Chulalongkorn Medical Journal

Primary biliary cholangitis in Thai woman: A case report

Likhasit Sanglutong — 2019-11-12

Primary biliary cholangitis or primary biliary cirrhosis (PBC) is a chronic, slowly progressive, autoimmune,
cholestatic liver disease. It is globally considered a rare disease. Herein, we presented a 55-year-old Thai woman
who gradually developed fatigue and generalized pruritis without fever for four months. Her physical examination
revealed only pallor and jaundice, no liver stigmata, and no hepatosplenomegaly; her blood tests showed:
Hb 8.1 g/dL, WBC 12,180/mm3, platelet 143,000/mm3, albumin 2.2 g/dL, globulin 4.0 g/dL, AST 164 U/L, ALT
102 U/L, alkaline phosphatase 384 U/L, total bilirubin 2.8 mg/dL, direct bilirubin 1.3 mg/dL, HBV, HCV and HIVnegative, ferritin 39.9 ng/ml, copper 125 ug/dL, ceruloplasmin 0.27 g/L, urine copper < 1 ug/g creatinine, antismooth muscle antibody-negative, anti-mitochondrial antibody-positive 1:1,600, ANA-positive, homogeneous
pattern 1:80, centromere pattern 1:1,280, anti-cytoplasmic antibody-positive 1:1,280, alpha fetoprotein 3.16 ng/ml,
creatinine 0.55 mg% and normal coagulogram. The ultrasonography and the computerized tomography of the
upper abdomen showed nodularity and heterogeneous parenchymal disease of the liver, no intrahepatic bile duct
dilatation, and slight splenomegaly, compatible with cirrhosis. The esophagogastroduodenoscopy showed acute
esophageal variceal bleeding that was successfully treated with the rubber band ligation. The diagnosis of PBC
was concluded and she was treated with ursodeoxycholic acid and propranolol. Within 6 months, her clinical
symptoms as well as transaminitis partially improved.

Workplace violence in convenience stores

Piyapat Pandee — 2019-11-12

Workplace violence is a problem that can occur in any occupation and at any operational level. Each occupation
has different levels of risks depending on factors including personal factors (i.e. workers and service users),
temporal factors and location factors. In all workplaces, convenience stores are considered one of the top places
with frequent violence. Partially, this is because there are many factors different from other workplaces. Those
factors may lead to violence and crimes such as verbal harassment, physical harms, robbery, and murder. The
mentioned violence does not only have direct physical effects but also has short-term and long-term mental effects as well as economic and social effects. This article presents the extensive review of the violence at convenience stores. Its contents consist of the introduction, the definition of the workplace violence, the sizes of the violence at the convenient stores, the effects from the workplace violence, the factors of the violence at the convenient stores and relevant studies about the convenient stores in Thailand, and conclusion.

Chulalongkorn Medical Journal Launches ScholarOne Online Submission Platform

Sittisak Honsawek — 2019-11-12

Happy New Year and welcome to 2020! This year marks my forth year as the Editor-in-Chief for Chulalongkorn Medical Journal (Chula Med J) and it has been a privilege to serve you. Along with this privilege comes the responsibility to assure that this journal keeps pace with the expeditious development in the field of biomedical science and medicine while maximizing its impact and efficiency. It is my great pleasure to report that Chula Med J has continued to do well in 2019.

In early this year, Chula Med J launches an online manuscript submission, review, and tracking system via utilizing the ScholarOne Manuscripts platform. It is anticipated that the use of this new system will result in more efficient review of manuscripts submitted to Chula Med J. This new online manuscript submission, tracking, and review system should reduce the amount of time that manuscripts are under review and improve an author’s ability to check the status of a submitted manuscript.

Sleep quality and associated factors of patients with mild cognitive impairment at King Chulalongkorn Memorial Hospital

Isara Akarapornprapa — 2019-11-12

Background: Thailand has shifted into aging society. Sleep disturbance is a common problem in the elderly
which affects emotion and cognitive level. Awareness of sleep problems can help implementing in the elderly
care and preventing dementia in the future.

Objective: To study sleep quality and determine factors associated with sleep quality among patients with mild
cognitive impairment (MCI).

