Thammasat Medical Journal - 10 vol 1 by Faculty Medicine Thammasat University

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

Thammasat Medical Journal Vol. 10 No. 2. April-June 2010

“√∫—≠ ∫√√≥“∏‘°“√·∂≈ß

Contents

93 Editor’s Note

∫∑∫√√≥“∏‘°“√√—∫‡™‘≠ ¡À¿“§ = ¡À—æ¿“§ °âÕß‡°’¬√μ‘ °Ÿ≥±å°—π∑√“°√ ¡™—¬ ∫«√°‘μμ‘

π‘æπ∏åμâπ©∫—∫ §«“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘° ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å «‘π‘∑√“ π«≈≈–ÕÕß

Guest Editorial

Kongkiat Kulkantrakorn Somchai Bovornkitti Original Articles

95 Stress in medical students of Thammasat University Winitra Nuallaong

°”‡π‘¥æ¬“∏‘¢Õß‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π æ‘∏“ æ√À¡≈‘¢‘μ™—¬

103 Pathogenesis of acute coronary syndrome (ACS) Pitha Promlikitchai

≈—°…≥–‡«™°√√¡·≈–º≈°“√μ√«® “√πÈ”‰¢ —πÀ≈—ß „π‡¥Á°∑’Ë¡’¿“«–‰¢â·≈–™—°„π‚√ßæ¬“∫“≈∏√√¡»“ μ√å ‡©≈‘¡æ√–‡°’¬√μ‘ ¬ß¬ÿ∑∏ ™ÿà¡§”≈◊Õ ÿ¥“∑‘æ¬å º“μ‘™’æ ÿ¥“ ®‘√ °ÿ≈‡¥™

117 Clinical characteristics and cerebrospinal fluid profiles in children presenting with fever and seizure at Thammasat University Hospital Yongyuth Chumkomlue Sudathip Paticheep Suda Jirasakuldej

ªí®®—¬∑’¡Ë º’ ≈μàÕ§«“¡√à«¡¡◊ÕºŸªâ «É ¬‡∫“À«“πª√–‡¿∑∑’Ë Ú 125 Factors influencing to compliance of type II diabetic patients æÿ¥ ¡æß «’‰≈ ÿ√»—°¥‘Ï ∫Ÿ√≥μ√’‡«∑¬å Phoutsomphong Vilay «‘»√’ «“¬ÿ√°ÿ≈ Surasak Buranatrevedh Wisree Wayurakul ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—Ëπ·≈–Õß§åª√–°Õ∫∑“ß‡§¡’¢Õß ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿåæ◊Èπ‡¡◊Õß¢Õß‰∑¬ ‡©≈‘¡ ®—π∑√å ¡ °ÿ≈ ¡Ÿ≈§” «π‘¥“ ®—π∑√å ¡ ‡Õ° ‘∑∏‘Ï °ÿ≈§Ÿ °√≥å°“≠®πå ¿¡√ª√–«—μ‘∏π–

136 Antioxidant activity and chemical constituents in purple glutinous rice Thailand local genotypes Chalerm Jansom Sakul Moolkam Vanida Jansom Ekasith Skulkhu Kornkarn Bhamarapravatana

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

“√∫—≠ π‘æπ∏åμâπ©∫—∫

Thammasat Medical Journal Vol. 10 No. 2. April-June 2010

Contents

Original Articles

°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥¢ÕßºŸâªÉ«¬‡¥Á°„π 144 Bactermia in pediatric patients in Thammasat University Hospital ‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ Supawut Suksantilirs »ÿ¿«ÿ≤‘ ÿ¢ —πμ‘‡≈‘» Auchara Tangsathapornpong Õ—®©√“ μ—Èß ∂“æ√æß…å Pornumpa Bunjoungmanee æ√Õ”¿“ ∫√√®ß¡≥’ °“√æ‘®“√≥“∑∫∑«π¢âÕ¡Ÿ≈°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬ 153 Reconsideration of occupational injuries and illness of Workerûs Compensation Fund in ‡π◊ËÕß®“°°“√∑”ß“π: ¢âÕ¡Ÿ≈®“°°Õß∑ÿπ‡ß‘π∑¥·∑π„π Thailand ª√–‡∑»‰∑¬ Suttipat Wongvitvichot ÿ∑∏‘æ—≤πå «ß»å«‘∑¬å«‘‚™μ‘ Pornchai Sithisarankul æ√™—¬ ‘∑∏‘»√—≥¬å°ÿ≈ Surasak Buranatrevedh ÿ√»—°¥‘Ï ∫Ÿ√≥μ√’‡«∑¬å §ÿ ≥ ¿“æ™’ «‘ μ ·≈–ªí ≠ À“°“√πÕπÀ≈— ∫ ¢ÕßºŸâ ªÉ « ¬‚√§ 165 Quality of life and sleep-related problems in patients with Parkinsonûs disease at Thammasat æ“√å°‘π —π„π‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ University Hospital ª√–«’≥ ‚≈àÀå‡≈¢“ Praween Lolekha °âÕß‡°’¬√μ‘ °Ÿ≥±å°—π∑√“°√ Kongkiat Kulkantrakorn

∫∑§«“¡ª√‘∑—»πå

Review Articles

“√‰ø‚μ‡Õ ‚μ√‡®π°≈ÿà¡‰Õ‚´ø≈“‚«π ·≈–º≈∑“ß‡«™°√√¡„π¡πÿ…¬å·≈– —μ«å∑¥≈Õß √—μπ“ ∑√—æ¬å∫”‡√Õ

175 Isoflavone phytoestrogens and clinical effects in humans and laboratory animals Ratana Sapbamrer

»‘≈ª°√√¡∫”∫—¥ Û : ªØ‘∫—μ‘°“√ ·≈–°√≥’»÷°…“ ‡≈‘»»‘√‘√å ∫«√°‘μμ‘

182 Art Therapy in Practice Lertsiri Bovornkitti

∫∑§«“¡øóôπ«‘™“ ∫∑∫“∑·æ∑¬å„π°“√¥Ÿ·≈¥â“π®‘μ —ß§¡„π‡¥Á°∑’Ë∂Ÿ° ∑“√ÿ≥°√√¡ »ÿ¿√“ ‡™“«åª√’™“

Refresher Course

188 Role of general practitioner for psychosocial intervention in maltreated child Supara Chaopricha

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

“√∫—≠ ∫∑§«“¡øóôπ«‘™“

Thammasat Medical Journal Vol. 10 No. 2. April-June 2010

Contents

Refresher Course

°“√√—°…“ºŸâªÉ«¬ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß·∫∫ª√–§—∫ 193 Expectant management of severe pre-eclampsia Kitti Krungkraipetch ª√–§Õß °‘μμ‘ °√ÿß‰°√‡æ™√ °≈ÿà¡Õ“°“√Œ’‚¡ø“‚°‰´μ‘° ≈‘¡‚øŒ’ μ‘‚Õ‰´‚μ´‘ æ™√æ√√≥ ÿ√æ≈™—¬

201 Hemophagocytic lymphohistiocytosis Pacharapan Surapolchai

°“√≈â¡„πºŸâ ŸßÕ“¬ÿ πææ≈ ª√–‚¡∑¬°ÿ≈

212 Falls in elderly Noppol Pramodhyakul

‰ø‚∫√¡—¬Õ—≈‡®’¬ «‘™‘μ »ÿ¿‡¡∏“ß°Ÿ√

219 Fibromyalgia Vichit Supamethangkoon Noppol Pramodhyakul

ª°‘≥°–

Miscellaneous

¥ŸÀπâ“ √Ÿâ‚√§ ; ‚√§ÕÕ ‡≈Õ√å-«’‡∫Õ√å-‡√π¥Ÿ π‘æπ∏å æ«ß«√‘π∑√å

230 Osler Weber Rendu disease Niphon Poungvarin

æ®π“πÿ°√¡»—æ∑å·æ∑¬å Õ—°…√ E (μàÕ) §≥–°√√¡°“√®—¥∑”æ®π“πÿ°√¡ »—æ∑å·æ∑¬»“ μ√å √“™∫—≥±‘μ¬ ∂“π

231 English Dictionary of Medical Terms : The Letter E (contd) The Royal Instituteûs Medical Dictionary Committer

®¥À¡“¬∂÷ß∫√√≥“∏‘°“√

238 Letter to the Editor

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

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* §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å ** ”π—°«‘∑¬“»“ μ√å √“™∫—≥±‘μ¬ ∂“π

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

π‘æπ∏åμâπ©∫—∫

§«“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘° ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å «‘π‘∑√“ π«≈≈–ÕÕß

∫∑§—¥¬àÕ «—μ∂ÿª√– ß§å·≈– «‘∏’°“√»÷°…“:

‡æ◊ËÕ»÷°…“√–¥—∫§«“¡‡§√’¬¥·≈–ªí®®—¬∑’Ë°àÕ„Àâ‡°‘¥§«“¡‡§√’¬¥√–¥—∫ Ÿß„ππ—°»÷°…“·æ∑¬å™—Èπ §≈‘π‘° ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å √«¡∂÷ß ”√«®æƒμ‘°√√¡·≈–·π«§‘¥¢Õßπ—°»÷°…“·æ∑¬å‡¡◊ËÕ ‡º™‘≠Àπâ“°—∫§«“¡‡§√’¬¥ º≈°“√»÷°…“: π—°»÷°…“·æ∑¬å√âÕ¬≈– ˜Û.ˆÛ ¡’§«“¡‡§√’¬¥„π√–¥—∫ª“π°≈“ß¢÷Èπ‰ª´÷Ëß‡ªìπ√–¥—∫∑’Ë‡Àπ◊Õ°«à“ §«“¡‡§√’¬¥ª√°μ‘„π™’«‘μª√–®”«—π·≈–æ∫«à“ Ÿß°«à“ª√–™“°√∑—Ë«‰ª Ò.Ù¯ ‡∑à“ ‰¡àæ∫§«“¡ ·μ°μà“ß¢Õß√–¥—∫§«“¡‡§√’¬¥√–À«à“ßπ—°»÷°…“™“¬·≈–À≠‘ß√«¡∂÷ß√–À«à“ß™—Èπªï∑’Ë Ù, ı ·≈– ˆ ªí®®—¬ §«“¡‡§√’¬¥∑’Ëπ—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘°√Ÿâ ÷°°—ß«≈¡“°∂÷ß¡“°∑’Ë ÿ¥ ‰¥â·°à °“√ Õ∫ (√âÕ¬≈– Ûı.˜), °“√‡ª≈’¬Ë π®“°«‘™“ª√’§≈‘π°‘ ‰ª Ÿ§à ≈‘π°‘ (√âÕ¬≈– ÛÒ.Û), °“√‡¢’¬π√“¬ß“π ºŸâªÉ«¬ (√âÕ¬≈– ÚÚ.ı), ·≈–º≈§–·ππ Õ∫ (√âÕ¬≈– Ú.˘) μ“¡≈”¥—∫ ‡°◊Õ∫§√÷ËßÀπ÷Ëß‰¡à °≈â“ª√÷°…“Õ“®“√¬å‡¡◊ËÕ‡°‘¥ªí≠À“¥â“π°“√‡√’¬π¢÷Èπ (√âÕ¬≈– ÙÒ.˘), ·≈–√âÕ¬≈– ÒÚ.ÒÚ ‡™◊Ë Õ «à “ °“√‡¢â “ æ∫Õ“®“√¬å ∑’Ë ª √÷ ° …“Õ“®¡’ ∫— π ∑÷ ° ‡°Á ∫ ‰«â · ≈– à ß º≈μà Õ °“√∑”ß“π„πÕπ“§μ Õ¬à“ß‰√°Áμ“¡°“√¥◊Ë¡·Õ≈°ÕŒÕ≈åÀ√◊Õ Ÿ∫∫ÿÀ√’Ë‡¡◊ËÕ‡°‘¥§«“¡‡§√’¬¥æ∫‡æ’¬ß√âÕ¬≈– Ú.ÚÒ √ÿªº≈°“√»÷°…“: ·¡â°“√‡√’¬π„π‚√ß‡√’¬π·æ∑¬å∑”„Àâπ—°»÷°…“·æ∑¬å à«π„À≠à‡°‘¥§«“¡‡§√’¬¥ Ÿß°«à“√–¥—∫∑’Ëæ∫ „π™’«‘μª√–®”«—π·μà§«“¡‡§√’¬¥∫“ßÕ¬à“ß°àÕ„Àâ‡°‘¥º≈¥’ ‡™àπ §«“¡‡§√’¬¥°àÕπ Õ∫∑’Ë°√–μÿâπ„Àâ ‡μ√’¬¡μ—«∑∫∑«π∫∑‡√’¬π °“√»÷°…“§«“¡ —¡æ—π∏å√–À«à“ß§«“¡‡§√’¬¥°—∫§ÿ≥¿“æ™’«‘μÀ√◊Õº≈ °“√‡√’¬π„π‚Õ°“ μàÕ‰ª®÷ß¡’ à«π™à«¬„π°“√«“ß·ºπ‡æ◊ËÕª√—∫μ—«À√◊Õ°”®—¥ªí®®—¬∑’Ë°àÕ„Àâ‡°‘¥ §«“¡‡§√’¬¥ „π°“√‡√’¬π·æ∑¬»“ μ√å‰¥âÕ¬à“ß‡À¡“– ¡ §” ”§—≠:

§«“¡‡§√’¬¥, π—°»÷°…“·æ∑¬å

‚§√ß°“√®—¥μ—ßÈ ¿“§«‘™“®‘μ‡«™»“ μ√å §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

∫∑π” §«“¡‡§√’¬¥ (stress) ‡ªìπÀπ÷Ëß„πªí≠À“ ÿ¢¿“æ®‘μ ∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥ À“°§ßÕ¬Ÿà‡ªìπ√–¬–‡«≈“π“π‚¥¬‰¡à‰¥â√—∫ °“√¥Ÿ·≈√—°…“∑’Ë‡À¡“– ¡Õ“®°≈“¬‡ªìπ§«“¡‡§√’¬¥‡√◊ÈÕ√—ß (burnout) À√◊ÕÀ“°¡’√–¥—∫ Ÿß·≈–√ÿπ·√ß¢÷ÈπÕ“®π”‰ª Ÿà ‚√§∑“ß®‘ μ‡«™ (mental disorders) ‰¥â Õ¬à“ß‰√°Áμ“¡ §«“¡‡§√’¬¥‰¡à„™àªí≠À“ ÿ¢¿“æ®‘μ∑’Ë àßº≈„π∑“ß≈∫‡æ’¬ß Õ¬à“ß‡¥’¬«‡∑à“π—Èπ §«“¡‡§√’¬¥„πª√‘¡“≥∑’ËæÕ‡À¡“–∑”„Àâ ‡°‘¥§«“¡√Ÿ â °÷ μ◊πË ‡μâπ (excitement), ∑â“∑“¬ (challenging) ·≈– æ—≤π“μπ‡Õß (personal growth) ‰¥â‡™àπ°—πÒ SelyeÚ π‘¬“¡ »—æ∑å∑’Ë°≈à“«∂÷ß§«“¡‡§√’¬¥„π√Ÿª·∫∫∑’Ë¥’ (healthy form of stress) «à“ ùeustressû ‚¥¬¡—°°≈à“«∂÷ß§«∫§Ÿà°—∫ ùdistressû ´÷Ëß ‡ªì π §«“¡‡§√’ ¬ ¥‡™‘ ß ≈∫ °“√»÷ ° …“„πªí ® ®ÿ ∫— π ‡™◊Ë Õ «à “ §«“¡‡§√’ ¬ ¥‡ªì π μ— « °√–μÿâ π „Àâ æ— ≤ π“»— ° ¬¿“æ à « π∫ÿ § §≈ (performance enhancer) À“° “¡“√∂∫√‘À“√®—¥°“√‰¥â ‡À¡“– ¡‚¥¬‰¡àμâÕß°”®—¥§«“¡‡§√’¬¥„ÀâÀ¡¥ ‘Èπ‰ªÛ °“√»÷°…“§«“¡™ÿ°¢Õß§«“¡‡§√’¬¥„πª√–™“°√Õ“¬ÿ Òı-ı˘ ªï‡¢μ°√ÿß‡∑æ¡À“π§√æ∫«à“ª√–™“°√√âÕ¬≈– Ùˆ.˘ ¡’ § «“¡‡§√’ ¬ ¥„π√–¥— ∫ ª“π°≈“ß Ù °“√»÷ ° …“„π‡¢μ “∏“√≥ ÿ¢∑’Ë ¯ æ∫«à“ª√–™“°√Õ“¬ÿ√–À«à“ß Òı-Ú˘ ªï¡’ §«“¡‡§√’¬¥√âÕ¬≈– ˆı.Ù „π∑ÿ°√–¥—∫§«“¡‡§√’¬¥ı °“√ »÷°…“„ππ—°»÷°…“·æ∑¬å¡À“«‘∑¬“≈—¬»√’π§√‘π∑√«‘‚√≤æ∫ «à“ √âÕ ¬≈– ÚÙ.ˆÛ ¡’ § «“¡‡§√’¬ ¥√ÿ π ·√ß®π‡ªì π ªí≠ À“ ÿ¢¿“æ®‘μ ‚¥¬ªí®®—¬∑’Ë —¡æ—π∏å°—∫ªí≠À“ ÿ¢¿“æ®‘μ ‰¥â·°à ªí≠À“¥â“π°“√‡ß‘π, ªí≠À“¥â“π∑’Ëæ—°, °“√¡’°‘®°√√¡πÕ° À≈—° Ÿμ√, §«“¡ —¡æ—π∏å°—∫∫‘¥“¡“√¥“, §«“¡ —¡æ—π∏å°—∫ Õ“®“√¬å ·≈–§«“¡ — ¡ æ— π ∏å °— ∫ ‡æ◊Ë Õ πˆ π— ° »÷ ° …“·æ∑¬å ™—πÈ ªï∑’Ë Û §≥–·æ∑¬»“ μ√å»√‘ √‘ “™æ¬“∫“≈æ∫«à“¡’§«“¡‡§√’¬¥ ‡≈Á°πâÕ¬√âÕ¬≈– Ò.ˆÛ ·≈–§«“¡‡§√’¬¥¡“°√âÕ¬≈– ˜.Úı˜ à«ππ—°»÷°…“·æ∑¬å§≥–·æ∑¬»“ μ√å√“¡“∏‘∫¥’∑ÿ°™—Èπªï æ∫«à“√âÕ¬≈– ˆÒ.Ù ¡’§«“¡‡§√’¬¥‡≈Á°πâÕ¬, √âÕ¬≈– Ú.Ù ¡’§«“¡‡§√’¬¥„π√–¥—∫ Ÿß ‚¥¬§«“¡™ÿ° Ÿß∑’Ë ÿ¥„π™—Èπªï∑’Ë Û ªí≠À“À≈—°∑’Ëπ”¡“´÷Ëß§«“¡‡§√’¬¥§◊Õªí≠À“¥â“π°“√‡√’¬π ‚¥¬‡©æ“–°“√ Õ∫¯ §«“¡‡§√’¬¥®“°°“√‡√’¬π«‘™“·æ∑¬»“ μ√åÕ“®‡°‘¥ ‰¥â®“°À≈“¬ªí®®—¬ Õ“®·∫àßÕÕ°‰¥â‡ªìπ Ù °≈ÿà¡ ‰¥â·°à Ò) ªí®®—¬∑’Ë‡°’Ë¬«¢âÕß°—∫°“√‡√’¬π (academic factors) ‡™àπ °“√ Õ∫·≈–º≈§–·ππ ˘, °“√®¥‡≈§‡™Õ√å À √◊ Õ °“√À“ Àπ—ß ◊Õª√–°Õ∫°“√‡√’¬πÒ, Ú) ªí®®—¬∑’Ë‡°’Ë¬«°—∫∫ÿ§≈‘°¿“æ ¢Õßπ— ° »÷ ° …“·æ∑¬å ‡ Õß ‡™àπ °“√¡’∫ÿ§≈‘°¿“æ·∫∫™Õ∫ §«“¡ ¡∫Ÿ √ ≥å · ∫∫ (perfectionism) ∑’Ë ª √— ∫ μ— « ‰¥â ‰ ¡à ¥’

(maladaptive)ÒÒ, Û) ªí®®—¬∑’Ë‡°’Ë¬«°—∫§«“¡ —¡æ—π∏å°—∫ ∫ÿ§§≈Õ◊Ëπ ‡™àπ ªí≠À“§«“¡¢—¥·¬âß°—∫§π„π§√Õ∫§√—«ÒÚ, ‡æ◊ËÕπ, ·øπÀ√◊Õ§Ÿà§√ÕßÒÛ, ·≈– Ù) ªí®®—¬Õ◊ËπÊ ‡™àπ ªí≠À“ ¥â“π°“√‡ß‘πÒÚ Õ¬à“ß‰√°Áμ“¡ Ross æ∫«à“®”π«πÀπ’È ‘π ‰¡à „ ™à “‡Àμÿ ‚ ¥¬μ√ß ·μà § «“¡°— ß «≈¢Õß∑’Ë ¡’ μà Õ Àπ’È ‘ π —¡æ—π∏å°—∫º≈°“√‡√’¬π¢Õßπ—°»÷°…“¡“°°«à“ÒÙ ·¡â«à“º≈°“√»÷°…“ à«π„À≠à∫àß™’È«à“π—°»÷°…“·æ∑¬å ¡’ ªí ≠ À“§«“¡‡§√’ ¬ ¥·μà „ π°“√„Àâ ∫ √‘ ° “√ª√÷ ° …“ªí ≠ À“ ÿ¢¿“æ®‘μ¢Õß¡À“«‘∑¬“≈—¬°≈—∫æ∫«à“π—°»÷°…“‡À≈à“π’È„™â ∫√‘ ° “√‰¡à ¡ “°π— ° π— ° »÷ ° …“ à « π„À≠à ¡— ° ·°â ªí ≠ À“¥â « ¬ μπ‡ÕßÀ√◊Õ¢Õ§”ª√÷°…“®“°§π„°≈â™‘¥°àÕπ·≈–§‘¥«à“ªí≠À“ ¢Õßμπ‰¡à √ÿ π ·√ß¡“°®πμâ Õ ß‡¢â “ √— ∫ §”ª√÷ ° …“°— ∫ »Ÿ π ¬å „ Àâ §”ª√÷°…“¥â“π ÿ¢¿“æ®‘μ¢Õß¡À“«‘∑¬“≈—¬Òı °“√»÷°…“¢Õß University Cork æ∫«à“√âÕ¬≈– ıÚ ¢Õßπ—°»÷°…“·æ∑¬å ™—Èπªï∑’Ë ı ¡’§«“¡‡§√’¬¥·≈â«‰¡à∑√“∫¢—ÈπμÕπ«à“®– “¡“√∂ À“§«“¡™à« ¬‡À≈◊ Õ ‰¥â ® “°„§√ √â Õ ¬≈– Û √Ÿâ ÷ ° «à“ °“√ ª√÷°…“Õ“®“√¬å®–‡ªìπ°“√∑”≈“¬Õπ“§μ (future career)Òˆ π—°»÷°…“·æ∑¬å∫“ß à«π‡≈◊Õ°°“√·°âªí≠À“ (coping) „π∑“ß ∑’Ë‰¡à‡À¡“– ¡ ‡™àπ ¥◊Ë¡‡§√◊ËÕß¥◊Ë¡·Õ≈°ÕŒÕ≈å‡æ◊ËÕ§≈“¬ §«“¡‡§√’¬¥Ò˜ °“√¥◊Ë¡ ÿ√“„ππ—°»÷°…“·æ∑¬å®“°ªï Ú ‰ª Ÿà ªï ı æ∫«à“ Ÿß¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μÒ¯ ‘

«—μ∂ÿª√– ß§å ‡æ◊ËÕ»÷°…“√–¥—∫§«“¡‡§√’¬¥·≈–ªí®®—¬∑’Ë°àÕ„Àâ‡°‘¥ §«“¡‡§√’¬¥√–¥—∫ Ÿß„ππ—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘° √«¡∂÷ß ”√«®æƒμ‘°√√¡·≈–·π«§‘¥¢Õßπ—°»÷°…“·æ∑¬å‡¡◊ËÕ‡º™‘≠ Àπâ“°—∫§«“¡‡§√’¬¥

«‘∏’°“√»÷°…“ π—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘° (ªï Ù-ˆ) ¡À“«‘∑¬“≈—¬ ∏√√¡»“ μ√åªï°“√»÷°…“ ÚıÙ˘ ®”π«π Ò¯Ú §π (√âÕ¬≈– ¯Ú.˜Ú) μÕ∫·∫∫ Õ∫∂“¡ (self-reported questionnaire) ´÷Ëßª√–°Õ∫¥â«¬¢âÕ¡Ÿ≈∑—Ë«‰ª ‡™àπ ‡æ»·≈–™—Èπªï, ·∫∫ ∑¥ Õ∫§«“¡‡§√’¬¥ «πª√ÿß (Suanprung stress test, SPSTÚ)Ò˘, √–¥—∫§«“¡°—ß«≈μàÕªí®®—¬∑’Ë°àÕ„Àâ‡°‘¥§«“¡‡§√’¬¥ (stressors), ·≈–·π«∑“ß°“√·°âªí≠À“‡¡◊ËÕ‡°‘¥§«“¡‡§√’¬¥ ·∫∫ Õ∫∂“¡‰¥â√—∫°“√π”‡ πÕ·°àπ—°»÷°…“∑ÿ°§π„π™—Èπªï ¥—ß°≈à“«‚¥¬π—°»÷°…“¡’ ‘∑∏‘ÏªØ‘‡ ∏°“√μÕ∫·∫∫ Õ∫∂“¡ ‚¥¬À—«Àπâ“‚§√ß°“√‰¥â™·’È ®âß«à“®–‰¡à¡º’ ≈ ◊∫‡π◊ÕË ß„π¿“¬À≈—ß ·≈–À“°¡’§«“¡°—ß«≈‡°’Ë¬«°—∫ªí≠À“ ÿ¢¿“æ®‘μ¢Õßμπ‡Õß ¿“¬À≈— ß ®“°∑”·∫∫∑¥ Õ∫ π— ° »÷ ° …“ “¡“√∂¢Õ√— ∫

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

§”ª√÷°…“®“°®‘μ·æ∑¬åÀ—«Àπâ“‚§√ß°“√‰¥â‡™àπ°—π‚¥¬‰¡à¡’ °“√‡ªî¥‡º¬™◊ËÕÀ√◊Õ¢âÕ¡Ÿ≈∑’Ë‡ªìπ§«“¡≈—∫·°à∫ÿ§§≈Õ◊Ëπ °“√ »÷°…“π’È‰¥âºà“π°“√Õπÿ¡—μ‘®“°§≥–°√√¡°“√®√‘¬∏√√¡°“√ «‘®¬— „π¡πÿ…¬å¢Õß§≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å ∂‘μ‘∑’Ë„™â„π°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈ ‰¥â·°à °“√À“§à“ §«“¡∂’Ë (frequency) ·≈– √ÿª‡ªìπ§à“®”π«π·≈–√âÕ¬≈– ”À√—∫ demographic data, §«“¡·μ°μà “ ß√–À«à “ ß√–¥— ∫ §«“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬åÀ≠‘ß·≈–™“¬ „™â ∂‘μ‘Õâ“ßÕ‘ß Mann-Whitney U test, §«“¡·μ°μà “ ß√–À«à “ ß√–¥— ∫ §«“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬å™—Èπªïμà“ßÊ „™â ∂‘μ‘Õâ“ßÕ‘ß Kruskal-Wallis H test, §«“¡∂’Ë¢Õßπ—°»÷°…“∑’Ë°—ß«≈¡“°μàÕ ªí®®—¬°√–μÿâπ§«“¡‡§√’¬¥„™â°“√À“§à“§«“¡∂’Ë, §à“®”π«π, √âÕ¬≈–, ˘ı CI, §«“¡∂’Ë¢Õß·π«∑“ß°“√·°âªí≠À“¢Õß π—°»÷°…“·æ∑¬å‡¡◊ËÕ‡°‘¥§«“¡‡§√’¬¥„™â§à“®”π«π, √âÕ¬≈–,

·≈– odds ratio ‡ª√’¬∫‡∑’¬∫°—∫º≈°“√»÷°…“§«“¡‡§√’¬¥ ª√–™“™π«—¬·√ßß“π‡¢μ “∏“√≥ ÿ¢∑’Ë ¯ı

º≈°“√»÷°…“ π—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘° (ªï∑’Ë Ù-ˆ) ®”π«π Ò¯Ú §π‡¢â“√à«¡°“√»÷°…“π’‚È ¥¬·∫àß‡ªìπ™—πÈ ªï∑’Ë Ù √âÕ¬≈– Û˜.˘Ò, ™—Èπªï∑’Ë ı √âÕ¬≈– Ûı.˜Ò, ·≈–™—Èπªï∑’Ë ˆ √âÕ¬≈– Úˆ.Û˜ º≈°“√∑¥ Õ∫§«“¡·μ°μà“ß¢Õß√–¥—∫§«“¡‡§√’¬¥√–À«à“ß ‡æ»™“¬·≈–À≠‘ß¥â«¬ ∂‘μ‘Õâ“ßÕ‘ß Mann-Whitney U test æ∫«à“§à“ Mann-Whitney U ‡∑à“°—∫ Ú¯ı˘.ı ·≈–§à“æ’ ‡∑à “ °— ∫ .ÛÚ ¡“°°«à “ .ı à « πº≈°“√∑¥ Õ∫ §«“¡·μ°μà“ß¢Õß√–¥—∫§«“¡‡§√’¬¥√–À«à“ß™—Èπªï¥â«¬ ∂‘μ‘ Õâ“ßÕ‘ß Kruskal-Wallis H test æ∫«à“ §à“æ’ ‡∑à“°—∫ .Ú˘˘ ¡“°°«à“ .ı

μ“√“ß∑’Ë Ò μ“√“ß·®°·®ß§«“¡∂’Ë√–¥—∫§«“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬å™—Èπªï∑’Ë Ù-ˆ

√–¥—∫ §«“¡‡§√’¬¥

™—Èπªï∑’Ë Ù ™—Èπªï∑’Ë ı ™—Èπªï∑’Ë ˆ Total Total ®”π«π ®”π«π ®”π«π ®”π«π ®”π«π (§π) √âÕ¬≈– (§π) √âÕ¬≈– (§π) √âÕ¬≈– (§π) √âÕ¬≈– (§π) √âÕ¬≈–

Mild stress

ÚÚ

ÒÚ.˘

Ò¯

˘.¯˘

Ù.Ù

Ù¯

Úˆ.Û˜

Moderate stress

Ú˘

Òı.˘Û

Ú˘

Òı.˘Û

Ú˜

ÒÙ.¯Ù

¯ı

Ùˆ.˜

High stress

Òı

¯.ÚÙ

Òı

¯.ÚÙ

ÒÚ

ˆ.ı˘

ÙÚ

ÚÛ.¯

Severe stress

Ò.ˆı

.ıı

Û.¯ı

Total

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ÛÒ.Û), °“√‡¢’¬π√“¬ß“πºŸâªÉ«¬ (√âÕ¬≈– ÚÚ.ı), ·≈– º≈§–·ππ Õ∫ (√âÕ¬≈– Ú.˘) Ú. ªí®®—¬∑’Ë‡°’Ë¬«¢âÕß°—∫ ∫ÿ§≈‘°¿“æ ‰¥â·°à °“√ª√—∫μ—«°—∫°≈ÿà¡‡æ◊ËÕπ∑’Ë‡ª≈’Ë¬π‰ªμ“¡ «‘™“‡√’¬π (√âÕ¬≈– Ú.ÛÛ) ·≈–°“√ª√—∫μ—«‡¢â“°—∫ºŸâªÉ«¬ ·≈–≠“μ‘ (√âÕ¬≈– Ò¯.ÒÛ), Û. ªí®®—¬∑’Ë‡°’Ë¬«¢âÕß°—∫§«“¡ —¡æ—π∏å ‰¥â·°à §«“¡¢—¥·¬âß°—∫·øπÀ√◊Õ§Ÿà§√Õß (√âÕ¬≈– ˜.ˆ˘), §«“¡¢—¥·¬âß°—∫‡æ◊ËÕπ (√âÕ¬≈– Ù.˘ı) ·≈–§«“¡ ¢—¥·¬âß„π§√Õ∫§√—« (√âÕ¬≈– Ù.Ù), ·≈– Ù. ªí®®—¬∑’Ë ‡°’Ë ¬ «¢â Õ ß°— ∫ ªí ≠ À“°“√‡ß‘ π ∑”„Àâ π— ° »÷ ° …“·æ∑¬å √â Õ ¬≈– Òı.˘Û √Ÿâ ÷°°—ß«≈¡“°∂÷ß¡“°∑’Ë ÿ¥

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

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100 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ «à“¡À“«‘∑¬“≈—¬¡’ŒÕμ‰≈πå§≈“¬‡§√’¬¥ ”À√—∫„Àâ§”ª√÷°…“ ·μà√âÕ¬≈– ÙÛ.ı¯ ‰¡à∑√“∫«à“§≥–·æ∑¬»“ μ√å¡’§≈‘π‘° ÿ¢¿“æ®‘μ∑’Ë„Àâ∫√‘°“√·°àπ—°»÷°…“·æ∑¬å ·≈–À“°®”‡ªìπ μâÕßæ∫®‘μ·æ∑¬å √âÕ¬≈– ÚÙ.ÛÒ ®–√Ÿâ ÷°μàÕμâ“π¢÷Èπ¡“∑—π∑’ à « π°“√„™â · Õ≈°ÕŒÕ≈å À √◊ Õ Ÿ ∫ ∫ÿ À √’Ë ‡ ªì π ª√–®”‡¡◊Ë Õ ‡°‘ ¥ §«“¡‡§√’¬¥æ∫√âÕ¬≈– Ú.ÚÒ

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·≈–®—¥°“√‡√’¬π°“√ Õπ‡æ◊ËÕ„Àâπ—°»÷°…“·æ∑¬å‰¥â√—∫§«“¡√Ÿâ ·≈–∑—°…–‰ªæ√âÕ¡°—∫¡’ ÿ¢¿“æ®‘μ¥’¢≥–°”≈—ß»÷°…“¥â«¬ Õ¬à “ ß‰√°Á μ “¡®“°·π«§‘ ¥ ‡√◊Ë Õ ß§«“¡‡§√’ ¬ ¥¢Õß SelyeÚ §«“¡‡§√’¬¥¡’∑—Èß∑’Ë°àÕ„Àâ‡°‘¥º≈‡ ’¬μàÕ ÿ¢¿“æ (distress) ‡™àπ §«“¡‡§√’¬¥®“°°“√∑”ß“πÀπ—° ·≈–°àÕ„Àâ‡°‘¥º≈¥’‚¥¬‡ªìπ ·√ß°√–μÿâπ„Àâæ—≤π“»—°¬¿“æ à«π∫ÿ§§≈ (eustress) ‡™àπ §«“¡‡§√’¬¥∑’Ë°√–μÿâπ„ÀâÕà“πÀπ—ß ◊Õ°àÕπ Õ∫ §«“¡‡§√’¬¥ ∑—Èß Õß·∫∫¡’«‘∏’¥Ÿ·≈√—°…“μà“ß°—π °“√ª√—∫μ—«„Àâ¬Õ¡√—∫ §«“¡‡§√’ ¬ ¥‰¥â Õ “®‡À¡“–°— ∫ °“√√— ∫ ¡◊ Õ ªí ® ®— ¬ ∑’Ë °à Õ „Àâ ‡ °‘ ¥ §«“¡‡§√’¬¥‡™‘ß∫«° (eustress) „π√–À«à“ß∑’Ë°“√°”®—¥ªí®®—¬ ¿“¬πÕ°∑’Ë°àÕ„Àâ‡°‘¥§«“¡‡§√’¬¥Õ“®‡À¡“– ¡°—∫°“√√—°…“ §«“¡‡§√’¬¥‡™‘ß≈∫ (distress) °“√»÷°…“π’È®÷ß¡’¢âÕ®”°—¥‚¥¬ º≈∑’Ë‰¥â‰¡à‡æ’¬ßæÕμàÕ°“√«“ß·ºπ àß‡ √‘¡ ÿ¢¿“æ®‘μ·≈–≈¥ §«“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬å‡π◊ËÕß®“°‰¡à “¡“√∂∫Õ°‰¥â «à“§«“¡‡§√’¬¥∑’Ë‡°‘¥¢÷Èπ‡ªìπ§«“¡‡§√’¬¥·∫∫„¥ °“√»÷°…“ §«“¡ —¡æ—π∏å√–À«à“ß§«“¡‡§√’¬¥°—∫§ÿ≥¿“æ™’«‘μ·≈–º≈ °“√‡√’¬πÀ√◊Õº≈°“√ªØ‘∫—μ‘ß“π„π∞“π–·æ∑¬åÀ≈—ß‡√’¬π®∫ ‡æ◊ËÕ·∫àß·¬°ª√–‡¿∑¢Õß§«“¡‡§√’¬¥®÷ß¡’ à«π™à«¬„π°“√ «“ß·ºπ‚§√ß°“√ àß‡ √‘¡ ÿ¢¿“æ®‘μ„π‚√ß‡√’¬π·æ∑¬å·≈– °“√«“ß√–∫∫„Àâ§”ª√÷°…“ªí≠À“ ÿ¢¿“æ®‘μ‰¥â„πÕπ“§μ

°‘μμ‘°√√¡ª√–°“» ¢Õ¢Õ∫§ÿ ≥ ¡À“«‘ ∑ ¬“≈— ¬ ∏√√¡»“ μ√å ºŸâ ¡ Õ∫∑ÿ π π—∫ πÿπ°“√«‘®¬— ‚§√ß°“√«‘®¬— √“¬‰¥âæ‡‘ »…ª√–®”ªï Úıı ª√–‡¿∑«‘®—¬∑—Ë«‰ª (°“√«‘®—¬ª√–¬ÿ°μå)

‡Õ° “√Õâ“ßÕ‘ß Ò. McKenna E. Business Psychology and Organisational Behaviour: A Student's Handbook. 4th ed. East Sussex: Psychology Press; 2006. Ú. Selye H. Stress and distress. Compr Ther 1975; 1:9-13. Û. Fevre ML, Matheny J, Kolt GS. Eustress, distress, and interpretation in occupational stress. J Manag Psychol 2003;18:726-44. Ù. °‘Ëß¥“« »√’«√π—π∑å ·≈–§≥–. °“√ ”√«®∑“ß√–∫“¥ «‘∑¬“ ÿ¢¿“æ®‘μ¢Õßª√–™“™π„π‡¢μ°√ÿß‡∑æ¡À“π§√ [Internet]. [cited 2010 Apr 20];Available from: http://www.dmhweb.dmh.go.th/sranrom/40 research_th1.html

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ı. π“¡ ∫‘π™—¬. §«“¡‡§√’¬¥ª√–™“™π«—¬·√ßß“π ‡¢μ “∏“√≥ ÿ¢∑’Ë ¯ [Internet]. [cited 2010 Apr 20]; Available from: http://110.164.197.218/library/ research/17_46.htm ˆ. «—π‡æÁ≠ ∏ÿ√°‘μμå«—≥≥°“√. °“√ ”√«® ÿ¢¿“æ®‘μ¢Õß π‘ ‘μ·æ∑¬å ¡À“«‘∑¬“≈—¬»√’π§√‘π∑√«‘‚√≤. «“√ “√ ¡“§¡®‘μ·æ∑¬å·Ààßª√–‡∑»‰∑¬ Úı;ÙÚ: ¯¯-Ò. ˜. ‡∏’¬√™—¬ ß“¡∑‘æ¬å«—≤π“, ÿ∏’√“ ¿—∑√“¬ÿμ«√√μπå, ¡“≈—¬ ‡©≈‘¡™—¬πÿ°Ÿ≈. §«“¡‡§√’¬¥·≈–√Ÿª·∫∫°“√·°âªí≠À“ ¢Õßπ—°»÷°…“™—Èπªï∑’Ë Û §≥–·æ∑¬»“ μ√å»‘√‘√“™ æ¬“∫“≈. «“√ “√ ¡“§¡®‘μ·æ∑¬å·Ààßª√–‡∑»‰∑¬ 2543;45:59-70. ¯. Saipanish R. Stress among medical students in a Thai medical school. Med Teach 2003;25:502-6. ˘. Foster-Williams K, Thomas P, Gordon A, WilliamsBrown S. An assessment of stress among clinical medical students of the University of the West Indies, Mona Campus. West Indian Med J 1996;45:51-4. Ò. Moffat KJ, McConnachie A, Ross S, Morrison JM. First year medical student stress and coping in a problem-based learning medical curriculum. Med Educ 2004;38:482-91. ÒÒ. Enns MW, Cox BJ, Sareen J, Freeman P. Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation. Med Educ 2001; 35:1034-42. ÒÚ. Omokhodion FO. Psychosocial problems of pre-clinical students in the University of Ibadan Medical School. Afr J Med Med Sci 2003;32:135-8. ÒÛ. Katz J, Monnier J, Libet J, Shaw D, Beach SR. Individual and crossover effects of stress on adjustment in medical student marriages. J Marital Fam Ther 2000;26:341-51. ÒÙ. Ross S, Cleland J, Macleod MJ. Stress, debt and undergraduate medical student performance. Med Educ 2006;40:584-9.

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Òı. Alipuria A. First-year college student decision making: How freshmen respond to the stress of the college transition. Dissertation Abstracts International Section A: Humanities and Social Sciences 2008;69:129. Òˆ. Gaughran F, Dineen S, Dineen M, Cole M, Daly RJ. Stress in medical students. Ir Med J 1997;90:184-5. Ò˜. Tyssen R, Vaglum P, Aasland OG, Gronvold NT, Ekeberg O. Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nation-wide Norwegian samples of medical students. Addiction 1998;93:1341-9. Ò¯. Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend 2001;64:265-70. Ò˘. ÿ«≤ — πå ¡À—μπ‘√π— ¥√å°≈ÿ , «π‘¥“ æÿ¡à ‰æ»“≈™—¬, æ‘¡æå¡“» μ“ªí ≠ ≠“. √“¬ß“π°“√«‘ ®— ¬ ‡√◊Ë Õ ß°“√ √â “ ß·∫∫«— ¥ §«“¡‡§√’¬¥ «πª√ÿß [Internet]. [cited 2010 Apr 20];Available from: http://www.dmh.go.th/test/stress/

102 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ π‘æπ∏åμâπ©∫—∫

Abstract

Stress in medical students of Thammasat University. Winitra Nuallaong Department of Psychiatry, Faculty of Medicine, Thammasat University Objectives and Methods:

This study aimed to find out stress levels and stressors as well as coping methods after stress in medical students at clinical level of Thammasat University, Thailand.

Results:

73.67% of medical students at clinical level felt stress more than normal daily level. The odds ratio was 1.48 compared with general population. There was no difference between stress levels among genders and academic years. Four major stressors causing high and severe anxiety were an examination (35.70%), changing from pre-clinical to clinical year (31.30%), writing patientûs reports (22.50%), and examination grades (20.90%) respectively. Almost half of them (41.90%) were unwilling to consult a supervisor and 12.12% believed that counselling a super visor would affect the future career life. However, only 2.21% were found drinking alcohol or smoking as coping methods.

Conclusion:

Although stress is a common mental health issue in medical students, sometimes it can be defined as functional stress, i.e. being source of challenge or performance enhancer. Thus, future research about correlation between stress and quality of life or performance of medical students would be advantageous to manage stress in a medical school environment.

Key words:

Stress, Medical students

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103

π‘π‘ææπ∏å π∏åμμâπâπ©∫— ©∫—∫∫

°”‡π‘¥æ¬“∏‘¢Õß‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π æ‘∏“ æ√À¡≈‘¢‘μ™—¬ ∫∑§—¥¬àÕ ‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π (acute coronary syndrome, ACS) ‡ªìπ°≈ÿà¡‚√§∑’Ë¡’Õ—μ√“°“√‡ ’¬™’«‘μ Ÿß„π°≈ÿà¡ª√–‡∑»μ–«—πμ°·≈–ª√–‡∑»∑’Ë°”≈—ßæ—≤π“√«¡∂÷ßª√–‡∑»‰∑¬¥â«¬ °“√«‘π‘®©—¬·≈–√—°…“∑’Ë≈à“™â“¡’§«“¡ —¡æ—π∏å‚¥¬·ª√º—πμ√ß°—∫Õ—μ√“°“√‡ ’¬™’«‘μ¢ÕßºŸâªÉ«¬∑’Ë Ÿß¢÷Èπ °“√‡¢â“„®∂÷ß°”‡π‘¥æ¬“∏‘¢Õß‚√§®÷ß‡ªìπ ‘Ëß∑’Ë¡’§«“¡ ”§—≠Õ¬à“ß¬‘Ëß‡æ◊ËÕ‡ªìπ°“√π”‰ª Ÿà°“√√—°…“ºŸâªÉ«¬ ACS „π√–¬–‡©’¬∫æ≈—π·≈–°“√ªÑÕß°—π°“√‡°‘¥‚√§´È”„π√–¬–¬“« √«¡∂÷ß°“√«“ß·ºπªÑÕß°—π°“√‡°‘¥‚√§„πª√–™“°√∑—Ë«‰ª∑’Ë¬—ß‰¡à¡’Õ“°“√· ¥ß‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ Ÿß ÿ¥ §” ”§—≠:

‚√§À≈Õ¥‡≈◊Õ¥À—«„®‡©’¬∫æ≈—π, °”‡π‘¥æ¬“∏‘

Abstract Pathogenesis of acute coronary syndrome (ACS) Pitha Promlikitchai Saraburi Hospital, Saraburi Acute coronary syndrome is the common cause of death in western countries and developing countries including Thailand. More delay in diagnasis and management will lead to higher mortality rate. The understanding of pathogenesis of acute coronary syndrome is very vital for effective short and long term management of the patients and for primary prevention of the general population. Key words: Acute coronary syndrome (ACS), Pathogenesis

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104 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ∫∑π” ‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π (acute coronary syndrome, ACS) ‡ªìπ°≈ÿà¡‚√§∑’Ë¡’Õ—μ√“°“√‡ ’¬™’«‘μ Ÿß„π °≈ÿà¡ª√–‡∑»μ–«—πμ°Ò,Ú ·≈–ª√–‡∑»∑’Ë°”≈—ßæ—≤π“√«¡∂÷ß ª√–‡∑»‰∑¬¥â«¬Û ¿“«–¥—ß°≈à“«¡—°‡°‘¥Õ¬à“ß√«¥‡√Á« °≈â“¡ ‡π◊ÕÈ À—«„®®–¡’°“√¢“¥‡≈◊Õ¥·≈–‡°‘¥°“√μ“¬Õ¬à“ß∂“«√‰¥â ‚¥¬ ª√‘¡“≥°≈â“¡‡π◊ÕÈ À—«„®∑’¢Ë “¥‡≈◊Õ¥·≈–μ“¬Õ“®¡’¢π“¥μà“ßÊ°—π ¢÷Èπ°—∫μ”·ÀπàßÀ≈Õ¥‡≈◊Õ¥À—«„®∑’Ëμ’∫μ—π ·≈– àßº≈μàÕ°“√ æ¬“°√≥å‚√§∑—Èß„π√–¬– —Èπ·≈–√–¬–¬“« °“√«‘π‘®©—¬·≈– √—°…“∑’Ë≈à“™â“∑”„Àâ¡’ª√‘¡“≥°≈â“¡‡π◊ÈÕÀ—«„®¢ÕßºŸâªÉ«¬μ“¬ ¡“°¢÷Èπ º≈∑’Ëμ“¡¡“§◊Õ °“√∑”ß“π¢ÕßÀ—«„®≈¥≈ß ‡°‘¥ ¿“«–À—«„®≈â¡‡À≈« (heart failure) ¿“«–§«“¡¥—π‚≈À‘μμË” (cardiogenic shock) ·≈–¿“«–À—«„®‡μâπº‘¥®—ßÀ«–™π‘¥ Õ—πμ√“¬ (ventricular arrhythmia) àßº≈„ÀâºŸâªÉ«¬¡’Õ—μ√“ °“√‡ ’¬™’«‘μ Ÿß °“√‡¢â“„®∂÷ßæ¬“∏‘°”‡π‘¥¢Õß‚√§ ®÷ß‡ªìπ ‘Ëß ∑’Ë¡’§«“¡ ”§—≠Õ¬à“ß¬‘Ëß ‡æ◊ËÕ‡ªìπ°“√π”‰ª Ÿà°“√√—°…“ºŸâªÉ«¬ Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ

°”‡π‘¥æ¬“∏‘¢Õß‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π (Pathogenesis of acute coronary syndrome) ‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π (ACS) ‡ªìπ °≈ÿà¡‚√§∑’Ë‡°‘¥®“°°≈â“¡‡π◊ÈÕÀ—«„®‰¥â√—∫‡≈◊Õ¥‰¡à‡æ’¬ßæÕ°—∫ §«“¡μâÕß°“√ Õ“°“√· ¥ß∑’Ë ”§—≠ §◊Õ Õ“°“√·πàπÀπâ“Õ° (angina pectoris) æ¬“∏‘°”‡π‘¥Õ“®‡°‘¥®“°À≈“¬ “‡Àμÿ ‚¥¬ “¡“√∂·∫àßÕÕ°‰¥â‡ªìπ Ú °≈ÿà¡„À≠àÊ §◊Õ Ò. °”‡π‘¥æ¬“∏‘Õ¬Ÿà∑’ËÀ≈Õ¥‡≈◊Õ¥À—«„®¡’°“√μ’∫À√◊Õ Õÿ¥μ—π‡©’¬∫æ≈—π ´÷Ëßæ∫‰¥â∑—Èß®“°°“√∑’Ë¡’§«“¡ —¡æ—π∏å°—∫ ≈‘Ë¡‡≈◊Õ¥„πÀ≈Õ¥‡≈◊Õ¥À—«„® (thrombus related) ·≈–‰¡à¡’ §«“¡ —¡æ—π∏å°∫— ≈‘¡Ë ‡≈◊Õ¥„πÀ≈Õ¥‡≈◊Õ¥À—«„® (non-thrombus related) ‚¥¬ “‡Àμÿ∑’Ëæ∫„π°≈ÿà¡∑’Ë — ¡æ—π∏å°— ∫≈‘Ë¡‡≈◊ Õ¥ Õÿ¥μ—π„πÀ≈Õ¥‡≈◊Õ¥À—«„®§◊Õ °“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π„π μ”·Àπàß∑’¡Ë °’ “√©’°¢“¥¢Õß§√“∫‰¢¡—π∑’ºË π—ßÀ≈Õ¥‡≈◊Õ¥À—«„® (atherosclerosis plaque rupture) ´÷Ëßæ∫„πºŸâ™“¬¡“°°«à“ ºŸâÀ≠‘ß„π™à«ßÕ“¬ÿπâÕ¬°«à“ ı ªï ·μà∂â“Õ“¬ÿ¡“°°«à“ ı ªï æ∫«à“Õÿ∫—μ‘°“√‰¡à·μ°μà“ß°—π À√◊Õ°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π„π μ”·Àπàß∑’Ë¡’°“√©’°¢“¥‡©æ“–√–¥—∫™—Èπ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥ ‡≈◊Õ¥∑’Ëª°§≈ÿ¡§√“∫‰¢¡—π‡∑à“π—Èπ (plaque erosion) ´÷Ëß¡—° æ∫„πºŸâÀ≠‘ßÕ“¬ÿπâÕ¬°«à“ ı ªï·≈– Ÿ∫∫ÿÀ√’ÙË À√◊Õ°“√‡°‘¥ ≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π„πμ”·Àπàß∑’Ë¡’°âÕπÀ‘πªŸπ∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥ (calcified nodule) ´÷Ëß¡’Õÿ∫—μ‘°“√πâÕ¬¡“° ¡—°æ∫„πºŸâªÉ«¬ ŸßÕ“¬ÿ·≈–À≈Õ¥‡≈◊Õ¥À—«„®§¥‡§’È¬«¡“°ı “‡ÀμÿÕ◊ËπÊ∑’Ëæ∫

‰¥â·μà‰¡à∫àÕ¬ §◊Õ °“√‡°‘¥≈‘Ë¡‡≈◊Õ¥®“°∑’ËÕ◊ËπÀ≈ÿ¥‡¢â“¡“Õÿ¥μ—π „πÀ≈Õ¥‡≈◊Õ¥À—«„® ‡™àπ ºŸªâ «É ¬∑’¡Ë ≈’ π‘È À—«„®‡∑’¬¡ (prosthetic heart valve) ‚√§≈‘ÈπÀ—«„®√Ÿ¡“μ‘§ (rheumatic heart disease) ‚¥¬‡©æ“–≈‘ÈπÀ—«„®‰¡∑√—≈μ’∫ (mitral stenosis) ´÷Ëß‰¥â√—∫ √–¥—∫¬“μâ“π°“√·¢Áßμ—«¢Õß‡≈◊Õ¥‰¡à‡æ’¬ßæÕ ”À√—∫„π °≈ÿ¡à ∑’‰Ë ¡à¡§’ «“¡ —¡æ—π∏å°∫— ≈‘¡Ë ‡≈◊Õ¥Õÿ¥μ—π„πÀ≈Õ¥‡≈◊Õ¥À—«„® “‡Àμÿ∑æ’Ë ∫§◊Õ °“√À¥√—¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥À—«„®¡“°º‘¥ª√°μ‘ (Prinzmetalûs angina) °“√‡°‘¥¿“«–°“√Õ—°‡ ∫¢Õßºπ—ß À≈Õ¥‡≈◊Õ¥ ‡™àπ Takayasuûs arteritis À√◊Õ °“√‡°‘¥ºπ—ß À≈Õ¥‡≈◊Õ¥À—«„®©’°¢“¥ (coronary dissection) „π°≈ÿà¡ºŸâ ªÉ«¬∑’Ë„™â¬“‡ æμ‘¥‚¥¬‡©æ“–‚§‡§π À√◊Õ ·Õ¡‡øìμμ“¡’π Ú. °”‡π‘¥æ¬“∏‘‰¡à‰¥âÕ¬Ÿà∑’ËÀ≈Õ¥‡≈◊Õ¥À—«„® §◊Õ À≈Õ¥‡≈◊Õ¥À—«„®ª√°μ‘ À√◊Õμ’∫·μà‰¡à¡“° „π¿“«–ª√°μ‘ “¡“√∂ àß‡≈◊Õ¥‰ª‡≈’È¬ß°≈â“¡‡π◊ÈÕÀ—«„®‰¥â‡æ’¬ßæÕ ·μàºŸâªÉ«¬ Õ¬Ÿà„π¿“«–º‘¥ª√°μ‘‡™àπ ¿“«–´’¥Õ¬à“ß√ÿπ·√ß (severe anemia) ¿“«–μ‘¥‡™◊ÈÕ„π°√–· ‡≈◊Õ¥√ÿπ·√ß (severe sepsis) ∑”„Àâ√à“ß°“¬‰¡à “¡“√∂ àß‡≈◊Õ¥‰ª‡≈’È¬ß°≈â“¡‡π◊ÈÕÀ—«„®‰¥â ‡æ’¬ßæÕ°—∫§«“¡μâÕß°“√ (secondary unstable angina) ‡π◊ËÕß®“°æ¬“∏‘°”‡π‘¥¢Õß‚√§ ACS ∑’Ëæ∫¡“° ∑’Ë ÿ¥§◊Õ °“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π‡©’¬∫æ≈—π„πμ”·Àπàß∑’Ë¡’ °“√©’°¢“¥¢Õß§√“∫‰¢¡—π∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥À—«„® (atherosclerosis plaque rupture) ¥—ßπ—Èπæ¬“∏‘°”‡π‘¥¢Õß ACS ∑’Ë æ∫¡“°∑’Ë ÿ¥®÷ß¡’®ÿ¥‡√‘Ë¡μâπ®“°°“√‡°‘¥§√“∫‰¢¡—π∑’Ëºπ—ß À≈Õ¥‡≈◊Õ¥À—«„® (atherosclerosis plaque) π—Ëπ‡Õß

°”‡π‘¥æ¬“∏‘¢Õß§√“∫‰¢¡—π∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥À—«„® (Pathogenesis of atherosclerosis plaque) ≈—°…≥–∑“ßæ¬“∏‘«‘∑¬“¢Õßºπ—ßÀ≈Õ¥‡≈◊Õ¥À—«„® ª√–°Õ∫¥â«¬ Û ™—Èπ §◊Õ ™—Èπ Tunica intima , Tunica media ·≈– Tunica adventitia ‡√’¬ß®“°™—πÈ „π ÿ¥ Ÿπà Õ° ÿ¥μ“¡≈”¥—∫ „π™—Èπ Tunica intima ¬—ß “¡“√∂·∫àß¬àÕ¬‰¥âÕ’° Û ™—Èπ §◊Õ ™—Èπ endothelium, subendothelium ·≈– internal elastic laminarˆ-¯ „π™—Èπ endothelium ¢ÕßÀ≈Õ¥‡≈◊Õ¥∑ÿ° ™π‘¥„π√à“ß°“¬∑—ßÈ À≈Õ¥‡≈◊Õ¥·¥ß·≈–À≈Õ¥‡≈◊Õ¥¥” ª√–°Õ∫ ¥â«¬‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ (endothelial cells) ‡√’¬ßμ—« °—πÕ¬Ÿà‡æ’¬ß™—Èπ‡¥’¬«ª√–¡“≥ ÒÒÛ ‡´≈≈å §√Õ∫§≈ÿ¡ºπ—ß À≈Õ¥‡≈◊Õ¥¥â“π„π∑—ÈßÀ¡¥‚¥¬¡’ gap junction ·≈– tight junction ‡ªìπ®ÿ¥‡™◊ËÕ¡μàÕ√–À«à“ß‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ ·μà≈–‡´≈≈åˆ,¯,˘ ¡’πÈ”Àπ—°√«¡°—πª√–¡“≥ Ò °‘‚≈°√—¡ ·≈– ¡’æπ◊È ∑’ºË «‘ √«¡∑—ßÈ À¡¥ª√–¡“≥ Ù, - ˜, μ“√“ß‡¡μ√Ò À√◊Õ§‘¥‡ªìπæ◊πÈ ∑’‚Ë ¥¬√«¡ª√–¡“≥ ı π“¡∫“ ‡°μ∫Õ≈˘ „π

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

¿“«–ª√°μ‘ ‡ ´≈≈å ‡ ¬◊Ë Õ ∫ÿ º‘ « À≈Õ¥‡≈◊ Õ ¥¡’ À πâ “ ∑’Ë ”§— ≠ §◊ Õ Ò) §«∫§ÿ¡°√–∫«π°“√°“√·¢Áßμ—«¢Õß‡≈◊Õ¥ (hemostatic balance) Ú) §«∫§ÿ¡°“√À¥√—¥·≈–¢¬“¬μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ (vascular tone) Û) §«∫§ÿ¡°“√μÕ∫ πÕßμàÕ¿“«–°“√Õ—°‡ ∫ (inflammatory response) Ù) ªÑÕß°—π‰¡à„Àâ‡≈◊Õ¥À√◊Õ à«π ª√–°Õ∫¢Õß‡≈◊Õ¥·∑√°ºà“π‡¢â“¡“„πºπ—ßÀ≈Õ¥‡≈◊Õ¥ (vascular permeability) ı) §«∫§ÿ ¡ °“√ √â “ ßÀ≈Õ¥‡≈◊ Õ ¥„À¡à (angiogenesis)ˆ,¯,˘,ÒÒ,ÒÚ √«¡∂÷ß¡’°“√ ≈“¬¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘« „π°√≥’∑’ËÀ≈Õ¥‡≈◊Õ¥‡ ◊ËÕ¡ ¿“æ (apoptosis) ∫∑∫“∑·≈– Àπâ“∑’Ë¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥¡’§«“¡·μ°μà“ß°—π¢÷ÈπÕ¬Ÿà °—∫μ”·Àπàß ·≈–™à«ß‡«≈“À√◊Õ ∂“π–¿“æ¢ÕßÀ≈Õ¥‡≈◊Õ¥ π—ÈπÊ«à“Õ¬Ÿà„π™à«ß‡«≈“„¥ÒÛ °“√§«∫§ÿ¡ vascular tone ·≈– hemostatic balance ¡’°≈‰°„π°“√∑”ß“π„°≈â™‘¥°—π¡“° ‚¥¬‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ √â“ß nitric oxide (NO) ®“° NO synthases, prostacyclin ·≈– prostaglandin I2ÒÙ,Òı ´÷Ëß πÕ°®“°ÕÕ°ƒ∑∏‘Ï„π°“√¢¬“¬À≈Õ¥‡≈◊Õ¥·≈â«¬—ß “¡“√∂ ¬—∫¬—Èß°“√∑”ß“π¢Õß‡°√Á¥‡≈◊Õ¥¥â«¬ (platelet inhibitors) „π ¢≥–∑’Ë platelet activator factor, endothelin-1 ·≈– thomboxane A2 πÕ°®“°°√–μÿâπ„Àâ¡’°“√À¥√—¥μ—«¢Õß À≈Õ¥‡≈◊Õ¥·≈â«¬—ß “¡“√∂°√–μÿâπ°“√∑”ß“π¢Õß‡°√Á¥‡≈◊Õ¥ ¥â « ¬ (platelet activators) ÒÙ,Òı ”À√— ∫ Àπâ “ ∑’Ë § «∫§ÿ ¡ vascular permeability §«∫§ÿ¡‚¥¬ tight junction, gap junction ·≈–º‘«¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥∑’Ë¡’≈—°…≥– ‡√’¬∫‰¡à¡’ adhesion molecules À√◊ÕÕ“®æ∫ intercellular adhesion molecule-1 (ICAM-1) ‰¥â∫â“ß„πª√‘¡“≥‰¡à¡“°Òˆ ®÷ß‰¡à¡’™àÕß∑“ßæ‘‡»… ”À√—∫‡´≈≈å‡¡Á¥‡≈◊Õ¥¢“«¡“‡°“–μ‘¥ ·≈–·∑√°μ—«ºà“π‡¢â“¡“„πºπ—ßÀ≈Õ¥‡≈◊Õ¥ ”À√—∫Àπâ“∑’Ë„π °“√μÕ∫ πÕßμàÕ¿“«–°“√Õ—°‡ ∫ (inflammatory response) ·≈–Àπâ “ ∑’Ë √â “ ßÀ≈Õ¥‡≈◊ Õ ¥„À¡à (angiogenesis) „π ¿“«–ª√°μ‘‡ªìπ°≈‰°°“√´àÕ¡·´¡ À√◊Õ ¡“π·º≈À≈—ß®“° ‡°‘¥§«“¡‡ ’¬À“¬μàÕºπ—ßÀ≈Õ¥‡≈◊Õ¥‡∑à“π—Èπ ®ÿ ¥°”‡π‘¥¢Õß§√“∫‰¢¡—π‡™◊ËÕ«à“¡’®ÿ¥‡√‘Ë¡μâ π®“° À≈“¬ªí®®—¬¥â«¬°—π ‡™àπ ¿“«–‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ ∑”ß“πº‘¥ª√°μ‘ (endothelial dysfunction) ‚√§‰¢¡—π„π ‡≈◊Õ¥ Ÿß (dyslipidemia) ‚¥¬‡©æ“–ºŸªâ «É ¬∑’¡Ë √’ –¥—∫‰¢¡—π LDL §Õ‡≈ ‡μÕ√Õ≈ ŸßÒ˜ √à«¡°—∫√–¥—∫ HDL §Õ‡≈ ‡μÕ√Õ≈„π ‡≈◊ Õ ¥μË” Ò¯ °“√ Ÿ ∫ ∫ÿ À √’Ë (smoking) ¿“«–°“√Õ— ° ‡ ∫ (inflammation)Ò˘ ·≈–°“√∑”ß“π¢Õß√–∫∫¿Ÿ¡§‘ ¡ÿâ °—πº‘¥ª√°μ‘ (immunologic factors)Ú „πªí®®ÿ∫—πªí®®—¬∑’Ë‡ªìπ∑’Ë¬Õ¡√—∫ ¡“°∑’Ë ÿ¥§◊Õ ¿“«–°“√∑”ß“π¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ ∑”ß“πº‘¥ª√°μ‘ ‚¥¬¡’√–¥—∫‰¢¡—π„π‡≈◊Õ¥ Ÿß‡ªìπ®ÿ¥‡√‘Ë¡μâπ

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∑”„Àâ°“√§«∫§ÿ¡ vascular permeability ¢Õßºπ—ßÀ≈Õ¥ ‡≈◊Õ¥º‘¥ª√°μ‘ LDL §Õ‡≈ ‡μÕ√Õ≈∑’ËÕ¬Ÿà„π°√–· ‡≈◊Õ¥ “¡“√∂·∑√°μ—«ºà“π gap junction √–À«à“ß‡´≈≈å‡¬◊ËÕ∫ÿº‘« À≈Õ¥‡≈◊Õ¥¯,˘,ÚÒ ‡¢â“¡“ – ¡„π™—Èπ subendothelium „π√Ÿª ¢Õß cholesterol, saturated fat, small lipoprotein particleÚÚ ´÷Ëß‡ªìπ®ÿ¥‡√‘Ë¡μâπ¢Õß°“√‡°‘¥¿“«–°“√Õ—°‡ ∫‚¥¬°√–μÿâπ„Àâ ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ √â“ß oxygen free radicals ¡“° ¢÷Èπ ·μà°≈—∫ √â“ß NO ≈¥≈ß √«¡∂÷ß°“√μÕ∫ πÕß¢Õß ºπ—ßÀ≈Õ¥‡≈◊Õ¥μàÕ NO ‡ªìπ‰ª„π∑‘»∑“ßμ√ß¢â“¡°—∫¿“«– ª√°μ‘ °≈à“«§◊Õ „π¿“«–ª√°μ‘ NO ∑”Àπâ“∑’¢Ë ¬“¬À≈Õ¥‡≈◊Õ¥ (flow-mediated vasodilator) ¬—∫¬—Èß°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥·≈– ¬—∫¬—Èß°“√‡°‘¥¿“«–°“√Õ—°‡ ∫ ·μà„π¿“«–∑’Ë‡´≈≈å‡¬◊ËÕ∫ÿº‘« À≈Õ¥‡≈◊Õ¥∑”ß“πº‘¥ª√°μ‘ NO °≈—∫∑”„Àâ‡°‘¥°“√À¥ √—¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ (vascular tone abnormality) ·≈– ‡æ‘Ë ¡ ‚Õ°“ °“√‡°‘ ¥ ≈‘Ë ¡ ‡≈◊ Õ ¥ (hemostatic imbalance) πÕ°®“°π’È oxygen free radicals ∑’Ë‡°‘¥¢÷Èπ¬—ß “¡“√∂‡ª≈’Ë¬π LDL §Õ‡≈ ‡μÕ√Õ≈‡ªìπ oxidized LDL ∑—Èß LDL ·≈– oxidized LDL “¡“√∂°√–μÿâπ„Àâ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥ ‡≈◊ Õ ¥∑”ß“πº‘ ¥ ª√°μ‘ ¡ “°¢÷È π ‚¥¬∑’Ë oxidized LDL ¡’ ∫∑∫“∑¡“°°«à “ ÚÛ ¿“«–°“√Õ— ° ‡ ∫∑’Ë ‡ °‘ ¥ ¢÷È π ∑”„Àâ ‡ ´≈å ‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥‡ ’¬À“¬ (endothelial cell injury) ¡’ °“√μÕ∫ πÕßμàÕ angiotensin II ∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥¡“°º‘¥ ª√°μ‘‡°‘¥¿“«–À≈Õ¥‡≈◊Õ¥À¥√—¥μ—«¡“°¢÷ÈπÚÙ ¡’°“√À≈—Ëß cytokines ™π‘¥ interleukin-1 (IL-1), tumor necrosis factor_(TNF-_)Úı,Úˆ ´÷Ëß¡’§ÿ≥ ¡∫—μ‘‡ª≈’Ë¬π·ª≈ßº‘«‡´≈≈å‡¬◊ËÕ ∫ÿº‘«À≈Õ¥‡≈◊Õ¥„Àâ¡’ adhesion molecules ‡°‘¥¢÷Èπ §◊Õ ICAM-1 ·≈– vascular cell adhesion molecule-1 (VCAM1) ‚¥¬‡©æ“– VCAM-1 ´÷Ëßæ∫ª√‘¡“≥¡“°°«à“·≈–æ∫∑’Ë ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥∫√‘‡«≥∑’Ë¡’°“√Õ—°‡ ∫‡∑à“π—ÈπÒˆ,Ú˜ ‚¥¬∑’Ë adhesion molecules ∑—Èß Ú ™π‘¥∑”Àπâ“∑’Ë‡ªìπ ™àÕß∑“ßæ‘‡»…„Àâ‡´≈≈å‡¡Á¥‡≈◊Õ¥¢“«¡“‡°“–μ‘¥·≈–·∑√°μ—« (diapedesis) ºà“π‡¢â“¡“„π™—Èπ subendothelium ‰¥âßà“¬¢÷Èπ πÕ°®“°π’È‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥·≈–‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ ¬—ßÀ≈—Ëß “√ chemo-attractive cytokines §◊Õ monocyte chemoattractant protein-1 (MCP-1), lymphocyte-selective chemokinesÚ¯ ÕÕ°ƒ∑∏‘‚Ï ¥¬°“√¥÷ß¥Ÿ¥‡´≈≈å monocytes ·≈– lymphocytes ∑’ËÕ¬Ÿà„π°√–· ‡≈◊Õ¥„Àâ¡“∫√‘‡«≥∑’Ë¡’¿“«–°“√ Õ—°‡ ∫¡“°¢÷πÈ μ“¡≈”¥—∫ À≈—ß®“°π—πÈ monocytes ∑’ÕË ¬Ÿ„à π™—πÈ subendothelium ®–‡ª≈’Ë¬π‡ªìπ macrophages ·≈–¡’°“√ ·∫àßμ—«‡æ‘¡Ë ®”π«π¢÷πÈ ¿“¬„μâ°“√§«∫§ÿ¡¢Õß cytokines ™π‘¥ macrophage colony stimulating factor (M-CSF),

106 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ interleukin-3 (IL-3), granulocyte-macrophage colony stimulating factor (GM-CSF)Ú˜ ‡æ◊ËÕæ¬“¬“¡°”®—¥ oxidized LDL „π§√“∫‰¢¡—π„Àâ¡’ª√‘¡“≥πâÕ¬≈ß‚¥¬ macrophages ®—∫°—∫ oxidized LDL ºà“π∑“ß scavenger receptor-B À√◊Õ CD 36Ú˘,Û ·≈â«°≈◊π oxidized LDL ‡¢â“‰ª„π‡´≈≈å (phagocytosis) ‡´≈≈å macrophages ∑’Ë¡’ oxidized LDL Õ¬Ÿ¿à “¬„π‡√’¬°«à“ foam cell À√◊Õ lipid-laden macrophagesÛÒ ‡™◊ËÕ«à“‡ªìπ°≈‰°¢Õß√à“ß°“¬‡æ◊ËÕæ¬“¬“¡≈¥§«“¡√ÿπ·√ß¢Õß ¿“«–°“√Õ—°‡ ∫ÛÚ ·μàº≈∑’Ë‰¥â°≈—∫∑”„Àâ¿“«–°“√Õ—°‡ ∫ √ÿπ·√ß¡“°¢÷Èπ‚¥¬ foam cell À≈—Ëß growth factor ·≈– chemo-attractive cytokine ‡™àπ platelet-derived growth factor (PDGF) ·≈– endothelin-1ÛÛ,ÛÙ °√–μÿâπ„Àâ¡’°“√ ‡§≈◊ËÕπμ—«¢Õß‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫®“°™—Èπ Tunica media ·∑√°μ—«‡¢â“¡“ – ¡„π™—Èπ subendothelium ‚¥¬‡´≈≈å °≈â“¡‡π◊ÈÕ‡√’¬∫‡À≈à“π’È¡’°“√·∫àßμ—«‡æ‘Ë¡®”π«π¢÷ÈπÕ¬à“ß™â“Ê ·≈–¡’°“√ √â“ß extracellular matrix „π∫√‘‡«≥∑’¡Ë °’ “√Õ—°‡ ∫ ·≈– endothelin-1 ¬—ß∑”„Àâ‡°‘¥°“√À¥√—¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ ¡“°º‘¥ª√°μ‘¥â«¬ πÕ°®“°π’È oxidized LDL „π foam cell ¬—ß ∑”„Àâ° “√∑”ß“π¢Õß mitochondria ¿“¬„π‡´≈≈åº‘ ¥ ª√°μ‘π”‰ª Ÿà°“√ ≈“¬¢Õß‡´≈≈å (apoptosis) º≈∑’Ëμ“¡¡“§◊Õ ¡’°“√À≈—Ëß lysosomal enzymes ∑”„Àâ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥ ‡≈◊Õ¥‡°‘¥§«“¡‡ ’¬À“¬ (endothelial injury) ·≈–∑”ß“π º‘¥ª√°μ‘¡“°¢÷Èπ ¡’°“√À≈—Ëß prothrombotic molecules ·≈– inflammatory cytokines ‡æ‘Ë¡¡“°¢÷Èπ°√–μÿâπ„Àâ monocytes ·∑√°μ—«‡¢â“¡“ – ¡¡“°¢÷Èπ·μà„π¢≥–‡¥’¬«°—π°≈—∫¬—∫¬—Èß ‰¡à„Àâ monocytes °≈—∫‡¢â“ Ÿà°√–· ‡≈◊Õ¥∫√‘‡«≥∑’Ë¡’°“√ Õ—°‡ ∫ÛÚ √–¬–π’È§◊Õ®ÿ¥‡√‘Ë¡μâπ¢Õß§√“∫‰¢¡—π “¡“√∂‡ÀÁπ ≈—°…≥–º‘¥ª√°μ‘∑“ß°“¬«‘¿“§¢Õßºπ—ßÀ≈Õ¥‡≈◊Õ¥‡ªìπ‡ âπ μ“¡·π«¬“«¢ÕßÀ≈Õ¥‡≈◊Õ¥‡√’¬°«à“ fatty streakÛı McGill ·≈–§≥–‰¥â∑”°“√»÷°…“ºπ—ßÀ≈Õ¥‡≈◊Õ¥„πºŸâ‡ ’¬™’«‘μ®“° “‡ÀμÿÕ◊Ëπ∑’Ë‰¡à„™à‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ·μà¡’ªí®®—¬‡ ’Ë¬ß ¢Õß‚√§À≈Õ¥‡≈◊ Õ ¥À— « „®μ’ ∫ “¡“√∂æ∫æ¬“∏‘ ¿“æ ¥—ß°≈à“«‰¥â„πºŸâªÉ«¬Õ“¬ÿμ—Èß·μà Òı ∂÷ß ÛÙ ªïÛˆ ´÷Ëß‡ªìπ À≈—°∞“π ”§—≠· ¥ß∂÷ßæ¬“∏‘°”‡π‘¥¢Õß§√“∫‰¢¡—π‰¡à„™à ‡°‘ ¥ ®“°¿“«–°“√‡ ◊Ë Õ ¡ ¿“æ¢ÕßÀ≈Õ¥‡≈◊ Õ ¥μ“¡Õ“¬ÿ ¢— ¬ (degenerative change) ·μà‡°‘¥®“°¿“«–°“√Õ—°‡ ∫ (inflammatory process) Tuzcu ·≈–§≥–‰¥â∑”°“√»÷°…“ºπ—ß À≈Õ¥‡≈◊Õ¥À—«„®„πºŸâªÉ«¬Õ“¬ÿπâÕ¬∑’Ë¬—ß‰¡à¡’Õ“°“√· ¥ß¢Õß À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‚¥¬„™â intravascular ultrasound æ∫ «à“æ¬“∏‘ ¿“æ¥—ß°≈à“«¡’Õÿ∫—μ‘°“√ Ÿß¢÷Èπ‡¡◊ËÕÕ“¬ÿ¡“°¢÷ÈπÛ˜ À≈—ß®“°‡°‘¥ fatty streak ∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥À—«„®

·≈â« ¿“«–°“√Õ—°‡ ∫¬—ß§ß¥”‡π‘πμàÕ‰ª‚¥¬¡’°“√ – ¡¢Õß oxidized LDL, extracellular matrix ·≈– macrophages, foam cell, dendritic cell, endothelial injury ‡ª√’¬∫‡ ¡◊Õπ‡ªìπ antigens ·≈– antigen-presenting cells μ“¡≈”¥—∫°√–μÿâπ √–∫∫¿Ÿ¡‘§ÿâ¡°—π¢Õß√à“ß°“¬™π‘¥ adaptive immune system ´÷Ëß¡’∫∑∫“∑„π°“√§«∫§ÿ¡§«“¡√ÿπ·√ß¢Õß¿“«–°“√Õ—°‡ ∫ ‚¥¬‡´≈≈å∑’Ë¡’∫∑∫“∑ ”§—≠§◊Õ T lymphocytes ª√–°Õ∫¥â«¬ T helper cells-1 (Th-1), T helper cell-2 (Th-2) ·≈– regulatory T cell (T reg cell) “¡“√∂°√–μÿâπ„Àâ‡´≈≈å‡¬◊ËÕ ∫ÿº‘«À≈Õ¥‡≈◊Õ¥, macrophages ·≈–‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫À≈—Ëß cytokines ·≈– growth factors μà“ßÊ ∑’Ë¡’º≈§«∫§ÿ¡¿“«– °“√Õ—°‡ ∫ ‡™àπ Th-1 T cell “¡“√∂°√–μÿâπ„Àâ¡’°“√À≈—Ëß pro-inflammatory cytokines ‡™àπ interferon-a (IFN-a), lymphotoxin, TNF-_, CD 40 ligand (CD40L) ´÷Ëß¡’ ∫∑∫“∑ ”§—≠„π°“√‡æ‘Ë¡§«“¡√ÿπ·√ß¢Õß¿“«–°“√Õ—°‡ ∫ (amplification of inflammation) ‚¥¬ TNF-_ °√–μÿâπ°“√ ‡°‘¥ adhesion molecules ∑’Ë‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥, IFN a ¬— ∫ ¬—È ß °“√ √â “ ß§≈Õ≈“‡®π¢Õß‡´≈≈å ° ≈â “ ¡‡π◊È Õ ‡√’ ¬ ∫∑”„Àâ fibrous cap ‰¡à·¢Áß·√ß √«¡∂÷ß¡’‚Õ°“ ‡°‘¥≈‘¡Ë ‡≈◊Õ¥ Ÿß¢÷πÈ à«π Th-2 T cell ·≈– Treg cell ∑”Àπâ“∑’Ë¬—∫¬—Èß§«“¡√ÿπ·√ß ¢Õß¿“«–°“√Õ—°‡ ∫Û¯ ‚¥¬ Th-2 T cell °√–μÿâπ„Àâ¡’°“√ À≈—ßË cytokines ™π‘¥ interleukin-10 (IL-10) ·≈– interleukin4 (IL-4)Û˘ ´÷Ëß “¡“√∂¬—∫¬—Èß°“√‡°‘¥§√“∫‰¢¡—π„π√–¬–·√° À√◊Õ fatty streak ‰¥âÛ¯ à«π Treg cell “¡“√∂≈¥¿“«– °“√Õ—°‡ ∫‚¥¬¬—∫¬—Èß°“√∑”ß“π¢Õß Th-1 T cell „π —μ«å ∑¥≈ÕßÙ,ÙÒ ∫∑∫“∑·≈–Àπâ“∑’Ë¬—ß‰¡à∑√“∫·πà™—¥ ‡™◊ËÕ«à“ ∑”ß“πºà“π IL-10 ·≈– transforming growth factor-` (TGF-`)Û˘,ÙÚ Õ¬à“ß‰√°Áμ“¡„πºŸâªÉ«¬∑’Ë¡’°“√¢¬“¬¢π“¥¢Õß §√“∫‰¢¡—πæ∫«à“∫∑∫“∑¢Õß Th-1 T cell ¡’¡“°°«à“ Th-2 T cellÛ¯ ”À√—∫ B cells ·≈–°“√ √â“ß¿Ÿ¡‘§ÿâ¡°—π (antibody) ¬—ß‰¡à “¡“√∂ √ÿª∫∑∫“∑∑’Ë™—¥‡®πμàÕ°“√‡°‘¥ §√“∫‰¢¡— π ‰¥â ‚¥¬∫“ß°“√»÷ ° …“æ∫«à “ °“√μ√«®æ∫ ¿Ÿ¡‘§ÿâ¡°—πμàÕ oxidized LDLÙÛ-Ùı À√◊Õ heat shock protein 65 (HSP65)Ùˆ ´÷Ëß‡ªìπ‚ª√μ’π™π‘¥Àπ÷Ëß„π§√“∫‰¢¡—π ¡’ §«“¡ —¡æ—π∏å°—∫°“√¢¬“¬¢π“¥¢Õß§√“∫‰¢¡—π ·μà∫“ß°“√ »÷°…“°≈—∫√“¬ß“πº≈μ√ß¢â“¡§◊Õ °“√æ∫¿Ÿ¡§‘ ¡ÿâ °—πμàÕ oxidized LDL “¡“√∂ªÑÕß°—π°“√‡°‘¥§√“∫‰¢¡—π‰¥â ®÷ß¡’§«“¡ ®”‡ªìπμâÕß¡’°“√»÷°…“‡æ‘¡Ë ‡μ‘¡‡æ◊ÕË √ÿª∫∑∫“∑¢Õß B cells μàÕ ‰ª ”À√—∫ cytolytic T cell (CD8) ¡’∫∑∫“∑°√–μÿâπ„Àâ¡’ °“√ ≈“¬ (apoptosis) ¢Õß‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫, ‡´≈≈å‡¬◊ËÕ ∫ÿº‘«À≈Õ¥‡≈◊Õ¥·≈– macrophagesÙ˜,Ù¯ ´÷Ëß‡´≈≈å∑’Ë ≈“¬μ—«

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

‡À≈à“π’È‡ªìπ‡ ¡◊Õπ “√∑’Ëæ√âÕ¡°√–μÿâπ°√–∫«π°“√°“√·¢Áß μ—«¢Õß‡≈◊Õ¥¿“¬„π§√“∫‰¢¡—π¥â«¬ (tissue factor)Ù˘ À≈—ß®“°‡°‘¥§√“∫‰¢¡—π∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥·≈–¡’ °“√¢¬“¬¢π“¥‡æ‘Ë¡¢÷Èπ §«“¡·¢Áß·√ßÀ√◊Õ°“√§ß ¿“æ¢Õß §√“∫‰¢¡— π ‡ªì π ‘Ë ß ®”‡ªì π ‚¥¬§«“¡·¢Á ß ·√ß¢Õß§√“∫ ‰¢¡—π ¢÷Èπ Õ¬Ÿà°—∫ ª√‘ ¡ “≥‡´≈≈å ° ≈â “ ¡‡π◊ÈÕ ‡√’¬ ∫´÷Ë ß ¡’ ° “√·∫à ß ‡´≈≈å‡æ‘Ë¡®”π«πÕ¬à“ß™â“Ê ·μà„π¢≥–‡¥’¬«°—π°Á¡’°“√ ≈“¬ μ—«¢Õß‡´≈≈å (apoptosis) §«∫§Ÿà°—π‰ª ¥—ßπ—Èπª√‘¡“≥‡´≈≈å °≈â“¡‡π◊ÈÕ‡√’¬∫„π§√“∫‰¢¡—π ®÷ß¢÷ÈπÕ¬Ÿà°—∫ ¡¥ÿ≈¢Õß°“√ √â“ß·≈–°“√ ≈“¬μ—«¢Õß‡´≈≈å„π§√“∫‰¢¡—πÙ¯ Õ¬à“ß‰√ °Áμ“¡‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫∑’ËÕ¬Ÿà„π§√“∫‰¢¡—π¡’‚§√ß √â“ß‰¡à ·¢Áß·√ß‡À¡◊Õπ‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ª√°μ‘∑’ËÕ¬Ÿà„π™—Èπ Tunca mediaı §«“¡ ”§—≠¢Õß‡´≈≈å°≈â“¡‡π◊ÕÈ ‡√’¬∫‡À≈à“π’§È Õ◊ √â“ß extracellular matrix ‡™àπ collagen type I, III ·≈– proteoglycans ‡™àπ versican, biglycan, aggrecan ·≈– decorinıÒ ‡æ◊ËÕ √â“ß§«“¡·¢Áß·√ß„Àâ°—∫§√“∫‰¢¡—π‚¥¬ ‡©æ“– à«π∑’Ë‡ªìπ°”·æß°—Èπ‰¡à„Àâ‡≈◊Õ¥‡´“–‡¢â“¡“„π§√“∫ ‰¢¡—π (fibrous cap) ´÷Ëßª√–°Õ∫¥â«¬§Õ≈≈“‡®π™π‘¥ Ò (collagen type I) Õ¬Ÿà¡“° ‚¥¬ cytokines ∑’Ë¡’º≈μàÕ °“√ √â“ß extracellular matrix §◊Õ PDGF, TGF-` ª√‘¡“≥ extracellular matrix ∑’Ë¡“°‡°‘π‰ª®–∂Ÿ°§«∫§ÿ¡À√◊Õ¬àÕ¬ ≈“¬‚¥¬ matrix metalloproteinase enzymes (MMPs) ´÷ËßÀ≈—ËßÕÕ°¡“®“° macrophagesıÚ „π√–¬–‡√‘Ë¡·√°¢Õß °“√‡°‘¥§√“∫‰¢¡—πæ∫«à“ MMPs ¡’º≈μàÕ°“√ª√—∫‡ª≈’Ë¬π ‚§√ß √â“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥À—«„®¥â«¬ (arterial remodeling) ‚¥¬ MMPs ¬àÕ¬ ≈“¬ extracellular matrix ∑”„Àâ‚§√ß √â“ß ¢Õß§√“∫‰¢¡—π‰¡à·¢Áß·√ß‡°‘¥°“√¢¬“¬μ—«¢Õß§√“∫‰¢¡—π ÕÕ°¥â“ππÕ° ‡√’¬°«à“ positive remodeling À√◊Õ eccentric plaque ‡™◊ËÕ«à“‡ªìπ°≈‰°°“√ª√—∫μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥‡æ◊ËÕ æ¬“¬“¡§ß¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß‰«â„Àâ¡“°∑’Ë ÿ¥‡æ◊ËÕ‰¡à„Àâ¡’ º≈μàÕ°“√‰À≈‡«’¬π¢Õß‡≈◊Õ¥ıÛ „π√–¬–‡√‘Ë¡μâπ°≈â“¡‡π◊ÈÕ À—«„®®÷ß‰¥â√—∫‡≈◊Õ¥‡æ’¬ßæÕ°—∫§«“¡μâÕß°“√ ºŸâªÉ«¬®÷ß‰¡à¡’ Õ“°“√„¥Ê∑—Èß ‘Èπ ∑—ÈßÊ∑’Ë¢π“¥§√“∫‰¢¡—πÕ“®¡’ª√‘¡“≥¡“° °Áμ“¡ ·μàÕ¬à“ß‰√°Áμ“¡„π√–¬–¬“« ‡¡◊ËÕ¡’ª√‘¡“≥¢Õß§√“∫ ‰¢¡—π¡“°¢÷Èπ‚¥¬‡©æ“–¡“°°«à“ Ù% ¢Õßæ◊Èπ∑’ËÀπâ“μ—¥ ¢ÕßÀ≈Õ¥‡≈◊Õ¥®–‡√‘Ë¡¡’°“√¢¬“¬¢π“¥¢Õß§√“∫‰¢¡—π‡¢â“ ¡“¥â“π„π¢ÕßÀ≈Õ¥‡≈◊Õ¥·≈–¡’°“√À¥√—¥μ—«¢Õß external elastic membrane ‡√’¬°«à“ negative remodeling àßº≈ „Àâ¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥≈¥≈ß‰¡à “¡“√∂ àß‡≈◊Õ¥‰ª‡≈’È¬ß°≈â“¡‡π◊ÈÕÀ—«„®‰¥â‡æ’¬ßæÕ°—∫§«“¡μâÕß°“√ ®÷ß‡°‘¥Õ“°“√ angina pectoris ‰¥âıÙ

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‡¡◊Ë Õ §√“∫‰¢¡— π ¡’ ¢ π“¥„À≠à ¢÷È π À√◊ Õ ¡’ ¿ “«–°“√ Õ—°‡ ∫¿“¬„π¡“° (advanced atherosclerosis plaque) “¡“√∂ æ∫À≈Õ¥‡≈◊Õ¥‡≈Á°Ê ¿“¬„π§√“∫‰¢¡—π¥â«¬ (micro-vessels) ‡°‘¥®“°°“√‡§≈◊ËÕπμ—«¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥‡¢â“¡“ „ π § √ “ ∫ ‰ ¢ ¡— π · ≈ – ¡’ ° “ √ √â “ ß À ≈ Õ ¥ ‡ ≈◊ Õ ¥ „ À ¡à (neovascularization) ‚¥¬°“√°√–μÿâπ¢Õß fibroblast growth factors, vascular endothelial growth factor (VEGF), placental growth factor (PlGF) ·≈– oncostatin Mıı,ıˆ ´÷Ëß∂◊Õ‡ªìπ à«πÀπ÷Ëß¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥∑”ß“πº‘¥ ª√°μ‘ ∫∑∫“∑¢Õß micro-vessels §◊Õ ‡ªìπ™àÕß∑“ß≈”‡≈’¬ß Õ“À“√·≈–ÕÕ°´‘‡®π ∑”„Àâ§√“∫‰¢¡—π¢¬“¬¢π“¥‡√Á«¢÷Èπ πÕ°®“°π’È¬—ß‡ªìπ™àÕß∑“ß≈”‡≈’¬ß‡´≈≈å∑’Ë¡’∫∑∫“∑ ”§—≠μàÕ ¿“«–°“√Õ—°‡ ∫ (inflammatory cells) ‡¢â“ Ÿà§√“∫‰¢¡—π ¡“°¢÷Èπ¥â«¬ ‚¥¬¡’À≈—°∞“π°“√μ√«®æ∫ VCAM-1 ∑’Ëº‘« ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥¢Õß micro-vessels ª√‘¡“≥¡“° “¡“√∂μ√«®æ∫≈‘Ë¡‡≈◊Õ¥¿“¬„π§√“∫‰¢¡—π (thrombosis in situ) ´÷Ëß‡™◊ËÕ«à“‡°‘¥®“°°“√©’°¢“¥¢Õß micro-vessels àßº≈ „Àâ thrombin ∑’ËÕ¬Ÿà¿“¬„π≈‘Ë¡‡≈◊Õ¥°√–μÿâπ„Àâ‡´≈≈å°≈â“¡‡π◊ÈÕ ‡√’¬∫‡§≈◊ËÕπμ—«‡¢â“¡“„π§√“∫‰¢¡—π·≈–¡’°“√·∫àßμ—«‡æ‘Ë¡ ®”π«π√«¥‡√Á«¢÷πÈ ∑”„Àâ§√“∫‰¢¡—π¡’¢π“¥‚μ¢÷πÈ “¡“√∂æ∫ adhesion molecules ∑’Ëº‘«‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥¡“°¢÷Èπ §◊Õ E-selectin ·≈– P-selectin ´÷Ëß‡ªìπ™àÕß∑“ßæ‘‡»…„Àâ neutrophils ·≈– platelets ¡“‡°“–μ‘¥·≈–·∑√°μ—«ºà“π‡¢â“¡“ „π§√“∫‰¢¡—π‰¥â¡“°¢÷Èπı˜ ‚¥¬ neutrophils “¡“√∂ √â“ß reactive oxygen species (ROS) ·≈–À≈—Ëß proteolytic enzymes ‡™àπ collagenases, gelatinases, elastases àß º≈„Àâ¿“«–°“√Õ—°‡ ∫√ÿπ·√ß‡æ‘Ë¡¢÷Èπ ·≈–§«“¡·¢Áß·√ß¢Õß §√“∫‰¢¡— π ≈¥≈ßı¯ ”À√—∫‡°√Á¥‡≈◊Õ¥∑’Ë‡¢â“¡“„π§√“∫ ‰¢¡—π “¡“√∂°√–μÿâπ∑—Èß°√–∫«π°“√°“√·¢Áßμ—«¢Õß‡≈◊Õ¥·≈– ¿“«–°“√Õ—°‡ ∫ı˘ ‚¥¬°“√À≈—ßË procoagulant microparticles ·≈– inflammatory factors ‡™àπ PDGF, platelet factor 4 (PF4), regulated on activation T-cell expressed and secreted (RANTES) ·≈– CD40L ‚¥¬‡©æ“– CD40L ´÷Ë ß „πªí ® ®ÿ ∫— π æ∫«à “ ¡’ ∫ ∑∫“∑ ”§— ≠ μà Õ ¿“«–°“√Õ— ° ‡ ∫ ‡π◊ÕË ß®“° “¡“√∂§«∫§ÿ¡°“√∑”ß“π¢Õß‡´≈≈å°≈â“¡‡π◊ÕÈ ‡√’¬∫, ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥ ·≈– macrophages ‚¥¬°√–μÿâπ„Àâ ‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ √â“ß extracellular matrix ¡“°¢÷Èπ °√–μÿâπ„Àâ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥‡æ‘Ë¡®”π«π adhesion molecules ∑—Èß ICAM-1, VCAM-1 ·≈– E-selectin √«¡∂÷ß ¡’∫∑∫“∑μàÕ°“√ √â“ßÀ≈Õ¥‡≈◊Õ¥„À¡à (neovascularization) ·≈– “¡“√∂°√–μÿâπ macrophages À≈—Ëß MMPs ‡æ‘Ë¡¢÷Èπˆ

108 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ πÕ°®“°π’È¬—ßæ∫ mast cells „π§√“∫‰¢¡—π¥â«¬ ·¡â«à“®–¡’ ª√‘¡“≥πâÕ¬°«à“ macrophages ·≈– neutophils ·μà¡’ ∫∑∫“∑ ”§—≠‚¥¬°“√À≈—Ëß histamine àßº≈„Àâ vascular permeability ·≈– vascular tone ¢ÕßÀ≈Õ¥‡≈◊Õ¥º‘¥ª√°μ‘ ·≈–À≈—Ëß proteinases ‡™àπ chymases ·≈– tryptases ´÷Ëß ¡’º≈μàÕ§«“¡·¢Áß·√ß¢Õß§√“∫‰¢¡—π·≈–°“√ª√—∫‡ª≈’Ë¬π ‚§√ß √â“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥ (arterial remodeling) √«¡∂÷ß °“√©’°¢“¥¢Õß§√“∫‰¢¡—π¥â«¬ˆÒ πÕ°®“°‚√§‰¢¡—π™π‘¥ LDL §Õ‡≈ ‡μÕ√Õ≈„π ‡≈◊Õ¥ Ÿß·≈â« ¿“«–‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥∑”ß“πº‘¥ª√°μ‘ ¬—ß¡’√“¬ß“πæ∫„πºŸâªÉ«¬‰¢¡—π™π‘¥‰μ√°≈’‡´Õ‰√¥å„π‡≈◊Õ¥ Ÿß¥â«¬ˆÚ ºŸâªÉ«¬∑’Ë Ÿ∫∫ÿÀ√’Ë ‚√§Õâ«πˆÛ ºŸâªÉ«¬‚√§‡∫“À«“π ∑’Ë æ ∫√–¥— ∫ Õ‘ π ´Ÿ ≈‘ π „π‡≈◊ Õ ¥ Ÿ ß ·≈–¥◊È Õ μà Õ Õ‘ π ´Ÿ ≈‘ π (hyperinsulinemia and insulin resistant states) ˆÙ,ˆı §πª√°μ‘∑’Ë¡’ª√–«—μ‘§√Õ∫§√—«‡ªìπ‡∫“À«“π∑—Èß™π‘¥ Ò (type I diabetes)ˆˆ,ˆ˜ ·≈–™π‘¥ Ú (type II diabetes)ˆ¯ §π ª√°μ‘∑’Ë‰¡à¡’ªí®®—¬‡ ’Ë¬ß·μà¡’ª√–«—μ‘§√Õ∫§√—«‡ªìπ‚√§À≈Õ¥ ‡≈◊Õ¥À—«„®μ’∫μ—Èß·μàÕ“¬ÿ¬—ßπâÕ¬ ´÷Ëß∑—ÈßÀ¡¥°Á§◊Õªí®®—¬‡ ’Ë¬ß∑’Ë æ∫∫àÕ ¬¢Õß°“√‡°‘¥ ‚√§ ACS π—Ë π ‡Õß πÕ°®“°π’È ¬—ß ¡’ √“¬ß“πæ∫„πºŸªâ «É ¬∑’¡Ë Õ’ “°“√·πàπÀπâ“Õ° (angina pectoris) ·μàÀ≈Õ¥‡≈◊Õ¥À—«„®ª√°μ‘ (syndrome X)ˆ˘ ºŸâªÉ«¬Õ“¬ÿπâÕ¬ ∑’Ë¡’§«“¡‡§√’¬¥´÷Ëß¡’√“¬ß“π«à“ “¡“√∂∑”„Àâ‡´≈≈å‡¬◊ËÕ∫ÿº‘« À≈Õ¥‡≈◊Õ¥∑”ß“πº‘¥ª√°μ‘·∫∫™—Ë«§√“«‰¥â˜,˜Ò ®÷ß‡ªìπ ‡Àμÿº≈ ”§—≠„π°“√Õ∏‘∫“¬°“√‡°‘¥‚√§ ACS „πºŸâªÉ«¬∑’Ë¡’ √–¥—∫ LDL §Õ‡≈ ‡μÕ√Õ≈„π‡≈◊Õ¥Õ¬Ÿà„π‡°≥±åª√°μ‘‰¥â

°”‡π‘¥æ¬“∏‘¢Õß°“√©’°¢“¥¢Õß§√“∫‰¢¡—π·≈– °“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π (Pathogenesis of atherosclerosis plaque rupture and thrombosis) Thieme ·≈–§≥–‰¥â∑”°“√»÷°…“≈—°…≥–∑“ß°“¬ «‘¿“§¢Õß§√“∫‰¢¡—π„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‚¥¬ °“√ àÕß°≈âÕß (coronary angioscopic study) æ∫«à“ ºŸâªÉ«¬ ∑’Ë¡’§√“∫‰¢¡—π∑’Ëºπ—ßÀ≈Õ¥‡≈◊Õ¥À—«„®¡’ ’‡À≈◊Õß (yellowish plaques) ¡’‚Õ°“ ‡°‘¥‚√§ ACS ¡“°°«à“ºŸâªÉ«¬∑’Ë¡’§√“∫ ‰¢¡—π ’¢“« (whitish plaques) ´÷Ëß¡—°®–æ∫„π°≈ÿà¡ºŸâªÉ«¬ À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡√◊ÈÕ√—ß (chronic stable angina)˜Ú μàÕ¡“ Ueda ·≈–§≥–∑”°“√»÷°…“ coronary angioscopic study „π °≈ÿà¡ºŸâªÉ«¬ ACS ™π‘¥ ST elevation myocardial infarction (STEMI) æ∫«à“§√“∫‰¢¡—π∑’Ë©’°¢“¥·≈–‡ªìπμ”·Àπàß∑’Ë‡°‘¥ ≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π (culprit lesion) ¡’≈—°…≥–‡ªìπ ’‡À≈◊Õß À≈—ß ®“°π—Èπμ‘¥μ“¡ºŸâªÉ«¬‡ªìπ‡«≈“ Ò¯ ‡¥◊Õπæ∫«à“§√“∫‰¢¡—π

¥—ß°≈à“«®–§àÕ¬Ê ‡ª≈’Ë¬π‡ªìπ ’¢“«√«¡∂÷ß‚Õ°“ °“√‡°‘¥≈‘Ë¡ ‡≈◊ Õ ¥Õÿ ¥ μ— π ‡©’ ¬ ∫æ≈— π ≈¥πâ Õ ¬≈ß¥â « ¬˜Û ¥—ßπ—Èπ®–‡ÀÁπ«à“ ≈—°…≥–§√“∫‰¢¡—π„πºŸªâ «É ¬ ACS ¡’§«“¡·μ°μà“ß®“°ºŸªâ «É ¬ chronic stable angina Õ¬à“ß™—¥‡®π ¥—ß∑’Ë°≈à“«·≈â«¢â“ßμâπ«à“§«“¡·¢Áß·√ß¢Õß§√“∫ ‰¢¡— π ¢÷È π Õ¬Ÿà °— ∫ §«“¡ ¡¥ÿ ≈ √–À«à “ ßª√‘ ¡ “≥¢Õß‡´≈≈å °≈â“¡‡π◊ÈÕ‡√’¬∫·≈–ª√‘¡“≥¢Õß extracellular matrix ∑’Ë √â“ß ‚¥¬‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫„π§√“∫‰¢¡—π‚¥¬‡©æ“– collagen type I ´÷Ëß‡ªìπ à«πª√–°Õ∫ ”§—≠¢Õß fibrous cap °—∫ °“√ ≈“¬¢Õß‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ (apoptosis) ·≈–°“√¬—∫¬—Èß °“√ √â“ß§≈Õ≈“‡®π¢Õß‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ √«¡∂÷ß°“√¬àÕ¬ ≈“¬¢Õß extracellular matrix ‚¥¬ MMPs ·≈– proteolytic enzymes ∑’ËÀ≈—ËßÕÕ°¡“®“° macrophages ·≈– neutrophils μ“¡≈”¥—∫ „πºŸâªÉ«¬ ACS ‡™◊ËÕ«à“ ¡¥ÿ≈¥—ß°≈à“«‡ ’¬‰ª ‚¥¬ ¡’°“√ ≈“¬À√◊Õ¬—∫¬—Èß°“√ √â“ß¢Õß extracellular matrix ¡“° °«à“°“√ √â“ß¢÷Èπ∑¥·∑π √«¡∂÷ßª√‘¡“≥‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ „π§√“∫‰¢¡—π≈¥≈ß¥â«¬ º≈§◊Õ fibrous cap ¡’≈—°…≥–∫“ß ≈ß·≈–‰¡à·¢Áß·√ß ‡√’¬°«à“ thin-cap fibroatheroma (TCFA) À√◊Õ vulnerable plaque ®“°°“√»÷°…“∑“ßæ¬“∏‘«‘∑¬“¢Õß TCFA æ∫«à“¡’≈—°…≥–¥—ßπ’È §◊Õ Ò) fibrous cap ¡’§«“¡ Àπ“πâÕ¬°«à“ ˆı ‰¡‚§√‡¡μ√ (thin fibrous cap)˜Ù Ú) æ∫ ª√‘¡“≥‰¢¡—π – ¡¿“¬„π¡“° (lipid-rich necrotic core) Û) æ∫ macrophages, T lymphocytes Õ¬Ÿà¿“¬„πª√‘¡“≥¡“° ‚¥¬‡©æ“–∑’Ë¢Õ∫¢Õß§√“∫‰¢¡—π (shoulder of plaque)¯ Ù) æ∫‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫‡æ’¬ß‡≈Á°πâÕ¬ ´÷Ëß·μ°μà“ß®“° §√“∫‰¢¡— π ∑’Ë æ ∫„πºŸâ ªÉ « ¬À≈Õ¥‡≈◊ Õ ¥À— « „®μ’ ∫ ‡√◊È Õ √— ß ∑’Ë ¡’ ≈—°…≥–ºπ—ß°—πÈ √–À«à“ßÀ≈Õ¥‡≈◊Õ¥°—∫§√“∫‰¢¡—πÀπ“ (thick fibrous cap), ¡’ª√‘¡“≥‰¢¡—π – ¡¿“¬„π·≈–ª√‘¡“≥‡¡Á¥ ‡≈◊Õ¥¢“«πâÕ¬·μàæ∫‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ª√‘¡“≥¡“° ‡√’¬° ≈—°…≥–§√“∫‰¢¡—π¥—ß°≈à“««à“ stable plaque °√–∫«π°“√ ∑’Ë∑”„Àâ‚§√ß √â“ß¢Õß§√“∫‰¢¡—π·μ°μà“ß°—π §◊Õ ¿“«–°“√ Õ—°‡ ∫ ¥—ß¡’À≈—°∞“π∑’Ë π—∫ πÿπ §◊Õ Ò) inflammatory markers „π°√–· ‡≈◊Õ¥ ·≈– Ú) ≈—°…≥–∑“ßæ¬“∏‘«‘∑¬“ ¢Õß TCFA ”À√—∫ inflammatory markers ∑’Ë¡’√“¬ß“π μ√«®æ∫„πºŸâªÉ«¬ ACS §◊Õ C-reactive protein (CRP), interleukin-6 (IL-6) ·≈– serum amyloid A˜ı ‚¥¬‡©æ“– CRP ´÷Ëß “¡“√∂μ√«®æ∫„π°√–· ‡≈◊Õ¥ Ÿß°«à“„πÀ≈Õ¥ ‡≈◊Õ¥À—«„®˜ˆ ‚¥¬√–¥—∫ CRP „π°≈ÿà¡ºŸâªÉ«¬ ACS æ∫¡’§à“ Ÿß°«à“°≈ÿà¡ºŸâªÉ«¬ chronic stable angina˜˜ ·≈–‡¡◊ËÕμ‘¥μ“¡ ºŸâªÉ«¬„π√–¬–¬“«æ∫«à“ °≈ÿà¡ºŸâªÉ«¬ ACS ∑’Ë¡’§à“ CRP „π °√–· ‡≈◊Õ¥ Ÿß¡’‚Õ°“ ‡°‘¥°≈â“¡‡π◊ÈÕÀ—«„®μ“¬´È” Ÿß°«à“

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

°≈ÿà¡ºŸâªÉ«¬ ACS ∑’Ë¡’§à“ CRP „π°√–· ‡≈◊Õ¥μË”˜¯ πÕ°®“° π’È¬—ßæ∫«à“°“√√—°…“‚√§‰¢¡—π„π‡≈◊Õ¥ Ÿß‚¥¬„™â¬“„π°≈ÿà¡ HMG CoA reductase (Hydroxymethylglutaryl CoA reductase) inhibitors À√◊Õ statins “¡“√∂≈¥√–¥—∫§Õ‡≈ ‡μÕ√Õ≈·≈–≈¥‚Õ°“ ‡°‘¥À≈Õ¥‡≈◊Õ¥À—«„®μ’∫´È”≈ß‰¥â·≈â« ¬—ßæ∫«à“√–¥—∫ CRP ¢ÕßºŸâªÉ«¬≈¥≈ß¥â«¬˜˘ ”À√—∫À≈—°∞“π ∑“ßæ¬“∏‘«‘∑¬“¢Õß TCFA ´÷Ëßª√–°Õ∫¥â«¬ª√‘¡“≥‡´≈≈å∑’Ë ¡’∫∑∫“∑ ”§—≠μàÕ¿“«–°“√Õ—°‡ ∫¡“°°«à“„π stable plaque ‡™àπ macrophages, lymphocytes, neutrophils, mast cells, platelets, ‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫ √«¡∂÷ß extracellular matrix, lipids, acellular lipid rich debrisÛ¯ ·≈– pro-inflammatory cytokines μà“ßÊ ‡™àπ IFN-a, TNF-_, IL-1, M-CSF ´÷Ëß ≈â«π·≈â«·μà¡’∫∑∫“∑‡æ‘Ë¡§«“¡√ÿπ·√ß¢Õß¿“«–°“√Õ—°‡ ∫ ‚¥¬‡©æ“–°√–μÿâπ„Àâ foam cells √â“ß MMPs ¡“°¢÷Èπ¯,¯Ò ·≈–¡’°“√μ√«®æ∫ neutral proteases ‡Õπ‰´¡å´÷Ëß¡’º≈μàÕ °“√¬àÕ¬ ≈“¬ extracellular matrix ‡æ‘Ë¡¡“°¢÷Èπ àßº≈„Àâ §«“¡·¢Áß·√ß¢Õß§√“∫‰¢¡—π≈¥≈ß¥â«¬ μ”·Àπàß¢Õß TCFA ¡—°æ∫∑’Ëμ”·Àπàß à«πμâπ ·≈–∫√‘‡«≥°≈“ßÊ ¢ÕßÀ≈Õ¥‡≈◊Õ¥‚¥¬æ∫∫√‘‡«≥ proximal left anterior descending artery, proximal left circumflex artery ·≈– mid to proximal right coronary artery¯Ú ´÷Ëß Õ¥§≈âÕß°—∫μ”·Àπàß¢Õß°“√‡°‘¥§√“∫‰¢¡—π´÷Ëß¡—°æ∫∑’Ë à«πμâπ¢ÕßÀ≈Õ¥‡≈◊Õ¥ (proximal segment) à«π‚§âß (bend point) À√◊Õμ”·Àπàß·¬° “¢“ (bifurcation)ÒÚ,¯Û,¯Ù ‚Õ°“ æ∫πâÕ¬„π à«πª≈“¬¢ÕßÀ≈Õ¥‡≈◊Õ¥ (distal segment)˘,¯Ù-¯ˆ ®“°μ”·Àπàß∑’μË √«®æ∫¥—ß°≈à“« ‡™◊ÕË «à“°“√‰À≈‡«’¬π¢Õß‡≈◊Õ¥ (hemodynamic factors) ¡’º≈μàÕ°“√‡°‘¥§√“∫‰¢¡—π ·≈– ¿“«–°“√Õ—°‡ ∫¿“¬„π§√“∫‰¢¡—π¥â«¬ ‚¥¬æ∫«à“ °“√‰À≈ ‡«’¬π¢Õß‡≈◊Õ¥∑’Ë¡’≈—°…≥–¢π“π‰ª°—∫À≈Õ¥‡≈◊Õ¥ (laminar flow) ´÷ßË ¡—°æ∫∑’μË ”·Àπàß à«πª≈“¬¢ÕßÀ≈Õ¥‡≈◊Õ¥ ‡π◊ÕË ß®“° ¡’ “¢“·¬°·≈– à«π‚§âßπâÕ¬ ·√ß°√–∑”Õ—π‡°‘¥®“°°“√ ‰À≈‡«’¬π¢Õß‡≈◊Õ¥μàÕºπ—ßÀ≈Õ¥‡≈◊Õ¥®÷ßª√°μ‘ (normal shear stress) ‡´≈≈å‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥„πμ”·Àπàßπ’È¡’√Ÿª√à“ßª√°μ‘ (elongated shape) ˜,¯,ÚÒ Àπâ “ ∑’Ë § «∫§ÿ ¡ vascular permeability ª√°μ‘ πÕ°®“°π’È laminar flow ¬—ß “¡“√∂ ªÑÕß°—π°“√‡°‘¥§√“∫‰¢¡—π‰¥â¥â«¬¯˜ ‚¥¬°√–μÿâπ‡´≈≈å‡¬◊ËÕ ∫ÿº«‘ À≈Õ¥‡≈◊Õ¥ºà“π∑“ß Krupple-like factor 2 (KLF-2) √â“ß NO ·≈– thrombomodulin (TM) ¡“°¢÷Èπ ´÷ËßπÕ°®“°¡’ §ÿ≥ ¡∫—μ‘„π°“√¢¬“¬À≈Õ¥‡≈◊Õ¥·≈â« ¬—ß¡’§ÿ≥ ¡∫—μ‘¬—∫¬—Èß °“√‡°‘¥¿“«–°“√Õ—°‡ ∫¥â«¬ πÕ°®“°π’È KLF-2 ¬—ß “¡“√∂ ¬—∫¬—Èß nuclear factor Kappa B (NFkB) ´÷Ëß∑”Àπâ“∑’Ë„π°“√

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§«∫§ÿ¡¬’π (genes) μà“ßÊ ∑’Ë¡’∫∑∫“∑μàÕ°“√‡°‘¥¿“«–°“√ Õ—°‡ ∫ º≈∑’Ë‰¥â§◊Õ ª√‘¡“≥ VCAM-1 ∑’Ëº‘«‡´≈≈å‡¬◊ËÕ∫ÿº‘« À≈Õ¥‡≈◊Õ¥≈¥≈ß ¡’°“√¬—∫¬—Èß°“√·¢Áßμ—«¢Õß‡≈◊Õ¥‚¥¬°“√ ≈¥°“√‡°‘¥ tissue factor ·≈–‡æ‘Ë¡°“√ ≈“¬μ—«¢Õß≈‘Ë¡‡≈◊Õ¥ ‚¥¬≈¥ plasminogen activator inhibitor-1 (PAI-1)¯¯,¯˘ „π¢≥–∑’Ë ° “√‰À≈‡«’ ¬ π¢Õß‡≈◊ Õ ¥∑’Ë ¡’ ° “√‡ª≈’Ë ¬ π·ª≈ß (disturbed flow) ‡π◊ËÕß®“°°√–∑∫ à«π‚§âßÀ√◊Õμ”·Àπàß ·¬° “¢“´÷Ëß¡—°æ∫∑’Ë à«πμâπ¢ÕßÀ≈Õ¥‡≈◊Õ¥ àßº≈„Àâ·√ß °√–∑”Õ—π‡°‘¥®“°°“√‰À≈‡«’¬π¢Õß‡≈◊Õ¥μàÕºπ—ßÀ≈Õ¥‡≈◊Õ¥ º‘¥ª√°μ‘ (abnormal shear stress) º≈∑’Ëμ“¡¡“§◊Õ‡´≈≈å ‡¬◊ËÕ∫ÿº‘«À≈Õ¥‡≈◊Õ¥„πμ”·Àπàß¥—ß°≈à“«¡’°“√À¥μ—« (retract) ‡ª≈’Ë¬π√Ÿª√à“ß‡ªìπ·∫∫ polygonal shape˜,¯,ÚÒ ∑”„Àâ°“√ §«∫§ÿ¡ vascular permeability º‘¥ª√°μ‘˜,˘,¯Ù LDL §Õ‡≈ ‡μÕ√Õ≈À√◊Õ‡´≈≈å‡¡Á¥‡≈◊Õ¥¢“« “¡“√∂·∑√°μ—«ºà“π‡¢â“¡“ „π™—Èπ subendothelium ‰¥â´÷Ëß‡ªìπ®ÿ¥‡√‘Ë¡μâπ¢Õß°“√‡°‘¥ §√“∫‰¢¡—π √«¡∂÷ß≈—°…≥–‚§√ß √â“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥ à«π μâπ¡’§«“¡Àπ“¢Õß™—Èπ Tunica media ¡“°°«à“„πμ”·Àπàß à«πª≈“¬ ª√‘¡“≥‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫´÷Ëß¡’∫∑∫“∑ ”§—≠ „π°“√‡°‘ ¥ §√“∫‰¢¡— π ®÷ ß ¡’ ¡ “°°«à “ ‚Õ°“ °“√‡°‘ ¥ §√“∫ ‰¢¡—π„πÀ≈Õ¥‡≈◊Õ¥ à«πμâπ®÷ß¡“°°«à“„π à«πª≈“¬˘,¯Ù-¯ˆ,˘ πÕ°®“°π’È§«“¡·√ß¢Õß°“√‰À≈‡«’¬π¢Õß‡≈◊Õ¥„πÀ≈Õ¥ ‡≈◊Õ¥ à«πμâπ¡’§à“ Ÿß àßº≈„Àâ‡°‘¥·√ß°√–∑”μàÕºπ—ßÀ≈Õ¥ ‡≈◊Õ¥ à«πμâπ¡’§à“ Ÿß¥â«¬ (high flow/high shear stress) ´÷Ë ß ·μ°μà “ ß®“°§«“¡·√ß¢Õß°“√‰À≈‡«’ ¬ π¢Õß‡≈◊ Õ ¥„π À≈Õ¥‡≈◊Õ¥ à«πª≈“¬∑’Ë¡’§à“μË”°«à“ (low flow/low shear stress)‚¥¬æ∫«à“μ”·Àπàß§√“∫‰¢¡—π∑’¡Ë ’ high flow/high shear stress “¡“√∂μ√«®æ∫ macrophages „π§√“∫‰¢¡—π ª√‘¡“≥¡“° ∫àß∫Õ°∂÷ß¡’§«“¡√ÿπ·√ß¢Õß¿“«–°“√Õ—°‡ ∫¡’ ¡“° „π¢≥–∑’Ëμ”·Àπàß§√“∫‰¢¡—π∑’Ë¡’ low flow/low shear stress “¡“√∂μ√«®æ∫‡´≈≈å°≈â“¡‡π◊ÈÕ‡√’¬∫„π§√“∫‰¢¡—π ª√‘¡“≥¡“°˘Ò ∫àß∫Õ°∂÷ß§√“∫‰¢¡—ππ—Èπ¡’§«“¡·¢Áß·√ß ¥—ßπ—Èπ§«“¡·¢Áß·√ß¢Õß§√“∫‰¢¡—π„π à«πμâπ®÷ßπâÕ¬°«à“ ‚Õ°“ °“√‡°‘¥§√“∫‰¢¡—π©’°¢“¥„πμ”·ÀπàßÀ≈Õ¥‡≈◊Õ¥ à«πμâπ ®÷ß¡’¡“°°«à“ ‡ ¡◊Ë Õ § √ “ ∫ ‰ ¢ ¡— π ©’ ° ¢ “ ¥ ® – ¡’ ° “ √ ° √ – μÿâ π °√–∫«π°“√°“√·¢Áßμ—«¢Õß‡≈◊Õ¥ (coagulation system) ´÷Ëß‡ªìπ°≈‰°∑“ß∏√√¡™“μ‘∑’Ë√à“ß°“¬æ¬“¬“¡ ¡“π√Õ¬·º≈ ‚¥¬‡√‘Ë¡®“° primary coagulation system §◊Õ‡°√Á¥‡≈◊Õ¥¡“ ‡°“–μ‘ ¥ °— ∫ §Õ≈≈“‡®π∫√‘ ‡ «≥∑’Ë ¡’ ° “√©’ ° ¢“¥‚¥¬ von Willebrand factor ‡√’¬°«à“ platelet adhesion˘Ú À≈—ß®“° π—Èπ¡’°“√‡ª≈’Ë¬π·ª≈ßº‘«‡´≈≈å¢Õß‡°√Á¥‡≈◊Õ¥‚¥¬‡©æ“–¡’

110 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ °“√‡æ‘¡Ë glycoprotein IIb/IIIa receptor ¡“°¢÷πÈ √«¡∂÷ß°“√À≈—ßË adhesive proteins ‡™àπ fribinogen, von Williban factor, P selectin, thrombospondin ¡’°“√À≈—ßË coagulation factors ‡™àπ factor V, factor XI, PAI-1 ¡’°“√À≈—Ëß inflammatory factors ‡™àπ PF4, PDGF, CD40L ®“° _ granules ·≈–¡’ °“√À≈—ßË platelet agonist ‡™àπ adenosine diphosphate (ADP), adenosine triphosphate (ATP), magnesium, calcium, serotonin ®“° a granules ´÷Ëß “√μà“ßÊ ∑’ËÀ≈—ËßÕÕ°¡“π’È °√–μÿâπ„Àâ¿“«–°“√Õ—°‡ ∫·≈–‚Õ°“ ‡°‘¥≈‘Ë¡‡≈◊Õ¥ Ÿß¢÷Èπ ‡√’¬°¢—ÈπμÕππ’È«à“ platelet activation ¢—ÈπμÕπ ÿ¥∑â“¬§◊Õ platelet aggregation ‚¥¬‡°√Á¥‡≈◊Õ¥‡°“–μ‘¥´÷ßË °—π·≈–°—π‚¥¬ fibrin ‡™◊ËÕ¡μàÕ∑’Ë glycoprotein IIb/IIIa receptors˘Û ”À√—∫ secondary coagulation system ‡√‘Ë¡μâ π®“° extrinsic pathway ‚¥¬‡≈◊Õ¥∑’Ë‡´“–ºà“π§√“∫‰¢¡—π∑’Ë©’°¢“¥ —¡º— °—∫ tissue factor (TF)˘Ù ∑’ËÕ¬Ÿà¿“¬„π§√“∫‰¢¡—π TF ®–®—∫°—∫ factor VII/VIIa „π°√–· ‡≈◊Õ¥‡°‘¥‡ªìπ TF-VIIa complex À≈—ß®“°π—Èπ®÷ß‡√‘Ë¡°√–μÿâπ intrinsic pathway ∑”ß“πμàÕ‚¥¬ ºà“π factor IXa, Xa μ“¡≈”¥—∫ ÿ¥∑â“¬‡°‘¥ thrombin ´÷Ëß “¡“√∂‡ª≈’Ë¬π fibrinogen ‡ªìπ fibrin ‡°‘¥‡ªìπ°âÕπ≈‘Ë¡‡≈◊Õ¥ (thrombus) „πÀ≈Õ¥‡≈◊Õ¥À—«„® „πºŸâªÉ«¬∫“ß√“¬°âÕπ≈‘Ë¡ ‡≈◊Õ¥∑’Ë‡°‘¥¢÷ÈπÕ“®¡’¢π“¥‡≈Á°∑”„Àâ¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß ¢ÕßÀ≈Õ¥‡≈◊Õ¥¡’°“√‡ª≈’Ë¬π·ª≈ß‡æ’¬ß‡≈Á°πâÕ¬‰¡à¡’º≈μàÕ °“√‰À≈‡«’¬π¢Õß‡≈◊Õ¥ ºŸªâ «É ¬Õ“®‰¡à¡Õ’ “°“√· ¥ß„¥Ê ∑—ßÈ ‘πÈ ·μàº≈∑’Ëμ“¡¡“§◊Õ ¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥¡’ ¢π“¥‡≈Á°≈ßÕ¬à“ß§àÕ¬‡ªìπ§àÕ¬‰ª ‡π◊ËÕß®“°¡’‡≈◊Õ¥‡´“–‡¢â“ ¡“„π§√“∫‰¢¡—π ·≈–¡’¢∫«π°“√ ¡“π·º≈ (healing process) ∑”„Àâ¡’°“√ √â“ß§Õ≈≈“‡®π·≈–°≈â“¡‡π◊ÈÕ‡√’¬∫ ¡“°¢÷Èπ °“√¢¬“¬¢π“¥¢Õß§√“∫‰¢¡—π “¡“√∂¢¬“¬‡¢â“¡“ ¥â“π„π¢ÕßÀ≈Õ¥‡≈◊Õ¥Õ¬à“ß™â“Ê˘ı °≈â“¡‡π◊ÈÕÀ—«„®®÷ß¡’°“√ ª√—∫μ—«®“°°“√¢“¥‡≈◊Õ¥‰ª‡≈’È¬ß „π¢≥–æ—°°≈â“¡‡π◊ÈÕÀ—«„® ¬—ß§ß‰¥â√—∫‡≈◊Õ¥„πª√‘¡“≥‡æ’¬ßæÕ ºŸâªÉ«¬®÷ß‰¡à¡’Õ“°“√ ·πàπÀπâ“Õ° ·μà„π¢≥–ÕÕ°°”≈—ß°“¬ °≈â“¡‡π◊ÈÕÀ—«„® μâÕß°“√ª√‘¡“≥‡≈◊Õ¥‰ª‡≈’È¬ß¡“°¢÷Èπ·μàÀ≈Õ¥‡≈◊Õ¥À—«„®∑’Ë μ’∫‰¡à “¡“√∂ àß‡≈◊Õ¥‰ª‡≈’È¬ß‰¥â‡æ’¬ßæÕ ºŸâªÉ«¬®÷ß¡’Õ“°“√ ·πàπÀπâ“Õ° (chest discomfort on exertion) ´÷Ëß‡ªìπ°≈ÿà¡ Õ“°“√¢Õß chronic stable angina ”À√—∫ºŸâªÉ«¬ ACS æ∫ «à“°“√©’°¢“¥¢Õß§√“∫‰¢¡—π¡—°‡°‘¥„πÀ≈Õ¥‡≈◊Õ¥∑’Ë¡’¢π“¥ °“√μ’∫μ—πμ—ÈßμâππâÕ¬°«à“ ı%˘ˆ ·≈–°âÕπ≈‘Ë¡‡≈◊Õ¥∑’Ë‡°‘¥ ¢÷Èπ„πÀ≈Õ¥‡≈◊Õ¥À—«„®¡’¢π“¥„À≠à®÷ß¡’°“√‡ª≈’Ë¬π·ª≈ß ‚¥¬°“√≈¥¢π“¥‡ âπºà“»Ÿπ¬å°≈“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥Õ¬à“ß√«¥‡√Á« à ß º≈„Àâ ° ≈â “ ¡‡π◊È Õ À— « „® à « πª≈“¬μà Õ μ”·Àπà ß π—È π ‰¥â √— ∫

‡≈◊Õ¥‰ª‡≈’È¬ß‰¡à‡æ’¬ßæÕ°—∫§«“¡μâÕß°“√ °≈â“¡‡π◊ÈÕÀ—«„®®÷ß ¢“¥‡≈◊Õ¥‰ª‡≈’È¬ßÕ¬à“ß‡©’¬∫æ≈—π ‚¥¬∑’Ë∂â“°âÕπ≈‘Ë¡‡≈◊Õ¥∑’Ë ‡°‘¥¢÷Èπ¡’¢π“¥„À≠à·≈–Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥∑—ÈßÀ¡¥ Ò% ®– ‡ªìπæ¬“∏‘°”‡π‘¥¢Õß‚√§ ACS ™π‘¥ STEMI ≈—°…≥–≈‘Ë¡ ‡≈◊Õ¥¡—°¡’ ’·¥ß (reddish thrombus) ª√–°Õ∫¥â«¬‰ø∫√‘π ‡ªìπ®”π«π¡“° (fibrin-rich thrombus)˘˜ ·μà∂â“°âÕπ≈‘Ë¡ ‡≈◊Õ¥∑’Ë‡°‘¥¢÷ÈπÕÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥À—«„®‡°◊Õ∫∑—ÈßÀ¡¥‚¥¬∑’Ë¬—ß ¡’‡≈◊Õ¥‰À≈ºà“π‰¥â∫â“ß·μà‰¡à‡æ’¬ßæÕμàÕ§«“¡μâÕß°“√¢Õß °≈â“¡‡π◊ÈÕÀ—«„® à«πª≈“¬ ®–‡ªìπæ¬“∏‘°”‡π‘¥¢Õß‚√§ ACS ™π‘¥ Non STEMI À√◊Õ Unstable angina (UA) ≈—°…≥– ≈‘Ë¡‡≈◊Õ¥¡—°¡’ ’¢“«À√◊Õ‡∑“ (grayish-white thrombus) ´÷Ëß ª√–°Õ∫¥â«¬‡°√Á¥‡≈◊Õ¥®”π«π¡“° (platelet-rich thrombus)˘˜ “¡“√∂«‘π®‘ ©—¬·¬°‚√§‚¥¬°“√μ√«® cardiac biomarkers „π °√–· ‡≈◊Õ¥‡™àπ Troponin T À√◊Õ Troponin I ´÷Ëß‡ªìπ À≈—°∞“π· ¥ß∂÷ß¡’°≈â“¡‡π◊ÈÕÀ—«„®μ“¬‡°‘¥¢÷Èπ‚¥¬∂â“æ∫º≈ ‡≈◊Õ¥ cardiac biomarkers „Àâ§à“∫«° °“√«‘π‘®©—¬§◊Õ Non STEMI ∂â“„Àâº≈≈∫ °“√«‘π‘®©—¬ §◊Õ UA

√ÿª °”‡π‘¥æ¬“∏‘¢Õß‚√§À≈Õ¥‡≈◊Õ¥À—«„®μ’∫‡©’¬∫æ≈—π (ACS) ∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥‡°‘¥®“°°“√©’°¢“¥¢Õß§√“∫‰¢¡—π (atherosclerosis plaque rupture) ‚¥¬¡’ “‡Àμÿ∑’Ë ”§—≠§◊Õ ¿“«–°“√Õ—°‡ ∫ (inflammatory process) ´÷Ëß¡’∫∑∫“∑μ—Èß ·μà®¥ÿ ‡√‘¡Ë μâπ¢Õß°“√‡°‘¥§√“∫‰¢¡—π (atherosclerosis plaque) ‚¥¬‡√‘Ë ¡ ®“°‡´≈≈å ‡ ¬◊Ë Õ ∫ÿ º‘ « À≈Õ¥‡≈◊ Õ ¥∑”ß“πº‘ ¥ ª√°μ‘ (endothelial dysfunction) √«¡∂÷ ß ¡’ ∫ ∑∫“∑ ”§— ≠ μà Õ °“√‡ª≈’Ë¬π·ª≈ß‚§√ß √â“ß¢ÕßÀ≈Õ¥‡≈◊Õ¥À—«„® (arterial remodeling) ·≈–§«“¡·¢Áß·√ß¢Õß§√“∫‰¢¡—π ‚¥¬§√“∫ ‰¢¡—π∑’Ëæ∫„πºŸâªÉ«¬ ACS ¡’≈—°…≥–∫“ßæ√âÕ¡©’°¢“¥‰¥âßà“¬ (vulnerable plaque À√◊Õ thin cap fibroatheroma) μ≈Õ¥ ®π¡’∫∑∫“∑ ”§—≠„π°“√°√–μÿâπ„Àâ‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥μ—π„π À≈Õ¥‡≈◊Õ¥À—«„®‚¥¬ºà“π°√–∫«π°“√°“√·¢Áßμ—«¢Õß‡≈◊Õ¥ (coagulation system) „Àâ ∑”ß“π¡“°°«à “ ª√°μ‘ §«“¡ √ÿπ·√ß¢Õß¿“«–°“√Õ—°‡ ∫„π√à“ß°“¬ºŸâªÉ«¬·μà≈–§π·μ° μà“ß°—π‡™◊ËÕ«à“‡°‘¥®“°ªí®®—¬À≈“¬Ê Õ¬à“ß ‡™àπ √–¥—∫‰¢¡—π „π‡≈◊Õ¥ Ÿß °“√ Ÿ∫∫ÿÀ√’Ë ‡∫“À«“π §«“¡¥—π‚≈À‘μ Ÿß ·≈– °√√¡æ—π∏ÿå Õ¬à“ß‰√°Áμ“¡‚Õ°“ °“√‡°‘¥‚√§ ACS „πºŸâªÉ«¬ ·μà≈–§π¢÷ÈπÕ¬Ÿà°—∫ ¡¥ÿ≈¢Õßªí®®—¬ Û ¢âÕ §◊Õ Ò. ¢π“¥¢Õß§√“∫‰¢¡—π (atherosclerosis plaque burden) Ú. §«“¡√ÿπ·√ß¢Õß¿“«–°“√Õ—°‡ ∫ (severity of

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inflammatory process) Û. ¢π“¥¢Õß°âÕπ≈‘Ë¡‡≈◊Õ¥∑’Ë‡°‘¥¢÷Èπ„πÀ≈Õ¥‡≈◊Õ¥ À—«„® (thrombus size) ºŸâªÉ«¬ ACS §◊Õ °≈ÿà¡ºŸâªÉ«¬∑’Ë¡’§«“¡√ÿπ·√ß¢Õß ªí®®—¬∑—ßÈ Û ¢âÕ Ÿß ¥—ßπ—πÈ À“°‡√“‡¢â“„®∂÷ßæ¬“∏‘°”‡π‘¥¢Õß‚√§ √«¡∂÷ß “¡“√∂§«∫§ÿ¡ªí®®—¬¥—ß°≈à“«∑—Èß Û ¢âÕ‰¥â °Á®– “¡“√∂π”‰ª Ÿà°“√√—°…“ºŸâªÉ«¬ ACS ∑—Èß„π√–¬–‡©’¬∫æ≈—π ·≈–ªÑÕß°—π°“√‡°‘¥‚√§´È”„π√–¬–¬“« (secondary prevention) √«¡∂÷ß°“√«“ß·ºπªÑÕß°—π°“√‡°‘¥‚√§ ACS „π°≈ÿà¡ ª√–™“°√ª√°μ‘∑’Ë¬—ß‰¡à¡’Õ“°“√· ¥ß (primary prevention) ‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ Ÿß ÿ¥

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∫∑π” ¿“«–™—°‡Àμÿ‰¢â (febrile seizure) „π‡¥Á° ‡ªìπÕ“°“√ ©ÿ°‡©‘π∑“ß√–∫∫ª√– “∑∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥„π‡«™ªØ‘∫—μ‘Ò æ∫ „π™à«ßÕ“¬ÿ√–À«à“ß Û ‡¥◊Õπ∂÷ß ı ªï ‚¥¬¡’Õÿ∫—μ‘°“√≥å √âÕ¬≈– Ú ∂÷ß ı “‡Àμÿ¿“«–™—°‡Àμÿ‰¢â¬ß— ‰¡à‡ªìπ∑’∑Ë √“∫·πà™¥— „π¢—πÈ μÕπ°“√«‘π®‘ ©—¬μâÕß«‘π®‘ ©—¬·¬°‚√§®“°¿“«–μ‘¥‡™◊ÕÈ ¢Õß ¡Õß·≈–‡¬◊ËÕÀÿâ¡ ¡ÕßÕ—°‡ ∫ §«“¡º‘¥ª√°μ‘¢Õß‡°≈◊Õ·√à „π‡≈◊Õ¥ À√◊Õª√–«—μ‘™—°‚¥¬‰¡à¡’‰¢â°àÕπÀπâ“‡ªìπ ”§—≠ ·π«∑“ß°“√¥Ÿ·≈ºŸâªÉ«¬‡¥Á°∑’Ë¡“¥â«¬¿“«–‰¢â·≈– ™—°„πªí®®ÿ∫—π (Guideline of American Academy of Pediatrics : AAP) ªï æ.». ÚıÛ˘ ·π–π”„Àâμ√«® “√ πÈ”‰¢ — π À≈— ß„π‡¥Á°∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ Ò ªï∑ÿ°√“¬ ·≈– æ‘®“√≥“μ√«® “√πÈ”‰¢ —πÀ≈—ß„π‡¥Á°∑’¡Ë Õ’ “¬ÿ√–À«à“ß Ò ªï∂ß÷ Ò ªï§√÷Ëß‡ªìπ√“¬ÊÚ °“√·π–π”„Àâμ√«® “√πÈ”‰¢ —πÀ≈—ß „π‡¥Á°∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ Ò ªï∑ÿ°√“¬‡π◊ËÕß®“°Õ“®μ√«®‰¡à æ∫Õ“°“√· ¥ß¢Õß°“√√–§“¬‡§◊ÕßμàÕ‡¬◊ËÕÀÿâ¡ ¡Õß‰¥â∂÷ß ·¡â«à“ºŸâªÉ«¬®–¡’°“√μ‘¥‡™◊ÈÕ„π√–∫∫ª√– “∑ ¡’√“¬ß“π°“√ »÷°…“®“°μà“ßª√–‡∑»∑’æË ∫«à“ ¡’°“√μ‘¥‡™◊ÕÈ ¢Õß‡¬◊ÕË Àÿ¡â ¡Õß ®“°‡™◊ÈÕ·∫§∑’‡√’¬„π°≈ÿà¡ºŸâªÉ«¬‡¥Á°Õ“¬ÿπâÕ¬°«à“ Ò ªï∑Ë’‰¥â °“√«‘π®‘ ©—¬‡∫◊ÕÈ ßμâπ‡ªìπ‚√§™—°‡Àμÿ‰¢â (febrile seizure)Û-ˆ ·¡â«à“‡ªìπ®”π«π∑’Ë‰¡à¡“° ·μà¡’§«“¡ ”§—≠‡π◊ËÕß®“°¿“«– °“√μ‘¥‡™◊ÈÕ„π√–∫∫ª√– “∑®—¥‡ªìπ‚√§∑’Ë√ÿπ·√ß‡ªìπ “‡Àμÿ ¢Õß°“√‡ ’¬™’«‘μ·≈–°àÕ„Àâ‡°‘¥§«“¡æ‘°“√‡¡◊ËÕ‰¡à‰¥â√—∫°“√ √—°…“À√◊Õ«‘π‘®©—¬™â“ ‡π◊ËÕß®“°§«“¡·¡àπ¬”®“°°“√μ√«®√à“ß°“¬∑’Ë®– æ∫°“√√–§“¬‡§◊Õß¢Õß‡¬◊ËÕÀÿâ¡ ¡Õß„π°√≥’∑’Ë¡’¿“«–‡¬◊ËÕÀÿâ¡ ¡ÕßÕ—°‡ ∫„π‡¥Á°Õ“¬ÿπâÕ¬°«à“ Ò ªï‰¡à∂÷ß√âÕ¬≈– Ò ®÷ß ¡’ ¢â Õ ¡Ÿ ≈ °“√»÷ ° …“∑’Ë ™’È π”‚Õ°“ ∑’Ë ºŸâ ªÉ « ¬®–¡’ ¿ “«–‡¬◊Ë Õ Àÿâ ¡ ¡ÕßÕ—°‡ ∫À√◊Õ ¡ÕßÕ—°‡ ∫∂â“¡’¿“«–¥—ßμàÕ‰ªπ’È˜ ‰¥â·°à ª√–«—μ‘√âÕß°«π ‡∫◊ËÕÕ“À“√ ´÷¡ ™—°∑’Ë‡°‘¥¢÷Èπ‡ªìπ√–¬–‡«≈“ π“π ™—°‡©æ“–∑’Ë À√◊Õ¡’¿“«–™—°À≈“¬§√—Èß„π°“√‡®Á∫ªÉ«¬ §√—Èß‡¥’¬«°—π À≈—ß™—°¡’°“√‡ª≈’Ë¬π·ª≈ß√–¥—∫§«“¡√Ÿâ ÷°μ—« §àÕπ¢â“ßπ“π À√◊Õ§«“¡º‘¥ª√°μ‘„π√–∫∫ª√– “∑·≈–¡’ ª√–«—μ‘‰¥â√—∫ª√–∑“π¬“ªØ‘™’«π–¡“°àÕπ ”À√—∫‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ ¬—ß‰¡à¡’ß“π«‘®—¬∑’Ë»÷°…“∂÷ß¢âÕ¡Ÿ≈¥—ß°≈à“«π’È ®÷ß§“¥«à“¢âÕ¡Ÿ≈ ∑’Ë‰¥â®“°°“√»÷°…“„π§√—Èßπ’È®–™à«¬„Àâ·æ∑¬å‡«™ªØ‘∫—μ‘ ·≈–

°ÿ¡“√·æ∑¬å‰¥âμ√–Àπ—°∂÷ß§«“¡ ”§—≠¢Õß°“√‡®“–μ√«® “√πÈ”‰¢ —πÀ≈—ß„πºŸâªÉ«¬‡¥Á°∑’Ë¡“¥â«¬¿“«–‰¢â·≈–™—°μàÕ‰ª

«—μ∂ÿª√– ß§å »÷°…“≈—°…≥–‡«™°√√¡·≈–º≈°“√μ√«® “√πÈ” ‰¢ —πÀ≈—ß¢ÕßºŸâªÉ«¬‡¥Á°Õ“¬ÿ Û ‡¥◊Õπ∂÷ß ı ªï∑’Ë¡’‰¢â√à«¡ °—∫™—° ·≈–‰¥â√—∫°“√«‘π‘®©—¬‡∫◊ÈÕßμâπ«à“‡ªìπ‚√§™—°‡Àμÿ‰¢â (febrile seizure) „π‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘

«— ¥ÿ·≈–«‘∏’°“√»÷°…“ √Ÿª·∫∫°“√«‘®—¬ °“√«‘®—¬‡™‘ßæ√√≥π“·∫∫¬âÕπ À≈—ß (retrospective descriptive study) °≈ÿà¡ª√–™“°√ ºŸâªÉ«¬‡¥Á°Õ“¬ÿ Û ‡¥◊Õπ ∂÷ß ı ªï ∑’Ë√—∫°“√√—°…“„π‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ ‚¥¬„Àâ°“√«‘π‘®©—¬‡∫◊ÈÕßμâπ«à“‡ªìπ‚√§™—°‡Àμÿ‰¢â (febrile seizure) ·≈–‰¥â√—∫°“√μ√«® “√πÈ”‰¢ —πÀ≈—ß „π™à«ß‡«≈“ μ—Èß·μà Ò ¡°√“§¡ æ.». ÚıÙ˜ ∂÷ß ÛÒ ∏—π«“§¡ æ.». ÚıÙ˘

º≈°“√»÷°…“ ®“°°“√√«∫√«¡¢â Õ ¡Ÿ ≈ æ∫¡’ ºŸâ ªÉ « ¬‡¥Á ° ∑—È ß À¡¥ ®”π«π ˜Ù §π —¥ à«π‡æ»™“¬μàÕ‡æ»À≠‘ß Ò.ÚÙ : Ò ™à«ßÕ“¬ÿ∑’Ëæ∫¡“°∑’Ë ÿ¥ §◊Õ Õ“¬ÿ Û ‡¥◊Õπ∂÷ß Ò ªï §‘¥‡ªìπ √âÕ¬≈– ˆÛ.ı à«π„À≠à‰¡à¡’‚√§ª√–®”μ—«§‘¥‡ªìπ√âÕ¬≈– ˘˜.Û ¡’ª√–«—μ‘‚√§™—°‡Àμÿ‰¢â„π§√Õ∫§√—«√âÕ¬≈– Ò¯.ˆ ¡’ª√–«—μ‘‚√§≈¡™—°„π§√Õ∫§√—«√âÕ¬≈– ¯.˜ “‡Àμÿ¢Õß‰¢â à « π„À≠à‡°‘¥®“°°“√μ‘¥‡™◊ÈÕ√–∫∫∑“ß‡¥‘πÀ“¬„®®”π«π ÛÙ §π §‘¥‡ªìπ√âÕ¬≈– Ùı.˘ √Õß≈ß¡“§◊Õ°“√μ‘¥‡™◊ÈÕ√–∫∫ ∑“ß‡¥‘πÕ“À“√ ÒÙ √“¬ §‘¥‡ªìπ√âÕ¬≈– Ò¯.˘ ®“°·ºπ¿Ÿ¡‘∑’Ë Ò æ∫Õÿ≥À¿Ÿ¡‘√à“ß°“¬ºŸâªÉ«¬·√°√—∫ à«π„À≠àÕ¬Ÿà„π™à«ß Û¯.-Û¯.˘ Õß»“‡´≈‡´’¬ ®”π«π ÛÒ §π §‘¥‡ªìπ√âÕ¬≈– ÙÒ.˘ √Õß≈ß¡“§◊Õ Û˜.-Û˜.˘ Õß»“‡´≈‡´’¬ ·≈– Û˘.-Û˘.˘ Õß»“‡´≈‡´’¬ μ“¡≈”¥—∫ ®“°μ“√“ß∑’Ë Ò æ∫«à“ºŸâªÉ«¬ à«π„À≠à¡’Õ“°“√™—° ¿“¬„π ÚÙ ™—Ë«‚¡ß·√°¢Õß°“√¡’‰¢â √–¬–‡«≈“™—°πâÕ¬°«à“ Òı π“∑’ ‰¡à ¡’ ° “√™— ° ´È” ‡ªì π °“√™— ° §√—È ß ·√° ·≈–¡’ ≈—°…≥–°“√™—°·∫∫‡°√Áß°√–μÿ°∑—Èßμ—«

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·ºπ¿Ÿ¡‘· ¥ßÕÿ≥À¿Ÿ¡‘√à“ß°“¬·√°√—∫¢ÕßºŸâªÉ«¬‡¥Á° ∑’Ë¡’¿“«–‰¢â·≈–™—° Ûı Û Úı Ú Òı Ò ı 

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ıÒ (Ò) Ú (¯ˆ.˘)

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120 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

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μ“√“ß∑’Ë Ú ¢âÕ¡Ÿ≈· ¥ßÕ“°“√·≈–Õ“°“√· ¥ß¢ÕßºŸâªÉ«¬·≈–º≈°“√μ√«® “√πÈ”‰¢ —πÀ≈—ß* ¡’Õ“°“√

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º≈°“√μ√«® “√πÈ”‰¢ —πÀ≈—ß ª√°μ‘ º‘¥ª√°μ‘ (√âÕ¬≈–) (√âÕ¬≈–)

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

„π°≈ÿà ¡ ºŸâ ªÉ « ¬∑’Ë ¡’ º ≈°“√μ√«® “√πÈ”‰¢ — π À≈— ß ‡ªìπª√°μ‘®”π«π∑—ÈßÀ¡¥ ˜Ò §π ¡’ºŸâªÉ«¬ Ú §π∑’Ëμ√«® æ∫Õ“°“√· ¥ß¢Õß°“√√–§“¬‡§◊ Õ ß¢Õß‡¬◊Ë Õ Àÿâ ¡ ¡Õß (meningeal irritation) §‘¥‡ªìπ√âÕ¬≈– Ú.¯ ®“°μ“√“ß∑’Ë Û · ¥ß≈—°…≥–§«“¡º‘¥ª√°μ‘¢Õß “√πÈ”‰¢ —πÀ≈—ß∑’Ëμ√«®æ∫„πºŸâªÉ«¬∑—Èß Û √“¬ ‚¥¬ºŸâªÉ«¬ Õ“¬ÿ Ù ‡¥◊Õπμ√«®æ∫‡¡Á¥‡≈◊Õ¥¢“«„π “√πÈ”‰¢ —πÀ≈—ß®”π«π Ò,ÙÙ μ—«μàÕ≈Ÿ°∫“»°å¡‘≈≈‘‡¡μ√ §‘¥‡ªìπ‡¡Á¥‡≈◊Õ¥¢“« ™π‘¥‚æ≈’¡Õ√åø√âÕ¬≈– ˜ˆ √–¥—∫‚ª√μ’π Ÿß ¯˜.Ú ¡‘≈≈‘°√—¡

μàÕ‡¥´‘≈‘μ√‡¢â“‰¥â°—∫°“√μ‘¥‡™◊ÈÕ¢Õß‡¬◊ËÕÀÿâ¡ ¡Õß®“°‡™◊ÈÕ ·∫§∑’‡√’¬ ºŸâªÉ«¬Õ“¬ÿ ÒÚ ‡¥◊Õπμ√«®æ∫‡¡Á¥‡≈◊Õ¥¢“«„π “√πÈ”‰¢ —πÀ≈—ß®”π«π Ò˜ı μ—«μàÕ≈Ÿ°∫“»°å¡‘≈≈‘‡¡μ√ ·≈–‡ªìπ‡¡Á¥‡≈◊Õ¥¢“«™π‘¥‚¡‚π‰´μå∑—ÈßÀ¡¥ √–¥—∫‚ª√μ’π ·≈–πÈ”μ“≈ª√°μ‘‡¢â“‰¥â°—∫°“√μ‘¥‡™◊ÈÕ¢Õß‡¬◊ËÕÀÿâ¡ ¡Õß®“° ‡™◊ÈÕ‰«√— ·≈–ºŸâªÉ«¬Õ“¬ÿ Ù ªïμ√«®æ∫‡¡Á¥‡≈◊Õ¥¢“«„π “√ πÈ”‰¢ —πÀ≈—ß ÛÙı μ—«μàÕ≈Ÿ°∫“»°å¡‘≈≈‘‡¡μ√ à«π„À≠à ‡ªìπ‡¡Á¥‡≈◊Õ¥¢“«™π‘¥‚¡‚π‰´μå√âÕ¬≈– ˘Ù √–¥—∫‚ª√μ’π ·≈–πÈ”μ“≈ª√°μ‘‡¢â“‰¥â°—∫°“√μ‘¥‡™◊ÈÕ‰«√— ¢Õß ¡Õß

μ“√“ß∑’Ë Û · ¥ß¢âÕ¡Ÿ≈ºŸâªÉ«¬∑’Ë¡’º≈°“√μ√«® “√πÈ”‰¢ —πÀ≈—ßº‘¥ª√°μ‘ ºŸâªÉ«¬ √“¬∑’Ë

Õ“¬ÿ (‡¥◊Õπ)

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“√πÈ”‰¢ —πÀ≈—ß ‡æ» ®”π«π PMN Monocyte ‚ª√μ’π πÈ”μ“≈„π “√πÈ”‰¢ —πÀ≈—ß º≈‡æ“–‡™◊ÈÕ (%) (¡°./¥≈.) μàÕ„π‡≈◊Õ¥ ‡¡Á¥‡≈◊Õ¥¢“« (%) M M F

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˜ˆ  ˆ

∫∑«‘®“√≥å ¿“«–‰¢â·≈–™—°∂◊Õ‡ªìπ°“√‡®Á∫ªÉ«¬∑’Ë∑”„ÀâæàÕ·¡à ºŸâª°§√Õßμ°„®·≈–‡ªìπ°—ß«≈Õ¬à“ß¡“° ¿“«–π’È®–æ∫‡©æ“– „π™à«ßÕ“¬ÿ∑‡’Ë ©æ“–‡®“–®ß °“√μ√«®√à“ß°“¬∑“ß√–∫∫ª√– “∑ ·≈–°“√μ√«® “√πÈ”‰¢ — π À≈— ß„π°≈ÿà ¡ ∑’Ë ‰ ¥â μ √«®®–‰¡à æ ∫ §«“¡º‘¥ª√°μ‘ ·≈–‰¡àæ∫ “‡ÀμÿÕπ◊Ë Ê ∑’∑Ë ”„Àâ‡°‘¥Õ“°“√™—° ®“°°“√»÷°…“π’Èæ∫«à“‡¥Á°∑’Ë¡’¿“«–‰¢â·≈–™—°æ∫ ‰¡à¡’§«“¡·μ°μà“ß∑“ß‡æ»Õ¬à“ß¡’π—¬ ”§—≠ ‚¥¬æ∫„π‡¥Á° ™“¬¡“°°«à“‡¥Á°À≠‘ß‡≈Á°πâÕ¬·≈– “‡Àμÿ¢Õß‰¢â‡°‘¥®“°°“√ μ‘¥‡™◊ÈÕ¢Õß√–∫∫∑“ß‡¥‘πÀ“¬„®‡ªìπ à«π„À≠à´÷Ëß Õ¥§≈âÕß °—∫°“√»÷°…“¢Õßæß…å»—°¥‘Ï «‘ ÿ∑∏‘æ—π∏å¯ ·≈–®ÿ≈æß…å ®—π∑√åμä–˘ ™à«ßÕ“¬ÿ∑’Ëæ∫¡“°∑’Ë ÿ¥ §◊Õ Û ‡¥◊Õπ ∂÷ß Ò ªï ‚¥¬ Õ¥§≈âÕß°—∫°“√»÷°…“¢Õßæß…å»—°¥‘Ï «‘ ÿ∑∏‘æ—π∏å¯ „π ¢≥–∑’Ë°“√»÷°…“¢Õß®ÿ≈æß…å ®—π∑√åμä–˘ æ∫∫àÕ¬„π™à«ßÕ“¬ÿ Ò ∂÷ß Ú ªï´÷Ëß Õ¥§≈âÕß°—∫°“√»÷°…“¢Õßμà“ßª√–‡∑»∑’Ëæ∫ ∫àÕ¬„π™à«ßÕ“¬ÿ Ò¯ ‡¥◊ÕπÒ,ÒÒ,ÒÚ Õ¬à“ß‰√°Áμ“¡∑ÿ°°“√»÷°…“ ‰¥â· ¥ß∂÷ß§«“¡∂’Ë¢Õß°“√‡°‘¥Õ“°“√®–≈¥≈ß‡¡◊ËÕºŸâªÉ«¬ Õ“¬ÿ¡“°¢÷Èπ´÷Ëß¡’°“√æ¬“¬“¡Õ∏‘∫“¬‡Àμÿº≈«à“πà“®–¡’ “‡Àμÿ ‡π◊ËÕß¡“®“°§«“¡ ¡∫Ÿ√≥å¢Õß ¡Õß (maturity of brain) ∑’Ëª√—∫μ—«μàÕ°“√‡ª≈’Ë¬π·ª≈ßÕÿ≥À¿Ÿ¡‘¢Õß√à“ß°“¬¥’¡“°¢÷Èπ μ“¡Õ“¬ÿ ®“°°“√»÷°…“π’È π—∫ πÿπ«à“‚√§‰¢â™—°¡’§«“¡‡°’Ë¬«

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Negative Negative Negative

‡π◊ÕË ß∑“ß°√√¡æ—π∏ÿ‚å ¥¬æ∫¡’ª√–«—μ‚‘ √§™—°‡Àμÿ‰¢â„π§√Õ∫§√—« Ÿß∂÷ß√âÕ¬≈– Ò¯.ˆ ´÷Ëß Õ¥§≈âÕß°—∫°“√»÷°…“„πμà “ ß ª√–‡∑»∑’Ëæ∫√–À«à“ß√âÕ¬≈– Úı-ÙÒÛ ®“°°“√»÷°…“π’Èæ∫«à“√–¥—∫Õÿ≥À¿Ÿ¡‘√à“ß°“¬·√°√—∫ ∑’ËÀâÕß©ÿ°‡©‘π∑’Ëæ∫∫àÕ¬ ÿ¥Õ¬Ÿà„π™à«ß Û¯.-Û¯.˘ Õß»“ ‡´≈‡´’¬ ´÷Ëß·μ°μà“ß®“°°“√»÷°…“¢Õß®ÿ≈æß…å ®—π∑√åμä–˘ ∑’Ëæ∫√–¥—∫Õÿ≥À¿Ÿ¡‘ºŸâªÉ«¬Õ¬Ÿà„π™à«ß Û˘.Ò-Ù. Õß»“‡´≈‡´’¬ ªí ® ®— ¬ ‡√◊Ë Õ ßÕÿ ≥ À¿Ÿ ¡‘ ¢ Õß‰¢â ∑’Ë μ √«®æ∫„π·μà≈– °“√»÷°…“Õ“®·μ°μà“ß°—π‰ª¡“°¡“¬¥â«¬À≈“¬ªí®®—¬ ‡™àπ °“√«—¥‰¢â‚¥¬ºŸâª°§√Õß∑’Ë∫â“πÕ“®º‘¥æ≈“¥ ®”μ—«‡≈¢§≈“¥ ‡§≈◊ËÕπ ºŸâªÉ«¬‡¥Á°‰¥â√—∫°“√¥Ÿ·≈‡∫◊ÈÕßμâπ‚¥¬√—∫ª√–∑“π¬“ ≈¥‰¢â À√◊Õ°“√‡™Á¥μ—«°àÕπ¡“∂÷ß‚√ßæ¬“∫“≈ ∑”„Àâ¢âÕ¡Ÿ≈∑’Ë ∫—π∑÷°Õ“®‰¡à‰¥â· ¥ß∂÷ßÕÿ≥À¿Ÿ¡‘∑’Ë·∑â®√‘ß¢≥–ºŸâªÉ«¬°”≈—ß¡’ Õ“°“√™—° ®÷ß‡ªìπ‡Àμÿº≈∑’ËÕ∏‘∫“¬º≈°“√»÷°…“§√—Èßπ’È∑’Ëæ∫ ºŸâªÉ«¬®”π«π ˜ √“¬´÷Ëßμ√«®‰¡àæ∫‰¢â¢≥–¡“∂÷ß‚√ßæ¬“∫“≈ „πªí®®ÿ∫—π¬—ß‰¡à¡’¢âÕ°”Àπ¥∑’Ë™—¥‡®π„π‡√◊ËÕßÕÿ≥À¿Ÿ¡‘°“¬ ¢Õß‚√§™—°‡Àμÿ‰¢â«à“®–μâÕß¡’Õÿ≥À¿Ÿ¡‘°“¬¡“°°«à“‡∑à“‰√ÒÙ ∫“ß°“√»÷°…“°”Àπ¥‰«â∑’ËÕÿ≥À¿Ÿ¡‘°“¬¡“°°«à“ Û¯ Õß»“ ‡´≈‡´’¬ ∫â“ß°”Àπ¥„Àâ¡“°°«à“ Û¯.Ù Õß»“‡´≈‡´’¬ ‡ªìπμâπ ·≈–¬—ß‰¡à¡’¢âÕ √ÿª∑’Ë™—¥‡®π√–À«à“ß§«“¡ Ÿß¢Õß‰¢â (peak of temperature) °—∫™à«ß√–¬–‡«≈“∑’Ë‡°‘¥¡’‰¢â (rate

122 .

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of temperature rise) «à“ªí®®—¬„¥‡ªìπ “‡Àμÿ∑’Ë ”§—≠°«à“ „π°“√∑”„Àâ‡°‘¥Õ“°“√™—°Òı,Òˆ ≈—°…≥–√Ÿª·∫∫¢Õß°“√™—°∑’æË ∫„π°“√»÷°…“π’æÈ ∫«à“ à«π„À≠à‡ªìπ°“√™—°∑’‡Ë ¢â“‰¥â°∫— ‚√§™—°‡Àμÿ‰¢â™π‘¥∏√√¡¥“Ò˜ §◊Õ ¡’Õ“°“√™—°¿“¬„π√–¬–‡«≈“ ÚÙ ™—Ë«‚¡ß·√°¢Õß‰¢â™—° ·∫∫‡°√Áß°√–μÿ°∑—Èßμ—« ™—°π“π‰¡à‡°‘π Òı π“∑’ ·≈–‰¡à¡’ °“√™—°´È” ®“°°“√»÷°…“π’Èæ∫«à“„πºŸâªÉ«¬∑’Ë‡ªìπ‚√§™—°‡Àμÿ‰¢â “¡“√∂æ∫¡’≈—°…≥–¢ÕßÕ“°“√·≈–Õ“°“√· ¥ß∑’Ë‰¡à·μ° μà“ß®“°ºŸªâ «É ¬®”π«π Û √“¬´÷ßË μ√«®æ∫«à“¡’°“√μ‘¥‡™◊ÕÈ ¢Õß √–∫∫ª√– “∑ Õ“°“√·≈–Õ“°“√· ¥ß¥—ß°≈à“« ‰¥â·°à °“√ ‡ª≈’Ë¬π·ª≈ß√–¥—∫§«“¡√Ÿâ ÷°μ—«À≈—ß™—° ¿“«–‡∫◊ËÕÕ“À“√ ´÷¡ Õ“‡®’¬π √âÕß°«π ·≈–°“√¡’°√–À¡àÕ¡Àπâ“‚ªÉßμ÷ß ‘Ëß ∑’Ëπà“ π„®„π°“√»÷°…“π’Èæ∫«à“¡’ºŸâªÉ«¬∑—ÈßÀ¡¥ Û √“¬∑’Ë μ√«®√à“ß°“¬‰¡àæ∫°“√√–§“¬‡§◊Õß¢Õß‡¬◊ÕË Àÿ¡â ¡Õß (meningeal irritation) ∑—Èß∑’Ë‰¥â√—∫°“√«‘π‘®©—¬«à“¡’°“√μ‘¥‡™◊ÈÕ¢Õß √–∫∫ª√– “∑®“°º≈§«“¡º‘¥ª√°μ‘¢Õß°“√μ√«® “√πÈ” ‰¢ —πÀ≈—ß ‚¥¬ºŸâªÉ«¬∑—Èß Û √“¬π’È¡’Õ“¬ÿ Ù, ÒÚ ·≈– Ù¯ ‡¥◊Õπμ“¡≈”¥—∫ ®÷ß‡ªìπ°“√»÷°…“∑’ Ë π—∫ πÿπ∂÷ß§«“¡·¡àπ¬” ¢Õß°“√·ª≈º≈°“√μ√«®√à“ß°“¬∑’Ëμ√«®À“Õ“°“√· ¥ß¢Õß °“√√–§“¬‡§◊Õß¢Õß‡¬◊ËÕÀÿâ¡ ¡Õß„πºŸâªÉ«¬‡¥Á°∑’ËÕ“¬ÿπâÕ¬°«à“ Ò ªï«à“‰¡à∂÷ß√âÕ¬≈– Ò ®÷ß¡’§”·π–π”∑’Ë‡ªìπ·π«∑“ß ™—¥‡®π„Àâ∑”°“√‡®“–μ√«® “√πÈ”‰¢ —πÀ≈—ß„πºŸâªÉ«¬‡¥Á°Õ“¬ÿ πâÕ¬°«à“ ÒÚ ‡¥◊Õπ∑ÿ°√“¬∑’Ë¡’¿“«–‰¢â·≈–™—°§√—Èß·√° ·≈– æ‘®“√≥“‡ªìπ√“¬Ê‰ª ”À√—∫Õ“¬ÿ ÒÚ-Ò¯ ‡¥◊ÕπÚ à«π„π °√≥’∑’Ë‡¥Á°¡’Õ“¬ÿ‡°‘π Ò ªï®–¡’§«“¡πà“‡™◊ËÕ∂◊Õ Ÿß„π°“√·ª≈ º≈°“√μ√«®°“√√–§“¬‡§◊Õß¢Õß‡¬◊ÕË Àÿ¡â ¡Õß ¥—ßπ—πÈ ∂â“μ√«® ‰¡àæ∫°“√√–§“¬‡§◊Õß¢Õß‡¬◊ÕË Àÿ¡â ¡Õß·μàºªŸâ «É ¬¡“¥â«¬ Õ“°“√ ‰¢â·≈–™—°§«√μâÕßπ÷°∂÷ß¿“«– ¡ÕßÕ—°‡ ∫ (encephalitis) À√◊Õ¡’ “‡ÀμÿÕ◊ËπÊ ∑’Ë∑”„Àâ‡°‘¥Õ“°“√™—°¥—ß„πºŸâªÉ«¬Õ“¬ÿ Ù¯ ‡¥◊Õπ„π°“√»÷°…“ π’È∑’Ë‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§‰¢â ¡Õß Õ—°‡ ∫‡π◊ËÕß®“°μ√«®‰¡àæ∫°“√√–§“¬¢Õß‡¬◊ËÕÀÿâ¡ ¡Õß·μà ¡’º≈°“√μ√«®πÈ”‰¢ —πÀ≈—ß∑’Ëº‘¥ª√°μ‘ ®“°°“√»÷°…“π’Èæ∫«à“Õ—μ√“ à«π¢ÕßºŸâªÉ«¬∑’Ëμ√«® æ∫«à “ ¡’ ° “√μ‘ ¥ ‡™◊È Õ„π√–∫∫ª√– “∑®“°°≈ÿà ¡ ∑’Ë ‰ ¥â √— ∫ °“√ «‘π‘®©—¬‡∫◊ÈÕßμâπ«à“‡ªìπ‚√§™—°‡Àμÿ‰¢âÕ¬Ÿà∑’Ë√âÕ¬≈– Ù.Ò ‚¥¬ ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§‡¬◊ËÕÀÿâ¡ ¡ÕßÕ—°‡ ∫®“° ‡™◊ÈÕ‰«√— ®“°‡™◊ÈÕ·∫§∑’‡√’¬ ·≈–‰¢â ¡ÕßÕ—°‡ ∫´÷Ëßπ—∫«à“

‡ªìπÕ—μ√“∑’Ë‰¡à Ÿßπ—°·μà‰¡à§«√«‘π‘®©—¬º‘¥æ≈“¥‡æ√“–ºŸâªÉ«¬ μâÕß‰¥â√—∫°“√√—°…“Õ¬à“ß‡√àß¥à«π ‡¡◊ËÕ»÷°…“‡ª√’¬∫‡∑’¬∫°—∫ √“¬ß“π„πμà“ßª√–‡∑»æ∫¡’√“¬ß“π°“√μ√«®æ∫°“√¡’‡¬◊ËÕ Àÿâ¡ ¡ÕßÕ—°‡ ∫®“°‡™◊ÈÕ·∫§∑’‡√’¬„π‡¥Á°∑“√°Õ“¬ÿ ˆ ‡¥◊Õπ ∂÷ß Ò ªï∑‰’Ë ¥â√∫— °“√«‘π®‘ ©—¬‡∫◊ÕÈ ßμâπ«à“‡ªìπ‚√§™—°‡Àμÿ‰¢â√Õâ ¬≈– .ÙÙ (˘ı% CI -.¯¯)Ò¯ °“√»÷°…“π’È¡’¢âÕ®”°—¥‡π◊ËÕß®“°‡ªìπ°“√»÷°…“¬âÕπ À≈—ß·≈–∑”°“√»÷°…“„π™à«ß√–¬–‡«≈“ —Èπ∑”„Àâ‰¡à “¡“√∂ «‘‡§√“–Àå≈ß≈÷°∂÷ß¢âÕ¡Ÿ≈Õ◊ËπÊ∑’Ëπà“ π„®‡°’Ë¬«°—∫‚√§™—°‡Àμÿ ‰¢â‰¥â ‡™àπ ‡¡◊ËÕ‡°‘¥‚√§™—°‡Àμÿ‰¢â§√—Èß·√° À√◊Õ§√—Èß∑’Ë Õß ·≈â«®–¡’§«“¡‡ ’Ë¬ß¢Õß°“√‡°‘¥‚√§™—°‡Àμÿ‰¢â´È”„πÕπ“§μ ‡ªìπ√âÕ¬≈–‡∑à“„¥ ªí®®—¬‡ ’Ë¬ß„¥∑’Ë‡ªìπμ—«∫Õ°∂÷ß‚Õ°“ °“√ ‡°‘¥‚√§™—°‡Àμÿ‰¢â´È”À√◊Õ°“√‡ªìπ‚√§≈¡™—°„πÕπ“§μ °“√ »÷°…“∂÷ßæ—π∏ÿ°√√¡À√◊Õ§«“¡º‘¥ª√°μ‘¢Õß¬’π∑’Ë‡°’Ë¬«¢âÕß °—∫°“√‡°‘¥‚√§™—°‡Àμÿ‰¢â ‚Õ°“ °“√μ√«®æ∫§«“¡º‘¥ª√°μ‘ ¢Õß§≈◊Ëπ‰øøÑ“ ¡Õß·≈–§«“¡®”‡ªìπ„π°“√μ√«®§≈◊Ëπ‰øøÑ“ ¡Õß„πºŸâªÉ«¬∑’Ë¡’‚√§™—°‡Àμÿ‰¢â´È”Ê ¡“°°«à“ Û §√—Èß¢÷Èπ‰ª ‡ªìπμâπ „πÕπ“§μ¢â“ßÀπâ“ºŸâ∑”°“√»÷°…“§‘¥«à“§«√∑”°“√ »÷°…“·∫∫‰ª¢â“ßÀπâ“ (prospective study) ‡æ◊ËÕ®–‰¥âπ” ¢âÕ¡Ÿ≈¡“«‘‡§√“–Àå„Àâ‡°‘¥ª√–‚¬™πåμàÕ‰ª

√ÿªº≈°“√«‘®—¬ ®“°º≈°“√»÷ ° …“≈— ° …≥–‡«™°√√¡·≈–º≈°“√ μ√«® “√πÈ”‰¢ —πÀ≈—ß¢ÕßºŸâªÉ«¬‡¥Á°Õ“¬ÿ Û ‡¥◊Õπ∂÷ß ı ªï ®”π«π ˜Ù §π∑’Ë¡’‰¢â√à«¡°—∫™—°·≈–‰¥â√—∫°“√«‘π‘®©—¬‡∫◊ÈÕß μâπ«à“‡ªìπ‚√§™—°‡Àμÿ‰¢â (febrile seizure) „π‚√ßæ¬“∫“≈ ∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ æ∫∫àÕ¬„π™à«ßÕ“¬ÿ Û ‡¥◊Õπ ∂÷ß Ò ªï§‘¥‡ªìπ√âÕ¬≈– ˆÛ.ı ‚¥¬¡’Õÿ≥À¿Ÿ¡‘°“¬·√°√—∫ à«π„À≠àÕ¬Ÿà„π™à«ß Û¯. - Û¯.˘ Õß»“‡´≈‡´’¬ √âÕ¬≈– Ò¯.ˆ ¡’ª√–«—μ‘‚√§™—°‡Àμÿ‰¢â„π§√Õ∫§√—« ≈—°…≥–°“√™—° à « π„À≠à ‡ ªì π ·∫∫‚√§™— ° ‡Àμÿ ‰ ¢â ™ π‘ ¥ ∏√√¡¥“Õ“°“√·≈– Õ“°“√· ¥ßÕ◊ËπÊ ∑’Ëæ∫√à«¡‰¥â∫àÕ¬ ‰¥â·°à °“√‡ª≈’Ë¬π·ª≈ß √–¥—∫§«“¡√Ÿâ ÷°μ—«À≈—ß™—° ¿“«–‡∫◊ËÕÕ“À“√ ´÷¡ Õ“‡®’¬π √âÕß°«π ·≈–°“√¡’°√–À¡àÕ¡Àπâ“‚ªÉßμ÷ß æ∫ºŸâªÉ«¬®”π«π Û √“¬§‘¥‡ªìπ√âÕ¬≈– Ù.Ò ∑’Ë‡ª≈’Ë¬π°“√«‘π‘®©—¬‡ªìπ°“√μ‘¥ ‡™◊ÈÕ„π√–∫∫ª√– “∑‡π◊ËÕß®“°º≈°“√μ√«® “√πÈ”‰¢ —πÀ≈—ß æ∫§«“¡º‘¥ª√°μ‘ ‚¥¬ºŸâªÉ«¬∑—Èß Û §πμ√«®√à“ß°“¬‰¡àæ∫ °“√√–§“¬‡§◊Õß¢Õß‡¬◊ËÕÀÿâ¡ ¡Õß

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‡Õ° “√Õâ“ßÕ‘ß Ò. Shlomo S. Febrile seizures. In: Swaiman KF, Ashwal S, Ferriero DM. Pediatric Neurology Principles and Practice 4th ed. Philadelphia. 2006:1079. Ú. American Academy of Pediatrics. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. American Academy of Pediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Pediatrics. 1996; 97:769-75. Û. Lee P, Verrier Jones K. Urinary tract infections in febrile convulsions. Arch Dis Child 1991; 66:1287-90. Ù. McIntyre PB, Gray SV, Vance JC. Unsuspected bacterial infections in febrile convulsion. Med J Aust 1990;152:183-6. ı. Joffe A, McCormick M, DeAngelis C. Which children with febrile seizures need lumbar puncture. Am J Dis Child 1983;137:1153-6. ˆ. Rutter N, Smales ORC. Role of routine investigations in children presenting with their first febrile convulsion. Arch Dis Child 1977;52: 188-91. ˜. Waruir CU, Appleton R. Febrile seizures: an update. Arch Dis Child 2004;89:751-66. ¯. æß»å»—°¥‘Ï «‘ ÿ∑∏‘æ—π∏å. §«“¡ ”§—≠¢Õß°“√μ√«®πÈ” ‰¢ —πÀ≈—ß„π‡¥Á°∑’Ë¡’‰¢â·≈–™—°§√—Èß·√°. ®¥À¡“¬‡Àμÿ ∑“ß·æ∑¬å. ÚıÚÛ;ˆÛ:ı˜-ˆ. ˘. ®ÿ≈æß…å ®—π∑√åμä–. §«“¡ ”§—≠¢Õß°“√μ√«®πÈ”‰¢ —πÀ≈—ß„π‡¥Á°∑’Ë™—°®“°‰¢â§√—Èß·√°. «“√ “√°ÿ¡“√‡«™»“ μ√å. ÚıÛ˜;ÛÛ:sıÚ-sıÛ.

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Ò. Annegers JF, Hauser WA, Shirts SB, et al. Factors prognostic of unprovoked seizures after febrile convulsions. N Engl J Med 1987;316: 493-8. ÒÒ. Hauser WA. The prevalence and incidence of convulsive disorders in children. Epilepsia 1994;35:S1-6. ÒÚ. Offringa M, Hazebroek-Kampschreur AAJM, Derksen-Lubsen G. Prevalence of febrile seizures in Dutch school children. Paediatr Perinat Epidemiol 1991;5:181-8. ÒÛ. Hauser WA, Annegers JF, Anderson VE, et al. The risk of seizure disorders among relatives of children with febrile convulsions. Neurology 1985;35:1268-73. ÒÙ. Shinnar S, Glauser TA. Febrile seizures. J Child Neurol 2002;17:S44-52. Òı. Berg AT. Are febrile seizures provoked by a rapid rise in temperature. Am J Dis Child 1993; 147:1101-3. Òˆ. Minchom PE, Wallace S. Febrile convulsions: electroencephalographic changes related to rectal temperature. Arch Dis Child 1984;59:371-3. Ò˜. Panayiotopoulos CP. A Clinical Guide to Epileptic Syndrome and their Treatment. 2002: 52. Ò¯. Sweeney A, Gibbs J, Monteil F, et al. The management of febrile seizures in the Mersey region. Dev Med Child Neurol 1996;38:57884.

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∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

Abstract Clinical characteristics and cerebrospinal fluid profiles in children presenting with fever and seizure at Thammasat University Hospital Yongyuth Chumkomlue, Sudathip Paticheep, Suda Jirasakuldej Department of Pediatrics, Faculty of Medicine, Thammasat University Muang, Nonthaburi Background: Fever with seizure is a common neurological problem in children. In clinical practice, the possibility of central nervous system infection should be excluded before diagnosing febrile seizure. Objective: To study the clinical manifestations and cerebrospinal fluid profiles in children presenting with fever and seizure at Thammasat University Hospital. Methodology: A retrospective descriptive study of the children age 3 months to 5 years who presented with fever and seizure at Thammasat University Hospital during January 1st, 2004 to December 31st, 2006. Lumbar puncture was performed in all cases. Results: 74 children (3 months to 5 years old) with fever and seizure were eligible for the study. Most (63.5%) of them were between 3 months to 1 year old. Family history of febrile seizure presented in 18.6%. Most of them had body temperature between 38.0-38.9°C and simple febrile seizure type described as seizure in the first 24 hours of fever, seizure less than 15 minutes in duration, no repeated seizure and generalized seizure type. Approximately 61 percent of the patients had no postictal conscious change. Poor feeding, lethargy, vomiting, irritability, meningeal irritation and anterior fontanel bulging were found in 36.8%, 32.8%, 25.7%, 14.3%, 2.7% and 1.8% respectively. Most of them (95.9%) had normal cerebrospinal fluid profiles. Three subjects (4.1%) ages 4 months, 12 months and 48 months old, who had abnormal cerebrospinal fluid results, had prolonged fever more than 24 hours, recurrent seizures within 24 hours and no signs of meningeal irritation. These three patients were finally diagnosed with bacterial meningitis, viral meningitis and viral encephalitis respectively. Conclusion: Febrile seizure was known as a benign condition without evidence of central nervous system infection. However, the physician should consider performing lumbar puncture according to the guideline or in highly suspicious patients.

Key words:

Febrile seizure, Clinical manifestation, Cerebrospinal fluid analysis, Children

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‡∫“À«“π‡ªìπ “‡Àμÿ ”§—≠¢Õß‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ‚√§‰μ ·≈–‚√§„π√–∫∫Õ◊ËπÊ ¢Õß√à“ß°“¬ °“√§«∫§ÿ¡‡∫“À«“π “¡“√∂≈¥¿“«–·∑√°´âÕπ¥—ß°≈à“«‰¥â ªí®®ÿ∫π— ®÷ß¡’§«“¡μ√–Àπ—°¡“°¢÷πÈ ‡°’¬Ë «°—∫‚√§ ‡∫“À«“π·≈–º≈∑’Ëμ“¡¡“„π “∏“√≥√—∞ª√–™“∏‘ª‰μ¬ª√–™“™π≈“« «—μ∂ÿª√– ß§å: ‡æ◊ÕË »÷°…“ªí®®—¬∑’¡Ë º’ ≈μàÕ§«“¡√à«¡¡◊ÕºŸªâ «É ¬‡∫“À«“π ªí®®—¬∑’»Ë °÷ …“·∫àß‡ªìπ ªí®®—¬¿“¬„π ªí®®—¬¿“¬πÕ° ·≈–°“√ π—∫ πÿπ∑“ß —ß§¡ «‘∏’°“√»÷°…“: °“√»÷°…“§√—Èßπ’È‡ªìπ·∫∫«‘‡§√“–Àå ‡°Á∫¢âÕ¡Ÿ≈„π°≈ÿà¡ºŸâªÉ«¬‡∫“À«“πª√–‡¿∑∑’Ë Ú ®”π«π Ò˘˜ §π ∑’Ë §≈‘π‘°‡∫“À«“π‚√ßæ¬“∫“≈¡‚À ∂·≈–‚√ßæ¬“∫“≈‡™…∞“∏‘√“™ ®—ßÀ«—¥π§√À≈«ß ‡«’¬ß®—π∑πå ´÷Ëß·∫àß ºŸªâ «É ¬‡∫“À«“π‡ªìπ Ú °≈ÿ¡à §◊Õ °≈ÿ¡à ºŸªâ «É ¬‡∫“À«“π∑’ Ë “¡“√∂§«∫§ÿ¡√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥‰¥â·≈–°≈ÿ¡à ºŸªâ «É ¬‡∫“À«“π∑’‰Ë ¡à “¡“√∂§«∫§ÿ¡√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥‰¥â™«à ß‡¥◊Õπ∏—π«“§¡ æ.». ÚııÒ ∂÷ß ¡°√“§¡ æ.». ÚııÚ º≈°“√»÷°…“: ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâªÉ«¬‡∫“À«“π∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â‡ªìπ‡∫“À«“π¡“°°«à“ ˆ ªï πâÕ¬°«à“°≈ÿà¡∑’Ë §«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¡à‰¥â (§à“æ’ = .Ú˘) °≈ÿà¡∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â¡’¥—™π’¡«≈°“¬¡“°°«à“ ÚÛ ¡’®”π«ππâÕ¬°«à“°≈ÿà¡∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¡à‰¥â (§à“æ’ = .ˆ) °≈ÿà¡∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈ ‰¥â¡§’ «“¡√Ÿ‡â °’¬Ë «°—∫‡∫“À«“π·≈–‡®μ§μ‘√–¥—∫ Ÿß¡“°°«à“°≈ÿ¡à ∑’§Ë «∫§ÿ¡√–¥—∫πÈ”μ“≈‰¡à‰¥â (§à“æ’ = .Ò ∑—Èß Õßªí®®—¬) ”À√—∫º≈°“√»÷°…“√–¥—∫§«“¡√à«¡¡◊Õ „π°“√»÷°…“æ∫«à“°≈ÿà¡∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â ¡’§«“¡√à«¡¡◊Õ¥â“π√—∫ª√–∑“πÕ“À“√ °“√√—∫ª√–∑“π¬“ °“√ÕÕ°°”≈—ß°“¬ °“√Õπ“¡—¬∑—«Ë ‰ª·≈–¥Ÿ·≈‡∑â“ ·≈–°“√¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥√–¥—∫ Ÿß¡“°°«à“°≈ÿà¡∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¡à‰¥â„π∑ÿ° ª√–‡¿∑§«“¡√à«¡¡◊Õ (§à“æ’ = . ”À√—∫∑—Èß ı ªí®®—¬) º≈°“√»÷°…“§«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬ μà“ßÊ °—∫§«“¡√à«¡¡◊Õ æ∫«à“°“√ π—∫ πÿπ¥â“π¢à“« “√ (§à“æ’ = .) ·≈–°“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß (§à“æ’ = .Ú) ¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘°—∫√–¥—∫§«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“π Õ“À“√ √–¬–‡«≈“‡ªìπ‚√§‡∫“À«“π (§à“æ’ = .Ú˘) ·≈–°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫ (§à“æ’ = .ÚÙ) ¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘μ°‘ ∫— √–¥—∫§«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—«Ë ‰ª·≈–¥Ÿ·≈‡∑â“ √–¬–‡«≈“ ‡ªìπ‚√§·≈–°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫ (§à“æ’ = .Ú ∑—ßÈ Õßªí®®—¬) ¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π¬— ”§—≠ ∑“ß ∂‘μ‘°—∫√–¥—∫§«“¡√à«¡¡◊Õ¥â“π°“√¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥ √ÿª: ºŸªâ «É ¬‡∫“À«“π∑’§Ë «∫§ÿ¡πÈ”μ“≈‰¥â¡√’ –¥—∫§«“¡√à«¡¡◊Õ Ÿß°«à“ºŸªâ «É ¬‡∫“À«“π∑’§Ë «∫§ÿ¡πÈ”μ“≈‰¡à‰¥â∑°ÿ ¥â“π °“√ π—∫ πÿπ∑“ß —ß§¡¡’§«“¡ —¡æ—π∏å°—∫§«“¡√à«¡¡◊Õ¢ÕßºŸâªÉ«¬‡∫“À«“π §” ”§—≠:

§«“¡√à«¡¡◊Õ, ‡∫“À«“π, “∏“√≥√—∞ª√–™“∏‘ª‰μ¬ª√–™“™π≈“«

* §≥–«‘∑¬“»“ μ√å°“√·æ∑¬å ¡À“«‘∑¬“≈—¬·Ààß™“μ‘≈“« ** ‚§√ß°“√®—¥μ—Èß ∂“π‡«™»“ μ√å™ÿ¡™π·≈–‡«™»“ μ√å§√Õ∫§√—« §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

126 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

∫∑π”

«‘∏’°“√»÷°…“

‚√§‡∫“À«“π‡ªìπ‚√§∑’‡Ë °‘¥¢÷πÈ ‡¡◊ÕË μ—∫ÕàÕπ‰¡à “¡“√∂ º≈‘μÕ‘π´Ÿ≈‘π´÷Ëß‡ªìπŒÕ√å‚¡π∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥ ‰¥â‡æ’¬ßæÕÀ√◊Õ¡’¿“«–¥◊ÕÈ μàÕÕ‘π´Ÿ≈π‘ °“√‰¡à “¡“√∂§«∫§ÿ¡ πÈ”μ“≈¢ÕßºŸâªÉ«¬‡∫“À«“π®–π”‰ª Ÿà¿“«–·∑√°´âÕπ¢Õß √–∫∫μà“ßÊ „π√à“ß°“¬ ‡™àπ √–∫∫ª√– “∑ √–∫∫À≈Õ¥‡≈◊Õ¥ Õß§å°“√Õπ“¡—¬‚≈°‰¥â§“¥°“√≥å«à“¡’ºŸâªÉ«¬¡“°°«à“ Ò¯ ≈â“π·≈–μ—«‡≈¢¥—ß°≈à“«π’È¡’§«“¡‡ªìπ‰ª‰¥â∑’Ë®–‡æ‘Ë¡¢÷Èπ‡ªìπ Õß‡∑à“„π æ.» Úı˜ÛÒ „πªï æ.». ÚıÙ¯ ¡’ºŸâªÉ«¬ ∑’Ë‡ªìπ‚√§‡∫“À«“π‡ ’¬™’«‘μ∂÷ß Ò.Ò ≈â“π§π ´÷Ëß¡’ºŸâªÉ«¬ ∑’Ë‡ ’¬™’«‘μ√âÕ¬≈– ¯ Õ“»—¬Õ¬Ÿà„πª√–‡∑»∑’Ë¡’√“¬‰¥âμË”∂÷ß ª“π°≈“ßÚ ®“°°“√√“¬ß“πÕß§å°“√Õπ“¡—¬‚≈°„πªï æ.». ÚıÙÛ ‡°’Ë¬«°—∫ºŸâªÉ«¬∑’Ë‡ªìπ‡∫“À«“π„πª√–‡∑» ≈“« πà“®– ¡’∂÷ß Ùˆ, §π·≈–§“¥°“√≥å«à“®–∂÷ß ÒÚ¯, §π„π ªï æ.». Úı˜ÛÛ ®“°°“√»÷°…“§«“¡™ÿ°¢Õß‚√§‡∫“À«“π„π Ú˜ À¡Ÿà∫â“π¢Õßπ§√À≈«ß‡«’¬ß®—π∑πå ´÷Ëß§«“¡™ÿ°‚¥¬√«¡ √âÕ¬≈– ˘.Úı ‚¥¬√âÕ¬≈– ˆ.ˆ˜ ‰¥â√—∫°“√«‘π‘®©—¬°àÕπ Àπâ“π’ÙÈ ®“°°“√√“¬ß“π¢Õß‚√ßæ¬“∫“≈‡™…∞“∏‘√“™¡’ ÛÚ √“¬„πªï æ.». ÚıÙı, ÙÚ √“¬ „πªï æ.». ÚıÙˆ ·≈– „πªï æ.». ÚıÙ˜ ‡æ‘¡Ë ¢÷πÈ ‡ªìπ ¯ı √“¬ı „πªï æ.». ÚıÙ˘ ºŸâ∑’Ë‡¢â“√—∫°“√√—°…“∑’Ë‚√ßæ¬“∫“≈¡‚À ∂®”π«π Òı √“¬ ´÷ßË „ππ—πÈ √âÕ¬≈– ˆ ‡¢â“√—∫°“√√—°…“‡π◊ÕË ß®“°¿“«–·∑√°´âÕπˆ ‡π◊ËÕß®“°°“√»÷°…“‡°’Ë¬«°—∫‡∫“À«“π¬—ß¡’‰¡à¡“°π—°∑”„Àâ ‰¡à ¡’ ¢â Õ ¡Ÿ ≈ ‡™‘ ß ≈÷ ° ‡æ◊Ë Õ π”‰ª«“ßπ‚¬∫“¬„π°“√§«∫§ÿ¡‚√§ ‡∫“À«“π„Àâ‰¥âº≈¥’ ¥—ßπ—πÈ ºŸ«â ®‘ ¬— ®÷ß¡’§«“¡ π„®»÷°…“√–¥—∫ §«“¡√à«¡¡◊Õ„π°“√√—°…“¢ÕßºŸâªÉ«¬‡∫“À«“π ª√–‡¿∑∑’Ë Ú „π°≈ÿà¡∑’Ë “¡“√∂·≈–‰¡à “¡“√∂§«∫§ÿ¡√–¥—∫πÈ”μ“≈ ·≈– §«“¡ — ¡ æ— π ∏å √ –À«à “ ßªí ® ®— ¬ °— ∫ §«“¡√à « ¡¡◊ Õ ¢ÕßºŸâ ªÉ « ¬ ‡∫“À«“π

°“√»÷°…“§√—ßÈ π’‡È ªìπ°“√»÷°…“·∫∫«‘‡§√“–Àå (analytical study) ‡æ◊ÕË »÷°…“ªí®®—¬∑’¡Ë º’ ≈μàÕ§«“¡√à«¡¡◊ÕºŸªâ «É ¬ ‡∫“À«“π ª√–‡¿∑∑’Ë Ú „π°≈ÿà¡∑’Ë “¡“√∂·≈–‰¡à “¡“√∂ §«∫§ÿ ¡ √–¥— ∫ πÈ” μ“≈∑’Ë ¡ “√— ∫ °“√√— ° …“∑’Ë § ≈‘ π‘ ° ‡∫“À«“π ®”π«π Ò˘˜ §π ∑’Ë‚√ßæ¬“∫“≈¡‚À ∂ ·≈–‚√ßæ¬“∫“≈ ‡™…∞“∏‘√“™ ®—ßÀ«—¥π§√À≈«ß‡«’¬ß®—π∑πå ‡°Á∫√«∫√«¡ ¢âÕ¡Ÿ≈‚¥¬°“√ —¡¿“…≥å ·≈–∫—π∑÷°¢âÕ¡Ÿ≈ ‚¥¬·∫∫ —¡¿“…≥å ´÷Ëßºà“π°“√∑¥ Õ∫®“°ºŸâ∑√ß§ÿ≥«ÿ≤‘¥â“π°“√·æ∑¬å ®“°π—Èπ ®÷ßπ”·∫∫ —¡¿“…≥å‰ªÀ“§«“¡‡™◊ËÕ¡—Ëπ (reliability) ‚¥¬ √«¡‡∑à“°—∫ .˜˘Ú ‚¥¬·∫àß·∫∫ —¡¿“…≥å‡ªìπ ˆ à«π §◊Õ à«π Ò ·∫∫ —¡¿“…≥å ¢âÕ¡Ÿ≈∑—«Ë ‰ª¢ÕßºŸªâ «É ¬‡∫“À«“π à«π ∑’Ë Ú ·∫∫ —¡¿“…≥å¥â“π§«“¡√Ÿâ‡°’Ë¬«°—∫‡∫“À«“π Ò¯ ¢âÕ à«π∑’Ë Û ·∫∫ —¡¿“…≥å¥â“π‡®μ§μ‘¢ÕßºŸâªÉ«¬‡∫“À«“π Ò ¢âÕ à«π∑’Ë Ù ·∫∫ —¡¿“…≥å¢âÕ¡Ÿ≈§«“¡√à«¡¡◊Õ¢ÕßºŸâªÉ«¬ ‡∫“À«“π à«π∑’Ë ı ·∫∫ —¡¿“…≥å¥â“π°“√ π—∫ πÿπ∑“ß —ß§¡ Ò˜ ¢âÕ à«π∑’Ë ˆ ‡®μ§μ‘‡°’Ë¬«°—∫§ÿ≥¿“æ∫√‘°“√ ª√–°Õ∫¥â«¬®”π«π ÒÚ ¢âÕ «‘‡§√“–Àå¢âÕ¡Ÿ≈‚¥¬ °“√æ√√≥π“·®°·®ß§«“¡∂’Ë æƒμ‘°√√¡°“√√à«¡¡◊Õ∑“ß¥â“π§«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“π Õ“À“√ °“√√—∫ª√–∑“π¬“ ¥â“π°“√ÕÕ°°”≈—ß°“¬ ¥â“π°“√ ¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥ ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª ·≈–¥Ÿ·≈‡∑â“ ®”·π°μ“¡ªí®®—¬ ·≈–„™â Chi-square ∑¥ Õ∫ ‡æ◊ËÕ¥Ÿ§«“¡ —¡æ—π∏å

º≈°“√«‘®¬— ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâªÉ«¬‡∫“À«“π ºŸâªÉ«¬ à«π„À≠à‡ªìπ‡æ»À≠‘ß Õ“¬ÿ‡©≈’Ë¬ ıı.Ù ªï „π°≈ÿ¡à ºŸªâ «É ¬∑’§Ë «∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â (μ“√“ß∑’Ë Ò) √–¬–‡«≈“ ‡ªìπ‡∫“À«“π√âÕ¬≈– ˆı Õ¬Ÿà„π™à«ß Ò-ı ªï ·≈– √âÕ¬≈– ÛÚ ¡’√–¬–‡ªìπ‚√§¡“°°«à“ ı ªï (§à“æ’ = .Ú˘) „π °≈ÿ¡à ºŸªâ «É ¬∑’§Ë «∫§ÿ¡√–¥—∫πÈ”μ“≈‰¡à‰¥â¡¥’ ™— π’¡«≈°“¬‰¡à‡°‘π ÚÛ √âÕ¬≈– Û˜ ·≈–¡’¥—™π’¡«≈°“¬¡“°°«à“ ÚÛ √âÕ¬≈– ˆÛ (§à“æ’ <.ˆ) §«“¡√Ÿ‡â °’¬Ë «°—∫‚√§‡∫“À«“π·≈–‡®μ§μ‘ ¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ (§à“æ’ = ., §à“æ’ = . μ“¡≈”¥—∫)

127

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

μ“√“ß∑’Ë Ò ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâªÉ«¬‡∫“À«“π∑’Ë “¡“√∂§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â°—∫§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¡à‰¥â §«∫§ÿ¡πÈ”μ“≈‰¥â §«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â ®”π«π = ˜Ò (√âÕ¬≈–) ®”π«π = ÒÚˆ (√âÕ¬≈–) ‡æ» À≠‘ß ™“¬ Õ“¬ÿ (ªï) ÛÚ-ıo >ıo ∂“π¿“æ ¡√ §Ÿà À¡â“¬ Õ“™’æ √—∫√“™°“√ ‡°…μ√°√√¡ §â“¢“¬ ‰¡à∑”ß“π ∫”π“≠ ·¡à‡√◊Õπ Õ◊ËπÊ √–¬–‡«≈“‡ªìπ‡∫“À«“π (ªï) Ò-ı >ˆ ®”π«π§√—Èß∑’Ë√—∫ª√–∑“π¬“μàÕ«—π Ò §√—Èß/«—π Ú-Û §√—Èß/«—π ™π‘¥¬“∑’Ë√—∫ª√–∑“πμàÕ«—π Glibenclamide Metformin Glibenclamide ·≈– Metformin Chlorpropamide ¥—™π’¡«≈°“¬ ≤ ÚÛ > ÚÛ §«“¡√Ÿâ Ÿß °≈“ß-μË” ‡®μ§μ‘ Ÿß °≈“ß-μË”

§à“æ’ .ˆ

Ùˆ (ˆı) Úı (Ûı)

˜˜ (ˆÒ) Ù˘ (Û˘) .Ú˜

ÚÒ (Û) ı (˜)

Ù˜ (Û˜) ˜˘ (ˆÛ) .ˆ˜

ˆı (˘Ò.ı) ˆ (¯.ı)

ÒÒÛ (˘) ÒÛ (Ò) .ıˆ

Ú˜ (Û¯) Û (Ù) Ú (Û) ˜ (Ò) ÒÙ (Ú) Òˆ (ÚÚ) Ú (Û)

ÚÙ (Ò˘) ˘ (˜) ÒÛ (Ò) Ò˜ (ÒÙ) ÚÚ (Ò¯) ÛÛ (Úˆ) ¯ (ˆ) .Ú˘

Ù¯ (ˆ¯) ÚÛ (ÛÚ)

ˆı (ıÚ) ˆÒ (Ù¯) .ÙÚ

ÛÙ (Ù¯) Û˜ (ıÚ)

ıÛ (ÙÚ) ˜Û (ı¯) .ˆ˜

ÙÚ (ı˘) Ò˘ (Ú˜) ˜ (Ò) Û (Ù)

¯Ò (ˆÙ.Û) ÛÒ (ÚÙ.ˆ) ÒÚ (˘.ı) Ú (Ò.ˆ) .ˆ

ÙÒ (ı¯) Ûo (ÙÚ)

Ù˜ (Û˜) ˜˘ (ˆÛ) <.Ò

ˆÛ (¯˘) ¯ (ÒÒ)

ˆ (Ù¯) ˆˆ (ıÚ) <.Ò

Ùˆ (ˆı) Úı (Ûı)

Û (ÚÙ) ˘ˆ (˜ˆ)

128 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

√–¥—∫§«“¡√à«¡¡◊Õ¢Õß°≈ÿà¡μ—«Õ¬à“ß „π°“√‡ª√’¬∫‡∑’¬∫ (μ“√“ß∑’Ë Ú) √–¥—∫§«“¡ √à«¡¡◊Õ (¥â“π√—∫ª√–∑“πÕ“À“√ °“√√—∫ª√–∑“π¬“ °“√ ÕÕ°°”≈—ß°“¬ °“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ °“√¥Ÿ·≈ μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥) „π°≈ÿà¡ºŸâªÉ«¬∑’Ë§«∫§ÿ¡ √–¥—∫πÈ”μ“≈‰¥â æ∫«à“§«“¡√à«¡¡◊Õ„π√–¥—∫ Ÿß ‰¥â·°à °“√ √—∫ª√–∑“π¬“√âÕ¬≈– ˘˜ (§à“æ’ < .Ò) §«“¡√à«¡¡◊Õ„π √–¥—∫ Ÿß·≈–√–¥—∫°≈“ß ‰¥â·°à °“√√—∫ª√–∑“πÕ“À“√√âÕ¬≈– ˆı ·≈– ÛÚ (§à“æ’ < .Ò) °“√®—¥°“√§«“¡‡§√’¬¥ √âÕ¬≈– ıı ·≈– Û¯ (§à“æ’ < .Ò) à«π°“√Õπ“¡—¬ ∑—Ë «‰ª·≈–¥Ÿ·≈‡∑â“¡’§«“¡√à«¡¡◊Õ „π√–¥—∫ Ÿß °≈“ß μË” √âÕ¬≈– ÛÚ, Û˜, ·≈– ÛÒ (§à“æ’ < .Ò) μ“¡≈”¥—∫ §«“¡ — ¡ æ— π ∏å √ –À«à “ ßªí ® ®— ¬ ¿“¬πÕ° ¿“¬„π °“√ π—∫ πÿπ∑“ß —ß§¡°—∫§«“¡√à«¡¡◊Õ §«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“πÕ“À“√ °≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â (μ“√“ß∑’Ë Û) °“√ π—∫ πÿπ¥â“π¢à“« “√√–¥—∫°≈“ß·≈–μË”¡’§«“¡√à«¡¡◊Õ¥â“π °“√√—∫ª√–∑“πÕ“À“√√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– ÚÛ ‡∑’¬∫°—∫ °“√ π—∫ πÿπ¥â“π¢à“« “√√–¥—∫ Ÿß∑’„Ë Àâ§«“¡√à«¡¡◊Õ¥â“π°“√ √—∫ª√–∑“πÕ“À“√√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– Ú.Û æ∫«à“°“√ π—∫ πÿπ¥â“π¢à“« “√¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ¥â“π ∂‘μ‘°—∫√–¥—∫§«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“πÕ“À“√ (§à“æ’ < .Ò) °“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß√–¥—∫°≈“ß·≈–

μË”¡’§«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“πÕ“À“√√–¥—∫ Ÿß§‘¥‡ªìπ √âÕ¬≈– Ú ‡∑’¬∫°—∫°“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß√–¥—∫ Ÿß∑’Ë„Àâ §«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“πÕ“À“√√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– ÒÚ.Û æ∫«à“°“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß¡’§«“¡ —¡æ—π∏åÕ¬à“ß ¡’ π— ¬ ”§— ≠ ∑“ß¥â “ π ∂‘ μ‘ °— ∫ √–¥— ∫ §«“¡√à « ¡¡◊ Õ ¥â “ π°“√ √—∫ª√–∑“πÕ“À“√ (§à“æ’ = .Ú) §«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ °≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â √–¬–‡«≈“¢Õß°“√‡ªìπ ‡∫“À«“π™à«ß Ò-ı ªï ¡’§«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª ·≈–¥Ÿ·≈‡∑â“√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– ˘.Ú ‡∑’¬∫°—∫√–¬–‡«≈“ ¢Õß°“√‡ªìπ‡∫“À«“π ¡“°°«à“ ı ªï ¡’§«“¡√à«¡¡◊Õ¥â“π °“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– Ò¯ æ∫«à“√–¬–‡«≈“¢Õß°“√‡ªìπ‚√§‡∫“À«“π¡’§«“¡ —¡æ—π∏å Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘°—∫√–¥—∫§«“¡√à«¡¡◊Õ¥â“π°“√ Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ (§à“æ’ = .Ú˘) ‡®μ§μ‘„π √–¥—∫ Ÿß¡’§«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ √–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– Úˆ.˜ ‡∑’¬∫°—∫‡®μ§μ‘√–¥—∫°≈“ßμË”∑’Ë„Àâ§«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– ˘ æ∫«à“‡®μ§μ‘¡’§«“¡ —¡æ—π∏åÕ¬à“ß ¡’π¬— ”§—≠∑“ß ∂‘μ°‘ ∫— √–¥—∫§«“¡√à«¡¡◊Õ ¥â“π°“√Õπ“¡—¬ ∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ (§à“æ’ = .ÚÙ)

μ“√“ß∑’Ë Ú ‡ª√’¬∫‡∑’¬∫√–¥—∫§«“¡√à«¡¡◊Õ·μà≈–¥â“π„πºŸªâ «É ¬‡∫“À«“π√–À«à“ß°≈ÿ¡à ∑’§Ë «∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â°∫— °≈ÿ¡à ∑’§Ë «∫§ÿ¡ √–¥—∫πÈ”μ“≈‰¡à‰¥â √–¥—∫§«“¡√à«¡¡◊Õ

§«∫§ÿ¡πÈ”μ“≈‰¥â ®”π«π = ˜Ò (√âÕ¬≈–) μË”

°“√§«∫§ÿ¡Õ“À“√ Ú (Û) °“√√—∫ª√–∑“π¬“  ÕÕ°°”≈—ß°“¬ ÒÒ (Òı.ı) °“√Õπ“¡—¬∑—Ë«‰ª ÚÚ (ÛÒ) °“√¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥ ı (˜)

°≈“ß

Ÿß

§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â ®”π«π = ÒÚˆ (√âÕ¬≈–) μË”

ÚÛ (ÛÚ) Ùˆ (ˆı) Ûı (Úı) Ú (Û) ˆ˘ (˘˜) ÒÚ (Ò) Ù˘ (ˆ˘) ÒÒ (Òı.ı) ˘ (˜Ú) Úˆ (Û˜) ÚÛ (ÛÚ) ˜˜ (ˆÒ) Ú˜ (Û¯) Û˘ (ıı) ÙÙ (Ûı)

°≈“ß

Ÿß

˜Ò (ıˆ) Ò˘ (Òı) Ú¯ (ÚÚ) ÛÚ (Úı) ÙÚ (ÛÛ)

Ú (Òˆ) ˘ı (˜ı) ¯ (ˆ) Ò˜ (ÒÙ) Ù (ÛÚ)

§à“æ’ <.Ò <.Ò <.Ò <.Ò <.Ò

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μ“√“ß∑’Ë Û §à“§«“¡ —¡æ—π∏å¢Õßªí®®—¬¿“¬πÕ° °“√ π—∫ πÿπ∑“ß —ß§¡·≈–§«“¡√à«¡¡◊Õ¥â“π°“√§«∫§ÿ¡Õ“À“√

Ÿß

§«∫§ÿ¡πÈ”μ“≈‰¥â §«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â §«“¡√à«¡¡◊Õ¥â“π°“√√—∫ª√–∑“πÕ“À“√ °≈“ß μË” §à“æ’ Ÿß °≈“ß μË”

°“√ π—∫ πÿπ∑“ßÕ“√¡≥å Ÿß Ò¯ (ˆÚ.Ò) Ò (ÛÙ.ı) °≈“ß-μË” Ú¯ (ˆ˜) ÒÛ (ÛÒ) °“√ π—∫ πÿπ¢âÕ¡Ÿ≈¢à“« “√ Ÿß ÒÚ (ıÙ.ı) ˘ (ÙÒ) °≈“ß-μË” ÛÙ (ˆ˘.Ù) ÒÙ (Ú¯.ˆ) °“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß Ÿß Û (ˆÙ) Òˆ (ÛÙ) °≈“ß-μË” Òˆ (ˆ˜) ˜ (Ú˘) °“√ π—∫ πÿπ¥â“π °“√¬Õ¡√—∫ Ÿß ÚÒ (ˆ) ÒÛ (Û˜) °≈“ß-μË” Úı (ˆ˘.Ù) Ò (Ú˜.¯) ‡®μ§μ‘‡°’Ë¬«°—∫§ÿ≥¿“æ ∫√‘°“√ Ÿß Ò˜ (ı) Òˆ (Ù˜) °≈“ß-μË” Ú˘ (˜¯) ˜ (Ò˘)

§à“æ’

Ò (Û.Ù) Ò (Ú)

.ÙÒ ¯ (Òˆ) Úı (ı) Ò˜ (ÛÙ) ÒÚ (Òı.¯) Ùˆ (ˆ.ı) Ò¯ (ÚÛ.˜)

Ò (Ù.ı) Ò (Ú)

<.Ò Ò (Ú.Û) ÚÛ (ıÛ.ı) Ò˘ (ÙÙ.Ú) Ò˘ (ÚÛ) Ù¯ (ı¯) Òˆ (Ò˘)

Ò (Ú) Ò (Ù)

.Ú ¯ (ÒÚ.Û) Ú (Ùˆ.Ú) Ú˜ (ÙÒ.ı) ÒÚ (Ú) ÙÒ (ˆ˜) ¯ (ÒÛ)

Ò (Û) Ò (Ú.¯)

Ò (Û) Ò (Û)

.˜Ò ˘ (Òı) ÛÛ (ıÙ) Ò˘ (ÛÒ) ÒÒ (Òˆ.˘) Û¯ (ı¯.ı) Ò (ÚÙ.ˆ)

˜ (ÒÚ.ı) Û (ıÛ.ˆ) Ò˘ (ÛÛ.˘) ÒÛ (Ò¯.ˆ) ÙÒ (ı¯.ˆ) Òˆ (ÚÚ.¯)

.ÛÚ

μ“√“ß∑’Ë Ù §à“§«“¡ —¡æ—π∏å¢Õßªí®®—¬¿“¬„π ·≈–§«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“

Ÿß

§«∫§ÿ¡πÈ”μ“≈‰¥â §«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â §«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ °≈“ß μË” §à“æ’ Ÿß °≈“ß

‡æ»

μË”

.˘ ™“¬ À≠‘ß

ÒÚ (Ù¯) ˆ (ÚÙ) ˜ (Ú¯) ÒÒ (ÚÛ.˘) Ú (ÙÛ.ı) Òı (ÛÚ.ˆ)

Õ“¬ÿ ÛÚ-ıo >ıo ∂“π¿“æ ¡√ §Ÿà À¡â“¬ Õ“™’æ ∫”π“≠ ‡°…μ√°√√¡ ·¡à‡√◊Õπ «à“ß∑”ß“π √—∫√“™°“√ §â“¢“¬ Õ◊ËπÊ

.ÒÙ Ù (¯.Ú) Ò (Ú.Ù) Ûı(˜Ò.Ù) ÒÛ (Òˆ.˘) ÚÚ (Ú¯.ˆ) ÙÚ (ıÙ.ı)

.˜ ˆ (Ú˘) Ò˜ (ÛÙ)

˜ (ÛÛ) Ò˘ (Û¯)

¯ (Û¯) ÒÙ (Ú¯)

ÚÒ (ÛÚ) ÚÚ (ÛÙ) Ú (ÛÛ.Û) Ù (ˆˆ.˜)

ÚÚ (ÛÙ) 

.Û¯ ¯ (Ò˜) ˘ (Ò˘) Û (ˆÙ) ˘ (ÒÒ.Ù) ÚÛ (Ú˘.Ò) Ù˜ (ı˘.ı)

Òı (ÒÛ.Û) Ú¯ (ÚÙ.¯) ˜ (ˆÒ.˘) Ú (Òı.Ù) Ù (Û.¯) ˜ (ıÛ.¯)

˜ (ı)  ˆ (Û˜) Ú (Ú¯.ˆ) ˆ (ÚÚ.Û)  Ú (Ò)

Ù (Ú¯.ˆ) Ú (ˆˆ.˜) Û (Ò˘) ı (˜Ò.Ù) ÒÚ (ÙÙ.Ù)  

Û (ÚÒ.Ù) Ò (ÛÛ.Û) Ò (ÙÙ)  ˘ (ÛÛ.Û) Ú (Ò) 

§à“æ’

Ù (Ò¯.Ú)  ¯ (ÚÙ.Ú) Ú (ÒÒ.¯) Ú (¯.Û)  Ò (ÒÚ.ı)

˘ (Ù.˘) ˘ (Ù.˘) Ú (ÚÚ.Ú) ˜ (˜˜.¯) ˘ (Ú˜.Û) Òˆ (Ù¯.ı) Ù (ÚÛ.ı) ÒÒ (ˆÙ.˜) Û (ÒÚ.ı) Ò˘ (˜˘.Ú) ı (Û¯.ı) ¯ (ˆÒ.ı)  ˜ (¯˜.ı)

130 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

μ“√“ß∑’Ë Ù §à“§«“¡ —¡æ—π∏å¢Õßªí®®—¬¿“¬„π ·≈–§«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ (μàÕ)

Ÿß √–¬–‡«≈“‡ªìπ‚√§‡∫“À«“π (ªï) Ò-ı >ˆ ®”π«π§√—Èß∑’Ë√—∫ª√–∑“π¬“ Ò §√—Èß/«—π Ú-Û §√—Èß/«—π ™π‘¥¬“∑’Ë√—∫ª√–∑“π Glibenclamide Metformin Glibenclamide ·≈– Metformin Chlorpropamide ¥—™π’¡«≈°“¬ ≤ÚÛ >ÚÛ §«“¡√Ÿâ Ÿß °≈“ß-μË” ‡®μ§μ‘ Ÿß °≈“ß-μË”

μË”

.¯ Òı (ÛÒ.Û) Òˆ (ÛÛ.Û) Ò˜ (Ûı.Ù) ¯ (ÛÙ.¯) Ò (ÙÛ.ı) ı (ÚÒ.˜)

.Ú˘ ˆ (˘.Ú) ÒÚ (Ò¯.ı) Ù˜ (˜Ú.Û) ÒÒ (Ò¯) Ú (ÛÛ) Û (Ù˘)

.ı¯ ÒÛ (Û¯.Ú) ÒÒ (ÛÚ.Ù) Ò (Ò˘.Ù) Ò (Ú˜) Òı (Ù.ı) ÒÚ (ÛÚ.ı)

.¯Ú ˆ (ÒÒ.Û) ÒÙ (Úˆ.Ù) ÒÒ (Òı) Ò¯ (Úı)

ÛÛ (ˆÚ.Û) ÙÙ (ˆ)

ÒÙ(ÛÛ.Û) ÒÙ(ÛÛ.Û) ÒÙ(ÛÛ.Û) ˜ (Ûˆ.¯) ¯ (ÙÚ.Ò) Ù (ÚÒ.Ò)

¯ (˘.˘) Ò¯ (ÚÚ.Ú) ı (Òˆ) ˘ (Ú˘)

ıı(ˆ˜.˘) Ò˜ (ıı)

Ú (Ú¯.ˆ) Ú (Ú¯.ˆ) Û (ÙÚ.¯)  Ú (ˆˆ.˜) Ò (ÛÛ.Û)

Û (Úı) Ò (ı)

ı (ÙÒ.˜) 

Ù (ÛÛ.Û) Ò (ıo)

.ÒÒ Ò¯ (ÙÛ.˘) Òı (Ûˆ.ˆ) ¯ (Ò˘.ı) ı (Òˆ.ˆ) ÒÒ (Ûˆ.˜) ÒÙ (Ùˆ.˜)

.˜Û ı (Òo.ˆ) ÒÛ (Ú˜.˜) Ú˘ (ˆÒ.˜) ÒÚ (Òı) Ò˘ (ÚÙ) Ù¯ (ˆÒ)

ÚÒ (ÛÛ.Û) Úı (Û˘.˜) Ò˜ (Ú˜) Ú (Úı) Ò (ÒÚ.ı) ı (ˆÚ.ı)

.ˆ ˜ (ÒÒ.˜) ÚÒ (Ûı) Òo (Òı) ÒÒ (Ò˜)

ÛÚ (ıÛ.Û) Ùı (ˆ¯)

¯ (Úˆ.˜) ˘ (Û) ˘ (˘) ÚÛ (ÚÙ)

ÒÛ (ÙÛ.Û) ˆÙ (ˆ˜)

.Ù¯ Òˆ (Ûı) ˜ (Ú¯)

Ò¯ (Û˘) ¯ (ÛÚ)

ÒÚ (Úˆ) Ò (Ù)

§«“¡√à«¡¡◊Õ¥â“π°“√¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥ °≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â√–¬–‡«≈“¢Õß°“√‡ªìπ ‡∫“À«“π™à«ß Ò-ı ªï ¡’§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√ §«“¡‡§√’¬¥√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– ÚÙ.ˆ ‡∑’¬∫°—∫√–¬– ‡«≈“¢Õß°“√‡ªìπ‡∫“À«“π¡“°°«à“ ı ªï ¡’§«“¡√à«¡¡◊Õ ¥â“π¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥√–¥—∫ Ÿß§‘¥‡ªìπ √âÕ¬≈– Û˘ æ∫«à“√–¬–‡«≈“¢Õß°“√‡ªìπ‚√§‡∫“À«“π¡’ §«“¡ —¡æ—π∏åÕ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘μ°‘ ∫— √–¥—∫§«“¡√à«¡¡◊Õ

§à“æ’

.ÚÙ

¥â“π°“√®—¥°“√§«“¡‡§√’¬¥ (§à“æ’ = .Ú) °“√ π—∫ πÿπ ¥â“π°“√¬Õ¡√—∫„π√–¥—∫ Ÿß¡’§«“¡√à«¡¡◊Õ„π¥â“π°“√®—¥°“√ §«“¡‡§√’¬¥√–¥—∫ Ÿß§‘¥‡ªìπ√âÕ¬≈– ÙÛ ‡∑’¬∫°—∫°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫√–¥—∫°≈“ß-μË”∑’Ë„Àâ§«“¡√à«¡¡◊Õ „π¥â“π°“√®—¥°“√§«“¡‡§√’¬¥√–¥—∫ Ÿß §‘¥‡ªìπ√âÕ¬≈– ÚÒ.ı æ∫«à“°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫¡’§«“¡ —¡æ—π∏åÕ¬à“ß ¡’π—¬ ”§—≠∑“ß ∂‘μ‘°—∫√–¥—∫§«“¡√à«¡¡◊Õ¥â“π¥Ÿ·≈μπ‡Õß „π°“√®—¥°“√§«“¡‡§√’¬¥ (§à“æ’ = .Ú)

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μ“√“ß∑’Ë ı §à“§«“¡ —¡æ—π∏å¢Õßªí®®—¬¿“¬„π·≈–§«“¡√à«¡¡◊Õ¥â“π°“√¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√§«“¡‡§√’¬¥

Ÿß ‡æ» ™“¬ À≠‘ß Õ“¬ÿ ÛÚ-ı >ı ∂“π¿“æ ¡√ §Ÿà À¡â“¬ Õ“™’æ ∫”π“≠ ‡°…μ√°√√¡ ·¡à‡√◊Õπ «à“ßß“π √—∫√“™°“√ §â“¢“¬ Õ◊ËπÊ √–¬–‡«≈“°“√‡ªìπ ‡∫“À«“π (ªï) Ò-ı >ˆ ®”π«π§√—ßÈ ∑’Ë √—∫ª√–∑“π¬“μàÕ«—π Ò §√—Èß/«—π Ú-Û §√—Èß/«—π ™π‘¥¬“∑’Ë√—∫ª√–∑“π Glibenclamide Metformin Glibenclamide ·≈– Metformin Chlorpropamide ¥—™π’¡«≈°“¬ ≤ÚÛ >ÚÛ §«“¡√Ÿâ Ÿß °≈“ß-μË” ‡®μ§μ‘ Ÿß °≈“ß-μË”

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132 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

μ“√“ß∑’Ë ˆ §«“¡ —¡æ—π∏å¢Õßªí®®—¬¿“¬πÕ° ·≈–°“√ π—∫ πÿπ∑“ß —ß§¡°—∫§«“¡√à«¡¡◊Õ¥â“π°“√¥Ÿ·≈μπ‡Õß„π°“√®—¥°“√ §«“¡‡§√’¬¥ ªí®®—¬ Ÿß

°“√ π—∫ πÿπ∑“ßÕ“√¡≥å Ÿß Ú (ˆ˘) °≈“ß-μË” Ò˘ (Ùı) °“√ π—∫ πÿπ¢âÕ¡Ÿ≈ ¢à“« “√ Ÿß ÒÙ (ˆÙ) °≈“ß-μË” Úı (ıÒ) °“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß Ÿß Ú¯ (ˆ) °≈“ß-μË” ÒÒ (Ùı.¯) √–¥—∫°“√ π—∫ πÿπ ¥â“π°“√¬Õ¡√—∫ Ÿß ÚÙ(ˆ¯.ˆ) °≈“ß-μË” Òı (ÙÚ) ‡®μ§μ‘‡°’Ë¬«°—∫§ÿ≥¿“æ ∫√‘°“√ Ÿß Ú (ı¯.¯) °≈“ß-μË” Ò˘ (ıÒ.Ù)

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¥â“π°“√§«∫§ÿ¡Õ“À“√ æ∫«à“ „π°≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à ‰¥â¡’ªí®®—¬ Ú ªí®®—¬§◊Õ °“√ π—∫ πÿπ¥â“π¢âÕ¡Ÿ≈¢à“« “√ ·≈–°“√ π—∫ πÿπ∑“ß¥â“π ‘Ëß¢Õß∑’Ë¡’§«“¡ —¡æ—π∏å°—∫§«“¡ √à « ¡¡◊ Õ ¥â “ π°“√§«∫§ÿ ¡ Õ“À“√Õ¬à “ ß¡’ π— ¬ ”§— ≠ ∑“ß ∂‘ μ‘ (§à“æ’ < .Ò, §à“æ’ = .Ú) μ“¡≈”¥—∫ ·μà§«“¡ —¡æ—π∏å ¥—ß°≈à“«‡ªìπ§«“¡ —¡æ—π∏å∑“ß≈∫ °≈à“«§◊Õ ‡π◊ËÕß®“°§à“ √â Õ ¬≈–¢Õß§«“¡√à« ¡¡◊Õ ¥â “ π√— ∫ ª√–∑“πÕ“À“√§à Õπ¢â“ ß ‚πâ¡‡Õ’¬ß®“°√–¥—∫ Ÿß‰ª„π√–¥—∫μË” Õ“®‡ªìπ‡π◊ËÕß®“°°≈ÿà¡ ∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â ‰¥â√—∫¢âÕ¡Ÿ≈¢à“« “√®“°§√Õ∫§√—«‰¡à ¡“°π—°·≈–Õ“®‡ªìπ‡æ√“–∫√‘∫∑∑’Ë≠“μ‘ºŸâªÉ«¬‰¡à‰¥â‡¢â“‰ª„π ÀâÕßμ√«®°—∫ºŸâªÉ«¬‡∫“À«“π„π‡«≈“∑’Ë·æ∑¬åμ√«®·≈–„Àâ §”·π–π”®÷ß‰¡à “¡“√∂‡μ◊ÕπÀ√◊Õ·π–π”ºŸâªÉ«¬∑’Ë∫â“π‰¥â ‡™àπ ‡¥’¬«°—π§«“¡ —¡æ—π∏å√–À«à“ß°“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß·≈– §«“¡√à«¡¡◊Õ¥â“π√—∫ª√–∑“πÕ“À“√Õ¬à“ß¡’π—¬ ”§—≠·μà‡ªìπ §«“¡ —¡æ—π∏å∑“ß≈∫ °≈à“«§◊Õ ‡π◊ËÕß®“°√–¥—∫§«“¡√à«¡¡◊Õ ‚πâ¡‡Õ’¬ß®“°√–¥—∫ Ÿß‰ª„π√–¥—∫μË” Õ“®‡ªìπ‡π◊ËÕß®“°°≈ÿà¡ ºŸâªÉ«¬¥—ß°≈à“«‰¥â√—∫°“√ π—∫ πÿπ¥â“π ‘Ëß¢Õß∑’Ë‰¡à‡æ’¬ßæÕ À√◊ÕÕ“®‡ªìπ‡æ√“–®”π«πºŸªâ «É ¬∑’∑Ë ”°“√»÷°…“¡’®”π«ππâÕ¬

133

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

®÷ß Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß ®√√¬“ ∏—≠πâÕ¡ »÷°…“ªí®®—¬ ∑’Ë¡’º≈μàÕ°“√¥Ÿ·≈μπ‡Õß¢ÕßºŸâªÉ«¬‡∫“À«“π æ∫«à“°“√ π— ∫ πÿ π ∑“ß — ß §¡‚¥¬√«¡¡’ § «“¡ — ¡ æ— π ∏å Õ ¬à “ ß¡’ π— ¬ ”§—≠∑“ß ∂‘μ‘ (§à“æ’ = .Ò)˘ ·≈–°“√»÷°…“¢Õß Garay-Sevilla (Ò˘˘ı) ·≈–§≥– æ∫«à“°“√ π—∫ πÿπ ∑“ß —ß§¡‚¥¬√«¡¡’§«“¡ —¡æ—π∏å°—∫§«“¡√à«¡¡◊Õ¥â“π°“√ §«∫§ÿ¡Õ“À“√Õ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘μ‘ (§à“æ’ = .˜)Ò º≈°“√»÷°…“§à“§«“¡ —¡æ—π∏å (μ“√“ß∑’Ë Ù) ¢Õß ªí®®—¬¿“¬„π ªí®®—¬¿“¬πÕ° °“√ π—∫ πÿπ∑“ß —ß§¡°—∫ §«“¡√à«¡¡◊Õ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ æ∫«à“„π °≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â¡’ªí®®—¬ Ú ªí®®—¬§◊Õ √–¬–‡«≈“ ‡ªìπ‡∫“À«“π·≈–‡®μ§μ‘¡’§«“¡ —¡æ—π∏å°—∫§«“¡√à«¡¡◊Õ ¥â“π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ (§à“æ’ = .Ú˘, §à“æ’ = .ÚÙ μ“¡≈”¥—∫) §«“¡ —¡æ—π∏å√–À«à“ß§«“¡√à«¡¡◊Õ¥â“πÕπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“ ·≈–√–¬–‡«≈“‡ªì π ‡∫“À«“πÕ¬à “ ß¡’ π— ¬ ”§— ≠ ‡ªì π §«“¡ —¡æ—π∏å∑“ß≈∫ °≈à“«§◊Õ ‡π◊ËÕß®“°§à“√âÕ¬≈–¢Õß§«“¡√à«¡ ¡◊ Õ ¥â “ πÕπ“¡— ¬ ∑—Ë «‰ª·≈–¥Ÿ · ≈‡∑â “ §à Õ π¢â “ ß‚πâ ¡ ‡Õ’ ¬ ß®“° √–¥—∫ Ÿß‰ª„π√–¥—∫μË” ·≈–Õ’°¥â“πÀπ÷ËßºŸâªÉ«¬∑’Ë¡’√–¬–‡«≈“ ‡ªìπ‡∫“À«“ππ“π°«à“ ˆ ªï ®–„Àâ § «“¡√à « ¡¡◊ Õ„π°“√ Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“¥’°«à“√–¬–‡«≈“‡ªìπ‚√§‡∫“À«“π Ò-ı ªï Õ“®‡π◊ËÕß®“°√–¬–‡«≈“‡ªìπ‡∫“À«“ππ“π°Á√—∫√Ÿâ ·π«∑“ß°“√ªØ‘∫—μ‘μ—«‡ÕßÕ¬à“ß¥’®“°∫ÿ§≈“°√°“√·æ∑¬å ´÷Ëß ‡ÀÁπ‰¥â®“° (μ“√“ß∑’Ë Ù) „π°≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â„π ™à«ßÕ“¬ÿ Ò-ı ªï¡’√–¥—∫§«“¡√à«¡¡◊Õ„π°“√Õπ“¡—¬∑—Ë«‰ª ·≈–¥Ÿ·≈‡∑â“μË”¡’®”π«π√âÕ¬≈–∑’¡Ë “°·≈–„π™à«ßÕ“¬ÿ¡“°°«à“ ı ªï √–¥—∫§«“¡√à«¡¡◊Õ„π°“√Õπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“μË” ¡’§“à √âÕ¬≈–≈¥≈ß §«“¡ —¡æ—π∏å√–À«à“ß§«“¡√à«¡¡◊Õ¥â“πÕπ“¡—¬∑—«Ë ‰ª ·≈–¥Ÿ·≈‡∑â“·≈–‡®μ§μ‘Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ (§à“æ’ = .Ú) ·μà§«“¡ —¡æ—π∏å¥—ß°≈à“«‡ªìπ§«“¡ —¡æ—π∏å∑“ß≈∫ °≈à“«§◊Õ ‡π◊ËÕß®“°§à“√âÕ¬≈–¢Õß§«“¡√à«¡¡◊Õ¥â“πÕπ“¡—¬ ∑—«Ë ‰ª·≈–¥Ÿ·≈‡∑â“§àÕπ¢â“ß‚πâ¡‡Õ’¬ß®“°√–¥—∫ Ÿß‰ª„π√–¥—∫μË” ´÷Ëß· ¥ß„Àâ‡ÀÁπ«à“∂â“À“°ºŸâªÉ«¬®”π«π¡“°∑’Ë¡’‡®μ§μ‘√–¥—∫ Ÿß®–∑”„Àâ§«“¡√à«¡¡◊Õ¥â“πÕπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“√–¥—∫ μË”¡’®”π«π≈¥≈ß·≈–°≈—∫°—π∂â“À“°ºŸâªÉ«¬®”π«π¡“°∑’Ë¡’ ‡®μ§μ‘ √ –¥— ∫ °≈“ß-μË” ®–∑”„Àâ § «“¡√à « ¡¡◊ Õ ¥â “ πÕπ“¡— ¬ ∑—Ë«‰ª·≈–¥Ÿ·≈‡∑â“√–¥—∫μË”¡’®”π«π‡æ‘Ë¡¢÷Èπ º≈°“√»÷°…“§à“§«“¡ —¡æ—π∏å (μ“√“ß∑’Ë ı) ¢Õß ªí®®—¬¿“¬„π ªí®®—¬¿“¬πÕ° °“√ π—∫ πÿπ∑“ß —ß§¡°—∫ §«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡‡§√’¬¥ æ∫«à“ „π°≈ÿà¡∑’Ë §«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â¡’ªí®®—¬ Ú ªí®®—¬§◊Õ √–¬–‡«≈“‡ªìπ‚√§

‡∫“À«“π·≈–°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫∑’¡Ë §’ «“¡ —¡æ—π∏å Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘°—∫§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√ §«“¡‡§√’¬¥ (§à“æ’ = .ÚÙ, §à“æ’ = .Ú˘ μ“¡≈”¥—∫) §«“¡ —¡æ—π∏å√–À«à“ß§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡‡§√’¬¥ ·≈–√–¬–‡«≈“‡ªìπ‚√§‡∫“À«“πÕ¬à“ß¡’π—¬ ”§—≠ ·μà§«“¡ —¡æ—π∏å¥—ß°≈à“«‡ªìπ§«“¡ —¡æ—π∏å∑“ß≈∫ °≈à“«§◊Õ ‡π◊ËÕß ®“°§à“√âÕ¬≈–¢Õß§«“¡√à«¡¡◊Õ¥â“πÕπ“¡—¬∑—Ë«‰ª·≈–¥Ÿ·≈ ‡∑â“§àÕπ¢â“ß‚πâ¡‡Õ’¬ß®“°√–¥—∫ Ÿß‰ª„π√–¥—∫μË” ‡Àμÿ¥ß— °≈à“« °Á‡æ√“–¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘°—∫°≈ÿà¡∑’Ë §«∫§ÿ¡πÈ”μ“≈‰¡à‰¥â´÷Ëß™’È„Àâ‡ÀÁπ«à“„π°≈ÿà¡∑’Ë§«∫§ÿ¡πÈ”μ“≈ ‰¡à‰¥â¡’§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡‡§√’¬¥μË” §«“¡ —¡æ—π∏å√–À«à“ß§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√ §«“¡‡§√’¬¥·≈–°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫Õ¬à“ß¡’π—¬ ”§—≠ (μ“√“ß∑’Ë ¯) ·μà§«“¡ —¡æ—π∏å¥—ß°≈à“«‡ªìπ§«“¡ —¡æ—π∏å∑“ß∫«° °≈à“«§◊Õ ‡π◊ËÕß®“°§à“√âÕ¬≈–¢Õß§«“¡ √à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡‡§√’¬¥§àÕπ¢â“ß‚πâ¡‡Õ’¬ß®“° √–¥— ∫ μË”‰ª„π√–¥—∫ Ÿß ´÷Ëß· ¥ß„Àâ ‡ ÀÁ π «à “ ∂â “ À“°ºŸâ ªÉ « ¬ ®”π«π¡“°∑’Ë ¡’ ° “√ π— ∫ πÿ π ¥â “ π°“√¬Õ¡√— ∫ √–¥— ∫ Ÿ ß ®– ∑”„Àâ§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡‡§√’¬¥√–¥—∫ Ÿß®–¡’ ®”π«π¡“°·≈–°≈—∫°—π∂â“À“°ºŸâªÉ«¬®”π«π¡“°∑’Ë¡’‡®μ§μ‘ √–¥—∫°≈“ß-μË”®–∑”„Àâ§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡ ‡§√’¬¥√–¥—∫μË”¡’®”π«π‡æ‘¡Ë ¢÷πÈ °≈—∫°—π∂â“À“°ºŸªâ «É ¬®”π«π ¡“°∑’Ë¡’°“√ π—∫ πÿπ¥â“π°“√¬Õ¡√—∫√–¥—∫°≈“ß-μË”¡“°®– ∑”„Àâ§«“¡√à«¡¡◊Õ¥â“π°“√®—¥°“√§«“¡‡§√’¬¥√–¥—∫ Ÿß®–¡’ ®”π«π≈¥≈ß

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‡Õ° “√Õâ“ßÕ‘ß Ò. World Health Organization. Country and regional data. Prevalence of diabetes worldwide. 2008 Nov. Available from: URL: http:// www.who.int/diabetes/facts/world_figures/en/ index.html. Ú. World Health Organization. Diabetes. Diabetes Fact. 2008 Nov. Available from: URL: http:// www.who.i/mediacentre/factsheets/fs312/en/ index.html. Û. World Health Organization. Country and regional data. Prevalence of diabetes in the WHO South-East Asia Region. 2008 Nov. Available from: http://www.who.int/diabetes/ facts/world_figures/en/index5.html. Ù. Phimpha B. Prevalence of diabetes in Vientiane capital. Masterûs thesis of tropical medicine: Institute of Francophony of Tropical medicine; 2006. ı. √“¬ß“πª√–®”ªï. ∂‘μ°‘ “√‡æ‘¡Ë ¢÷πÈ ¢ÕßºŸªâ «É ¬‚√ßæ¬“∫“≈ ‡™…∞“∏‘√“™. ÚÙ. ˆ. Vasana V. The study on prevalence of type 2 diabetes mellitus complication at Mahosot hospital. Masterûs thesis: National University of Laos. Faculty of Postgraduate and Research; 2005.

˜. °—≠≠“∫ÿμ√ »√π√‘π∑√å. ªí®®—¬∑’Ë¡’º≈μàÕ°“√≈¥≈ß¢Õß √–¥—∫πÈ”μ“≈„π‡≈◊Õ¥¢ÕßºŸªâ «É ¬‡∫“À«“π∑’¡Ë “√—∫°“√√—°…“ Õ¬à“ßμàÕ‡π◊ËÕß„π‚√ßæ¬“∫“≈∫â“π≈“¥ ®—ßÀ«—¥‡æ™√∫ÿ√’. («‘∑¬“π‘æπ∏åª√‘≠≠“ “∏“√≥ ÿ¢»“ μ√å¡À“∫—≥±‘μ). ∫—≥±‘μ«‘∑¬“≈—¬. ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à; ÚıÙ. ¯. «√“¿√≥å Àπÿà¡»√’. °“√¥Ÿ·≈μπ‡Õß¢ÕßºŸâªÉ«¬‡∫“À«“π ™π‘¥∑’Ë Ú „π°≈ÿà¡∑’Ë§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â¥’¡“°·≈– °≈ÿ¡à ∑’‰Ë ¡à “¡“√∂§«∫§ÿ¡√–¥—∫πÈ”μ“≈‰¥â„π·ºπ°ºŸªâ «É ¬ πÕ°‚√ßæ¬“∫“≈ —πªÉ“μÕß Õ”‡¿Õ —πªÉ“μÕß ®—ßÀ«—¥ ‡™’¬ß„À¡à. («‘∑¬“π‘æπ∏åª√‘≠≠“ “∏“√≥ ÿ¢»“ μ√å ¡À“∫—≥±‘μ). ∫—≥±‘μ«‘∑¬“≈—¬. ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à; ÚıÙ˘. ˘. ®√√¬“ ∏—≠πâÕ¡. ªí®®—¬∑’Ë¡’º≈μàÕ°“√¥Ÿ·≈μπ‡Õß¢Õß ºŸªâ «É ¬‡∫“À«“πμ”∫≈‡«’¬ß¬Õ Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥≈”æŸπ. («‘∑¬“π‘æπ∏åª√‘≠≠“ “∏“√≥ ÿ¢»“ μ√å¡À“∫—≥±‘μ). ∫—≥±‘μ«‘∑¬“≈—¬. ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à; ÚıÙ˘. Ò. Garay-Sevilla ME, Nava LE, Malacara JM, et al. Adherence to treatment and social support in patients with non-insulin dependent diabetes mellitus. J Diabetes Complications. 1995;9:81-6.

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Abstract Factors influencing to compliance of type II diabetic patients Phoutsomphong Vilay* Surasak Buranatrevedh** Wisree Wayurakul** *Faculty of Medical Sciences, National University of Laos **Department of Community Medicine and Family Medicine, Faculty of Medicine, Thammasat University Background: Diabets mellitus is the important cause of cardisvascular disease kingney disease and other systemic complications. Control of diabetes mellitus can reduce these complications. Curently, there has been increasing awareness in type II diabetes and its consequences in Laos PDR. Objective: To determine the factors influencing compliance in diabetic patients. The factors were divided into internal factors, external factors and social support factors. Method: The study was designed as analytical study. A total of 197 type II diabetic patients both male and female attending the diabetes mellitus (DM) clinics at the Mahosot and Sethathirat hospitals, Vientiane Capital were interviewed during December 2008 and January 2009 by using validated questionnaires. Patients were divided into two groups: patients who were able to control blood glucose (well controlled patients) and patients who were unable to control blood glucose (poor controlled patients). Result: The finding showed that from general information, percentage of well controlled patients who were diabetic more than 6 years was less than that of poorly controlled patients (p=0.029). Percentage of well controlled patients who had body mass index more than 23 was less than that of poorly controlled patients (p=0.006). Well controlled patients had higher level of knowledge and attitudes than poorly controlled patients (p=0.001 for both factors). For level of compliance, well controlled patients had higher level of compliance for diet, medication, exercise, general and foot care, and stress management than poorly controlled patients (p=0.00 for all 5 factors). For relationship between factors and compliance level, information and instrument support were significantly related to general and foot care compliance level (p=0.029 and 0.024, respectively). Duration of being diabetic patients and admittance support were significantly related to stress management compliance level (p=0.02 for both factors). Conclusion: Well controlled patients had higher level of compliance than poorly controlled patients in all aspects. Social support were significantly related to compliance level. Key words: Compliance, Diabetes Mellitus, Laos Peoples Democratic Republic

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∫∑§—¥¬àÕ §«“¡À≈“°À≈“¬∑“ßæ—π∏ÿ°√√¡·≈– ¿“æ·«¥≈âÕ¡∑’Ë„™â‡æ“–ª≈Ÿ° ¡’º≈∑”„Àâ¢â“«‡Àπ’¬«°Ë” (Oryza sativa L.) ¡’ª√‘¡“≥ “√ ”§—≠·μ°μà“ß°—π ’∑’Ë‡°‘¥„πºπ—ßº≈ª√–°Õ∫‰ª¥â«¬·Õπ‚∑‰´¬“π‘πÕ¬Ÿà Ù ™π‘¥ §◊Õ ‰´¬“π‘¥‘π‰¥‡Œ°‚´‰´¥å, ‰´¬“π‘¥‘π Û-°≈Ÿ‚§‰´¥å, ‰´¬“π‘¥‘π-‡Œ°‚´‰´¥å ·≈–æ’‚Õπ‘¥‘π Û-°≈Ÿ‚§‰´¥å ®—¥Õ¬Ÿà„π°≈ÿà¡ø≈“‚«πÕ¬¥å ·≈–¡’ƒ∑∏‘Ïμâ“πÕπÿ¡Ÿ≈Õ‘ √– °“√»÷°…“π’ÈμâÕß°“√∑’Ë®–À“æ—π∏ÿå¢â“«æ◊Èπ‡¡◊Õß∑’Ëæ∫„π∑âÕß∂‘Ëπ¢Õßª√–‡∑»‰∑¬ ∑’Ë¡’ª√‘¡“≥ Õß§åª√–°Õ∫∑“ß‡§¡’·≈–ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π¡“°∑’Ë ÿ¥ ‚¥¬‡°Á∫√«∫√«¡μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ◊Èπ‡¡◊Õß¢Õß‰∑¬®”π«π Ûˆ “¬æ—π∏ÿå ∑—Èß®“°¿“§‡Àπ◊Õ·≈–¿“§μ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ‡ªìπæ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ DPPH radical scavenging assay ¥’∑’Ë ÿ¥ (IC50 = Úˆ.ˆÙ ± Ò.ÒÙ μg/ml) ·≈–ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π«‘∏’ lipid peroxidation assay ¥’∑’Ë ÿ¥¥â«¬ (IC50 = ı.ÚÚ ± ı.ıÒ μg/ml) πÕ°®“°π’Èμ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ¬—ß¡’ª√‘¡“≥ “√ª√–°Õ∫øïπÕ≈‘°√«¡·≈–‰´¬“π‘¥‘π Û-°≈Ÿ‚§‰´¥å¡“°∑’Ë ÿ¥ §◊Õ Ò.˜Û ± .Ù mg GAE/g (grain) ·≈– ıÛˆ.ı˜ ± Ù.ı μg/g (grain) μ“¡≈”¥—∫ ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π·≈–ª√‘¡“≥Õß§å ª√–°Õ∫∑“ß‡§¡’√Õß≈ß¡“ §◊Õ ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ ‚¥¬¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π«‘∏’ lipid peroxidation assay ¥’ (IC50 = ˜.ÚÙ ± Ú.Ú μg/ml) ·≈–¡’ª√‘¡“≥‰´¬“π‘¥‘π Û-°≈Ÿ‚§‰´¥å¡“° [Ù¯¯.ÚÚ ± Û.Ùı μg/g (grain)] ®“°¢âÕ¡Ÿ≈¥—ß°≈à“« §«√ àß‡ √‘¡„Àâ¡’°“√ª≈Ÿ°¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ·≈– “¡“√∂„™â ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥”π’È ‡ªìπ«—μ∂ÿ¥‘∫„π°“√æ—≤π“«‘®—¬„Àâ‰¥âº≈‘μ¿—≥±å ‡ √‘¡ ÿ¢¿“æ∑’Ë¡’§ÿ≥¿“æ μàÕ‰ª §” ”§—≠: ¢â“«‡Àπ’¬«°Ë”, ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π, º≈‘μ¿—≥±å‡ √‘¡ ÿ¢¿“æ

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137

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

∫∑π” ¢â“«‡Àπ’¬«°Ë”À√◊Õ¢â“«‡Àπ’¬«¥” (Oryza sativa L.) ‡ªìπ¢â“«‡Àπ’¬«æ—π∏ÿåæ◊Èπ‡¡◊Õß™π‘¥Àπ÷Ëß ≈—°…≥–‡¥àπ §◊Õ ºπ—ßº≈ (pericarp) ¡’ ’¡à«ß¥” ¡’§«“¡À≈“°À≈“¬∑“ß æ—π∏ÿ°√√¡ “¡“√∂®”·π°μ“¡≈—°…≥–∑“ß —≥∞“π«‘∑¬“ ≈—°…≥–μà“ßÊ ‡™àπ ’¢Õß·ºàπ„∫ ’¢Õß°“∫„∫ ’¢Õß≈‘Èπ„∫ √Ÿª√à“ß¢Õß≈‘Èπ„∫ ’¢ÕßÀŸ„∫ ’¢Õßª≈âÕß ∑√ß°Õ ’¢Õß¬Õ¥ ‡° √‡æ»‡¡’¬ ≈—°…≥–„∫∏ß ≈—°…≥–√«ß °“√·μ°√–·ßâ °“√ ·°à¢Õß„∫ ’‡ª≈◊Õ°‡¡≈Á¥ ’¢Õß¢â“«°≈âÕß·≈–√Ÿª√à“ß¢â“«°≈âÕß ‡ªìπμâπÒ §«“¡À≈“°À≈“¬¢Õß ’∑’Ë‡°‘¥®“°ªØ‘°‘√‘¬“¢Õß ·Õπ‚∑‰´¬“π‘π (anthocyanin) „π¢â“«‡Àπ’¬«°Ë” ‚¥¬ ‡©æ“– à«π¢Õß‡¡≈Á¥Õ—π‰¥â·°à ·°≈∫¢â“« (husk) ·≈–ºπ—ß º≈∑’Ë¡’≈—°…≥– ’¡à«ß§≈â“¬°—π∑—ÈßÀ¡¥ ·μàÕ¬Ÿà„π√–¥—∫ ’∑’Ë ·μ°μà“ß°—π “√ ’∑’Ëæ∫„π¢â“«°Ë” §◊Õ ‰´¬“π‘¥‘π Û-°≈Ÿ‚§ ‰´¥å (cyanidin 3-glucoside) Ÿß∂÷ß ıÙ.Ù˜ mg/Ò g (grain) ´÷Ëß‡ªìπ “√∑’Ë‰¡àæ∫„π¢â“«¢“«∑—Ë«‰ªÚ ‰´¬“π‘¥‘π Û-°≈Ÿ‚§‰´¥å‡ªìπ “√∑’Ë¡’§ÿ≥ ¡∫—μ‘„π°“√μâ“πÕÕ°´‘‡¥™—π (antioxidation) ∑’Ë¥’∑’Ë ÿ¥„π°≈ÿà¡·Õπ‚∑‰´¬“π‘π ·≈–¬—ß¡’ ƒ∑∏‘μÏ “â π°“√Õ—°‡ ∫Û ¡’§«“¡‡ªìπæ‘…μàÕ‡´≈≈å¡–‡√Áß≈Ÿ§‡’ ¡’¬Ù ¬—∫¬—Èß°“√‡®√‘≠¢Õß‡´≈≈å¡–‡√ÁßªÕ¥ı ·≈–¬—∫¬—Èß‡Õπ‰´¡å Õ—≈‚¥ √’¥—°‡μ (aldose reductase)ˆ „π¢â“«‡Àπ’¬«°Ë” ª√–°Õ∫¥â«¬ “√·°¡¡“-‚Õ‰√´“πÕ≈ (γ-oryzanol) ª√‘¡“≥ Ÿß∂÷ß ˜Ú.˘ı mg/Ò g (grain) ´÷Ëß Ÿß°«à“¢â“«¢“«∂÷ß Ú-Û ‡∑à“˜ ·°¡¡“-‚Õ‰√ ´“πÕ≈‡ªìπ “√∑’¡Ë §’ ≥ ÿ ¡∫—μ„‘ π°“√μâ“πÕÕ°´‘‡¥™—π¯ ≈¥°“√ ¥Ÿ¥´÷¡§Õ‡≈ ‡μÕ√Õ≈®“°Õ“À“√ Ÿà√à“ß°“¬ ¡’º≈∑”„Àâ≈¥°“√ —ß‡§√“–Àå§Õ‡≈ ‡μÕ√Õ≈„πμ—∫˘ ≈¥ª√‘¡“≥§Õ‡≈ ‡μÕ√Õ≈ „πæ≈“ ¡“Ò ·≈–≈¥√–¥—∫πÈ”μ“≈„π‡≈◊Õ¥ÒÒ πÕ°®“°π’È „π¢â“«‡Àπ’¬«°Ë”¬—ßæ∫«à“¡’ “√„π°≈ÿà¡‚∑§Õ≈ (tocols) ‡™àπ «‘μ“¡‘πÕ’, ·°¡¡“-‚∑‚§‡øÕ√Õ≈ ·≈â«¬—ßæ∫ “√æ’‚Õπ‘¥‘π Û-°≈Ÿ‚§‰´¥å (peonidin 3-glucoside), §«Õ‡´μ‘π (quercetin) ·≈–°√¥‡øÕ√Ÿ≈‘° (ferulic acid) Õ’°¥â«¬ÒÚ ®“°°“√ ∑¥ Õ∫ª≈Ÿ°æ—π∏ÿå¢â“«‡Àπ’¬«¥”®”π«π Òˆ æ—π∏ÿå ·≈–æ—π∏ÿå μ√«® Õ∫Õ’° Ú æ—π∏ÿå „π Ù ¿“æ·«¥≈âÕ¡ §◊Õ ƒ¥Ÿπ“ªï ÚıÙ¯ ∑’Ë»Ÿπ¬å«‘®—¬¢â“« °≈π§√ »Ÿπ¬å«‘®—¬¢â“«Õÿ∫≈√“™∏“π’ ·≈–»Ÿπ¬å«‘®—¬¢â“«™ÿ¡·æ ·≈–„πƒ¥Ÿπ“ªï ÚıÙ˘ ∑’Ë»Ÿπ¬å«‘®—¬ ¢â“«¢Õπ·°àπ º≈®“°°“√»÷°…“ª√‘¡“≥·°¡¡“-‚Õ‰√´“πÕ≈ æ∫«à“ æ—π∏ÿå∑’Ë„Àâ§à“‡©≈’Ë¬¢Õßª√‘¡“≥·°¡¡“-‚Õ‰√´“πÕ≈ Ÿß §◊Õ æ—π∏ÿå Niewdam Gs No. ˆÚÒ, KKU-GL-BLı-Û, KKU-GL-BL-ı-Ú ·≈– Niewdam Gs No. ˘Ù˜ı ‚¥¬¡’ª√‘¡“≥·°¡¡“-‚Õ‰√´“πÕ≈‡∑à“°—∫ ÒÛ.ÚÚ, ÒÒ., Ò.ı˘ ·≈– Ò.ÛÙ ppm μ“¡≈”¥—∫ÒÛ

«—μ∂ÿª√– ß§å¢Õßß“π«‘®—¬§√—Èßπ’È §◊ÕμâÕß°“√∑’Ë®– À“æ—π∏ÿå¢â“«æ◊Èπ‡¡◊Õß∑’Ëæ∫„π∑âÕß∂‘Ëπ¢Õßª√–‡∑»‰∑¬ ∑’Ë¡’ ª√‘¡“≥Õß§åª√–°Õ∫∑“ß‡§¡’·≈–¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π ¡“°∑’Ë ÿ¥

«‘∏’°“√∑¥≈Õß Ò. °≈ÿà¡μ—«Õ¬à“ß∑’Ëπ”¡“»÷°…“ μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ◊Èπ‡¡◊Õß¢Õß‰∑¬æ—π∏ÿåμà“ßÊ ´÷Ëß¡’π—°«‘™“°“√‡°…μ√‡ªìπºŸâ®”·π°æ—π∏ÿå μ“¡≈—°…≥–∑“ß —≥∞“π«‘∑¬“ ®“°¿“§‡Àπ◊Õ (»Ÿπ¬å«®‘ ¬— ¢â“«®—ßÀ«—¥‡™’¬ß„À¡à) Ù “¬æ—π∏ÿå ·≈–¿“§μ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ (»Ÿπ¬å«‘®—¬¢â“« ™ÿ¡·æ ®—ßÀ«—¥¢Õπ·°àπ) ÛÚ “¬æ—π∏ÿå √«¡∑—ÈßÀ¡¥ Ûˆ “¬æ—π∏ÿå ‡°Á∫√—°…“‰«â∑’ËÕÿ≥À¿Ÿ¡‘ -Ú Õß»“‡´≈‡´’¬ Ú. °“√»÷°…“§ÿ≥ ¡∫—μ°‘ “√μâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ DPPH radical scavenging assayÒÙ ‡μ√’¬¡ “√≈–≈“¬μ—«Õ¬à“ß·≈– “√¡“μ√∞“π butylate hydroxytoluene (BHT) ‚¥¬≈–≈“¬„π methanol „Àâ ¡’§«“¡‡¢â¡¢âπ‡∑à“°—∫ Ò, Ò, ı, Ò μg/ml ·≈â«ªî‡ªμ (Ò μl) „ à„π ˘ˆ well plate ‡μ‘¡ Ò μl DPPH (Ú.Ù mg/Ò ml „π methanol) μ—Èß∑‘Èß‰«âπ“π Û π“∑’ π”‰ª«—¥§à“°“√¥Ÿ¥°≈◊π· ß∑’Ë ıÒ˜ nm ·≈â« §”π«≥À“ §à“ % inhibition ®“° ¡°“√ % Inhibition = [(Acontrol›Asample)/Acontrol] × Ò §”π«≥À“§à“§«“¡‡¢â¡¢âπ∑’ Ë “¡“√∂μâ“πÕÕ°´‘‡¥™—π‰¥â ı% (IC50) ‚¥¬„™â Graphpad prism program Û. °“√»÷°…“§ÿ≥ ¡∫—μ‘°“√μâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ lipid peroxidation of liposome assayÒı ‡μ√’¬¡ liposome ®“° bovine brain ‚¥¬„™â .Ú ml ¢Õß liposomes, .Ò ml FeCl3, .Ò ml ascorbic acid (Ò mM), .ı ml PBS ·≈– .Ò ml ¢Õß “√ °—¥ ‚¥¬‡μ√’¬¡‡ªìπ§«“¡‡¢â¡¢âπμà“ßÊ §◊Õ .Ò, Ò, .ı, .Ò, .ı, .Ò, .ı ·≈– ı. mg/ml ( ”À√—∫ control „™â ethanol ·∑π “√ °—¥·≈–„™â propylgallate ‡ªìπ positive control) ∑” Ù replicates π”‰ª incubated ∑’Ë Û˜ Õß»“‡´≈‡´’¬ π“π Û π“∑’ ·≈â«∑”°“√∑¥ Õ∫ ¥â«¬«‘∏’ Thiobarbituric acid (TBA) method ‚¥¬ªî‡ªμ Ú ml Ú% trichloroacetic acid ·≈– Ú ml .ˆ˜% 2-thiobarbituric acid ·≈– Ò ml sample solution „ à „πÀ≈Õ¥∑¥≈Õß π”‰ª∑”„Àâ√âÕπ„πÕà“ßπÈ”§«∫§ÿ¡Õÿ≥À¿Ÿ¡‘∑’Ë ¯ Õß»“‡´≈‡´’¬ π“π Ú π“∑’ ∑‘Èß‰«â„Àâ‡¬Áπ ·≈â« centrifuge ∑’Ë Û rpm π“π Ú π“∑’ ·≈â«¥Ÿ¥ “√≈–≈“¬

138 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

„ ÕÕ° ‡μ‘¡ butanol Ú ml º ¡ √Õ„Àâ·¬°™—Èπ·≈â«¥Ÿ¥™—Èπ butanol ¡“«—¥§à“°“√¥Ÿ¥°≈◊π· ß∑’Ë ıÛÚ nm ∂â“‡°‘¥ ¢∫«π°“√ lipid peroxidation ®–∑”„Àâ TBA ‡ª≈’Ë¬π ’ ‡ªìπ ’™¡æŸ¢Õß malonaldehyde ·≈â«§”π«≥À“ % inhibition ®“° ¡°“√

ance) ‡¡◊ËÕæ∫§«“¡·μ°μà“ß®–∑¥ Õ∫§«“¡·μ°μà“ß‡ªìπ √“¬§Ÿà (Mulltiple comparisons) ¥â«¬«‘∏’ Duncanûs new multiple range test (p < .ı)

% Inhibition = [(Acontrol › Asample)/Acontrol] × Ò

®“°º≈°“√∑¥ Õ∫ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ DPPH radical scavenging assay æ∫«à“μ—«Õ¬à“ß¢â“« ‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ï¥’∑’Ë ÿ¥ §◊Õ K-Entry ÒÚ ‡Àπ’¬«¥” (IC50 = Úˆ.ˆÙ ± Ò.ÒÙ μg/ml) ·≈–μ—«Õ¬à“ß¢â“« ‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ï√Õß≈ß¡“ §◊Õ K-Entry Ò ‡Àπ’¬« ¥”®“° ¡¢. (IC50 = Ûı.¯ ± .Úı μg/ml) ·≈– K-entry ÒÙ ‡Àπ’¬«¥” (IC50 = Û¯.Úı ± Ò.ÚÒ μg/ ml) ¥—ßμ“√“ß∑’Ë Ò º≈°“√∑¥ Õ∫ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ lipid peroxidation assay æ∫«à“μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ ƒ∑∏‘Ï¥’∑’Ë ÿ¥ §◊Õ K-Entry ÒÚ ‡Àπ’¬«¥” (IC50 = ı.ÚÚ ± ı.ıÒ μg/ml) ·≈–μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ï √Õß≈ß¡“ §◊Õ K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ (IC50 = ˜.ÚÙ ± Ú.Ú μg/ml) ·≈– K-entry Ò ‡Àπ’¬«¥” ®“° ¡¢. (IC50 = ¯ı.Úı ± Ú.Ú μg/ml) º≈°“√«‘‡§√“–Àåª√‘¡“≥ total phenolics compound æ∫«à“μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ª√‘¡“≥ total phenolics compound ¡“°∑’ Ë ¥ÿ §◊Õ K-Entry ÒÚ ‡Àπ’¬« ¥” [Ò.˜Û ± .Ù mg GAE/g (grain)] ·≈–μ—«Õ¬à“ß ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå C-Ù °Ë”‡™’¬ß„À¡à [Ò.˜Ò ± .Ò mg GAE/g (grain)] à«πμ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿ∑å ¡’Ë ª’ √‘¡“≥ total phenolics compound √Õß≈ß¡“ §◊Õ K-Entry ÒÙ ‡Àπ’¬«¥” [Ò.ıÙ ± .Ú mg GAE/g (grain)] ®“°°“√«‘‡§√“–Àå¥â«¬ HPLC æ∫«à“¢â“«‡Àπ’¬« °Ë”ª√–°Õ∫‰ª¥â«¬·Õπ‚∑‰´¬“π‘πÕ¬Ÿà Ù ™π‘¥ §◊Õ cyanidin dihexoside, cyanidin 3-glucoside, cyanidin hexoside ·≈– peonidin 3-glucoside ¥—ß√Ÿª∑’Ë Ò ‚¥¬·Õπ‚∑‰´ ¬“π‘πÀ≈—°„π¢â“«‡Àπ’¬«°Ë” §◊Õ cyanidin 3-glucoside ´÷Ëß º≈°“√«‘‡§√“–Àåª√‘¡“≥ cyanidin 3-glucoside æ∫«à“ μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ª√‘¡“≥ cyanidin 3-glucoside ¡“°∑’Ë ÿ¥ §◊Õ K-Entry ÒÚ ‡Àπ’¬«¥” [ıÛˆ.ı˜ ± Ù.ı μg/g (grain)] ·≈–μ—«Õ¬à“ß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå ∑’Ë¡’ª√‘¡“≥ cyanidin 3-glucoside √Õß≈ß¡“ §◊Õ K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ [Ù¯¯.ÚÚ ± Û.Ùı μg/g (grain)] ·≈– K-Entry ÒÙ ‡Àπ’¬«¥” [Ù˜ı.Ú˘ ± Ò.˜Ú μg/g (grain)]

§”π«≥À“§à“§«“¡‡¢â¡¢âπ∑’ Ë “¡“√∂μâ“πÕÕ°´‘‡¥™—π‰¥â ı% (IC50) ‚¥¬„™â Graphpad prism program Ù. °“√«‘‡§√“–Àåª√‘¡“≥ total phenolics compoundÒˆ «‘‡§√“–Àåª√‘¡“≥ total phenolic compounds „π μ—«Õ¬à“ß¥â«¬ Folin-Ciocalteuûs reagent ‚¥¬‡μ√’¬¡ “√≈–≈“¬ “√μ—«Õ¬à“ß §«“¡‡¢â¡¢âπ .Ò mg/ml ªî‡ªμ “√≈–≈“¬μ—«Õ¬à“ß Ú μl ≈ß„π ˘ˆ-well plate ‡μ‘¡ Folin-Ciocalteuûs reagent Ò μl ·≈â«‡μ‘¡ sodium carbonate (˜.ı%) ¯ μl μ—Èß∑‘Èß‰«â Û π“∑’ π”‰ª«—¥ §à“°“√¥Ÿ¥°≈◊π· ß∑’Ë§«“¡¬“«§≈◊Ëπ ˜ˆı nm „π·μà≈– §«“¡‡¢â¡¢âπ∑Ì“°“√∑¥ Õ∫´È” Û §√—ßÈ ·≈â«§Ì“π«≥À“ª√‘¡“≥ total phenolic compounds ‡∑’¬∫®“°°√“ø¡“μ√∞“π¢Õß gallic acid (Gallic acid equivalent, GAE) ı. °“√«‘‡§√“–Àåª√‘¡“≥ cyanidin 3-glucoside ·≈– peonidin 3-glucoside ¥â«¬ High performance liquid chromatography (HPLC)Ò˜ Pump: ConstaMetric ÙÒ (Thermo Separation Products-TSP, Riviera Beach, CA, USA) Data acquisition and processing: PC Ò (TSP) software Detector: SpectroMonitor ÙÒ (TSP) Visible (λ = ıÒ nm) Column: CÒ¯, Ù.ˆ × Úı mm (ı μm), Phenomenex (USA) Mobile phase:(Solvent A) Formic acid Ò%, (Solvent B) Acetonitrile Linear gradient ı - Û% A Û min. Isocratic ı% A Ò min. Flow rate: .¯ ml/min Injection: Ò μl fixed loop (Auto-sampler, AS Ûı), Cyanidin 3-glucoside standard inject Ò μl (n=Û) Sample inject Ò μl (n=Û) ˆ. °“√«‘‡§√“–Àå¢âÕ¡Ÿ≈∑“ß ∂‘μ‘ ‡ª√’¬∫‡∑’¬∫§à“‡©≈’Ë¬‚¥¬„™â«‘∏’°“√«‘‡§√“–Àå§«“¡ ·ª√ª√«π·∫∫∑“ß‡¥’¬« (One way analysis of vari-

º≈°“√∑¥≈Õß

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μ“√“ß∑’Ë Ò º≈°“√»÷°…“§ÿ≥ ¡∫—μ‘°“√μâ“πÕÕ°´‘‡¥™—π·≈–ª√‘¡“≥Õß§åª√–°Õ∫∑“ß‡§¡’„π¢â“«‡Àπ’¬«°Ë” μ—«Õ¬à“ß

K-Entry Ò ‡Àπ’¬«¥” GS.No.ÚÒˆÚ˘ K-Entry Ú ¢â“«°Ë” GS.No.¯¯¯Ù K-Entry Û IR˜ıÚÙ˜-Ò-Ú-B-Ò-B-B K-Entry Ù KKU-GL-BL-ı-ˆ K-Entry ı KKU-GL-BL-ı-˘ K-Entry ˆ KKU-GL-BL›ı-ÒÒ K-Entry ˜‡Àπ’¬«¥”®“° ¡¢. K-Entry ¯ ‡Àπ’¬«¥”®“° ¡¢. K-Entry ˘ ‡Àπ’¬«¥”®“° ¡¢. K-Entry Ò ‡Àπ’¬«¥”®“° ¡¢. K-Entry ÒÒ ‡Àπ’¬«¥”®“° ¡¢. K-Entry ÒÚ ‡Àπ’¬«¥” K-Entry ÒÛ ‡Àπ’¬«¥” K-Entry ÒÙ ‡Àπ’¬«¥” K-Entry Òı ‡Àπ’¬«¥” K-Entry Òˆ ‡Àπ’¬«¥”πâÕ¬ K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ K-Entry Ò¯ ‡Àπ’¬«¥” K-Entry Ò˘ ‡Àπ’¬«¥” K-Entry Ú ‡Àπ’¬«¥” K-Entry ÚÒ ‡Àπ’¬«·¥ß K-Entry ÚÚ ‡Àπ’¬«¥” K-Entry ÚÛ ‡Àπ’¬«¥” K-Entry ÚÙ ¢â“«°≈Ë” K-Entry Úı ¢â“«°≈Ë” K-Entry Úˆ ‡Àπ’¬«¥” K-Entry Ú˜ ¢â“«°≈Ë” K-Entry Ú¯ ¢â“«°≈Ë” K-Entry Ú˘ ¢â“«°≈Ë” K-Entry Û ¢â“«°≈Ë” K-Entry ÛÒ ¢â“«°≈Ë” K-Entry ÛÚ ¢â“«°≈Ë” C-Ò °Ë”‡¡◊Õßπà“π C-Ú ·¥ß‡¡◊Õß≈Õß C-Û °Ë”π“¬æ√âÕ¡ C-Ù °Ë”‡™’¬ß„À¡à

DPPH assay Lipid peroxidation Total phenolics Cyanidin Peonidin (IC50, μg/ml) (IC50, μg/ml) compound 3-glucoside 3-glucoside [mg GAE/g (grain)] [μg/g (grain)] [μg/g (grain)] ıÛ.Úˆ ± .¯ı Ù˜.Ú ± Ù.ÛÚ ı¯.˜ ± Ú.ıı >Ò >Ò >Ò >Ò >Ò ıı.Úˆ ± .˜ı Ûı.¯ ± .Úı >Ò ÚÙ.ˆÙ ± Ò.ÒÙ >Ò Û¯.Úı ± Ò.ÚÒ ¯Ù.ıÙ ± Ù.Ú˜ ˜˘.¯ ± ˆ.ÛÚ ıÒ.¯Ù ± Ò.ı¯ >Ò >Ò ˜˘.ˆÙ ± Ú.Ùˆ >Ò Ù˜.˘˘ ± Û.Û˘ >Ò >Ò ¯Û.Ùˆ ± Ò.Ú ¯ˆ.ıÛ ± ¯.ÚÙ ˘ˆ.Ú¯ ± Ú. >Ò >Ò >Ò ˆ˘.ÒÛ ± ı.ı ˘.Ûˆ ± Û.Úˆ ˆÚ.¯Û ± Ò.ÚÙ Ù˘.Ùı ± ˆ.Òˆ Ù˘.Úˆ ± Û.ÒÚ ˜Ù.Ú ± Ò.Ù˜

ÒÛÛ.ÒÚ ± Ò.¯ ˘Ú.ˆÙ ± ı.ıˆ ÚÚÛ.¯Û ± ˜.Ú˜ >ı >ı >ı >ı >ı ÒÛ˜.ÒÙ ± .ˆÛ ¯ı.Úı ± Ú.Ú >ı ı.ÚÚ ± ı.ıÒ >ı ¯ˆ.ÛÙ ± Û.¯Ú >ı >ı ˜.ÚÙ ± Ú.Ú >ı >ı >ı ÙÙ.Úı ± ı.Òı ÒÙÙ.ÙÚ ± ˘.˘Ò >ı >ı Úı˜.˜ı ± Ù.Ú >ı >ı >ı >ı >ı ÚÙı.ı˘ ± Ú.ÚÙ >ı Òı¯.¯Û ± ı.¯Ò >ı ÒÛ.Ò ± ı.Ò ˘˜.˜˘ ± ˆ.¯ı

Ò.Ú˜ ± .ÒÒ Ò.Ùı ± .˜ Ò. ± .ı .ÙÙ ± .ı .ıˆ ± .Ú .ı ± .Ò .ıÙ ± .Ù .ıÒ ± .Ò Ò.ÚÙ ± .Û Ò.ÙÛ ± .Ò .ıÙ ± .˜ Ò.˜Û ± .Ù .ˆ˜ ± .ı Ò.ıÙ ± .Ú .˜˘ ± .¯ .˘¯ ± .ÒÚ Ò.ıÚ ± .Û .˜Ò ± .˜ .˜˘ ± .Ò Ò. ± .Ú Ò.ˆ ± .ˆ Ò.Û¯ ± .ı .˜¯ ± .Û .ˆÒ ± .Ò .˘¯ ± .ÒÚ Ò.ˆ ± .Ú .˜ ± .Ù .ı˘ ± .ˆ .ˆˆ ± . .ı˘ ± .Ò .¯ı ± .Û .¯Û ± .˘ Ò.Ú¯ ± .˜ Ò. ± .¯ Ò.ÛÙ ± .Ò Ò.˜Ò ± .Ò

ÒˆÚ.ÒÛ ± Û.Û Ú˜Ò.Ò ± Ú.˜ ˘ˆ.ˆ ± .˜ı ıÚ.ÚÙ ± Ò.Ò¯ ¯˘.Ùı ± .˘ ˘.Ûı ± Ò.¯ Ò.Ú ± .ÛÚ ˘ı.ˆ˘ ± .ıˆ ÛÛÛ.ıÒ ± Ò. Ûˆ.ÛÙ ± Ú.Ú¯ Òˆ.Úı ± Ò.ÚÛ ıÛˆ.ı˜ ± Ù.ı ÒˆÙ.¯ ± .˜ Ù˜ı.Ú˘ ± Ò.˜Ú Ò.˘Û ± .Ò¯ ÒÚÛ.Ò˘ ± .˘ı Ù¯¯.ÚÚ ± Û.Ùı ˜˜.˜˘ ± Û.ˆ ˘.˘ ± .Ò ÒıÙ.ÛÚ ± .˘ ND Úı¯.¯ ± .˜Û ˆˆ.ˆ˜ ± Ú.Ò ıˆ.ˆÛ ± Ò.ÙÙ ÒÒı.ı ± Ú.Û ÒÚ.˘ ± .Ûˆ ˆ˜.ı¯ ± .ı ıÒ.˘ ± .Ú˜ ¯.ı ± Ò.ÒÒ ˜ı.Ûˆ ± Ò.ˆˆ ˜ˆ.˘Ú ± Ú.Ú ˆ˘.¯˘ ± .˘Ù ÚÛ¯.ÚÙ ± Ò.˜ˆ ND ÛÙˆ.ÛÚ ± Ú.˘ Ú˜.Ò˘ ± .ıı

À¡“¬‡Àμÿ Positive control ®“°°“√∑¥ Õ∫ DPPH assay §◊Õ BHT ¡’§à“ IC50 = ÒÙ.Ú ± Ú.Û˜ μg/ml ND = not detected

ÒÚ.ÒÛ ± Ò.Ù Û.Ú˘ ± .¯ Ò.¯ ± Ú.ÚÛ Û.ıˆ ± .ıÒ ÒÚ.Ò˘ ± Û.Û Ò.ˆ ± .ˆ ÒÛ.Ú˜ ± .˜Ù Ò.Òı ± Ò.ı Ú¯.˜ˆ ± .ˆˆ Úı.ˆÚ ± Ú. ı.ı¯ ± .˘Ú Û˜.Ûˆ ± Ò.ÚÙ ÒÙ.Ú˘ ± Ò.ı˜ Û.Ò¯ ± Ò.ÒÙ ÒÒ.Ùı ± .ˆÒ ¯.ı¯ ± .Úı Ú¯.˘¯ ± .¯ ˆ.˜ ± .ıÛ ˜.Ú ± .ÚÚ ÒÛ.ÛÛ ± Ò.ˆ ND Òı.ÚÙ ± Ú.ı ÒÚ.Úˆ ± .Û¯ Ù.¯˜ ± .¯ˆ ˜.ˆı ± Ò.˜˜ ÚÛ.ÛÒ ± .ˆ ¯.¯Û ± Ò.Ú Û.Úˆ ± Ò.Ûı ı.ˆÙ ± .ÚÛ Ò.Û˘ ± .˜¯ ÒÛ.ÛÙ ± Ú.ÒÙ ˘.˘Ú ± .Ú Úˆ.ˆˆ ± .ıÚ ND Û.Û ± .Û˜ Ú˜¯.Û¯ ± Ú.ˆ

140 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

√Ÿª∑’Ë Ò HPLC chromatogram ¢Õß¢â“«‡Àπ’¬«°Ë”·≈– cyanidin 3-glucoside Peak Peak Peak Peak

1 2 3 4

= = = =

cyanidin cyanidin cyanidin peonidin

peonidin 3-glucoside ‡ªìπ·Õπ‚∑‰´¬“π‘π„π ¢â“«‡Àπ’¬«°Ë” ∑’Ë¡’ª√‘¡“≥¡“°√Õß≈ß¡“®“° cyanidin 3glucoside ¬°‡«âπ ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå C-Ù °Ë”‡™’¬ß„À¡à ´÷Ëß ‡ªìπæ—π∏ÿå‡¥’¬«∑’Ë¡’ª√‘¡“≥ peonidin 3-glucoside ¡“°°«à“ cyanidin 3-glucoside ‰¡àæ∫·Õπ‚∑‰´¬“π‘π„π¢â“«æ—π∏ÿå K-Entry ÚÒ ‡Àπ’¬«·¥ß·≈–æ—π∏ÿå C-Ú ·¥ß‡¡◊Õß≈Õß

√ÿª·≈–Õ¿‘ª√“¬º≈ ®“°º≈°“√»÷°…“§ÿ≥ ¡∫—μ„‘ π°“√μâ“πÕÕ°´‘‡¥™—π ·≈–º≈°“√«‘ ‡ §√“–Àå ª √‘ ¡ “≥Õß§å ª √–°Õ∫∑“ß‡§¡’ μà “ ßÊ ¢Õß¢â“«‡Àπ’¬«°Ë”æ—π∏ÿåμà“ßÊ æ∫«à“ §ÿ≥ ¡∫—μ‘„π°“√μâ“π

dihexoside 3-glucoside hexoside 3-glucoside ÕÕ°´‘‡¥™—π·≈–ª√‘¡“≥ total phenolics compound, cyanidin 3-glucoside ·≈– peonidin 3-glucoside π—Èπ ·μ°μà“ß°—π ‚¥¬¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬« ¥” ‡ªìπæ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ DPPH radical scavenging assay (IC50 = Úˆ.ˆÙ ± Ò.ÒÙ μg/ ml) ·≈–«‘∏’ lipid peroxidation assay ¥’∑’Ë ÿ¥ (IC50 = ı.ÚÚ ± ı.ıÒ μg/ml) πÕ°®“°π’Èμ—«Õ¬à“ß¢â“«‡Àπ’¬« °Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ¬—ß¡’ª√‘¡“≥ total phenolics compound ·≈– cyanidin 3-glucoside ¡“°∑’Ë ÿ¥ §◊Õ Ò.˜Û ± .Ù mg GAE/g (grain) ·≈– ıÛˆ.ı˜ ± Ù.ı μg/g (grain) μ“¡≈”¥—∫ (μ“√“ß∑’Ë Ú)

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μ“√“ß∑’Ë Ú √ÿªæ—π∏ÿå¢â“« Û Õ—π¥—∫·√°∑’Ë¡’§ÿ≥ ¡∫—μ‘°“√μâ“πÕÕ°´‘‡¥™—π·≈–ª√‘¡“≥Õß§åª√–°Õ∫∑“ß‡§¡’¡“°∑’Ë ÿ¥ Test DPPH assay (IC50, μg/ml) Lipid peroxidation assay (IC50, μg/ml) Total phenolics compound [mg GAE/g (grain)] Cyanidin 3-glucoside [μg/g (grain)] Peonidin 3-glucoside [μg/g (grain)]

Ò K-Entry ÒÚ ‡Àπ’¬«¥” (Úˆ.ˆÙ ± Ò.ÒÙ)a K-Entry ÒÚ ‡Àπ’¬«¥” (ı.ÚÚ ± ı.ıÒ)a K-Entry ÒÚ ‡Àπ’¬«¥” (Ò.˜Û ± .Ù)a K-Entry ÒÚ ‡Àπ’¬«¥” (ıÛˆ.ı˜ ± Ù.ı)a C-Ù °Ë”‡™’¬ß„À¡à (Ú˜¯.Û¯ ± Ú.ˆ)a

Õ—π¥—∫ Ú

K-Entry ÒÚ ‡Àπ’¬«¥”®“° ¡¢. K-Entry ÒÙ ‡Àπ’¬«¥” b (Ûı.¯ ± .Úı) (Û¯.Úı ± Ò.ÚÒ)b K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ K-Entry Ò ‡Àπ’¬«¥”®“° ¡¢. (˜.ÚÙ ± Ú.Ú)b (¯ı.Úı ± Ú.Ú)c C-Ù °Ë”‡™’¬ß„À¡à K-Entry ÒÙ ‡Àπ’¬«¥” a (Ò.˜Ò ± .Ò) (Ò.ıÙ ± .Ú)b K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ K-Entry ÒÙ ‡Àπ’¬«¥” b (Ù¯¯.ÚÚ ± Û.Ùı) (Ù˜ı.Ú˘ ± Ò.˜Ú)c K-Entry ÒÚ ‡Àπ’¬«¥” C-Û °Ë”π“¬æ√âÕ¡ b (Û˜.Ûˆ ± Ò.ÚÙ) (Û.Û ± .Û˜)c

§à“‡©≈’Ë¬∑’Ë¡’μ—«Õ—°…√·μ°μà“ß°—π„π·π«πÕπ ¡’§«“¡·μ°μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠ (p

¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå∑’Ë¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π·≈– ª√‘¡“≥Õß§åª√–°Õ∫∑“ß‡§¡’√Õß≈ß¡“ §◊Õ ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry Ò˜ ‡Àπ’¬«¥”μ—∫À¡Ÿ ‚¥¬¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π «‘∏’ lipid peroxidation assay ¥’ (IC50 = ˜.ÚÙ ± Ú.Ú μg/ml) ·≈–¡’ª√‘¡“≥ cyanidin 3-glucoside ¡“° [Ù¯¯.ÚÚ ± Û.Ùı μg/g (grain)] ·≈–¢â“«‡Àπ’¬«°Ë” æ—π∏ÿå K-Entry Ò ‡Àπ’¬«¥”®“° ¡¢. ‚¥¬¡’ƒ∑∏‘Ïμâ“π ÕÕ°´‘‡¥™—π«‘∏’ DPPH assay ¥’ (IC50 = Ûı.¯ ± .Úı μg/ml) ·≈–¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π«‘∏’ lipid peroxidation assay §àÕπ¢â“ß¥’ (IC50 = ¯ı.Úı ± Ú.Ú μg/ ml) ®“°º≈°“√«‘‡§√“–Àåª√‘¡“≥·Õπ‚∑‰´¬“π‘π¥â«¬«‘∏’ HPLC æ∫«à“ Õ¥§≈âÕß°—∫√“¬ß“π°“√«‘®—¬¢Õß Hiemori ·≈–§≥–Ò¯ ‚¥¬¢â“«‡Àπ’¬«°Ë”ª√–°Õ∫‰ª¥â«¬·Õπ‚∑‰´¬“π‘π Õ¬Ÿà Ù ™π‘¥ §◊Õ cyanidin dihexoside, cyanidin 3-glucoside, cyanidin hexoside ·≈– peonidin 3-glucoside ´÷Ëß·Õπ‚∑‰´¬“π‘πÀ≈—°„π¢â“«‡Àπ’¬«°Ë” §◊Õ cyanidin 3-glucoside (ª√–¡“≥ ˘% ¢Õß·Õπ‚∑‰´¬“π‘π ∑—ÈßÀ¡¥) ·≈– peonidin 3-glucoside ‡ªìπ·Õπ‚∑‰´¬“π‘π „π¢â“«‡Àπ’¬«°Ë”∑’¡Ë ª’ √‘¡“≥¡“°√Õß≈ß¡“ (ª√–¡“≥ ˆ% ¢Õß ·Õπ‚∑‰´¬“π‘π∑—ÈßÀ¡¥) ·≈–æ∫ cyanidin dihexoside ª√–¡“≥ Û% ·≈– cyanidin hexoside ª√–¡“≥ Ò% ¬°‡«âπ ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå C-Ù °Ë”‡™’¬ß„À¡à ´÷Ëß‡ªìπæ—π∏ÿå ‡¥’¬«∑’Ë¡’ peonidin 3-glucoside ª√‘¡“≥¡“° (ª√–¡“≥ ı% ¢Õß·Õπ‚∑‰´¬“π‘π∑—ÈßÀ¡¥)

.ı, DMRT)

®“°º≈°“√∑¥ Õ∫ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π¥â«¬«‘∏’ DPPH radical scavenging assay ·≈–«‘∏’ lipid peroxidation assay æ∫«à“ƒ∑∏‘μÏ “â πÕÕ°´‘‡¥™—π¡’§«“¡ —¡æ—π∏å ‚¥¬·ª√º—πμ√ß°—∫ª√‘¡“≥ total phenolics compound „π¢â“«‡Àπ’¬«°Ë” ´÷Ëß Õ¥§≈âÕß°—∫√“¬ß“π¢Õß Siddhuraju ·≈– BeckerÒ˘ „π¢≥–∑’Ë¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ·≈– C-Ù °Ë”‡™’¬ß„À¡à¡’ª√‘¡“≥ total phenolics compound ‡∑à“°—∫ Ò.˜Û ± .Ù ·≈– Ò.˜Ò ± .Ò mg/g (grain) μ“¡≈”¥—∫ ´÷Ëß®“°°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈∑“ß ∂‘μ‘æ∫«à“‰¡à¡’§«“¡·μ°μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠ ·μà¢â“« ‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥”π—Èπ¡’ƒ∑∏‘Ïμâ“π ÕÕ°´‘‡¥™—π¥’°«à“¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå C-Ù °Ë”‡™’¬ß„À¡à ∑—ßÈ π’È Õ“®‡ªìπ‡æ√“–ª√‘¡“≥¢Õß cyanidin 3-glucoside ∑’Ë ¡’ ¡“°„π¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ´÷Ëß‡ªìπ “√μâ“πÕÕ°´‘‡¥™—π∑’Ë¥’∑’Ë ÿ¥„π°≈ÿà¡·Õπ‚∑‰´¬“π‘π à«π peonidin 3-glucoside ´÷Ëß¡’¡“°„π¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå C-Ù °Ë”‡™’¬ß„À¡à ·μà¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—ππâÕ¬°«à“ cyanidin 3-glucoside ®÷ß∑”„Àâ¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå C-Ù °Ë” ‡™’¬ß„À¡à ¡’ƒ∑∏‘μÏ “â πÕÕ°´‘‡¥™—ππâÕ¬°«à“¢â“«‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ´÷Ëß Õ¥§≈âÕß°—∫√“¬ß“π¢Õß Hu ·≈–§≥–Û ‰¡àæ∫·Õπ‚∑‰´¬“π‘π„π¢â“«æ—π∏ÿå K-Entry ÚÒ ‡Àπ’¬«·¥ß·≈–æ—π∏ÿå C-Ú ·¥ß‡¡◊Õß≈Õß∑”„Àâ∑—Èß Õßæ—π∏ÿåπ’È ¡’ƒ∑∏‘Ïμâ“πÕÕ°´‘‡¥™—π∑—Èß«‘∏’ DPPH radical scavenging assay ·≈–«‘∏’ lipid peroxidation assay μË”

142 .

∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ

®“°¢âÕ¡Ÿ≈¥—ß°≈à“« §«√ àß‡ √‘¡„Àâ¡’°“√ª≈Ÿ°¢â“« ‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥” ·≈– “¡“√∂„™â¢â“« ‡Àπ’¬«°Ë”æ—π∏ÿå K-Entry ÒÚ ‡Àπ’¬«¥”π’È ‡ªìπ«—μ∂ÿ¥‘∫„π °“√æ—≤π“«‘®¬— „Àâ‰¥âº≈‘μ¿—≥±å‡ √‘¡ ÿ¢¿“æ∑’¡Ë §’ ≥ ÿ ¿“æμàÕ‰ª

‡Õ° “√Õâ“ßÕ‘ß Ò. Õ—≠™≈’ ™“«π“, ª√‡¡» ∫√√‡∑‘ß, ª√– ‘∑∏‘Ï „®»‘≈, ∫ÿ≠√—μπå ®ß¥’. °“√®”·π°§«“¡À≈“°À≈“¬∑“ßæ—π∏ÿ°√√¡ ¢Õß¢â“«‡Àπ’¬«¥”æ—π∏ÿæå π◊È ‡¡◊Õß‚¥¬„™â≈°— …≥–∑“ß —≥∞“π«‘∑¬“. —¡¡π“«‘™“°“√‡°…μ√ ª√–®”ªï ÚıÙ˘. §≥– ‡°…μ√»“ μ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ. ÚÛ-ÚÙ ¡°√“§¡ ÚıÙ˘: Àπâ“ Ú˘-Û. Ú. ¡πμ√’ ªí≠≠“∑Õß, æ—π∑‘æ“ æß…å‡æ’¬®—π∑√å, ‡æ∑“¬ æß…å‡æ’¬®—π∑√å, ¥”‡π‘π °“≈–¥’, ”√’ ¡—Ëπ‡¢μ°√≥å. °“√ μ√«® Õ∫§«“¡‡ªìπæ‘…μàÕ‡´≈≈å¢Õß “√ °—¥‚ª√·Õπ‚∑‰´¬“π‘¥‘π®“°¢â“«‡Àπ’¬«¥”·≈– “√‰´¬“π‘¥‘π Û°≈Ÿ‚§‰´πå∑¡’Ë μ’ Õà ‡´≈≈å¡–‡√Áß‡¡Á¥‡≈◊Õ¥®“°ÀπŸÀ√◊Õ‰¡Õ‘‚≈¡“‡´≈≈å™π‘¥ XˆÛ. —¡¡π“«‘™“°“√∫—≥±‘μ»÷°…“‡°…μ√»“ μ√å §√—Èß∑’Ë ı. §≥–‡°…μ√»“ μ√å ¡À“«‘∑¬“≈—¬ ‡™’¬ß„À¡à ‡™’¬ß„À¡à. Û-Ù ∏—π«“§¡ Úıı. Û. Hu C, Zawistowski J, Ling W, Kitts DD. Black rice (Oryza sativa L. indica) pigmented fraction suppresses both reactive oxygen species and nitric oxide in chemical and biological model systems. J Agric Food Chem 2003;51:5271-7. Ù. Hyun JW and Chung HS. Cyanidin and malvidin from Oryza sativa CV. Heugjinjubyeo mediate cytotoxicity against human monocytic leukemia cells by arrest of G(2)/M phase and induction of apoptosis. J Agric Food Chem 2004;52:22137. ı. Chen PN, Chu SC, Chiou HL, Ching CL, Yang SF, Hsieh YS. Cyanidin 3-glucoside and peonidin 3-glucoside inhibit tumor cell growth and induce apoptosis in vitro and suppress tumor growth in vivo. Nutr Cancer 2005;53:232›43. ˆ. Yawadio R, Tanimori S, Morita N. Identification of phenolic compounds isolated from pigmented rices and their aldose reductase inhibitory activities. Food Chem 2007;101:1616-25.

˜. ª≥‘μ“ ∫ÿ≠ ‘∑∏‘,Ï ¥”‡π‘π °“≈–¥’, æ—π∑‘æ“ æß…å‡æ’¬®—π∑√å. ª√‘¡“≥·°¡¡à“‚Õ‰√´“πÕ≈„π¢â“«‡Àπ’¬«°Ë”æ◊πÈ ‡¡◊Õß¢Õß ‰∑¬. Agricultural Sci J 2006;37:191-4. ¯. Huang D, Ou B, Hampsch-Woodill M, Flanagan JA, Deermer EK. Development and validation of oxygen radical absorbance capacity assay for lipophilic antioxidants using randomly methylated beta-cyclodextrin as the solubility enhancer. J Agric Food Chem 2002;50:1815-21. ˘. Nakamura H. Effect of γ-oryzanol on Hepatic Cholesterol Biosynthesis and Fecal Excretion Metabolites. Radioisotopes 1996;25:371-4. Ò. Lichtenstein AH, Ausman LM, Carrasco W, Gualtieri LJ, Ordovas JM, et al. Rice bran oil consumption and plasma lipid levels in moderately hypercholesterolemic humans. Arterioscler Thromb 1994;14:549-56. ÒÒ. Qureshi AA, Sami SA, Salser WA, Khan FA. Synergistic effect of tocotrienol-rich fraction (TRF(25)) of rice bran and lovastatin on lipid parameters in hypercholesterolemic humans. J Nutr Biochem 2001;12:318-29. ÒÚ. º¥ÿß¢«—≠ ®‘μ‚√¿“ , Õ√ÿ≥»√’ ª√’‡ª√¡, ∫ÿ≠¡’ »‘√‘, ™‘¥™π° §”‡≈‘», ∫—ßÕ√ »√’æ“π‘™°ÿ≈™—¬. ªí®®—¬∑’¡Ë º’ ≈μàÕ°“√μâ“π ÕÕ°´‘‡¥™—π·≈–·°¡¡“‚Õ‰√´“πÕ≈„π‡¡Á¥√”¢â“«ÀÕ¡ ¥Õ°¡–≈‘ Òı ∑’Ëæ—≤π“¢÷Èπ. «“√ “√«‘®—¬¡À“«‘∑¬“≈—¬ ¢Õπ·°àπ ÚıÙ˜;˘:ı˘›ˆ˜. ÒÛ. π“√’√μ— πå · π‡¡◊Õß™‘π, ª√‡¡» ∫√√‡∑‘ß , Õ—≠™≈’ ™“«π“. °“√ª√–‡¡‘π¢â“«‡Àπ’¬«¥”æ—π∏ÿåæ◊Èπ‡¡◊Õß. KKU Agri cultural Sciences Seminar 2008. ÒÙ. Farrukh A, Iqbal A, Zafar M. Antioxidant and free radical scavenging properties of twelve traditionally used indian medicinal plants. Turk J Biol 2006;30:177-83. Òı. Uchiyama M, Mihara M. Determination of malonaldehyde precursor in tissues by thiobarbituric acid test. Anal Biochem 1978;86:271›8. Òˆ. Kahkonen MP, Hopia AI, Vuorela HJ, Rauha JP, Pihlaja K, Kujala TS, et al. Anti-oxidant activity of plant extracts containing phenolic compounds. J Agric Food Chem 1999;47:3954-62.

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

Ò˜. Cantos E, Espin JC, Thomas-Barbreran FA. Varietal differences among the polyphenol profiles of seven table grape cultivars studied by LC-DAD-MS-MS. J Agric Food Chem 2002;50:5691-96. Ò¯. Hiemori M, Koh E, Mitchell AE. Influence of cooking on anthocyanins in black rice (Oryza sativa L. japonica var. SBR). J Agric Food Chem 2009;57:1908-14.

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Ò˘. Siddhuraju P, Becker K. Antioxidant Properties of Various Solvent Extracts of Total Phenolic Constituents from Three Different Agroclimatic Origins of Drumstick Tree (Moringa oleifera Lam.) Leaves. J Agric Food Chem 2003;51: 2144-55.

Abstract Antioxidant activity and chemical constituents in purple glutinous rice Thailand local genotypes Chalerm Jansom*, Sakul Moolkam**, Vanida Jansom*, Ekasith Skulkhu***, Kornkarn Bhamarapravatana**** * Research office, Faculty of Medicine, Thammasat University ** Chiang Mai rice research center, Sanpatong District, Chiang Mai *** Chum Phae rice research center, Chum Phae District, Khonkaen **** Graduate studies, Faculty of Medicine, Thammasat University Genetic diversity and growing environment cause differentiation of chemical constituents in purple glutinous rice (Oryza Sativa L.) The colors of pericarp layers are characterized by anthocyanins profile. The anthocyanins are cyanidin dihexoside, cyanidin 3-glucoside, cyanidin hexoside and peonidin 3-glucoside. They belong to parent class of flavonoids, which have antioxidant activity. In this study was to investigate for antioxidant activity and chemical constituents in purple glutinous rice Thailand local genotypes. The 36 local genotypes of purple glutinous rice were collected from the north and northeast of Thailand. K-Entry 12 Niewdam gave the highest antioxidant activity both DPPH radical scavenging assay (IC50 = 26.64 ± 1.14 μg/ml) and lipid peroxidation assay (IC50 = 50.22 ± 5.51 μg/ml). Furthermore, the highest content of total phenolics compound and cyanidin 3-glucoside were 1.73 ± 0.04 mg GAE/g (grain) and 536.57 ± 4.05 μg/g (grain), respectively. K-Entry 17 Niewdamtubmhoo gave high antioxidant activity by lipid peroxidation assay (IC50 = 70.24 ± 2.20 μg/ml) and high cyaniding 3-glucoside content [488.22 ± 3.45 μg/g (grain)]. This data demonstrated to cultivated K-Entry 12 Niewdam promotion. This genotype could be useful raw material for nutraceutical product. Key words: Purple glutinous rice, Antioxidant, Nutraceutical

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

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145

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ºŸâªÉ«¬∑’Ë‰¡à¡’‚√§ª√–®”μ—« (®”π«π Ú˜ §π) (√âÕ¬≈–)

√«¡ (®”π«π Û¯ §π) (√âÕ¬≈–)

Ú (Ò¯.Ò) Ù (Ûˆ.Û)  () ı (Ùı.ı)

Ú (˜Ù.˜) Û (ÒÒ.Ò) Ò (Û.˜) Û (ÒÒ.Ò)

ÚÚ (ı˜.˘) ˜ (Ò¯.Ù) Ò (Ú.ˆ) ¯ (ÚÒ.Ò)

˘ (¯Ò.¯) Ú (Ò¯.Ò)

Ò˘ (˜.Ù) ˆ (ÚÚ.Ú)

Ú¯ (˜Û.˜) Ò (Úˆ.Û)

Ù (Ûˆ.Û) ˜ (ˆÛ.ˆ) Ú (Ò¯.Ò)

ÚÙ (¯¯.˘) Û (ÒÒ.Ò) Ù (ÒÙ.¯)

Ú¯ (˜Û.˜) Ò (Úˆ.Û) ˆ (Òı.¯)

Ù (Ûˆ.Û) Ò (˘.Ò) Ú (Ò¯.Ú)  ()  () Ò (˘.Ò)  () Ò (˘.Ò)

ˆ (ÚÚ.Ú) ˆ (ÚÚ.Ú) Û (ÒÒ.Ò) Ù (ÒÙ.¯) Û (ÒÒ.Ò)  () Ò (Û.˜)  ()

Ò (Úˆ.Û) ˜ (Ò¯.Ù) ı (ÒÛ.Ò) Ù (Ò.ı) Û (ı.Ú) Ò (Ú.ˆ) Ò (Ú.ˆ) Ò (Ú.ˆ)

ı (Ùı.ı) Ù (Ûˆ.Û) Ú (Ò¯.Ò)

ÒÙ (ıÒ.¯) ÒÛ (Ù¯.Ú)  ()

Ò˘ (ı.) Ò˜ (ÙÙ.˜) Ú (ı.Û)

() Ò(˘.Ò) Ò(˘.˘)

Ú (˜.Ù) ¯ (Ú˘.ˆ) Ò˜ (ˆÛ.)

Ú (ı.Û) ˘ (ÚÛ.˜) Ú˜ (˜Ò.)

Ò(˘.Ò) ı (Ùı.ı) Ú(Ò¯.Ò) Û(Ú˜.Û)

Ò (Û.˜) ı (Ò¯.ı) ˆ (ÚÚ.Ú) Òı (ıı.ˆ)

Ú (ı.Û) Ò (Úˆ.Û) ¯ (ÚÒ.) Ò¯ (Ù˜.Ù)

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

ºŸâªÉ«¬Õ“¬ÿπâÕ¬°«à“ Ò ªï∑’Ëμ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π °√–· ‡≈◊Õ¥®”π«π ÚÚ √“¬ ‡ªìπºŸâªÉ«¬∑’Ë¡’‚√§ª√–®”μ—« Ú √“¬ §‘¥‡ªìπ√âÕ¬≈– Ò à«πºŸâªÉ«¬Õ“¬ÿ¡“°°«à“ Ò ªï®”π«π Òˆ √“¬¡’‚√§ª√–®”μ—« ˘ √“¬ §‘¥‡ªìπ√âÕ¬≈– ıˆ.Û ºŸâªÉ«¬‡¥Á°∑’Ëμ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥ ‡ªìπ ºŸâªÉ«¬∑’Ë¡’‚√§ª√–®”μ—« ÒÒ √“¬ §‘¥‡ªìπ√âÕ¬≈– Ú¯.˘ ‡ªìπ ‚√§ª√–®”μ—«∑’∑Ë ”„Àâ¡¿’ “«–¿Ÿ¡§‘ ¡ÿâ °—π∫°æ√àÕß ˜ √“¬ ‰¥â·°à ºŸâªÉ«¬μ—¥¡â“¡ Ò √“¬ ºŸâªÉ«¬¡–‡√Áß‡¡Á¥‡≈◊Õ¥¢“« Ù √“¬ ºŸâªÉ«¬ nephrotic syndrome Ò √“¬ ·≈– juvenile rheumatoid arthritis ∑’Ë‰¥â¬“ ‡μ’¬√Õ¬¥å Ò √“¬ ºŸâªÉ«¬‡¥Á°∑’Ëμ‘¥‡™◊ÈÕ ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥∑’Ë¡’‚√§ª√–®”μ—« ‡ªìπ°“√μ‘¥‡™◊ÈÕ „π‚√ßæ¬“∫“≈√âÕ¬≈– ˆÛ.ˆ ®“°°“√»÷ ° …“¡’ ºŸâ ªÉ « ¬‡¥Á ° ∑’Ë μ‘ ¥ ‡™◊È Õ ·∫§∑’ ‡ √’ ¬ „π °√–· ‡≈◊Õ¥‡ ’¬™’«‘μ Ú √“¬ ‚¥¬¡’¿“«– septic shock

147

§‘¥‡ªìπ√âÕ¬≈– ı.Û ºŸâªÉ«¬∑—Èß Ú √“¬ ‡ªìπ‡æ»™“¬ Õ“¬ÿ¡“° °«à“ ı ªï μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫„π‚√ßæ¬“∫“≈ ·≈–¡’ ‚√§ª√–®”μ—« ‚¥¬‡ªìπ°“√μ‘¥‡™◊ÈÕ√–∫∫∑“ß‡¥‘πÀ“¬„®·≈– √–∫∫∑“ß‡¥‘πªí “«–Õ¬à“ß≈– Ò √“¬ ™π‘¥¢Õß‡™◊ÈÕ·∫§∑’‡√’¬°àÕ‚√§„π°√–· ‡≈◊Õ¥„πºŸâ ªÉ « ¬‡¥Á ° æ∫‡ªì π °“√μ‘ ¥ ‡™◊È Õ ·∫§∑’ ‡ √’ ¬ °√— ¡ ≈∫¡“°°«à “ ·∫§∑’‡√’¬°√—¡∫«° (√âÕ¬≈– ˜Û.ˆ ·≈– Úˆ.Ù μ“¡≈”¥—∫) ‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫æ∫‡™◊ÈÕ E. coli ·≈– K. pneumoniae ¡“°∑’Ë ÿ¥ à«π·∫§∑’‡√’¬°√—¡∫«° æ∫‡™◊ÈÕ S. aureus, S. pneumoniae ·≈– S. viridans ¡“°∑’Ë ÿ¥ ‚¥¬æ∫«à“°“√μ‘¥ ‡™◊ÈÕ„π‚√ßæ¬“∫“≈‡°‘¥®“°‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫√âÕ¬≈– ˘ à«π°“√μ‘¥‡™◊ÈÕ„π™ÿ¡™π ‡°‘¥®“°‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫ √âÕ¬≈– ˆ˜.˘ ¥—ßμ“√“ß∑’Ë Ú

μ“√“ß∑’Ë Ú · ¥ß‡™◊ÈÕ·∫§∑’‡√’¬∑’Ë‡ªìπ “‡Àμÿ¢Õß°“√μ‘¥‡™◊ÈÕ„π°√–· ‡≈◊Õ¥®”·π°μ“¡°“√μ‘¥‡™◊ÈÕ„π™ÿ¡™π ·≈–„π‚√ßæ¬“∫“≈ °“√«‘π‘®©—¬

μ‘¥‡™◊ÈÕ„π™ÿ¡™π (N=Ú¯) ®”π«π (√âÕ¬≈–)

μ‘¥‡™◊ÈÕ„π‚√ßæ¬“∫“≈ (N=Ò) ®”π«π (√âÕ¬≈–)

®”π«πºŸâªÉ«¬ (N=Û¯) ®”π«π (√âÕ¬≈–)

‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫ E. coli K. pneumoniae Enterobacter spp. A. baumannii A. lwoffii P. auruginosa P. stutzeri Moraxella spp. Salmonella spp. H. influenzae

Ò˘ (ˆ˜.˘) ı (Ò˜.˘) Û (Ò.˜) Ú (˜.Ò) Ò (Û.ˆ) Ò (Û.ˆ) Ò (Û.ˆ) Ú (˜.Ò) Ò (Û.ˆ) Ú (˜.Ò) Ò (Û.ˆ)

˘ (˘) Ú (Ú) Ù (Ù) Ú (Ú) Ò (Ò)  ()  ()  ()  ()  ()  ()

Ú¯ (˜Û.˜) ˜ (Ò¯.Ù) ˜ (Ò¯.Ù) Ù (Ò.ı) Ú (ı.Ú) Ò (Ú.˜) Ò (Ú.˜) Ú (ı.˜) Ò (Ú.˜) Ú (ı.Ú) Ò (Ú.˜)

‡™◊ÈÕ·∫§∑’‡√’¬°√—¡∫«° S. aureus S. viridans S. pneumoniae

˘ (ÛÚ.Ò) Û (Ò.˜) Û (Ò.˜) Û (Ò.˜)

Ò (Ò) Ò (Ò)  ()  ()

Ò (Úˆ.Û) Ù (Ò.ı) Û (ı.Ú) Û (ı.Ú)

ºŸâªÉ«¬μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥∑’Ë¡’°“√μ‘¥ ‡™◊ÈÕ∑’Ë√–∫∫∑“ß‡¥‘πÀ“¬„® æ∫‡ªìπ‡™◊ÈÕ K. pneumoniae ¡“°∑’Ë ÿ¥ πÕ°®“°π’È¬—ß¡’ “‡Àμÿ®“°‡™◊ÈÕ Enterobacter spp., A. baumannii, Moraxella spp., P. stutzeri, S. aureus ·≈–

S. viridans ”À√—∫ºŸâªÉ«¬∑’Ë¡’°“√μ‘¥‡™◊ÈÕ√–∫∫∑“ß‡¥‘π ªí “«–æ∫‡©æ“–‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫‚¥¬æ∫‡™◊ÈÕ E. coli ¡“°∑’Ë ÿ¥√Õß≈ß¡“§◊Õ P. stutzeri ·≈– A. lwoffii ºŸâªÉ«¬∑’Ë¡’ °“√μ‘¥‡™◊ÈÕ√–∫∫∑“ß‡¥‘πÕ“À“√æ∫‡ªìπ‡™◊ÈÕ·∫§∑’‡√’¬°√—¡

148 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ≈∫‡™àπ‡¥’¬«°—π ‰¥â·°à E. coli, Enterobacter spp. ·≈– Salmonella spp. º≈∑¥ Õ∫§«“¡‰«¢Õß‡™◊ÈÕ·∫§∑’‡√’¬ æ∫«à“‡™◊ÈÕ ·∫§∑’‡√’¬ E. coli, K. pneumoniae ·≈– Enterobacter spp. à « π„À≠à ¥◊È Õ μà Õ ¬“ ampicillin ·μà ¬— ß ‰«μà Õ ¬“ªØ‘ ™’ « π–

°≈ÿà ¡ aminoglycosides ‚¥¬¡’ § «“¡‰«μà Õ gentamicin √âÕ¬≈– ˆ˜-¯ˆ ·≈–‰«μàÕ amikacin, netilmicin, ertapenem, imipenem ·≈– meropenem √âÕ¬≈– Ò à«π cefotaxime ¡’§«“¡‰« √âÕ¬≈– ˆ˜-¯ˆ ¥—ßμ“√“ß∑’Ë Û

μ“√“ß∑’Ë Û · ¥ß§«“¡‰«¢Õß‡™◊ÈÕ·∫§∑’‡√’¬ E. coli, K. pneumoniae ·≈– Enterobacter spp. μàÕ¬“ªØ‘™’«π–§‘¥‡ªìπ√âÕ¬≈–

¬“ªØ‘™’«π–

E. coli √âÕ¬≈– (N=˜)

K. pneumoniae √âÕ¬≈– (N=˜)

Enterobacter spp. √âÕ¬≈– (N=Ù)

Ampicillin

ÒÙ



ÛÛ

Amoxy-clavulanic acid

Ò

¯

ı

Cephalothin

¯ˆ

ˆ˜

ı

Cefotaxime

¯ˆ

ˆ˜

Ceftriaxone

¯ˆ

ˆ

ı

Ceftazidime

¯ˆ

ˆ˜

ı

Gentamicin

¯ˆ

ˆ˜

Amikacin

Ò

Netilmicin

Ò

Imipenem

Ò

Meropenem

Ò

Piperacillin/tazobactam

Ò

ˆ˜

Ò

Cefoperazone

Ò

ˆ˜

Ò

Cefirome

¯ˆ

ˆ

Ò

Ciprofloxacin

¯ˆ

Ò

Cotrimoxazole

ÙÛ

ˆ

ˆ˜

Cefoxitin

Ò

ˆ˜

ı

Ertapenem

Ò

‡™◊ÈÕ·∫§∑’‡√’¬

‚¥¬æ∫‡™◊ÈÕ E. coli ·≈– K. pneumoniae ¥◊ÈÕ¬“ ™π‘¥ Extended spectrum beta-lactamase (ESBL) §‘¥ ‡ªìπ√âÕ¬≈– ÚÚ.Ú à«π‡™◊ÈÕ S. aureus ¡’§«“¡‰«μàÕ oxacillin √âÕ¬≈– Ò ‰¡àæ∫‡™◊ÈÕ MRSA (methicillin resistant S. aureus) ”À√—∫‡™◊ÈÕ S. viridans ¡’§«“¡‰«μàÕ¬“ penicillin √âÕ¬≈– Ò æ∫‡™◊ÈÕ S. pneumoniae ¥◊ÈÕμàÕ¬“ penicillin

(Penicillin resistant S. pneumoniae, PRSP) ®“°°“√ ∑¥ Õ∫‚¥¬«‘∏’ disc diffusion „πºŸªâ «É ¬∑’¡Ë ‡’ ¬◊ÕË Àÿ¡â ¡ÕßÕ—°‡ ∫ Ò √“¬ ‚¥¬ S. pneumoniae ¡’§«“¡‰«μàÕ penicillin, vancomycin, cotrimoxazole, chloramphenicol ·≈– erythromycin §‘¥‡ªìπ√âÕ¬≈– ˆ˜, Ò, ˆ˜, ÛÛ ·≈–  μ“¡≈”¥—∫

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

∫∑«‘®“√≥å ®“°°“√»÷°…“π’Èæ∫«à“ºŸâªÉ«¬‡¥Á°Õ“¬ÿ Ò ‡¥◊Õπ∂÷ß Òı ªï„π‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ ∑’Ë¡’º≈‡æ“– ‡™◊ÈÕ·∫§∑’‡√’¬„π‡≈◊Õ¥æ∫‡™◊ÈÕ·∫§∑’‡√’¬°àÕ‚√§ à«π„À≠à ¡’ Õ “¬ÿ πâ Õ ¬°«à “ Ò ªï ‡ªì π °“√μ‘¥ ‡™◊È Õ „π™ÿ ¡ ™π μ‘¥ ‡™◊È Õ ·∫§∑’‡√’¬°√—¡≈∫ ·≈–¡’°“√μ‘¥‡™◊ÈÕ‡©æ“–∑’Ë ‰¥â·°à μ‘¥‡™◊ÈÕ∑’Ë √–∫∫∑“ß‡¥‘πÀ“¬„® ·≈–∑“ß‡¥‘πªí “«– ºŸâªÉ«¬μ‘¥‡™◊ÈÕ ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥∑’ÕË “¬ÿπÕâ ¬°«à“ Ò ªï¡‡’ æ’¬ß√âÕ¬≈– Ò ∑’Ë¡’‚√§ª√–®”μ—« à«πºŸâªÉ«¬μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥∑’ËÕ“¬ÿ¡“°°«à“ Ò ªï ¡’‚√§ª√–®”μ—«∂÷ß√âÕ¬≈– ıˆ.Û ‡¥Á°‚μ∑’Ëμ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥¡—°®–¡’‚√§ª√–®” μ—«∑’∑Ë ”„Àâ‡ ’¬Ë ßμàÕ°“√μ‘¥‡™◊ÕÈ ·μà‡¥Á°‡≈Á°Õ“¬ÿπÕâ ¬°«à“ Ò ªï‡ªìπ °≈ÿà ¡ ‡ ’Ë ¬ ßμà Õ °“√μ‘ ¥ ‡™◊È Õ ·∫§∑’ ‡ √’ ¬ „π°√–· ‡≈◊ Õ ¥‚¥¬‰¡à ®”‡ªìπμâÕß¡’‚√§ª√–®”μ—« ®“°°“√»÷°…“π’È à«π„À≠àºŸâªÉ«¬∑’Ëμ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ „π°√–· ‡≈◊Õ¥¡’°“√μ‘¥‡™◊ÈÕ‡©æ“–∑’Ë ‚¥¬‡ªìπ°“√μ‘¥‡™◊ÈÕ √–∫∫∑“ß‡¥‘πÀ“¬„®¡“°∑’Ë ÿ¥ √Õß≈ß¡“§◊Õ√–∫∫∑“ß‡¥‘π ªí “«– ´÷Ëß‡ªìπ°“√μ‘¥‡™◊ÈÕ∑’Ë‡ªìπªí≠À“ ”§—≠·≈–æ∫∫àÕ¬ ¢ÕßºŸâªÉ«¬‡¥Á° ºŸâªÉ«¬√âÕ¬≈– Òı.¯ ‰¡à¡’°“√μ‘¥‡™◊ÈÕ‡©æ“–∑’Ë ‚¥¬¡’Õ“°“√‰¢â‡æ’¬ßÕ¬à“ß‡¥’¬« ·π«∑“ß„π°“√ª√–‡¡‘πºŸâ ªÉ«¬‡æ◊ËÕ®”·π°„Àâ‰¥â«à“ºŸâªÉ«¬∑’Ë¡’‰¢â√“¬„¥¡’§«“¡‡ ’Ë¬ßμàÕ °“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥ ¡’°“√»÷°…“„πμà“ß ª√–‡∑»‚¥¬„™â Yale observation scale ¡“™à«¬∫Õ°°“√ μ‘¥‡™◊ÕÈ ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥„π‡¥Á°Õ“¬ÿ Û-Ûˆ ‡¥◊Õπ ∑’¡Ë “ æ∫·æ∑¬å ¥â « ¬Õ“°“√‰¢â ˜,¯ ¡’ À ≈“¬°“√»÷ ° …“∑’Ë æ ∫«à “ Õÿ≥À¿Ÿ¡‘√à“ß°“¬∑’Ë Ÿß‡ªìπμ—«∫àß™’ÈÕ¬à“ßÀπ÷Ëß∂÷ß‚Õ°“ æ∫°“√ μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥˘,Ò ´÷Ëß°“√»÷°…“§√—Èßπ’È ºŸâªÉ«¬‡¥Á°∑’Ë¡’°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥∑ÿ°√“¬¡’ Õ“°“√‰¢â ·≈– à«π¡“°¡’¿“«–Õÿ≥À¿Ÿ¡‘°“¬·√°√—∫∑’Ë Ÿß ¡“°°«à“ Û˘ Õß»“‡´≈‡´’¬ (√âÕ¬≈– ˜Ò.˜) à«π®”π«π ‡¡Á¥‡≈◊Õ¥¢“«„π‡≈◊Õ¥ „π°“√»÷°…“π’Èæ∫ºŸâªÉ«¬‡æ’¬ß§√÷ËßÀπ÷Ëß ¡’®”π«π‡¡Á¥‡≈◊Õ¥¢“«¡“°°«à“ Òı, ‡´≈≈åμàÕ≈Ÿ°∫“»°å ¡‘≈≈‘≈‘μ√ (√âÕ¬≈– Ù˜.Ù) ·μ°μà“ß®“°°“√»÷°…“¢Õß„πμà“ß ª√–‡∑»∑’æË ∫«à“®”π«π‡¡Á¥‡≈◊Õ¥¢“«∑’¡Ë “°°«à“ Òı, ‡´≈≈å μà Õ ≈Ÿ ° ∫“»°å ¡‘ ≈ ≈‘ ≈‘ μ √ À√◊ Õ πâ Õ ¬°«à “ ı, ‡´≈≈å μà Õ ≈Ÿ°∫“»°å¡‘≈≈‘≈‘μ√ ¡’§«“¡‡ ’Ë¬ßμàÕ°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π °√–· ‡≈◊Õ¥¯,˘-ÒÒ ºŸâªÉ«¬∑’Ëμ‘¥‡™◊ÈÕ√ÿπ·√ßÕ“®¡’¿“«– septic shock ·≈–‡ ’¬™’«‘μ‰¥â °“√»÷°…“π’ÈºŸâªÉ«¬∑’Ë‡ ’¬™’«‘μ∑—Èß Ú √“¬ ‡ªìπ ºŸâªÉ«¬∑’Ë¡’‚√§ª√–®”μ—« ·≈–μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫„π ‚√ßæ¬“∫“≈ „π°“√»÷°…“∑’Ëºà“π¡“æ∫«à“Õ—μ√“μ“¬¢ÕßºŸâªÉ«¬

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∑’Ë μ‘ ¥ ‡™◊È Õ ·∫§∑’ ‡ √’ ¬ „π°√–· ‡≈◊ Õ ¥®– Ÿ ß „πºŸâ ªÉ « ¬∑’Ë μ‘ ¥ ‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫ ·≈–ºŸâªÉ«¬∑’Ë¡’‚√§ª√–®”μ—«‡™àπ‡¥’¬« °—πÒÚ-ÒÙ ºŸâªÉ«¬∑’Ëμ‘¥‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫®–¡’ lipid A ¢Õß lipopolysaccharide (LPS) À√◊ Õ endotoxin ¢Õß ºπ—ß‡´≈≈å·∫§∑’‡√’¬ ´÷Ëß®–∑”„Àâ¡’°“√À≈—Ëß cytokine ·≈– °√–μÿπâ √–∫∫ complement, clotting factor ·≈– fibrino-lytic activity ”À√—∫ arachidonic metabolite, kinin ·≈– bradykinin ´÷Ëß‡ªìπ mediator ∑’Ë∂Ÿ°°√–μÿâπ∑—ÈßÀ¡¥π’È®– ∑”„Àâ‡°‘¥ªØ‘°‘√‘¬“≈Ÿ°‚´à àßº≈μàÕ√–∫∫μà“ßÊ ∑—Ë«√à“ß°“¬Òı πÕ°®“°π’ÈºŸâªÉ«¬∑’Ë¡’‚√§ª√–®”μ—«®—¥‡ªìπ°≈ÿà¡‡ ’Ë¬ßμàÕ°“√μ‘¥ ‡™◊ÈÕ·∫§∑’‡√’¬∑’Ë√ÿπ·√ß ‚√§ª√–®”μ—«∑’Ë∑”„Àâ√–∫∫¿Ÿ¡‘§ÿâ¡°—π ∫°æ√à Õß‡ªìπ “‡Àμÿ ∑”„Àâ ‡æ‘Ë ¡‚Õ°“ μ‘ ¥‡™◊ÈÕ ·≈–§«“¡ √ÿπ·√ß¢Õß°“√μ‘¥‡™◊ÈÕ¡“°¢÷ÈπÒˆ ®“°°“√»÷°…“π’Èæ∫‡™◊ÈÕ·∫§∑’‡√’¬°àÕ‚√§°√—¡≈∫ ¡“°°«à“‡™◊ÈÕ°√—¡∫«° μà“ß®“°°“√»÷°…“Õ◊ËπÊ„π‡¥Á°‰∑¬ ´÷Ë ß æ∫°“√μ‘ ¥ ‡™◊È Õ ·∫§∑’ ‡ √’ ¬ „π°√–· ‡≈◊ Õ ¥‡°‘ ¥ ®“°‡™◊È Õ S. pneumoniae ¡“°∑’Ë ÿ¥Ò˜,Ò¯ ‡™◊ÈÕ∑’Ëæ∫¡“°∑’Ë ÿ¥§◊Õ E. coli ·≈– K. pneumoniae ´÷Ëß‡ªìπ‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫∑’Ëæ∫ ¡“°∑’Ë ÿ¥∑’Ë‡ªìπ “‡Àμÿ°àÕ„Àâ‡°‘¥°“√μ‘¥‡™◊ÈÕ„π°√–· ‡≈◊Õ¥ „πºŸâªÉ«¬‡¥Á°Ò˘ ºŸâ ªÉ « ¬‡¥Á ° ∑’Ë ‡ ¢â “ √— ∫ °“√√— ° …“„πÀÕºŸâ ªÉ « ¬¢Õß ‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ à«π¡“°‡ªìπºŸâªÉ«¬ ∑’Ë¡’Õ“°“√‡©’¬∫æ≈—π·≈–‰¡à¡’‚√§ª√–®”μ—« ≈—°…≥–°“√μ‘¥ ‡™◊ÈÕ à«π„À≠à®÷ß‡ªìπ°“√μ‘¥‡™◊ÈÕ„π™ÿ¡™π ¡’ºŸâªÉ«¬∑’Ëμ‘¥‡™◊ÈÕ„π ‚√ßæ¬“∫“≈®”π«ππâÕ¬ ºŸâªÉ«¬∑’Ëμ‘¥‡™◊ÈÕ„π‚√ßæ¬“∫“≈ à«π¡“° (√âÕ¬≈– ˘) ‡°‘¥®“°‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫ ¥—ßπ—Èπ °“√‡≈◊ Õ°„™â ¬“ªØ‘™’ «π–„πºŸâªÉ «¬‡¥Á°∑’Ë ß — ¬¡’°“√μ‘¥‡™◊È Õ ·∫§∑’ ‡ √’ ¬ „π°√–· ‡≈◊ Õ ¥∑’Ë ¬— ß ‰¡à ∑ √“∫º≈‡æ“–‡™◊È Õ ∂â “ ‡ªìπ°“√μ‘¥‡™◊ÈÕ„π‚√ßæ¬“∫“≈§«√„Àâ¬“ªØ‘™’«π–∑’Ë “¡“√∂ §√Õ∫§≈ÿ¡‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫‡ªìπÀ≈—°‰ª°àÕπ ·μàÕ¬à“ß‰√ °Á μ “¡„πμà “ ßª√–‡∑»√–¬–À≈— ß √“¬ß“π°“√μ‘ ¥ ‡™◊È Õ „π ‚√ßæ¬“∫“≈æ∫‡™◊ÈÕ·∫§∑’‡√’¬°√—¡∫«°¡“°°«à“Ú °“√‡≈◊Õ° „™â¬“ªØ‘™’«π–Õ“®¡’°“√ª√—∫‡ª≈’Ë¬π‰ªμ“¡ ∂“π°“√≥å ‡™àπ ‚√§ª√–®”μ—« μ”·Àπàß°“√μ‘¥‡™◊ÈÕ ‡™◊ÈÕ∑’Ëæ∫∫àÕ¬ ·≈–Õ—μ√“ °“√¥◊ÈÕ¬“ªØ‘™’«π–¢Õß·μà≈–‚√ßæ¬“∫“≈ ªí ® ®ÿ ∫— π æ∫ªí ≠ À“‡™◊È Õ ·∫§∑’ ‡ √’ ¬ ¥◊È Õ ¬“ªØ‘ ™’ « π– ¡“°¢÷Èπ ‡™◊ÈÕ E. coli ·≈– K. pneumoniae ¡’§«“¡‰«μàÕ ampicillin πâÕ¬¡“° ·μà¬—ß‰«æÕ ¡§«√μàÕ cefotaxime ·≈– gentamicin ·≈–∑—ÈßÀ¡¥¬— ß‰«μà Õ amikacin °“√√— ° …“ ºŸâªÉ«¬∑’Ë ß —¬μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬°√—¡≈∫„π°√–· ‡≈◊Õ¥®÷ß‰¡à §«√‡≈◊Õ°„™â¬“ ampicillin ·μà§«√„™â¬“°≈ÿà¡ third generation

150 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ cephalosporin À√◊Õ aminoglycoside ”À√—∫°“√¥◊ÈÕ¬“ ¢Õß‡™◊ÕÈ ·∫§∑’‡√’¬°√—¡∫«°®“°°“√»÷°…“π’®È ”π«π ‘ßË àßμ√«® ∑’Ë¢÷Èπ‡™◊ÈÕ·∫§∑’‡√’¬°√—¡∫«°¡’πâÕ¬ S. pneumoniae ¥◊ÈÕ penicillin ®“°«‘ ∏’ disc diffusion Ò √“¬ §‘ ¥ ‡ªì π √â Õ ¬≈– ÛÛ.Û ‚¥¬‡ªì π ºŸâ ªÉ « ¬∑’Ë ¡’ ‡ ¬◊Ë Õ Àÿâ ¡ ¡ÕßÕ— ° ‡ ∫ Õ¬à “ ß‰√°Á μ “¡„π™à « ßπ—È π ‰¡à ‰ ¥â μ √«®À“§à “ minimum inhibitory concentration (MIC) ®÷ß¡’§«“¡‡ªìπ‰ª‰¥â∑’Ë ‡™◊ÈÕÕ“®‰« °÷Ëß‰«/°÷Ëß¥◊ÈÕ À√◊Õ ¥◊ÈÕ¬“ penicillin ·≈–‰¡à‰¥â ∑¥ Õ∫À“§à“ MIC μàÕ cefotaxime À√◊Õ ceftriaxone ®÷ß ‰¡à “¡“√∂∫Õ°§«¡‰«μàÕ¬“‡À≈à“π’È‰¥â ªí®®ÿ∫—π°“√¥◊ÈÕ¬“ ¢Õß‡™◊ÈÕ S. pneumoniae μàÕ penicillin π—∫‡ªìπªí≠À“ ”§—≠·≈–æ∫¡“°¢÷ÈπÕ¬à“ßμàÕ‡π◊ËÕß„πª√–‡∑»μà“ßÊ ∑—Ë«‚≈° ‚¥¬„πμà“ßª√–‡∑»æ∫ PRSP μ—ßÈ ·μà√Õâ ¬≈– Ò.Û-˜Ò.ÙÚÒ,ÚÚ,ÚÛ ®“°º≈°“√»÷ ° …“§√—È ß π’È æ ∫«à “ °“√‡æ“–‡™◊È Õ ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥¢ÕßºŸªâ «É ¬‡¥Á°æ∫‡™◊ÕÈ ªπ‡ªóÕô π Ÿß¡“° ‚¥¬æ∫∂÷ß√âÕ¬≈– ˜˜ ‡™◊ÈÕ∑’Ëæ∫¡“°§◊Õ Coagulase-negative Staphylococcus ´÷Ëß‡ªìπ‡™◊ÈÕ∑’Ëæ∫∫àÕ¬∑’Ëº‘«Àπ—ß °“√∑’Ëº≈ ‡æ“–‡™◊È Õ ®“°‡≈◊ Õ ¥¢÷È π ‡™◊È Õ ªπ‡ªóô Õ π®”π«π¡“° ¡’ § «“¡ ‡°’Ë ¬ «¢â Õ ß°— ∫ ‡∑§π‘ § ª≈Õ¥‡™◊È Õ μ—È ß ·μà ¢—È π μÕπ°“√‡°Á ∫ μ—«Õ¬à“ß‡≈◊Õ¥∑’Ë®–μ√«® √«¡∂÷ß¢—ÈπμÕπμà“ßÊ ¢Õß°“√‡æ“– ‡≈’È¬ß‡™◊ÈÕ ´÷Ëß∂â“·æ∑¬å·≈–∫ÿ§≈“°√ºŸâ‡°’Ë¬«¢âÕßμ√–Àπ—°∂÷ß §«“¡ ”§— ≠ ¢Õß‡∑§π‘ § ª≈Õ¥‡™◊È Õ ®– “¡“√∂≈¥Õ— μ √“ °“√ªπ‡ªóôÕπ‰¥â ∑”„Àâ∑√“∫Õÿ∫—μ‘°“√≥å∑’Ë·∑â®√‘ß¢Õß°“√μ‘¥ ‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥ ·≈–™à«¬ª√–À¬—¥§à“„™â®à“¬∑’Ë ‡°‘¥®“°°“√„Àâ¬“ªØ‘™’«π–„π™à«ß·√° ¥—ßπ—Èπ®”‡ªìπÕ¬à“ß¬‘Ëß ∑’Ë®–μâÕß¡’¡“μ√°“√ª√—∫ª√ÿß«‘∏’°“√‡°Á∫ ‘Ëß àßμ√«®‡æ◊ËÕ≈¥ ‡™◊ÈÕ·∫§∑’‡√’¬ªπ‡ªóôÕπ®“°º‘«Àπ—ß ‡™àπ °“√„™â chorhexidine „π°“√∑”§«“¡ –Õ“¥º‘«Àπ—ß°àÕπ‡°Á∫ ‘Ëß àßμ√«® √«¡∂÷ß ¢—ÈπμÕπ°“√‡æ“–‡≈’È¬ß‡™◊ÈÕμàÕ‰ªÚÙ,Úı,Úˆ °“√»÷°…“§√—Èßπ’È¡’¢âÕ®”°—¥‡π◊ËÕß®“°‡ªìπ°“√»÷°…“ ·∫∫¬âÕπÀ≈—ß ‰¡à¡’°≈ÿà¡§«∫§ÿ¡¡“‡ª√’¬∫‡∑’¬∫ ∑”„Àâ‰¡à “¡“√∂∫àß∫Õ°∂÷ßÕÿ∫—μ‘°“√≥å √«¡∂÷ßªí®®—¬‡ ’Ë¬ß∑’Ë®–∑”„Àâ ‡°‘¥°“√μ‘¥‡™◊ÈÕ·∫§∑’‡√’¬„π°√–· ‡≈◊Õ¥„πºŸâªÉ«¬‡¥Á°‰¥âÕ¬à“ß ™—¥‡®π

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152 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ Abstract Bactermia in pediatric patients in Thammasat University Hospital Supawut Suksantilirs, Pornumpa Bunjoungmanee, Auchara Tangsathapornpong Department of Pediatrics, Faculty of Medicine, Thammasat University Hospital Background: Objectives: Methodology:

Results:

Conclusion:

Key words:

Bacteremia is a life-threatening condition. Delayed treatment of this condition may lead to sepsis or septic shock which increase mortality in children. To study epidemiological data, causative agents, and antibiotic susceptibility in pediatric patients with bacteremia at Thammasat University Hospital. A retrospective study was conducted for patients, aged between 1 month and 15 years, diagnosed with bacteremia at Thammasat University hospital between January 2002 and October 2008. The sample group was 38 children with bacteremia. Bacteremia mostly occurred in infants aged 1 month to 1 year (57.9%). They acquired infection in the community more than in the hospital (73.6% and 26.4% respectively). Most children (84.2%) had a focal site of infection. Respiratory tract infection (26.3 %) and urinary tract infection (18.4%) were most common found. 71.1% of children had a fever higher than 39 ÌC. In 44.7% of patient had white blood cell more than 15,000 cells/cumm. Ten percent of infants and 56.3% of children aged more than 1 year had underlying disease. Two children (5.3%) who had underlying disease died with gram negative septic shock. Gram negative bacteria were isolated more frequently than gram positive bacteria (73.6% vs 26.4%). Among the gram negative bacteria, E. coli and K. pneumoniae were the predominant group, followed by Enterobacter spp. These organisms were susceptible to amikacin (100%), gentamicin (67-86%), cefotaxime (67-86%) and ampicillin (0-33%). In this study, the isolated gram positive bacteria included S. aureus, S. pneumoniae and S. viridans. Sixty seven percent of S. pneumoniae was susceptible to penicillin. In children, bacteremia mostly occurred in infants and caused by community acquired gram negative infections. The common gram negative organisms were highly susceptible to amikacin but resisted to ampicillin. The relatively this study should alert pediatrician to aware of bacteremia in infant without underlying diseases. Bactermia, Children

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‡¡◊ÕË ®—¥‡√’¬ß≈”¥—∫§«“¡ ”§—≠μ“¡®—ßÀ«—¥/æ◊πÈ ∑’Ë ‚¥¬ „Àâ § «“¡ ”§— ≠ ∑—È ß ®— ß À«— ¥ /æ◊È π ∑’Ë ∑’Ë ¡’ ®”π«π°“√ª√– ∫ Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ÕË ß®“°°“√∑”ß“π Ÿß ·≈–®—ßÀ«—¥/æ◊πÈ ∑’Ë ∑’Ë¡’Õ—μ√“Õÿ∫—μ‘°“√≥å Ÿß‚¥¬„ÀâπÈ”Àπ—°‡∑à“ Ê °—π ‚¥¬°“√π” §à“‡©≈’Ë¬¢Õß≈”¥—∫¢Õß®”π«π·≈–≈”¥—∫Õ—μ√“ Õÿ∫—μ‘°“√≥å °“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π ´÷Ëß¡’ ºŸâ‡ πÕ„Àâ‡√’¬°«à“ Prevention Index (PI)ˆ,˜ æ∫«à“ PI Ò ≈”¥—∫·√° ‰¥â·°à ¡ÿ∑√ª√“°“√ ¡ÿ∑√ “§√ °√ÿß‡∑æ¡À“π§√ ‡¢μæ◊Èπ∑’Ë ˜ ™≈∫ÿ√’ ©–‡™‘ß‡∑√“ °√ÿß‡∑æ¡À“π§√‡¢μæ◊Èπ∑’Ë Ò π§√ª∞¡ √–¬Õß ª∑ÿ¡∏“π’ ·≈–°√ÿß‡∑æ¡À“π§√‡¢μ æ◊Èπ∑’Ë ¯

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Õ—μ√“ Õÿ∫—μ‘°“√≥å Ò

Òı ı,˜˜ Ò,˜¯Ú ÚÛÒ Ò˜ˆ Û,¯Ú ÒÚÛ Úˆ˘ ˘Û Ù¯˘ Ú¯ ÒÙ¯ Òı Û˘ ˘¯Û ˜Û Ú¯ Ò˘Ú ˜Û ÒıÙ ı˘ Ò˜ˆ ÒÙ ıÚ

ÒÒ,˜ÙÛ Òˆ˘,˘ˆ˘ Òı,Ù¯¯ ÒÙ,Ò˜¯ ÒÙ,˘Òˆ ÚÚ,ÚÛı Ú˘,¯˘Û Úı,˘ˆ˜ Ò¯,ÒÙ˘ Ù˘,ˆˆ¯ Ò,Ùˆ˘ Úı,ÛıÒ Ù,˘ı ˜,ÚÚÒ Òı,˜ÒÒ Ù˜,ˆˆ ÒÚ,˜ˆˆ Ò˜,Ù˘Ú ÚÚ,ˆÙÛ Úˆ,ÚÚı Ò˜,ıÙÙ Ú,ˆÛˆ Ò,ıÙı ˘,

¯.˘Ù Ú˘.¯˜ Òˆ.¯˘ Òˆ.Ú˘ ÒÒ.¯ Ò¯.¯˘ Ù.ÒÒ Ò.Ûˆ ı.ÒÚ ˘.¯ı Ú.ˆ˜ ı.¯Ù Û.Û ı.Ù ˘.Û Òı.ÛÛ Ú.Ò˘ Ò.˘¯ Û.ÚÚ ı.¯˜ Û.Ûˆ ¯.ıÛ Ò.ÛÛ ı.˜¯

μ√“¥ ©–‡™‘ß‡∑√“ ª√“®’π∫ÿ√’ π§√π“¬° √–·°â« π§√√“™ ’¡“ ∫ÿ√’√—¡¬å ÿ√‘π∑√å »√’ –‡°… Õÿ∫≈√“™∏“π’ ¬‚ ∏√ ™—¬¿Ÿ¡‘ Õ”π“®‡®√‘≠ ÀπÕß∫—«≈”¿Ÿ ¢Õπ·°àπ Õÿ¥√∏“π’ ‡≈¬ ÀπÕß§“¬ ¡À“ “√§“¡ √âÕ¬‡ÕÁ¥ °“Ã ‘π∏ÿå °≈π§√ π§√æπ¡ ¡ÿ°¥“À“√ Ò

Õ—μ√“Õÿ∫—μ‘°“√≥åμàÕºŸâª√–°—πμπ Ò, √“¬

Count Rate PI rank rank rank ˜ ˘ ÚÙ ıÙ ˆ Òˆ ˆˆ ı ˜Ò ÙÒ ¯ ˆÚ ¯Ò ˜˘ Û Û¯ ¯ ı¯ ˜Ù ˆÒ ˜ˆ ˆ ¯Ú ˜¯

ˆÚ ı ÚÙ Ú¯ Ù¯ ÚÛ ˜˜ ı˜ ˜ˆ ı˘ ¯Ú ˜Û ¯Ò ˜ı ˆ ÛÚ ¯Û ıÙ ¯ ˜Ú ˜˘ ˆÙ ¯Ù ˜Ù

ıÛ ı Ò˜ ÛÛ Ùı ÒÙ ı˜ ÙÙ ı˘ Ù ˆÙ ıı ˆÙ ˆÚ Ûˆ Ú¯ ˆı Ù¯ ˆÚ ıÙ ˆÛ ıÚ ˆˆ ˆ

158 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ μ“√“ß∑’Ë Ò · ¥ß®”π«π°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π ®”π«πºŸâª√–°—πμπ Õ—μ√“Õÿ∫—μ‘°“√≥å ≈”¥—∫¢Õß ®”π«π ·≈–≈”¥—∫¢ÕßÕ—μ√“Õÿ∫—μ‘°“√≥å ®”·π°μ“¡®—ßÀ«—¥ / æ◊Èπ∑’Ë (μàÕ)

®—ßÀ«—¥/æ◊Èπ∑’Ë

®”π«π°“√ª√– ∫ Õ—πμ√“¬·≈– ‡®Á∫ªÉ«¬

®”π«π ºŸâª√–°—πμπ

Õ—μ√“ Õÿ∫—μ‘°“√≥å Ò

Count Rate PI rank rank rank

Ú,¯Úı ˘ÚÚ ˜˘˜ Ò˘ı Ò˘ ¯Û ¯¯ Û˜˘  Ò,Òıı ˘Û ÒÛÒ Òˆ ÒÛˆ ÙÒÒ Ò˘Ù Ùˆ Ò,˜Ò˘ ¯˜Ò ¯¯Ù Ù,ıÚ ÒÒ,ˆ˜ Ù˜ ˘Úı

Ò˜Ù,Û¯ ˜˜,Ò˘ˆ Ù¯,ÛÛÙ ÒÙ,Ùıˆ Òˆ,˘Ú Ò,˜Òı ÒÛ,ıı˘ ÙÙ,˘Òˆ Ù,˘ÙÙ Ùˆ,˜Ù ¯,Úˆ˜ Ò¯,ÙÙ Òı,¯ˆÚ ÒÛ,ÛÚÙ Ùı,ÒÚ Òˆ,˘ÙÒ ÚÙ,ˆÒ ¯Ò,Û˜¯ ÙÒ,Ú¯Û Ûˆ,ÙÛÙ Ò˘Ò,˜¯¯ ÛÒ˘,ı˜Ú ÒÚ,˘˜Û Û¯,˜¯Û

Òˆ.Ú ÒÒ.˘Ù Òˆ.Ù˘ ÒÛ.Ù˘ ÒÒ.¯Ò ˜.˜ı ˆ.Ù˘ ¯.ÙÙ  Úı.˜ ÒÒ.Úı ˜.Ò ˆ.ˆ¯ Ò.ÚÒ ˘.ÒÒ ÒÒ.Ùı Ò˘.ÒÚ ÚÒ.ÒÚ ÚÒ.Ò ÚÙ.Úˆ ÚÛ.ı˜ Ûˆ.ÛÚ ÛÒ.Û˜ ÚÛ.¯ı

Ò˘ ÛÚ Ûˆ ıı ı˘ ˜Û ˜Ú Ùˆ ¯Û Ú¯ ˜Ò ˆÙ ˆ˘ ˆÛ ÙÙ ıˆ ÙÚ Úı Ûı ÛÛ ÒÛ Û Ùı ÛÒ

‡™’¬ß„À¡à ≈”æŸπ ≈”ª“ß Õÿμ√¥‘μ∂å ·æ√à πà“π æ–‡¬“ ‡™’¬ß√“¬ ·¡àŒàÕß Õπ π§√ «√√§å Õÿ∑—¬∏“π’ °”·æß‡æ™√ μ“° ÿ‚¢∑—¬ æ‘…≥ÿ‚≈° æ‘®‘μ√ ‡æ™√∫Ÿ√≥å √“™∫ÿ√’ °“≠®π∫ÿ√’ ÿæ√√≥∫ÿ√’ π§√ª∞¡ ¡ÿ∑√ “§√ ¡ÿ∑√ ß§√“¡ ‡æ™√∫ÿ√’ Ò

Õ—μ√“Õÿ∫—μ‘°“√≥åμàÕºŸâª√–°—πμπ Ò, √“¬

Ú˘ ÙÙ Ú˜ Ù Ù˜ ˆˆ ˜Ò ˆı ¯ı ˜ ıÒ ˆ¯ ˜ ı¯ ˆÒ Ù˘ ÚÚ Òı Òˆ ¯ ÒÒ Û Ù ˘

Ò˜ ÛÒ ÚÙ Û˜ ÙÛ ıˆ ı˜ Ù˜ ˆ˜ ÒÚ ıÒ ıÛ ıˆ ı ÙÚ ÙÚ Úı Òı Ò˘ Òˆ ˜ Ú Ò¯ Òı

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®—ßÀ«—¥/æ◊Èπ∑’Ë

®”π«π°“√ª√– ∫ Õ—πμ√“¬·≈– ‡®Á∫ªÉ«¬

®”π«π ºŸâª√–°—πμπ

Õ—μ√“ Õÿ∫—μ‘°“√≥å Ò

˜¯ˆ ı˘˘ Û˜Û Ò˘ Ò,ˆ˘Û Ò,ÒıÚ ıÙ ÛÙÚ Ú,Ûˆı ÒÚÚ ˜ÒÛ ÒÛ ÚÙı ÚˆÚ ˆÒ

Ù˘,ÚÛ¯ Ù¯,ÙÙ ÛÛ,˘˘Û ÒÙ,Ù¯˜ ÒÒˆ,¯ıÒ ¯Û,˘Ù˘ ˜,˘Ù ÚÛ,˘¯Ú ÒıÚ,Ûı ˘,Úˆ ÛÚ,ı˜Û ÒÒ,ˆÚ Ú,ˆÒ˘ Ò¯,ı¯ Òı,Ûıı

Òı.˘ˆ ÒÚ.Ù˜ Ò.˘˜ ˜.ıÚ ÒÙ.Ù˘ ÒÛ.˜Ú ˆ.¯Û ÒÙ.Úˆ Òı.ıÚ ÒÛ.Úı ÚÒ.¯˘ ÒÒ.Ú ÒÒ.¯¯ ÒÙ.Òˆ Û.˘˜

Ò˜ˆ,ıÚ

¯,˜˜˘,ÒÛÒ

Ú.Ò

ª√–®«∫§’√’¢—π∏å π§√»√’∏√√¡√“™ °√–∫’Ë æ—ßß“ ¿Ÿ‡°Áμ ÿ√“…Æ√å∏“π’ √–πÕß ™ÿ¡æ√ ß¢≈“ μŸ≈ μ√—ß æ—∑≈ÿß ªíμμ“π’ ¬–≈“ π√“∏‘«“ √«¡ Ò

Õ—μ√“Õÿ∫—μ‘°“√≥åμàÕºŸâª√–°—πμπ Ò, √“¬

Count Rate PI rank rank rank Û˜ Ù Ù˜ ˆ¯ Úˆ Ú˘ ˜˜ Ù¯ ÚÚ ˆ˜ Û˘ ˆı ıÚ ıÒ ˜ı

Û ÙÛ ıı ˆ˜ ÛÛ Û˜ ˆ˘ ÛÙ ÛÒ ÙÚ ÒÙ ıÚ Ùı Ûˆ ˜¯

Ú˜ ÛÙ ÙÒ ıı ÚÚ Úˆ ı¯ ÛÛ Ú Ùˆ Ú Ù˘ Û¯ Ûı ˆÒ

160 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ μ“√“ß∑’Ë Ú · ¥ß®”π«π°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π ®”π«πºŸâª√–°—πμπ Õ—μ√“Õÿ∫—μ‘°“√≥å ≈”¥—∫ ¢Õß®”π«π ·≈–≈”¥—∫¢ÕßÕ—μ√“Õÿ∫—μ‘°“√≥å ®”·π°μ“¡™à«ßÕ“¬ÿ ®”π«π°“√ª√– ∫ Õ—πμ√“¬·≈– ‡®Á∫ªÉ«¬

®”π«π ºŸâª√–°—πμπ

Õ—μ√“ Õÿ∫—μ‘°“√≥å Ò

Òı - Ò˘ Ú - ÚÙ Úı - Ú˘ Û - ÛÙ Ûı - Û˘ Ù - ÙÙ Ùı - Ù˘ ı - ıÙ ıı - ı˘ ˆ+

Ò,ÛÙÚ ÛÒ,ˆÒ˜ Ù,ıÚ ÛÛ,Ò¯ ÚÙ,ˆÚı Òˆ,ˆ˜˜ Ò,ÙıÒ ı,¯ıÚ Ú,Ù¯¯ ˜ı

ˆ˘Û,ı˜Û ÛÒ˘,ı˜Ú Úı,ÚÙ˜ ıÚ¯,ˆÙ˘ Òˆ˘,˘ˆ˘ Ú˜,ÒÙ Ò˘Ò,˜¯¯ Ú˘Ù,ÛÒ˜ ÙÒÒ,˘˜ ı˘Ù,ıÚÚ

Ûˆ.ˆˆ ÚÙ.˜˘ Ò˘.ı˜ Ò˘.ı Ò¯.˘¯ Ò˜.Ú˘ Òˆ.¯ Òˆ.¯ˆ Òı.Ú¯ ÒÛ.Û

√«¡

Ò˜ˆ,ıÚ

¯,˜˜˘,ÒÛÒ

Ú.Ò

™à«ßÕ“¬ÿ

Õ—μ√“Õÿ∫—μ‘°“√≥åμàÕºŸâª√–°—πμπ Ò, √“¬

Count Rate PI rank rank rank ˜ Û Ò Ú Ù ı ˆ ¯ ˘ Ò

Ò Ú Û Ù ı ˆ ¯ ˜ ˘ Ò

Ù Ú Ò Û ı ˆ ˜ ¯ ˘ Ò

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μ“√“ß∑’Ë Û · ¥ß®”π«π°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬ ®”π«πºŸâª√–°—πμπÒ Õ—μ√“Õÿ∫—μ‘°“√≥åÚ ≈”¥—∫¢Õß®”π«π ·≈–≈”¥—∫¢ÕßÕ—μ√“Õÿ∫—μ‘°“√≥å ®”·π°μ“¡ª√–‡¿∑°‘®°“√

®—ßÀ«—¥/æ◊Èπ∑’Ë

®”π«π°“√ª√– ∫ Õ—πμ√“¬·≈– ‡®Á∫ªÉ«¬

®”π«π ºŸâª√–°—πμπ

Õ—μ√“ Õÿ∫—μ‘°“√≥å Ò

°“√ ”√«® °“√∑”‡À¡◊Õß·√à °“√º≈‘μÕ“À“√‡§√◊ËÕß¥◊Ë¡ °“√º≈‘μ ‘Ëß∑Õ∂—° ‡§√◊ËÕßª√–¥—∫ °“√∑”ªÉ“‰¡â º≈‘μ¿—≥±å®“°‰¡â º≈‘μ¿—≥±å®“°°√–¥“… °“√æ‘¡æå º≈‘μ¿—≥±å‡§¡’ πÈ”¡—πªî‚μ√‡≈’¬¡ º≈‘μ¿—≥±å®“°·√àÕ‚≈À– °“√º≈‘μ‚≈À–¢—Èπ¡Ÿ≈∞“π º≈‘μ¿—≥±å®“°‚≈À– º≈‘μ ª√–°Õ∫¬“πæ“Àπ– Õÿμ “À°√√¡°“√º≈‘μÕ◊Ëπ Ê “∏“√≥Ÿª‚¿§ °“√°àÕ √â“ß °“√¢π àß °“√§¡π“§¡ °“√§â“ ª√–‡¿∑°‘®°“√Õ◊Ëπ Ê

˜˜ı ÒÛ,˜Ò Ò,ÛÚÙ ˜,¯˜ Ù,ÛıÙ ÒÙ,ıı¯ Ù,Ò˜Ò Ò,ˆÛ˘ ÛÚ,Ú˘ˆ ÒÛ,Û˜ Ú,ÚÒ ıÛ¯ Ò˜,ÒÒ ı,ˆ¯˘ Ú,ˆˆ Ò˘,ÛˆÚ

ıı,ıÚ ˆˆˆ,˘Û ˆÛÒ,Ù˘Ú Ò˜,˜ı Ò¯Ú,˘Ù¯ ı˘Ò,ÙÒ˘ ÒˆÒ,ıÙ ÒÛÛ,˜ˆ Ò,ıÒ,˜˘Ù ÙÛÙ,¯ıı ÒÙ¯,˘˜ˆ Ûı,ˆıÙ Û˘Ù,¯Ù¯ Û˘Ù,¯˜˘ Ò,ÛÛ,ÛÛ Ò,˜ıÒ,¯˘Ò

ÒÙ.¯ Ú.ıˆ Òˆ.Ûı ÙÒ.ˆ˜ ÚÛ.¯ ÚÙ.ˆÚ Úı.˘ ˜˘.ı˜ Û.˜Ò Ú˘.˘¯ ÒÙ.˜˜ Òı.˘ ÙÛ.ÛÒ ÒÙ.ÙÒ Òı.ıÛ ÒÒ.ı

√«¡

Ò˜ˆ,ıÚ

¯,ÒÛı,ˆˆ

ÚÒ.˜

Count Rate PI rank rank rank Òı ˆ ˘ Ò ÒÚ ı ÒÛ ¯ Ò ˜ ÒÙ Òˆ Ù ÒÒ Ú Û

Òı ˘ Ò Û ¯ ˜ ˆ Ò Ù ı ÒÛ ÒÚ Ú ÒÙ ÒÒ Òˆ

ÒÚ ˆ ˜ ı ¯ Ù ˜ Û Ò Ù Ò ÒÒ Ú ˘ ı ˜

®”π«πºŸâª√–°—πμπ ‰¡à√«¡ºŸâª√–°—πμπ„π ∂“πª√–°Õ∫°“√ à«π√“™°“√ Õ—μ√“Õÿ∫—μ‘°“√≥åμàÕºŸâª√–°—πμπ Ò, √“¬

√ÿª·≈–«‘®“√≥å º≈°“√»÷ ° …“æ∫«à “ Õ— μ √“Õÿ ∫— μ‘ ° “√≥å ° “√ª√– ∫ Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“πªï ÚııÒ ‡∑à“°—∫ Ú.Ò √“¬μàÕºŸâª√–°—πμπ Ò, √“¬ ºŸâª√– ∫Õ—πμ√“¬ ·≈–‡®Á∫ªÉ«¬‡π◊ÕË ß®“°°“√∑”ß“π à«π„À≠à‡ªìπ‡æ»™“¬·≈–Õ“¬ÿ Ú - ÙÙ ªï ™à«ßÕ“¬ÿ Òı - Ò˘ ªï ¡’Õ—μ√“Õÿ∫—μ‘°“√≥å Ÿß∑’Ë ÿ¥ °√ÿß‡∑æ¡À“π§√‡ªìπ®—ßÀ«—¥∑’Ë¡’°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ ªÉ«¬¡“°∑’Ë ÿ¥ ·μà®—ßÀ«—¥ ¡ÿ∑√ª√“°“√¡’Õ—μ√“Õÿ∫—μ‘°“√≥å Ÿß ∑’Ë ÿ¥ ª√–‡¿∑°‘®°“√∑’Ëª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬¡“°

∑’Ë ÿ¥§◊Õº≈‘μº≈‘μ¿—≥±å®“°‚≈À– °‘®°“√¬àÕ¬§◊Õ°“√°àÕ √â“ß ·μà°“√º≈‘μ‚≈À–¢—Èπ¡Ÿ≈∞“π¡’Õ—μ√“Õÿ∫—μ‘°“√≥å Ÿß∑’Ë ÿ¥ ≈”¥—∫ ¢Õß®”π«π·≈–≈”¥—∫¢ÕßÕ—μ√“¡’§«“¡·μ°μà“ß°—π °“√ ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π “‡Àμÿ‡°‘¥ ®“°«—μ∂ÿÀ√◊Õ ‘ßË ¢Õßμ—¥/∫“¥/∑‘¡Ë ·∑ß (√âÕ¬≈– ÚÛ.ı) Õ«—¬«– ∑’Ë‰¥â√—∫Õ—πμ√“¬ §◊Õ π‘È«¡◊Õ (√âÕ¬≈– Ú˜.˘) μ”·Àπàßß“π∑’Ë ª√– ∫Õ—πμ√“¬¡“°∑’Ë ÿ¥§◊Õæπ—°ß“π¢“¬¢ÕßÀπâ“√â“π ·≈– “∏‘μ ‘π§â“ (√âÕ¬≈– ˜.¯) ¡ÿ∑√ª√“°“√ ¡ÿ∑√ “§√ ·≈–

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

¢âÕ‡ πÕ·π– Ò. æ—≤π“√–∫∫∞“π¢âÕ¡Ÿ≈„Àâ¡’°“√‡™◊ËÕ¡‚¬ß°—π √–À«à “ ß¢â Õ ¡Ÿ ≈ ¢Õß°Õß∑ÿ π ‡ß‘ π ∑¥·∑π·≈–¢âÕ ¡Ÿ≈ °Õß∑ÿπ ª√–°—π —ß§¡ Ú. ¢âÕ¡Ÿ≈ª√–™“°√°≈ÿà¡‡ ’Ë¬ß∑’Ë‡ªìπμ—«À“√ §«√¡’ °“√¥÷ ß ¢â Õ ¡Ÿ ≈ ÕÕ°¡“«‘ ‡ §√“–Àå „ Àâ — ¡ æ— π ∏å °— ∫ ¢â Õ ¡Ÿ ≈ ¢ÕßºŸâ ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π ‡æ◊ËÕ§«“¡ ∂Ÿ°μâÕß·¡àπ¬”¢Õß°“√§”π«≥Õ—μ√“¢Õß¢âÕ¡Ÿ≈ À√◊Õ¡’°“√®—¥ ‡°Á∫¢âÕ¡Ÿ≈™—Ë«‚¡ß°“√∑”ß“π ‡æ◊ËÕÀ“Õ—μ√“§«“¡∂’Ë¢Õß°“√ ª√– ∫Õ—πμ√“¬ Õ—μ√“§«“¡√ÿπ·√ß¢Õß°“√ª√– ∫Õ—πμ√“¬ ·≈–§«“¡√ÿπ·√ß¢Õß°“√ª√– ∫Õ—πμ√“¬‚¥¬‡©≈’Ë¬‰¥â ·≈– π”‰ª‡ª√’¬∫‡∑’¬∫¢âÕ¡Ÿ≈°—∫μà“ßª√–‡∑»‰¥â Û. ¡’°“√°”Àπ¥≈”¥—∫¢—Èπ¢Õß°“√√“¬ß“π¢âÕ¡Ÿ≈ ·≈–™—Èπ§«“¡≈—∫¢Õß¢âÕ¡Ÿ≈ ‡π◊ËÕß®“°§«“¡μâÕß°“√ ·≈– °“√π”‰ª„™âª√–‚¬™πå¢âÕ¡Ÿ≈°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π·μ°μà“ß°—π Ù. °Õß∑ÿπ‡ß‘π∑¥·∑π§«√¡’°“√‡°Á∫·≈–«‘‡§√“–Àå ¢âÕ¡Ÿ≈‡æ‘Ë¡‡μ‘¡ ‡™àπ ™à«ß‡«≈“°“√‡°‘¥‡Àμÿ ·≈– ∂“π∑’Ë∑’Ë ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π®√‘ß ı. ¡’°“√°”Àπ¥√Ÿª·∫∫°“√√“¬ß“πº≈„À¡à „Àâ Õ¥§≈âÕß°—∫ªí®®—¬∑’Ë¡’º≈μàÕ°“√ª√– ∫Õ—πμ√“¬·≈–‡®Á∫ ªÉ«¬‡π◊ËÕß®“°°“√∑”ß“π ‡™àπ §«“¡ —¡æ—π∏å√–À«à“ß®—ßÀ«—¥/ æ◊Èπ∑’Ë·≈–ª√–‡¿∑°‘®°“√ §«“¡ —¡æ—π∏å√–À«à“ßª√–‡¿∑ °‘®°“√·≈– “‡Àμÿ∑∑’Ë ”„Àâª√– ∫Õ—πμ√“¬·≈–‡®Á∫ªÉ«¬ ‡ªìπμâπ ˆ. »÷ ° …“°“√ª√– ∫Õ— π μ√“¬·≈–‡®Á ∫ ªÉ « ¬ ‡π◊ËÕß®“°°“√∑”ß“π„π°Õß∑ÿπ‡ß‘π∑¥·∑π‚¥¬„™â√Ÿª·∫∫ ¢Õß°“√»÷°…“‡»√…∞»“ μ√å “∏“√≥ ÿ¢

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Û. International Labor Organization. Main statistics (annual) - occupational injuries [online]. 2009. Available from: http://labosta.ilo.org/applv8/data/ c8e.html [2009, October 21] Ù. ™— ™ ™π° æ≈Õ¬·°â « . °“√»÷ ° …“√–∫∫¢â Õ ¡Ÿ ≈ §«“¡ ª≈Õ¥¿—¬ Õ“™’«Õπ“¡—¬·≈– ¿“æ·«¥≈âÕ¡°“√∑”ß“π „π°√–∑√«ß·√ßß“π. ”π—°ß“πª√–°—π —ß§¡ °√–∑√«ß ·√ßß“π. ππ∑∫ÿ√’. ÚıÙˆ ı. Siriratanapruk S, Anatagulnathi P. Occupational health and safety situation and research priority in Thailand. Ind Health 2004;42:135-40. ˆ. Bonauto D, Silverstein B, Adams D, Foley M. Prioritizing industries for occupational injury and illness prevention and research, Washington State Workers' compensation claims, 1999 - 2003. J Occup Environ Med 2006;48:840-51. ˜. Silverstein B, Viikari-Juntura E, Kalat J. Use of a prevention index to identify industries at high risk for work-related musculoskeletal disorders of the neck, back, and upper extremity in Washington State, 1990 - 1998. Am J Ind Med 2002;41:149-69. ¯. Neff RA, Curriero FC, Burke TA. Just in the wrong place...?: geographic tools for occupational injury/ illness surveillance. Am J Ind Med 2008;51: 680-90. ˘. Horwitz IB, McCall BP. Occupational injury among Rhode Island adolescents: an analysis of workers' compensation claims, 1998 to 2002. J Occup Environ Med 2005;47:473-81. Ò. Richardson D, Loomis D, Bailer AJ, Bena J. The effect of rate denominator source on US fatal occupational injury rate estimates. Am J Ind Med 2004;46:261-70 .

164 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ Abstract Reconsideration of occupational injuries and illness of Workerûs Compensation Fund in Thailand Suttipat Wongvitvichot*, Pornchai Sithisarankul*, Surasak Buranatrevedh** *Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University **Department of Community and Family Medicine, Faculty of Medicine, Thammasat University

This descriptive study aimed to determine the incidence rate of occupational injury and illness and compare between data presentation of count rank (old format of Workerûs Compensation Fund) and rate rank. We used data of annual report of Social Security statistics in 2008, and used number of insured persons as denominators. The result showed that incidence rate was 20.1 persons per 1,000 insured persons. Bangkok had the highest injury count but Samut Prakan had the highest incidence rates. Workers aged 20 - 24 had the highest injury count but those aged 15 - 19 had the highest incidence rates. Metal production had the highest injury count but production of basic metals had the highest incidence rates. In conclusion, this study shows that the data of Workerûs Compensation Fund was under utilized for prevention and control of occupational injury and illness. This problem reveals the need to improve format and data presentation in order to reduce the numbers and incidence rate of occupational injury and illness. Key words: Occupational injury and illness, Workerûs Compensation Fund, Incidence rate

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

165

π‘æπ∏åμâπ©∫—∫

§ÿ≥¿“æ™’«‘μ·≈–ªí≠À“°“√πÕπÀ≈—∫¢ÕßºŸâªÉ«¬‚√§æ“√å°‘π —π „π‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ ª√–«’≥ ‚≈àÀå‡≈¢“, °âÕß‡°’¬√μ‘ °Ÿ≥±å°—π∑√“°√ ∫∑§—¥¬àÕ «—μ∂ÿª√– ß§å:

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æ∫ªí≠À“°“√πÕπÀ≈—∫„πºŸªâ «É ¬‚√§æ“√å°π‘ —π√âÕ¬≈– ˘˜ ‚¥¬ªí≠À“ª«¥ªí “«–°≈“ß¥÷° ªí≠À“ πÕπ‰¡àÀ≈—∫ μ◊Ëπßà“¬ ·≈–ªí≠À“°“√πÕπ°√π‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬ ªí≠À“°“√πÕπÀ≈—∫∑’Ëμ√«® æ∫®“°·∫∫ Õ∫∂“¡§«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫©∫—∫ª√—∫ª√ÿß¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘°—∫§–·ππ®“°·∫∫ Õ∫∂“¡§ÿ≥¿“æ™’«‘μ©∫—∫ ¯ ¢âÕ (§à“æ’ <.Ò, r = -.ıÚ) ªí≠À“¬“À¡¥ƒ∑∏‘Ï°àÕπ‡«≈“ (§à“æ’ = .ÙÙ, r = -.ÚÛ) ·≈–§«“¡ “¡“√∂„π°“√∑”ß“π¢Õß ºŸâªÉ«¬ (§à“æ’ = .ÒÚ, r = .Ú˘)

√ÿª:

ªí≠À“°“√πÕπÀ≈—∫æ∫‰¥â∫àÕ¬„πºŸâªÉ«¬‚√§æ“√å°‘π —π ·≈–¡’§«“¡ —¡æ—π∏å°—∫√–¥—∫§ÿ≥¿“æ™’«‘μ °“√‡æ‘Ë¡§ÿ≥¿“æ°“√πÕπÀ≈—∫·≈–√—°…“Õ“°“√∑’ËπÕ°‡Àπ◊Õ®“°Õ“°“√∑“ß°“√‡§≈◊ËÕπ‰À«§«√‡ªìπ ‡ªÑ“À¡“¬∑’Ë ”§—≠„π°“√√—°…“ºŸâªÉ«¬‚√§æ“√å°‘π —π

§” ”§—≠:

§ÿ≥¿“æ™’«‘μ, ªí≠À“°“√πÕπÀ≈—∫, ‚√§æ“√å°‘π —π

‚§√ß°“√®—¥μ—Èß¿“§«‘™“Õ“¬ÿ√»“ μ√å §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

166 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ∫∑π”

«‘∏’°“√»÷°…“

‚√§æ“√å°‘π —π (Parkinsonûs disease: PD) ‡ªìπ ‚√§‡√◊ÈÕ√—ß∑“ß√–∫∫ª√– “∑∑’Ëæ∫‰¥â∫àÕ¬„πºŸâ ŸßÕ“¬ÿ∑—Ë«‚≈° ·≈–‡ªìπ “‡Àμÿ ”§—≠∑’Ë∑”„ÀâºŸâ ŸßÕ“¬ÿ¡’Õ“°“√‡§≈◊ËÕπ‰À«∑’Ë º‘¥ª√°μ‘ ª√–¡“≥‰¥â«“à ®–æ∫ºŸªâ «É ¬‚√§æ“√å°π‘ —π√âÕ¬≈– Ò ¢ÕßºŸâ∑’Ë¡’Õ“¬ÿ¡“°°«à“ ˆı ªï¢÷Èπ‰ªÒ ·≈–¡’·π«‚πâ¡∑’Ë®– ‡æ‘Ë¡¢÷Èπμ“¡®”π«πª√–™“°√ ŸßÕ“¬ÿ∑’Ë‡æ‘Ë¡¢÷Èπ„πÕπ“§μ ºŸâ ªÉ«¬‚√§æ“√å°‘π —π®–¡“æ∫·æ∑¬å¥â«¬Õ“°“√‡§≈◊ËÕπ‰À«™â“ (bradykinesia) °≈â“¡‡π◊ÕÈ ·¢Áß‡°√Áß (rigidity) ¡◊Õ —πË „π¢≥–æ—° (resting tremor) ·≈–¢“¥ ¡¥ÿ≈¢Õß°“√∑√ßμ—« (postural instability) πÕ°‡Àπ◊Õ®“°Õ“°“√∑“ß°“√‡§≈◊ËÕπ‰À«∑’Ëº‘¥ ª√°μ‘·≈â«ºŸªâ «É ¬‚√§æ“√å°π‘ —π¬—ßÕ“®¡’Õ“°“√Õ◊πË Ê ‡™àπ Õ“°“√ À≈ß≈◊¡ ´÷¡‡»√â“ ∑âÕ·∑â ª√– “∑À≈Õπ ∑âÕßºŸ° ªí “«– ∫àÕ¬ ·≈–¡’ªí≠À“‡√◊ËÕß°“√πÕπÀ≈—∫ ªí≠À“‡√◊ËÕß°“√πÕπÀ≈—∫‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬ ∑—Èß„πºŸâ ŸßÕ“¬ÿ·≈–ºŸâªÉ«¬‚√§æ“√å°‘π —π ®“°°“√»÷°…“æ∫«à“ √âÕ¬≈– Ùˆ.Û ¢ÕßºŸâ ŸßÕ“¬ÿ„πª√–‡∑»‰∑¬¡’ªí≠À“°“√ πÕπÀ≈—∫Ú „π¢≥–∑’ËºŸâªÉ«¬‚√§æ“√å°‘π —πª√–¡“≥√âÕ¬≈– ˆ-˘¯Û,Ù ®–¡’ª≠ í À“‡√◊ÕË ß°“√πÕπÀ≈—∫Õ¬à“ßπâÕ¬ Ò ª√–‡¿∑ ‡™à π Õ“°“√πÕπ‰¡à À ≈— ∫ (insomnia) Õ“°“√º‘ ¥ ª√°μ‘ ∑“ß°“√‡§≈◊ËÕπ‰À«∑“ß√à“ß°“¬ Õ“√¡≥å æƒμ‘°√√¡ √–À«à“ß °“√πÕπÀ≈—∫ (parasomnia) Õ“°“√ßà«ßπÕπ¡“°°«à“ª√°μ‘ „π‡«≈“°≈“ß«—π (excessive daytime sleepiness) Õ“°“√ πÕπ°√π (snoring) Õ“°“√Ωíπ√â“¬ (nightmares) Õ“°“√ ª«¥ªí “«–„π‡«≈“°≈“ß§◊π (nocturia) À“°π”§«“¡™ÿ° ¢Õßªí≠À“°“√πÕπÀ≈—∫∑—ÈßÀ¡¥¡“‡ª√’¬∫‡∑’¬∫°—∫§πª√°μ‘ ®–æ∫«à“ºŸâªÉ«¬‚√§æ“√å°‘π —π¡’ªí≠À“°“√πÕπÀ≈—∫¡“°°«à“ §πª√°μ‘∂÷ß 1.5-3 ‡∑à“Û-ı Õ“°“√πÕπÀ≈—∫∑’Ëº‘¥ª√°μ‘ πÕ°®“°®–°àÕ„Àâ‡°‘¥ªí≠À“μàÕ°‘®«—μ√ª√–®”«—π·≈â« ¬—ß ∑”≈“¬§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬‡À≈à“π’È‡ªìπÕ¬à“ß¡“° ¥—ßπ—Èπ À“°·æ∑¬åºŸâ√—°…“‰¥â∑√“∫∂÷ß§«“¡™ÿ°¢Õßªí≠À“¥—ß°≈à“« °Á ®– “¡“√∂ àß‡ √‘¡·≈–æ—≤π“§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬‚√§ æ“√å°‘π —π‰¥âÕ¬à“ß¡’§ÿ≥¿“æμàÕ‰ª

‡ªìπ°“√»÷°…“¿“§μ—¥¢«“ß„πºŸâªÉ«¬‚√§æ“√å°‘π —π ∑’Ë ‡ ¢â “ ∑”°“√√— ° …“∑’Ë À πà « ¬μ√«®ºŸâ ªÉ « ¬πÕ°ª√– “∑«‘ ∑ ¬“ ‚√ßæ¬“∫“≈∏√√¡»“ μ√å‡©≈‘¡æ√–‡°’¬√μ‘ ®”π«π ˜Ù §π ∑’Ë‡¢â“√—∫°“√√—°…“„π™à«ß‡¥◊Õπ ¡‘∂ÿπ“¬π æ.». ÚııÚ ∂÷ß ‡¥◊Õπ∏—π«“§¡ æ.». ÚııÚ À≈—ß®“°ºŸâªÉ«¬‰¥â√—∫∑√“∫√“¬ ≈–‡Õ’¬¥ «—μ∂ÿª√– ß§å ¢—ÈπμÕπ°“√«‘®—¬ ºŸâªÉ«¬∑’Ë¬‘π¬Õ¡‡¢â“ √à«¡°“√«‘®—¬®–‰¥â√—∫°“√μ√«®√à“ß°“¬‡æ◊ËÕª√–‡¡‘π√–¬–¢Õß ‚√§μ“¡ Modified Hoehn and Yahr Staging Õ∫∂“¡√“¬ ≈–‡Õ’¬¥‡°’Ë¬«°—∫Õ“°“√¢Õß‚√§ °“√√—°…“ ·≈–√–¥—∫§«“¡ “¡“√∂„π°“√™à«¬‡À≈◊Õμπ‡Õß¢ÕßºŸªâ «É ¬‚√§æ“√å°π‘ —πμ“¡ Schwab & England Activities of Daily Living Scale ‚¥¬ ·æ∑¬åºŸâ‡™’Ë¬«™“≠∑“ßª√– “∑«‘∑¬“ ®“°π—ÈπºŸâªÉ«¬∑’Ë‡¢â“√à«¡ °“√«‘®—¬®–‰¥â√—∫·∫∫ Õ∫∂“¡ Ú ™ÿ¥ ‡°’Ë¬«°—∫§ÿ≥¿“æ™’«‘μ ·≈–ªí ≠ À“°“√πÕπÀ≈— ∫ ‚§√ß°“√«‘ ®— ¬ ‡√◊Ë Õ ßπ’È ‰ ¥â ºà “ π §«“¡‡ÀÁπ™Õ∫®“°§≥–Õπÿ°√√¡°“√®√‘¬∏√√¡°“√«‘®—¬„π§π ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√«‘®—¬ ª√–°Õ∫¥â«¬·∫∫ Õ∫ Ú ™ÿ¥‰¥â·°à Ò. ·∫∫ Õ∫∂“¡§«“¡º‘ ¥ ª√°μ‘ ¢ Õß°“√πÕπ À≈—∫„πºŸâªÉ«¬‚√§æ“√å°‘π —π©∫—∫ª√—∫ª√ÿß¿“…“‰∑¬®”π«π Ò˘ ¢âÕ (Modified Parkinson's Disease Sleep Scale; MPDSS)ˆ ´÷Ëß¡’§”∂“¡‡æ‘Ë¡‡μ‘¡ Ù ¢âÕ®“°·∫∫ Õ∫∂“¡§«“¡º‘¥ª√°μ‘ ¢Õß°“√πÕπÀ≈—∫„πºŸâªÉ«¬‚√§æ“√å°‘π —π©∫—∫¿“…“‰∑¬ ®”π«π Òı ¢âÕ (Parkinson's Disease Sleep Scale; PDSS) °“√„ÀâπÈ”Àπ—°„π§”∂“¡·μà≈–¢âÕ„™â«‘∏’ visual analog scale (Ò-Ò) ‚¥¬§–·ππ∑’ËμË”°«à“ ˆ „π·μà≈–¢âÕ· ¥ß∂÷ßªí≠À“ °“√πÕπÀ≈—∫„π≈—°…≥–π—ÈπÊ˜ Ú. ·∫∫ Õ∫∂“¡§ÿ ≥ ¿“æ™’ «‘ μ ¢ÕßºŸâ ªÉ « ¬‚√§ æ“√å°‘π —π©∫—∫¿“…“‰∑¬®”π«π ¯ ¢âÕ (Parkinson's Disease Questionnaire; PDQ8) º≈√«¡¢Õß§–·ππ∑—ÈßÀ¡¥ (-Ò) ®–∂Ÿ°π”¡“„™â„π°“√ª√–‡¡‘π§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬‚¥¬√«¡ ‚¥¬§–·ππ√«¡∑’Ë Ÿß· ¥ß∂÷ß§ÿ≥¿“æ™’«‘μ∑’Ë‰¡à¥’

«—μ∂ÿª√– ß§å¢Õß°“√«‘®—¬ Ò. ‡æ◊ËÕ»÷°…“§«“¡™ÿ°¢Õßªí≠À“°“√πÕπÀ≈—∫ ª√–‡¿∑μà“ßÊ „πºŸâªÉ«¬‚√§æ“√å°‘π —π Ú. ‡æ◊ËÕ»÷°…“§«“¡ —¡æ—π∏å¢Õß§ÿ≥¿“æ™’«‘μ·≈– ªí≠À“°“√πÕπÀ≈—∫¢ÕßºŸâªÉ«¬‚√§æ“√å°‘π —π

°“√«‘‡§√“–Àå∑“ß ∂‘μ‘ «‘‡§√“–Àå¢Õâ ¡Ÿ≈¥â«¬‚ª√·°√¡ SPSS Version Ò˜. ∂‘μ‘æ◊Èπ∞“π ‰¥â·°à §à“√âÕ¬≈– §à“‡©≈’Ë¬ ·≈–§à“§«“¡‡∫’Ë¬ß ‡∫π¡“μ√∞“π °“√«‘‡§√“–ÀåÀ“§à“§«“¡·μ°μà“ß¢Õß¢âÕ¡Ÿ≈

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

‚¥¬ ∂‘μ‘·∫∫ T-test ·≈–°“√«‘‡§√“–Àå§«“¡ —¡æ—π∏å¢Õß ¢âÕ¡Ÿ≈¥â«¬ Simple ·≈– Multiple linear regression analysis §à“π—¬ ”§—≠∑“ß ∂‘μ‘ (§à“æ’ < .ı)

º≈°“√»÷°…“ °“√»÷°…“π’¡È º’ ªŸâ «É ¬‡¢â“√à«¡°“√»÷°…“∑—ßÈ À¡¥ ˜Ù √“¬ ‡ªìπ‡æ»™“¬ ÛÛ √“¬ (√âÕ¬≈– ÙÙ.ˆ) ‡æ»À≠‘ß ÙÒ √“¬ (√âÕ¬≈– ıı.Ù) Õ“¬ÿ‡©≈’Ë¬ ± §à“‡∫’Ë¬ß‡∫π¡“μ√∞“π ‡∑à“°—∫ ˜.˘˘ ± ˘.ıˆ ªï (Ù¯-˘ı ªï) ºŸâªÉ«¬®”π«π ˆ˘ √“¬ (√âÕ¬≈– ˘Û.Ú) ‰¡à‰¥âª√–°Õ∫Õ“™’æ ºŸâªÉ«¬ à«π„À≠à

167

ı¯ √“¬ (√âÕ¬≈– ˜¯.Ù) “¡“√∂„™â ‘∑∏‘‡∫‘°§à“√—°…“ æ¬“∫“≈‰¥â ºŸâªÉ«¬‡√‘Ë¡¡’Õ“°“√¢Õß‚√§æ“√å°‘π —π‡¡◊ËÕÕ“¬ÿ ‡©≈’Ë¬ ˆ˜.ÚÛ ± Ò.Úı ªï ºŸâªÉ«¬∑’Ë‡¢â“√à«¡°“√»÷°…“¡’ Õ“°“√¢Õß‚√§æ“√å°‘π —π¡“·≈â«‡©≈’Ë¬ Û.˜ı ± Û.ÒÒ ªï ºŸâªÉ«¬¡’§«“¡ “¡“√∂„π°“√™à«¬‡À≈◊Õμπ‡Õßμ“¡ Schwab & England ADL ‡©≈’Ë¬‡∑à“°—∫ ˜Ú.Û ± Ò˘.Ú˜ (Ò-˘) ¡’ √–¬–°“√¥”‡π‘π¢Õß‚√§æ“√å°π‘ —πμ“¡ Modified Hoehn and Yahr ‡©≈’Ë¬‡∑à“°—∫ Ú.Òˆ ± Ò.Ù (Ò-ı) ·≈–¡’§–·ππ ‡©≈’Ë¬®“°·∫∫ Õ∫∂“¡§ÿ≥¿“æ™’«‘μ PDQ-8 ‡∑à“°—∫ Ú˘.ıÙ ± ÚÒ.Û (μ“√“ß∑’Ë Ò)

μ“√“ß∑’Ë Ò ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâ‡¢â“√à«¡°“√»÷°…“ §ÿ≥ ¡∫—μ‘ ‡æ»™“¬ ‡æ»À≠‘ß Õ“¬ÿ (ªï) ª√–°Õ∫Õ“™’æª√–®”‰¥â ‡∫‘°§à“√—°…“‰¥â Õ“¬ÿ∑’Ë‡√‘Ë¡¡’Õ“°“√ (ªï) √–¬–‡«≈“∑’ËªÉ«¬ (ªï) Schwab & England ADL Scale Modified Hoehn and Yahr PDQ-8

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Ù¯-˘ı ı (ˆ.¯) ı¯ (˜¯.Ù)

ˆ˜.ÚÛ (Ò.Úı) Û.˜ı (Û.ÒÒ) ˜Ú.Û (Ò˘.Ú˜) Ú.Òˆ (Ò.Ù) Ú˘.ıÙ (ÚÒ.Û)

®“°ºŸâ‡¢â“√à«¡°“√»÷°…“∑—ÈßÀ¡¥ ‡ªìπºŸâªÉ«¬„À¡à´÷Ëß ‰¥â√—∫°“√«‘π‘®©—¬‚√§æ“√å°‘π —π‡ªìπ§√—Èß·√° ÒÛ √“¬ (√âÕ¬≈– Ò˜.ˆ) ®“°ºŸªâ «É ¬∑’‡Ë §¬‰¥â√∫— °“√√—°…“ ºŸªâ «É ¬®”π«π Ú˘ √“¬ (√âÕ¬≈– Û˘.Ò˘) ‰¥â√—∫°“√√—°…“¥â«¬¬“√—°…“‚√§ æ“√å°‘π —π‡æ’¬ß™π‘¥‡¥’¬« ºŸâªÉ«¬®”π«π ˆ √“¬ (√âÕ¬≈– ¯Ò.¯) ‰¥â√—∫°“√√—°…“¥â«¬¬“ levodopa ºŸâªÉ«¬®”π«π ÚÒ √“¬ (√âÕ¬≈– Ú¯.Û¯) ‰¥â√—∫¬“„π°≈ÿà¡ dopamine agonists ºŸâªÉ«¬®”π«π ÒÒ √“¬ (√âÕ¬≈– ÒÙ.¯ˆ) ‰¥â√—∫¬“„π°≈ÿà¡ COMT inhibitors ºŸâªÉ«¬®”π«π Ò √“¬ (√âÕ¬≈– Ò.Ù) ‰¥â √—∫¬“ Selegiline ·≈–ºŸâªÉ«¬®”π«π ˜ √“¬ (√âÕ¬≈– ˘.ı) ‰¥â √—∫¬“„π°≈ÿ¡à anticholinergics πÕ°®“°π’¬È ß— æ∫ºŸªâ «É ¬®”π«π ˜ √“¬ (√âÕ¬≈– ˘.ı) ‰¥â√—∫¬“√—°…“‚√§ ¡Õß‡ ◊ËÕ¡ ºŸâªÉ«¬

ÙÛ-˘Û -Òˆ.Úı Ò-˘ Ò-ı  - Ò

®”π«π Ò √“¬ (√âÕ¬≈– ÒÛ.ı) ‰¥â√—∫¬“™à«¬πÕπÀ≈—∫ æ∫ º≈¢â“ß‡§’¬ß∑“ß°“√‡§≈◊ÕË π‰À«®“°°“√√—°…“ (motor complications) ∑—ÈßÀ¡¥ Òı √“¬ (√âÕ¬≈– Ú) ‚¥¬¿“«–∑’Ëæ∫ ¡“°∑’Ë ÿ¥ ‰¥â·°à ¿“«–¬“À¡¥ƒ∑∏‘Ï°àÕπ‡«≈“ (wearing off) √âÕ¬≈– ˆˆ.˜ ¿“«–¬ÿ°¬‘° (peak dose dyskinesia) √âÕ¬≈– ÛