13:22
Electrolyte Conference
Bone Pain and Hyperchloremic
Metabolic Acidosis
æ≠.«—π«√ÿ≥ æÿà¡™ÿ¡æ≈1, √».æ≠.»‘√‘√—µπå ‡√◊Õß®ÿâ¬2
1
·æ∑¬åª√–®”∫â“π, 2 “¢“«‘™“‚√§‰µ·≈–‰µ‡∑’¬¡ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
ºŸâªÉ«¬™“¬‰∑¬§Ÿà Õ“¬ÿ 45 ªï Õ“™’æ∑”π“ ∑’ËÕ¬Ÿà ®—ßÀ«—¥√âÕ¬‡ÕÁ¥
Vital signs : BT 37 ÌC, RR 20 times/min, PR 78
Õ“°“√ ”§—≠ :
ª«¥°√–¥Ÿ°¡“°¡“ 2 ‡¥◊Õπ
ª√–«—µ‘‡®Á∫ªÉ«¬ªí®®ÿ∫—π :
CBC
ª√–«—µ‘Õ¥’µ :
ªØ‘‡ ∏‚√§ª√–®”µ—« —߇°µªí “«–¡“°¢÷Èπ
¡“ 2 ‡¥◊Õπ
‰¡à‰¥â„™â¬“„¥‡ªìπª√–®”
Physical examination
General appearance : A cachexic, middle-aged
man with good consciousness, no dyspnea
: Hb 8.8 g/dL, Hct 25.7 vol %, WBC
5,700 /mm3, Plt 239,000 /mm3, PMN
42.2 %, L 42 %, M 8.6 %, Eo 6.3 %
Blood chemistry : FBS 79 mg/dL, BUN 17,
Cr 2.3 mg/dL, Na 139, K 3.3, HCO3
16.8, Cl 116 mEq/L, Ca 7.8, PO4 1.3,
Mg 2.8 mg/dL, uric 2.3 mg/dL
LFT
: Cholesterol 116 mg/dL, alb 4.3, glob
3 g/dL, TB 0.5, DB 0.1 mg/dL, ALT
33, AST 31, ALP 211 U/L
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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Laboratory investigation
IJM
1 ªï °à Õ π¡“√æ. ¡’ Õ “°“√ª«¥„µâ √ “«π¡
2 ¢â“ߪ«¥≈÷°Ê ‰¡à¡’‰¢â Õ“°“√ª«¥‰¡à —¡æ—π∏å°—∫
∑à“∑“ßÀ√◊Õ°“√À“¬„® ¡—°ª«¥‡«≈“°≈“ߧ◊π ¡’Õ“°“√
‡∫◊ËÕÕ“À“√πÈ”Àπ—°≈¥ 20 kg„π 1 ªï ‡§¬µ√«®∑’Ë
√æ.‡Õ°™π‰¡à∑√“∫«‘π‘®©—¬‚√§
2 ‡¥◊Õπ °àÕπ¡“‚√ß欓∫“≈ Õ“°“√ª«¥‡ªìπ
¡“°¢÷È𠇫≈“ª«¥®–¡’‡Àß◊ËÕ·µ°„® —Ëπ ‡√‘Ë¡ª«¥À≈—ß
–∫—° 2 ¢â“ß ·≈– –‚æ° ‡«≈“‡§≈◊ËÕπ‰À«®–ª«¥
¡“°¢÷È𠉪√æ. ‡Õ°™π‰¥â√—∫°“√‡Õ°´‡√¬å ·æ∑¬å∫Õ°
¡’°√–¥Ÿ°æ√ÿπ
beats/min, BP 110/70 mm Hg
HEENT : mild pale, no jaundice, dry lips and
tongue, impalpable cervical lymph nodes
Chest & Lungs : tender at anterior chest wall,
normal breath sound, no adventitious
sound
Heart : normal S1 S2 , no murmur
Abdomen : soft, not tender, impalpable liver
and spleen
Extremities : no edema
Neurological examination : normal
UA
: sp.gr 1.015 , pH 7.0, alb 2+, sugar
4+, no RBC , no WBC
Urine Bence Jones protein : positive
Serum electrophoresis : no gammopathy
Bone marrow aspiration : plasma cell > 10%
CXR
: generalized osteopenia, multiple
fractures of right 5th, 6th, 8th and 9th ribs
Bone scan : increase uptake of humerus, scapular,
sacroiliac joint and inferior pubic rami
Film skull: multiple small osteolytic lesions
Ultrasound : normal size of both kidneys
Urine 24 hr :
Cr 1.7 g, uric acid 0.76 g, Na 341,
K 119.4, Cl 248 mEq
Ca 77, PO4 2.3, Mg 0.7 mg, protein
9735 mg, volume 5500 ml
√ÿªªí≠À“¢ÕߺŸâªÉ«¬
IJM
Vol. 7 No.1
1. Bone pain and multiple ribs fracture
2. Acute renal failure
3. Hyperchloremic metabolic acidosis
°“√ª√–‡¡‘πªí≠À“¢ÕߺŸâªÉ«¬
1. Bone pain and multiple ribs fracture
ºŸâªÉ«¬™“¬Õ“¬ÿ 45 ªï ¡“¥â«¬Õ“°“√ª«¥°√–¥Ÿ°
À≈“¬µ”·Àπà ß “‡Àµÿ ∑’Ë Õ “®‡ªì 𠉪‰¥â ‰¥â · °à
malignancy-bone metastasis, hyperparathyroidism,
multiple myeloma ·≈– metabolic bone disease
ºŸªâ «É ¬√“¬π’‰È ¥â√∫— °“√«‘π®‘ ©—¬ multiple myeloma
‡π◊ËÕß®“°¡’‡°≥±å°“√«‘π‘®©—¬§√∫ §◊Õ
1. ®“°°“√∑” bone marrow aspiration æ∫
plasma cell > 10%
2. Urine Bence Jones protein positive
3. ¡’ clinical criteria ¡“°°«à“ 2 ¢âÕ §◊Õ
anemia (Hb <10 g/dL) , renal failure (Cr > 2) ·≈–
osteolytic lesion
2. Acute renal failure
®“°°“√µ√«®∑“ßÀâ Õ ßªØ‘ ∫— µ‘ ° “√æ∫¡’ ° “√
‡æ‘¡Ë ¢÷πÈ ¢Õß§à“ serum creatinine ‡π◊ÕË ß®“°ºŸªâ «É ¬‰¡à‡§¬
¡’ª√–«—µ‘‡ªìπ‚√§‰µ‡ ◊ËÕ¡∑’Ëπ“π°«à“ 12 —ª¥“Àå ·≈–
¢π“¥‰µª°µ‘®÷ߧ‘¥∂÷ß¿“«– acute renal failure
“‡Àµÿ¢Õß°“√‡°‘¥ acute renal failure „π
ºŸâªÉ«¬√“¬π’È Õ“®‡°‘¥®“° “‡Àµÿµà“ß Ê ¥—ßπ’È
1. ¿“«–¢“¥ “√πÈ” (volume depletion)
‡π◊ËÕß®“°ºŸâªÉ«¬√“¬π’Èªí “«–¡“°¡“ª√–¡“≥ 2 ‡¥◊Õπ
µ√«®√à “ ß°“¬æ∫¿“«–¢“¥ “√πÈ” ·≈–ª√‘ ¡ “≥
ªí “«–¡“°°«à“ 3 ≈‘µ√µàÕ«—π ´÷ßË °“√∑’ºË ªŸâ «É ¬ multiple
myeloma ¡’ polyuria Õ“®‡°‘¥®“°°“√∑”ß“π¢Õß
renal tubule º‘¥ª°µ‘‡π◊ËÕß®“°º≈¢Õß light chain
immunoglobulin À√◊Õ®“°¿“«– hypercalcemia ´÷Ëß
àߺ≈„À⇰‘¥ nephrogenic diabetes insipidus „π
ºŸâªÉ«¬√“¬π’ȉ¡àæ∫ hypercalcemia ·≈–°“√µ√«®
ªí “«–æ∫ Bence Jones protein ´÷Ë߇ªìπ°“√µ√«®
À“ monoclonal light chain immunoglobulin ∑”„Àâ
§‘¥∂÷ßªí “«–ÕÕ°¡“°®“°º≈¢Õß light chains ∑”„Àâ
renal tubule ∑”ß“πº‘¥ª°µ‘
°“√¢“¥ “√πÈ” ∑”„Àâ ‡ °‘ ¥ ¿“«– prerenal
azotemia ´÷Ëß°“√„Àâ “√πÈ”∑¥·∑π∑’ˇ撬ßæÕ ®–
∑”„Àâ¿“«–‰µ«“¬‡©’¬∫æ≈—π¥’¢÷ÈπÕ¬à“ß√«¥‡√Á«
2. Myeloma cast nephropathy (myeloma
kidney) ‡ªì𠓇Àµÿ∑æ’Ë ∫∫àÕ¬¢Õß¿“«–‰µ«“¬ „πºŸªâ «É ¬
multiple myeloma ‡°‘¥¢÷Èπ‡π◊ËÕß®“°¡’ light chains
ª√‘¡“≥¡“°∂Ÿ°°√Õߺà“π®“° glomeruli ∑”„À⇰‘¥
Õ—πµ√“¬µàÕ renal tubule ·≈–‡°‘¥°“√ – ¡·≈–
√«¡°—∫ Tamm-Horsfall protein ‡°‘¥‡ªìπ intratubular
cast ®÷߇°‘¥°“√Õÿ¥µ—π¢Õß renal tubule ·≈–‡°‘¥
¿“«–‰µ«“¬µ“¡¡“
70 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
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Light chains ∑’Ë∂Ÿ°°√ÕßÕÕ°¡“Õ“®∑”„Àâ
‡°‘¥°“√∑”ß“π¢Õß renal tubule º‘¥ª°µ‘ ‚¥¬∑’Ë
proximal tubules ®–‡ªì πµ”·Àπàß ∑’Ë¡’º≈°√–∑∫
¡“°∑’Ë ÿ¥‡æ√“–‡ªìπµ”·Àπàß∑’Ë¥Ÿ¥°≈—∫ light chains
∑”„À⇰‘¥°“√ – ¡¢Õß light chains „π proximal
°“√√—°…“ªí≠À“¢ÕߺŸâªÉ«¬
1. √— ° …“‚√§ª√–®”µ— « ‰¥â · °à °“√√— ° …“
multiple myeloma ¥â«¬°“√„Àâ chemotherapy
ºŸâªÉ«¬ √“¬π’ȉ¥â√—∫ vincristine, adriamycin ·≈–
dexamethasone
2. √— ° …“¿“«–‰µ«“¬‡©’ ¬ ∫æ≈— π ¥â « ¬°“√
√—°…“‚√§ª√–®”µ—« ·≈–„Àâ “√πÈ”‡æ◊ËÕ∑¥·∑π¿“«–
¢“¥πÈ”
3. ·°â‰¢¿“«– pRTA ·≈– ‡°≈◊Õ·√ຑ¥ª°µ‘
¥â«¬°“√„Àâ‚´‡¥’¬¡‰∫§“√å∫Õ‡πµ øÕ ‡ø∑ ·≈–
‚æ·∑ ‡´’¬¡∑¥·∑π ‡æ◊ËÕ„Àâ√–¥—∫‰∫§“√å∫Õ‡πµ
øÕ ‡ø∑ ·≈–‚æ·∑ ‡´’¬¡„πæ≈“ ¡à“ª°µ‘
« “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1
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Vol. 7 No.1
3. Hyperchloremic metabolic acidosis
tubular cells ´÷Ëß àߺ≈„À⇰‘¥°≈ÿà¡Õ“°“√ Fanconi
Õ—πª√–°Õ∫¥â«¬ proximal renal tubular acidosis
(pRTA), hypophosphatemia, hypouricosuria,
aminoaciduria ·≈– renal glycosuria
ºŸªâ «É ¬√“¬π’¡È ¿’ “«– hyperchloremic metabolic
acidosis ‚¥¬∑’Ë¡’ hypokalemia, urine pH > 7.0 ·≈–
urine net charge‰¥âº≈‡ªìπ∫«° ·¡â«à“ºŸâªÉ«¬®–‰¡à‰¥â
√—∫°“√µ√«®À“ fractional excretion ¢Õ߉∫§“√å∫Õ‡πµ
„π°“√∑¥ Õ∫ bicarbonate loading ‡æ◊ËÕ π—∫ πÿπ
¿“«– pRTA ·µà‡π◊ÕË ß®“°ºŸªâ «É ¬¡’¿“«– renal glycosuria,
hypophosphatemia, hypouricemia ·≈–æ∫¡’°“√
Ÿ≠‡ ’¬°√¥¬Ÿ√‘§ (fractional excretion ; FEuric=
44.7% §à“ª°µ‘ 4-14%) ‚´‡¥’¬¡ ·≈–‚æ·∑ ‡´’¬¡
„πªí “«– ∑”„Àâ §‘ ¥ ∂÷ ß Fanconiûs syndrome
∑’Ë —¡æ—π∏å°—∫¿“«– multiple myeloma
IJM
„πºŸâªÉ«¬√“¬π’È¡’°“√ π—∫ πÿπ°“√æ∫ light
chains „πªí “«– ®“°°“√∑’Ë µ √«®æ∫ª√‘ ¡ “≥
‚ª√µ’π®”π«π¡“°„πªí “«– (9,735 mg) „π¢≥–∑’Ë
æ∫ª√‘¡“≥Õ—≈∫Ÿ¡‘π„π°“√µ√«®¥â«¬ urine dipstick
‡æ’¬ß 2+ ∑”„Àâ π—∫ πÿπ«à“ª√‘¡“≥‚ª√µ’π à«π„À≠à
∑’ËÕÕ°¡“„πªí “«–‡ªìπ‚ª√µ’πÕ◊Ëπ∑’ˉ¡à„™àÕ—≈∫Ÿ¡‘π
√à«¡°—∫°“√µ√«®æ∫ urine Bence Jones ∑”„Àâ
π—∫ πÿπ«à“‚ª√µ’πÕ◊ËπÊπ—Èππà“®–‡ªìπ light chain
immunoglobulin
πÕ°®“° light chains ®–∑”„À⇰‘¥ myeloma
cast nephropathy ·≈â« ¬—ßÕ“®®–‰ª – ¡„π glomeruli
‡°‘¥‡ªìπ≈—°…≥–¢Õß light chain deposition disease
À√◊ÕÕ“®‡°‘¥ amyloidosis ´÷ßË ºŸªâ «É ¬®–¡“¥â«¬Õ“°“√¢Õß
nephritic syndrome (∫«¡, hypoalbuminemia ·≈–
heavy proteinuria ‚¥¬ à«π„À≠à‡ªìπÕ—≈∫Ÿ¡‘π∑’Ë√—Ë«
ÕÕ°¡“®“° glomeruli) ´÷Ë ß „πºŸâ ªÉ « ¬√“¬π’È ‰ ¡à æ ∫
≈—°…≥–¥—ß°≈à“«
“‡ÀµÿÕ◊Ëπ Ê ¢Õß°“√‡°‘¥¿“«–‰µ«“¬‡©’¬∫
æ≈—π„πºŸªâ «É ¬ multiple myeloma ‰¥â·°à hypercalcemia,
hyperuricemia, tubulointerstitial nephritis ·≈–
hyperviscosity syndrome ‡π◊Ë Õ ß®“°ºŸâ ªÉ « ¬√“¬π’È
‰¡à¡’°“√µ√«®æ∫≈—°…≥–‡À≈à“π’È ®÷߉¡à§‘¥∂÷ß “‡Àµÿ
µà“ß Ê ¥—ß°≈à“«
Journal Reading
Association between HLA-B* 1502 Allele
and Antiepileptic Drug-induced Cutaneous
Reactions in Han Chinese
∑’Ë¡“ Man CBL, Kwan P, Baum L, et al. Epilepsia 2007; 48:1015-8.
√ÿª·≈–«‘®“√≥å ‚¥¬ √».πæ. ¡»—°¥‘Ï ‡∑’¬¡‡°à“
¬“°—π™—°‡ªì𬓙π‘¥Àπ÷ßË ∑’æË ∫«à“°àÕ„À⇰‘¥°“√
·æâ·∫∫º◊πË ¢÷πÈ ‰¥â∫Õà ¬ ‚¥¬º◊πË ∑’æË ∫¡’µß—È ·µà maculopapular
exanthema (MPE) ®π√ÿπ·√ß¡“°Õ—πµ√“¬∂÷ß™’«µ‘ ‡™àπ
Stevens-Johnson syndrome (SJS), toxic epidermal
necrolysis (TEN) ·≈– drug hypersensitivity syndrome
(HSS) ¬“°—π™—°∑’æË ∫°“√·æ≥â∫Õà ¬§◊Õ carbamazepine,
phenobarbital, phenytoin ·≈– lamotrigine ‚¥¬
æ∫«à“ªí®®—¬∑“ßæ—π∏ÿ°√√¡Õ“®‡ªìπ‡Àµÿ¢Õß°“√·æ⬓‰¥â
‡™àπ °“√æ∫§«“¡ —¡æ—π∏å√–À«à“ß HLA-B* 1502
°—∫°“√‡°‘¥ SJS ®“°¬“ carbamazepine °“√»÷°…“π’È
®÷ß¡’«—µ∂ÿª√– ߧå‡æ◊ËÕµâÕß°“√∑√“∫∂÷ߧ«“¡ —¡æ—π∏å
√–À«à“ß HLA-B* 1502 °—∫°“√‡°‘¥º◊Ëπ·æ⬓°—π™—°
„πºŸâªÉ«¬ Han Chinese
IJM
Vol. 7 No.1
“¢“«‘™“ª√– “∑«‘∑¬“ ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ
«‘∏’°“√»÷°…“
°“√»÷ ° …“·∫∫ case-control, cohort „π
ºŸâªÉ«¬∑’ˉ¥â¬“°—π™—°·≈–‡°‘¥º◊Ëπ¿“¬„π 8 —ª¥“Àå
‚¥¬‰¡à¡’ “‡ÀµÿÕ◊ËπÊ „πºŸâªÉ«¬ 24 √“¬ ª√–°Õ∫¥â«¬
MPE 16 √“¬ ·≈– SJS À√◊Õ TEN 8 √“¬ ¡’
°≈ÿࡧ«∫§ÿ¡ 48 √“¬
º≈°“√»÷°…“
ºŸâªÉ«¬ severe cutaneous reaction (SCR)
8 √“¬ ·≈– MPE 16 √“¬ æ∫§«“¡ —¡æ—π∏å√–À«à“ß
HLA-B* 1502 °—∫ SCR √âÕ¬≈– 75 ‡¡◊ËÕ‡∑’¬∫
°—∫°≈ÿࡧ«∫§ÿ¡‡æ’¬ß√âÕ¬≈– 14.5 (P-value 0.001)
‚¥¬æ∫∑ÿ°§π„πºŸâªÉ«¬ SJS ·≈– TEN æ∫ 1 §π
¢ÕߺŸâªÉ«¬ HSS ·µà‰¡àæ∫§«“¡ —¡æ—π∏å°—∫ MPE √“¬
≈–‡Õ’¬¥¥—ßµ“√“ß∑’Ë 1 ·≈– 2
µ“√“ß∑’Ë 1 Number of subjects in each patient group taking different antiepileptic drugs
Drug
SCR
MPE
Controls
CBZ
LTG
PB
PHT
TPM
VPA
Total
4
2
1
1
8
CBZ, carbamazepine; LTG, lamotrigine; MPE,
maculopapular exanthema; PB, phenobarbital;
4
4
0
5
1
2
16
PHT, phenytoin; SCR, severe cutaneous reaction;
TPM, topiramate; VPA, valproate.
72 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ › ¡’π“§¡ 2551
09-journal reading
72
16
11
2
13
2
4
48
2/4/08, 13:24
µ“√“ß∑’Ë 2 Characteristics of patients with severe cutaneous reactions
Associating
Type of SCR
Patient Sex
Agea (years)
b
AED
1
2
3
4
5
6
7
8
F
M
F
M
F
F
M
M
28
23
53
10
53
41
14
44
CBZ
CBZ
CBZ
CBZ
PHT
LTG
PB
LTG
SJS
SJS
SJS
TEN
SJS
TEN
HSS
HSS
HLA-B*
1502 allele
Positive
Positive
Positive
Positive
Positive
Positive
Negative
Negative
AED, antiepileptic drug; CBZ, carbamazepine; HSS,
drug hepersensitivity syndrome; LTG, lamotrigine;
PB, phenobarbital; PHT, phenytoin; SCR, severe
cutaneous reactions; SJS, Stevens Johnson syndrome;
TEN, toxic epidermal necrolysis.
a
«‘®“√≥å
¬“°—π™—°Õ◊ËπÊ π—Èπ ¡’‚Õ°“ ‰¡à Ÿßª√–¡“≥ 1:10,000
·≈– à«π¡“°·≈â«∂â“·π–π”ºŸªâ «É ¬≈à«ßÀπâ“«à“∂â“¡’Õ“°“√
§—πÀ√◊Õº◊Ëπ¢÷Èπ‡≈Á°πâÕ¬„Àâ√’∫À¬ÿ¥¬“·≈â«¡“æ∫·æ∑¬å
∑—π∑’ ‚Õ°“ ∑’Ë®–‡°‘¥ SCR π—ÈππâÕ¬¡“°
°“√»÷°…“π’æÈ ∫§«“¡ —¡æ—π∏å√–À«à“ß HLA-B*
1502 °—∫°“√·æ⬓·∫∫ SCR ™—¥‡®π ‚¥¬‡©æ“–¬“
CBZ ´÷Ëß°Á®–¡’ª√–‚¬™πå„π°“√»÷°…“µàÕ‰ª„πÕ𓧵
«à “ ºŸâ ªÉ « ¬°≈ÿà ¡ ‰Àπ∑’Ë ¡’ HLA ¥— ß °≈à “ « ®–‰¥â
√–¡—¥√–«—ß„π°“√„™â¬“ ”À√—∫ª√–‡∑»‰∑¬‡Õß°Áπà“
®–µâÕß»÷°…“§«“¡ —¡æ—π∏å¢Õ߬’π«à“„πºŸâªÉ«¬∑’Ë·æ⬓
°—π™—°π—Èπ¡’¬’πÕ–‰√∑’Ëæ∫§«“¡ —¡æ—π∏å∫â“ß ‡æ◊ËÕ∑’Ë®–
™à«¬§—¥°√Õß·≈–≈¥‚Õ°“ °“√·æ⬓¥—ß°≈à“«
Õ¬à“߉√°Á¡’°“√„™â¬“°—π™—°π—È𠧫√„™â‡©æ“–
„π√“¬∑’Ë®”‡ªìπ‡∑à“π—Èπ À√◊Õ¡’¢âÕ∫àß™’È™—¥‡®π«à“µâÕ߉¥â
¬“°—π™—° ·≈–µâÕß·π–π”„À⺟âªÉ«¬À¬ÿ¥¬“∑—π∑’∂â“¡’
Õ“°“√„¥Ê °Áµ“¡∑’ Ë ß —¬«à“®–·æ⬓‚¥¬‡©æ“–º◊πË ∑’¢Ë π÷È
°Á ® –≈¥‚Õ°“ °“√‡°‘ ¥ º≈Õ— π ‰¡à æ÷ ß ª√– ß§å ® “°¬“
°—π™—°‰¥â
°“√»÷ ° …“π’È ‡ ªì π °“√»÷ ° …“Àπ÷Ë ß ∑’Ë æ ¬“¬“¡
À“§«“¡ —¡æ—π∏å√–À«à“ß°“√·æ⬓°—π™—°°—∫¬’π∑’Ëæ∫
„πºŸâªÉ«¬π—Èπ ®“°ª√– ∫°“√≥å°“√√—°…“ºŸâªÉ«¬‚√§
≈¡™—°·≈–°“√„™â¬“°—π™—°√—°…“ºŸâªÉ«¬‚√§µà“ßÊ ‡™àπ
trigeminal neuralgia À√◊Õ neuropathic pain Õ◊ËπÊ
æ∫«à“¬“ CBZ ‡ªìπ¬“∑’ˉ¥âº≈¥’„π°“√√—°…“°“√™—°
·≈– neuropathic pain ·µà·æ∑¬å à«π„À≠à®–‰¡à°≈â“
„™â¬“ CBZ ‡æ√“–°≈—«‡√◊ËÕß°“√·æ⬓‚¥¬‡©æ“– SJS
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®“°º≈°“√»÷ ° …“π’È π— ∫ πÿ 𠧫“¡ — ¡ æ— π ∏å
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carbamazepine ´÷Ëßπà“®–‡ªìπª√–‚¬™πåµàÕ°“√∑”π“¬
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within 8 weeks prior to the development of SCR
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Special Article
How to Success in International Publication
«‘‚√®πå ‰««“π‘™°‘®
Professor of Tropical Medicine, Hainan Medical College, China
Editor, Journal of Medical Association of Thailand
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µ—¥ ‘𠇪ìπ§”∂“¡ ”À√—∫π—°«‘™“°“√«à“∑”Õ¬à“߉√
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2. ∫∑§«“¡ª√‘∑—»πå À√◊Õ ∑∫∑«π«√√≥°√√¡
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µ“¡§«“¡‡À¡“– ¡
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1. ß“π‡¢’¬π∑’Ë¥’µâÕ߇√‘Ë¡®“°¢âÕ¡Ÿ≈∑’Ë¥’ ´÷Ëß
°Á §◊ Õ ¢â Õ ¡Ÿ ≈ ®“°°“√«‘ ®— ¬ ∑’Ë ¥’ À√◊ Õ ¢â Õ ¡Ÿ ≈ ∑’Ë√ «∫√«¡
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∫√‘°“√√—∫µ√«®¿“…“¡“°¡“¬ ·≈–∫“ß«“√ “√∂◊Õ«à“
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2. ∂‘µ‘ ¡’§«“¡®”‡ªìπ §◊Õ∂Ÿ°µâÕß Õ“®µâÕß
Õ“»—¬ºŸ‡â ™’¬Ë «™“≠∑“ß ∂‘µ™‘ «à ¬µ√«® Õ∫°àÕπ°“√µ’æ¡‘ æå
3. §«√ª√–¡“≥§«“¡ “¡“√∂¢Õßµπ‡Õß
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¡°√“§¡ › ¡’π“§¡ 2551
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Vol. 7 No.1
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1. §π«‘ ®— ¬ µâ Õ ß‡ªì π §π∑’Ë ¡’ ° “√«“ß·ºπ ¡’
√–∫∫√–‡∫’¬∫∑’Ë™—¥‡®π ·≈–∑«π Õ∫‰¥â
2. ºŸâ √â“ßß“π«‘®—¬µâÕ߇ªìπºŸâ∑’Ë¡’§«“¡√Ÿâ¥’„π
‡√◊ËÕß∑’Ë∑”°“√»÷°…“ µâÕß¡’°“√∑∫∑«π«√√≥°√√¡¡“
°àÕπ∑”°“√«‘®—¬
3. ºŸâ √â “ ßß“π«‘ ®— ¬ µâ Õ ß¡’ § «“¡√Ÿâ æ◊È π ∞“π∑’Ë
”§—≠§◊Õ À≈—°°“√∑“ß«‘∑¬“»“ µ√å À≈—°°“√¢Õß°“√
«‘®—¬ ·≈–À≈—°°“√∑“ß«‘™“ ∂‘µ‘
4. ºŸ∑â ”«‘®¬— µâÕß¡’§«“¡¢¬—πÕ¥∑π·≈–´◊ÕË —µ¬å
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1. µâÕß¡’§«“¡§‘¥ √â“ß √√§å
µâ Õ ß«‘ ‡ §√“–Àå — ß ‡°µ ‘Ë ß √Õ∫µ— « ‡æ◊Ë Õ π”¡“µ—È ß
§”∂“¡π” Ÿà°“√«‘®—¬ ¥—ßµ—«Õ¬à“ß∑’Ë ”§—≠√–¥—∫‚≈°
§◊ Õ ‡√◊Ë Õ ß‡≈à “ ‡°’Ë ¬ «°— ∫ °“√ — ß ‡°µ¢Õß·Õª‡ªîô ≈ ¢Õß
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µ“¡¢âÕ‡ πÕ·π–
4. ‡¢’¬π∫∑§«“¡‡ √Á®·≈⫵âÕßÕà“π∑∫∑«π
‚¥¬Õà“π¥â«¬µπ‡Õß°àÕπ ·≈–Õ“®„À⺟⇙’ˬ«™“≠„π
“¢“‡¥’ ¬ «°— π Õà “ π∑∫∑«π‡æ◊Ë Õ ¢Õ§”·π–𔵓¡
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§◊Õ§«“¡√Ÿâ∑“ß¿“…“·≈–«“√ “√»“ µ√å
°‘µµ‘°√√¡ª√–°“»
ºŸπâ æ‘ π∏å¢Õ‡ πÕ°‘µ°‘ √√¡ª√–°“»§◊Õ Professor
Singhal ª√–‡∑»Õ— ß °ƒ… ·≈– Professor Dow
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Vol. 7 No.1
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76 « “ √ “ √ Õ “ ¬ÿ √ » “ µ √å Õ’ “ π
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IJM
Vol. 7 No.1
§”·π–π” ”À√—∫ºŸâ‡¢’¬π∫∑§«“¡
✬ «“√ “√Õ“¬ÿ√»“ µ√åÕ’ “π‡ªìπ«“√ “√∑’Ë¡’«—µ∂ÿª√– ߧåÀ≈—°‡æ◊ËÕ‡ªìπ°“√ à߇ √‘¡°“√»÷°…“µàÕ‡π◊ËÕߢÕß·æ∑¬å
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article, mortality-morbidity conference, arterial blood gas conference, ECG conference electrolyte,
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π—Èπ‡¡◊ËÕ¡’°“√‡¢’¬π∂÷ߧ”π—ÈπÕ’° „Àâ„™âÕ—°…√¬àÕ·∑π
✬ Topic review §◊Õ∫∑§«“¡∑’Ë¡’≈—°…≥–°“√∑∫∑«π«√√≥°√√¡µà“ßÊ Õ¬à“ß ¡∫Ÿ√≥å„π‡√◊ËÕßπ—È𠧫√‡ªìπ‡√◊ËÕß
∑’Ëæ∫∫àÕ¬ ¡’º≈µàÕ°“√¥Ÿ·≈√—°…“¡“°À√◊Õ‡ªìπ‡√◊ËÕß∑’Ë°”≈—ßÕ¬Ÿà„𧫓¡ π„®„π¢≥–π—Èπ ‡æ◊ËÕ‡ªìπ°“√∑∫∑«π
Õߧ姫“¡√Ÿâ∑’Ë¡’Õ¬Ÿà„À⥒¢÷Èπ
✬ Recent advances §◊Õ∫∑§«“¡∑’Ë¡’§«“¡‡©æ“–§àÕπ¢â“ß Ÿß ·≈–¡’¢âÕ¡Ÿ≈∑“ß°“√·æ∑¬å„À¡à ‡æ◊ËÕ„À⺟âÕà“π‰¥â√—∫
∑√“∫§«“¡√Ÿâ„À¡à„π‡√◊ËÕßπ—Èπ
✬ Interesting case §◊Õ√“¬ß“πºŸâªÉ«¬∑’Ë¡’§«“¡πà“ π„®„π¥â“πµà“ßÊ ´÷ËßÕ“®‡ªìπºŸâªÉ«¬∑’Ëæ∫∫àÕ¬ À√◊ÕºŸâªÉ«¬
∑’Ëæ∫‰¥â ‰¡à∫àÕ¬ ·µà¡’§«“¡πà“ π„® ‡æ◊ËÕ„À⺟âÕà“π‰¥âµ√–Àπ—°∂÷ß‚√§À√◊Õ¿“«–¥—ß°≈à“« Õ—π®–𔉪 Ÿà°“√¥Ÿ·≈
√—°…“ºŸªâ «É ¬∑’¥Ë ¢’ π÷È µàÕ‰ª
✬ Original article §◊Õ°“√𔇠πÕº≈ß“π«‘®—¬¢Õß·æ∑¬åª√–®”∫â“π ·æ∑¬åºŸâ„Àâ —≠≠“ ·æ∑¬åµàÕ¬Õ¥ Õ“®“√¬å
·æ∑¬å ¿“§«‘™“Õ“¬ÿ√»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ °≈ÿà¡ß“πÕ“¬ÿ√°√√¡‚√ß欓∫“≈»Ÿπ¬å
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✬ Mortality-Morbidity conference §◊Õ°“√ √ÿª√“¬ß“πºŸâªÉ«¬∑’Ëπà“ π„®·≈–‡ ’¬™’«‘µ √«¡∑—ÈßÕ“®¡’¢âÕº‘¥æ≈“¥
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✬ Arterial blood gas, electrocardiography (ECG) ·≈– electrolyte conference §◊Õ°“√ √ÿªºŸâªÉ«¬∑’ˉ¥â√—∫
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2. °“√‡¢’¬π‡Õ° “√Õâ“ßÕ‘ß„Àℙⵓ¡·∫∫¢Õß Uniform Requirements for Manuscripts Submitted to Biomedical
Journals (JAMA 1993; 269: 2282-6.)
3. ™◊ËÕ¬àÕ¢Õß«“√ “√„Àℙⵓ¡ Index Medicus
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µ‘¥µàÕ àß∫∑§«“¡‡æ◊ËÕµ’æ‘¡æå∑’Ë . . .
IJM
1. «“√ “√∑—Ë«‰ª
™◊ËÕºŸâ·µàß. ™◊ËÕ∫∑§«“¡. ™◊ËÕ«“√ “√ ªïæ‘¡æå; ªï∑’Ëæ‘¡æå: Àπâ“·√°-Àπâ“ ÿ¥∑⓬.
π≈‘π∑‘æ¬å µ”π“π∑Õß. °“√»÷°…“™—°π”°√–· ª√– “∑¢Õ߇ âπ¡’‡¥’¬π·≈–Õ—≈πà“. »√’π§√‘π∑√凫™ “√ 2529;
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Scully RE. Gonadoblastoma : a review of 74 cases. Cancer 1970; 25: 1340-56. „π°√≥’∑’˺Ÿâ‡¢’¬π
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2. Àπ—ß ◊Õ
™◊ËÕºŸâ·µàß. ™◊ËÕÀπ—ß ◊Õ. ∂“π∑’Ëæ‘¡æå : ”π—°æ‘¡æå, ªï∑’Ëæ‘¡æå.
«‘π—¬ ÿµ∂’, ¡πµ√’ µŸâ®‘π¥“. ¿“«–©ÿ°‡©‘π∑“ß°ÿ¡“√‡«™»“ µ√å. °√ÿ߇∑æœ: ∫’ ‡Õø ‰Õ, 2522.
Ellenberger C.Perimetry: principles, technique and interpretation. New York: Raven Press, 1980.
3. ∫∑„πÀπ—ß ◊Õ
™◊ËÕºŸâ‡¢’¬π. ™◊ËÕ∫∑„πÀπ—ß ◊Õ. „π : ™◊ËÕ∫√√≥“∏‘°“√. ™◊ËÕÀπ—ß ◊Õ. ∂“π∑’Ëæ‘¡æå : ”π—°æ‘¡æå. ªï∑’Ëæ‘¡æå:
Àπâ“·√°-Àπâ“ ÿ¥∑⓬.
°‘®®“ ‘π∏«“ππ∑å. ∫“¥‡®Á∫∑’Ë°√–‡æ“–Õ“À“√·≈–¥Ÿ‚Õ¥’π—Ë¡. „π: ‡ª√¡ ∫ÿ√’, ∑Õߥ’ ™—¬æ“π‘™, ∫°.‡™‘ߪؑ∫—µ‘°“√
°“√∫“¥‡®Á∫. °√ÿ߇∑æœ: ”π—°æ‘¡æå °√ÿ߇∑æ¡À“π§√, 2520: 70-3.
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1974-1976.
«“√ “√
ISSN 1685 3091
«“√ “√Õ“¬ÿ√»“ µ√åÕ’ “π
ë
ë Dermatologic Adverse Effects of
Antiretroviral Therapy
ë Diagnostic Test for Latent TB Infection
ë Abdominal Pain with Hypertension
ë ‚√§∫“¥∑–¬—°„π‚√ß欓∫“≈Õÿ¥√∏“π’
ë Stroke in the Young in Udonthani
Hospital
ë °“√»÷°…“ “‡Àµÿ¢Õߧ«“¡‰¡à√à«¡¡◊Õ„π°“√„™â¬“
¢ÕߺŸâªÉ«¬‚√§≈¡™—°
ë Fast Track Acute STEMI „π‚√ß欓∫“≈
¡À“√“™π§√√“™ ’¡“
ë Tetanus
ë Arrythmia in COPD and Bronchiectasis
Patient
ë Dyspnea in Patient with Bronchiectasis
ë Bone Pain and Hyperchloremic
Metabolic Acidosis
ë How to Success in International
Publication
ªï∑’Ë 7 ©∫—∫∑’Ë 1 ¡°√“§¡ - ¡’π“§¡ 2551
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