Methods: The cross-sectional descriptive study was conducted in MCI patients, aged 50 years and above, from
psychiatric outpatient clinic and cognitive fitness center. The data were collected by questionnaires including
demographic data and sleep environment questionnaires; Pittsburgh Sleep Quality Index (PSQI); Sleep Hygiene
Index (SHI); STOP-Bang questionnaire; Thai Mental State Examination (TMSE); Montreal Cognitive Assessment
(MoCA); Thai Geriatric Depression Scale (TGDS) and Neuropsychiatric Inventory Questionnaire (NPI-Q).
The sleep quality was presented by frequency and percentage. The associated factors were analyzed by
Chi-square test, Fisher’s exact test, and Pearson’s correlation coefficient. The predictors of poor sleep quality were
analyzed by multiple logistic regression analysis.

Results: Of the 100 subjects, 65 were female with the mean age of 71.3 7.5 years old: 64% of them had poor
sleep quality. The associated factors of sleep quality were having history of psychiatric disorders, use of
sedating psychotropic drugs, low to moderate sleep hygiene and anxiety domain of neuropsychiatric symptoms.
TGDS and STOP-Bang score were correlated with PSQI score (r = 0.215 and 0.230 respectively). The predictors
of poor sleep quality were the use of sedating psychotropic drugs (P < 0.01), low to moderate sleep hygiene
(P < 0.05) and anxiety domain of neuropsychiatric symptoms (P < 0.05).

Conclusion: The prevalence of poor sleep quality in MCI patient was 64%. The associated factors and predicted
factors of poor sleep quality were the use of sedating psychotropic drugs, low to moderate sleep hygiene and
anxiety domain of neuropsychiatric symptoms. Therefore, sleep quality should be screened in patients with MCI
due to the high prevalence.

A simple and rapid molecular detection of Staphylococcus aureus strain B using multiplex PCR

Fatemeh Sheikhi — 2019-11-12

Background: Staphylococcucs aureus (S. aureus) is one of the most important and pathogenic species from
Staphylococcaceae family. S. aureus is capable produced several enterotoxins (SEs) that classified in different
groups from A-R.

Objective: The present study aimed to set up simple and rapid detection of S. aureus strain B to develop a multiplex. polymerase chain reaction (PCR) assay for identification of genus and strain B of this bacteria.

Methods: In this work, after designing of specific primers for 23S rRNA and SEB, one step multiplex PCR was
carried out and the PCR product analyzed by agarose gel electrophoresis. The specificity of this method was
determined using different strains of S. aureus A (SEA), S.aureus C (SEC), Bacillus subtilis, Bacillus cereus, and
Listeria monocytogenes. Also, the sensitivity was distinguished by serial dilution of DNA genome from S. aureus.

Results: The PCR product was indicated at 226 and 1,250 bp specific amplified fragments according to amplification of SEB and 23SrRNA, respectively. The sensitivity of this method determined about 2 10³ CFU/ml and also the results showed that according to specific primers, the PCR is very specific.

Conclusion: This multiplex PCR assay can be used like a simple diagnostic test in clinical laboratories for identification of S. aureus.

Bipolarity among pregnant women at King Chulalongkorn Memorial Hospital and relationship with depression score during pregnancy and postpartum periods

Ratsamimarn Siripalanon — 2019-11-12

Background: Previous studies demonstrated associations between bipolarity and perinatal depression.
However, there is still no study in this issue in Thailand.

Objectives: To examine the prevalence of bipolarity and associations with depressive symptoms during pregnancy
and postpartum periods.

Methods: We recruited 165 pregnant women who were in their third trimester (gestational age 28 weeks).
The self-rated questionnaires used include The Edinburgh Postnatal Depression Scale (EPDS) - Thai version,
Mood Disorder Questionnaire scales (MDQ) - Thai version, The Personal Resource Questionnaire (PRQ)-
Part II and The Dyadic Adjustment Scale (DAS). Then we followed up EPDS score at 2 - 7 days after delivery.
Univariate and multivariate statistics were used to examine the associated factors of bipolarity.

Results: The prevalence of bipolarity was 3%. Unemployment, inadequacy of income, history of lifetime smoking,
and smoking during pregnancy, were found to be significantly associated with bipolarity (P < 0.05). Bipolarity
was also associated with lower PRQ score (assistance and guidance subscale) and lower marital satisfaction
score (dyadic cohesion subscale) (r = 0.507, P < 0.05). Moreover, bipolarity was also associated with higher
EPDS total score during pregnancy, and in the item of anxiety/ worry, sad/ miserable, crying, and suicidal thought,
lower PRQ score (social integration subscale), lower marital satisfaction score (dyadic satisfaction subscale),
higher marital satisfaction score (dyadic consensus subscale) when compared to those without bipolarity (P < 0.01).

Conclusions: The prevalence of bipolarity in this study is somewhat higher than in the general population.
Bipolarity was significantly associated with substance abused during pregnancy, poorer functions (work/ financial), higher severity of antenatal depression, especially in the symptoms of anxiety/ worry, sad/ miserable, crying, and suicidal thought. They also significantly have lower social support and lower marital satisfaction when compared to those without bipolarity.

Incidences and characteristics of monkey-related injuries among locals and tourists in Mueng District, Lopburi Province, 2013 - 2017

Anothai Juttuporn — 2019-11-12

Background: Conflicts between monkeys and humans are increasing, mainly because of urbanization and deforestation. Mueng district of Lopburi Province is one of the greatest conflict areas in Thailand, where public
health concerned of zoonoses transmission from monkey - bites and scratches are high. Currently, there is no
epidemiological research of monkey-related injuries in Thailand.

Objectives: The purposes of this study were to determine incidence of monkey-related injuries and investigate
trends and characteristics of the injured cases in Mueng District, Lopburi Province, in 2013 - 2017.

Methods: A cross - sectional analytical study was conducted to compare monkey-related injuries and investigate
the incidences between locals, Thai, and foreign tourists by collecting secondary data from medical records in
3 hospitals in the study area. The cumulative incidences were used to calculate relative risk between the tourists
and the locals. Characteristics of the injury cases are presented by frequency and percentage.

Results: Yearly incidences of locals, Thais, and foreign tourists were in range of 9.16 - 18.33, 190.16 - 379.13, and
254.07 – 736.91 per 100,000 population, respectively. The trend of injury was remarkably increased in foreign
tourists. Recently, in 2016 - 2017, Thai and foreign tourists had relative risks of injury estimated as 20 and 40 times
compared to that of the local, respectively. Time, place and circumstance of injury, and wound site suggested
monkey provisioning with food as the main risk factor of monkey-related injuries.

Conclusion: The incidences of monkey-related injury was highest in foreign tourists, followed by Thai tourists.
Preventive measures should primarily focus on the tourists, such as training on safety behaviors with monkey,
promoting pre- and post-exposure prophylaxis, and providing safeguards, warning signs, first aids stations at
monkey provisioning sites.

Personality change and associated factors in patients with mild cognitive impairment

Chawin Promchaiwattana — 2019-11-12

Background: Previous studies have shown that a history of personality change might guide to the diagnosis of
early mild cognitive impairment (MCI), which would lead to early treatment and better outcome of dementia.

Objectives: To investigate personality change and other factors associated with MCI.

Methods: This cross-sectional descriptive study was conducted by recruiting information from 83 patients with
MCI at King Chulalongkorn Memorial Hospital by using Thai version of questionnaires about demographic
data, Thai Mental State Examination (TMSE), Montreal Cognitive Assessment (MoCA), Thai Geriatric Depression
Scale, Neuropsychiatric Inventory Questionnaire (NPI-Q) and International Personality Item Pool (IPIP).
The patients’ caregivers were also asked to evaluate the patients’ personality during the prior 5 years before
the diagnosis and their current personality. The statistical analyses were frequency, percentage, mean and t - test.
Analysis of factors correlated with personality change was performed with logistic regression.

Results: Eighty-three patients were included, showing the mean age of 72.1 7.1 years old with 61.4% of
them were female. The mean TMSE was 27.6 1.9 and the mean MoCA was 21.6 3.1. Personality change
in patients with MCI showed a statistically significant increase in neuroticism and a decrease in openness to
experience, agreeableness and conscientiousness (P < 0.05). There was a negative correlation between
emotional stability, agreeableness, and NPI-Q (r = - 0.442 and - 0.227) (P < 0.001 and P = 0.039). A positive
correlation between extraversion and MoCA was found (r = 0.336) (P = 0.002). Neuroticism was detected to have
a correlation with the neuropsychiatric symptoms (NPS), including irritability, anxiety, depression, apathy, disinhibition, and agitation. There was a significant correlation between agreeableness and NPS (apathy) (P < 0.05).

Conclusions: Our findings suggested that there was personality change in MCI patients, featuring an increase
in neuroticism, openness to experience, agreeableness and a decrease in extraversion and conscientiousness.
Extraversion was found to be positively correlated with cognitive functions and there was a positive and negative
correlation with NPS among neuroticism and agreeableness, respectively.

Volumetric kinetic assessment in dynamic contrast enhanced-MRI (DCE-MRI) of breast cancer: A new method for evaluation of whole tumor enhancing pattern

Jatuporn Chayakulkheeree — 2019-11-12

Background: At present, dynamic contrast enhancement-MRI (DCE-MRI) has immense role in diagnosis and
evaluation extent of breast cancer. As for diagnosis, evaluation pattern of kinetic enhancement in dynamic
contrast study is performed after gadolinium injection. Since each breast cancer has internal pathophysiological
variety, the kinetic enhancement patterns are supposed to be varied within each mass as well.

Objective: This study aimed to investigate characteristics and additional value of volumetric analysis of kinetic
enhancement patterns on DCE-MRI in evaluating breast cancer in Thai patients.

Methods: We retrospectively studied 52 women, 67 lesions which were histologically proven breast cancer,
using software of breast MRI and generating 3D volumetric voxels covered total tumor volume in DCE-MRI
which performed between January 2014 and December 2017. Measurement of enhancement pattern was categorized by software into percentage of part of tumor which enhanced in each pattern. Consequently, percentages of enhancement in different types were collected which allocated in type I (persistent), type II (plateau) and type III (washout) enhancements. Analysis of the kinetic pattern was done together with subgroup analysis of each type of tumor (IDC, DCIS and other subtypes of breast cancer) as well as tumor grades.

Results: The mean percentages of enhancement pattern in kinetic assessment by 3D voxels of tumor volume
showed the most common 72% type I enhancement, followed by 14.3% type III enhancement and 13.7% type II
enhancement. Subgroup analysis showed similar higher type I enhancement in both IDC (68.3%) and DCIS
(81.3%). However, there were slightly higher suspicious malignant pattern of enhancement (31.7% type II and
18.7% type III enhancements) in IDC more than DCIS as well as in high tumor grade (grade 3) more than low
tumor grade (grade 1) (37% type II and 30.7% type III enhancements), but there were no significant differences.

Conclusion: Volumetric analysis showed heterogeneity of kinetic curve enhancement patterns inside each tumor.
That means each tumor has a variety of enhancement patterns in itself and dissimilarity with others. The majority
of pattern was found as type I enhancement which was not particular for malignant, whereas there was only 28%
with suspicious kinetic enhancement patterns (type II and type III enhancements). The slightly higher suspicious
malignant pattern of enhancement (type II and III enhancements) in IDC more than DCIS along with high tumor
grade was observed, deprived of statistical significance.

Accuracy of ultrasound-guided vacuum-assisted fineneedle aspiration for diagnosis and management of BI-RADS 4 lesion

Somchanin Pipatpajong — 2019-11-12

Background: Breast imaging-reporting and data system (BI-RADS) 4 lesion is in the category of suspicion for
malignancy which has to be managed with core needle biopsy as specified in the standard guideline. Nonetheless,
at King Chulalongkorn Memorial Hospital, an ultrasound-guided vacuum-assisted fine-needle aspiration (FNA)
is performed in some cases of BI-RADS 4 lesion because it has been considered a simple and cost-effective tool
for managing breast lesion in previous study.

Objectives: This study aimed to evaluate the accuracy of an ultrasound-guided vacuum-assisted fine-needle
aspiration in the diagnosis and management of BI-RADS 4 lesion.

Methods: A retrospective review was conducted on 251 female patients with BI-RADS 4 lesion who underwent
an ultrasound-guided vacuum-assisted FNA, together with a subsequent procedure of either surgical biopsy or
follow-up imaging for at least 2 years at King Chulalongkorn Memorial Hospital from January 2011 to December
2013. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the study
data were evaluated. Also, the underestimation rate of unsatisfactory samples (C1) was calculated.

Results: The sensitivity, specificity, PPV and NPV for ultrasound-guided vacuum-assisted FNA were 72.73%
(95%CI: 67.22 - 78.24%), 98.07% (95%CI: 96.36 - 99.77%), 88.89% (95%CI: 85.0 - 92.78%) and 94.42% (95%CI:
91.58 - 97.26%) respectively. Sixteen patients with discordant lesions between FNA cytology and surgical
pathology were found; 4 of them (1.9%) were false positives and 12 (27.3%) were false negatives. Among
71 patients with unsatisfactory samples (C1), 67 cases (94.4%) showed benign results, while 4 cases (5.6%)
showed malignant results.

Conclusion: An ultrasound-guided vacuum-assisted FNA is a reliable diagnostic tool for BI-RADS 4 lesion.
However, there are some limitations that may cause false negative, especially in the case of a very small lesion,
an inexperienced performer along with other uncontrollable factors e.g. heterogeneity type of a tumor. Therefore,
subjects should be properly selected to prevent an error.

Oblique direction reach test: a pilot test to measure limits of stability in oblique direction and its psychometric properties

Jaya Shanker Tedla — 2019-11-12

Background: Activities of daily living require balance in oblique direction and persons with neurological
disorders have balance issues in oblique direction for performing functional tasks. There is dearth of literature
for assessing dynamic balance in oblique direction.

Objectives: To establish and report reference values for oblique direction reach test and to assess the validity
and reliability of the oblique direction reach test in Saudi young adults.

Methods: Two hundred and six medical students (120 males, 86 females) were recruited by random sampling for
this study. Subjects had been measured for distance reached oblique, forward, lateral direction on a graph paper,
which was mounted on a white board.

Results: The mean and standard deviation for oblique direction reach was 22.06 7.17 cm. A positive correlation
was observed between oblique reach and height with r - value of 0.56 (P < 0.01). The intra and inter-rater reliability
shown with intraclass correlation coefficiency value of 0.97 and 0.86, respectively (P < 0.001). Concurrent
validity with forward reach test and lateral reach test shown with r - value of 0.78 and 0.73, respectively (P < 0.01).

Conclusion: We established the normal values for oblique direction reach test in Saudi young adults. This test
is valid and reliable for measuring limits of stability in oblique direction.

Effect of board games to enhance visuospatial working memory in preschool children in Foundation for Children

Thawanrat Sriwilas — 2019-11-12

Background: Working memory impairment is a risk factor predicting learning difficulties in children, particularly, visuospatial working memory was found to be associated with mathematical skills and concentration.
Objective: This study aimed to develop board games to train visuospatial working memory in preschool children to prepare them for school.
Methods: Thirty children aged 4 - 6 years in the Foundation for Children were divided into experimental and control groups (n = 15 per group). A simple random sampling was conducted to assign the children into each group. Corsi block-tapping test was administered to assess visuospatial working memory. The scores were retrieved from block span test (the number of block longest correct sequence); children with scores between 2.63 to 4.63 were in normal range. Within two months, the children in the experimental group obtained 10 – 30 minutes board games training twice a week.
Results: The mean of visuospatial working memory scores after having received board game training to improve visuospatial working memory among the children in the experimental group was significantly higher than that of the pre-training scores (P < 0.01) and also higher than in the control group (P < 0.01).
Conclusions: Board games effectively improved visuospatial working memory in preschool children, which would positively influence their learning performance in school.

Effects of a self-efficacy enhancement program on recurrence prevention behaviors among patients with urolithiasis

Kanokporn Trongmatee — 2019-11-12

Background: Patients with urolithiasis have inappropriate recurrence prevention behaviors caused by lack of
confidence in performing behaviors, thereby causing increased recurrence of the disease. As a nurse, the researcher plays a major role in promoting recurrence prevention behaviors among patients using a self-efficacy enhancement program.
Objective: To study the effects of the self-efficacy enhancement program on recurrence prevention behaviors
among patients with urolithiasis.
Methods: This study recruited 50 subjects aged 18 – 59 years who had been diagnosed with urolithiasis and received their surgery at King Chulalongkorn Memorial Hospital. The subjects were selected based on set inclusion criteria and assigned to experimental and control groups. The control groups received conventional care while the experimental groups attended a four-week self-efficacy enhancement program.
Results: The mean score on recurrence prevention behaviors of the control and experimental groups was 53.36 3.70 and 61.76 3.55 respectively. Therefore, the mean score on recurrence prevention behaviors of patients with urolithiasis in the experimental group who attended the self-efficacy enhancement program were significantly higher than the control group who received conventional care (P < 0.05).
Conclusion: The self-efficacy enhancement program was able to improve knowledge of recurrence urolithiasis
prevention behaviors.

Effects of family members’ empowerment program on family members’ food preparing behaviors for elderly diabetic patients

Jintana Attaprajong — 2019-11-12

Background: The lose power of family members which leads to inappropriate food preparations behaviors for
elderly diabetics. As a result, older people with diabetes control the blood sugar level more difficult. Empowering
family members in the appropriate food preparations behavior will help elderly diabetes patients have the right
dietary behavior, while enabling normal control of the progression of the disease to normal conditions.
Objective: To study the effects of a family member empowerment program on family members’ food preparation
behaviors for elderly diabetic patients.
Methods: The subjects were family members aged 25 - 59 years who performed the main duty of preparing food
for elderly diabetic patients, with 33 people in each group. Data collection tools are three questionnaires and
empowerment program administered over a period of six weeks.
Results: The program contributed to higher mean scores for the food preparation behavior of family members
who were caregivers for elderly diabetic patients in the experimental group than in the control group. Furthermore, the experimental group had significantly higher mean posttest scores than pretest scores, while there were no differences in the pre- and posttest mean scores for the food preparation behaviors in the control group.
Conclusions: The empowerment program received by the family members of elderly diabetic patients gave
family members of elderly diabetic patients’ self-confidence and feelings of being empowered to prepare appropriate foods for elderly diabetic patients.

Subjective well-being, self-esteem, and attitude towards imagined couples of yaoi fangirls in Thailand

Nynah Thanartatnattanon — 2019-11-12

Background: A number of studies on yaoi fangirls, who are interested in homoromantic/ homoerotic relationship
between men, is increasing all over the world, but there are only few studies of mental health on yaoi fangirls in
Thailand.
Objectives: To study subjective well-being, self-esteem, and attitude towards imagined couples of yaoi fangirls,
and to determine factors associated with subjective well-being of yaoi fangirls in Thailand.
Methods: A cross-sectional descriptive study was conducted among literate Thai yaoi fangirls, aged from 18-yearold in August 2018. The instruments were online questionnaires, consisting of general information, Imagined
Couple Attitude Scale, Self-esteem Inventory, and Thai Happiness Indicator (THI-15). Statistics used to analyze
data were descriptive statistics, Chi-square test, Pearson correlation, One-way ANOVA, logistic regression, and
multiple linear regression.
Results: Of the total 1,745 participants, 70.5% had their attitude towards imagined couples categorized as moderate level of imagined couple worship, 46.6% had moderate self-esteem, and 38.8% were as happy as general Thai population. There was a strong positive correlation between self-esteem and subjective well-being (r = 0.745,
P < 0.001), while low negative correlations were found between attitude towards imagined couples and self-esteem
and subjective well-being. Of all other factors, self-esteem seemed to be the major one that can explain the 55.5%
of the variance in subjective well-being.
Conclusion: Most of yaoi fangirls in Thailand were found to have normal level of imagined couple worship, selfesteem, and subjective well-being. Self-esteem was a factor that could predict subjective well-being and attitude towards imagined couples. The results of this study would be beneficial for understanding yaoi fangirls in Thailand, and providing the appropriate care.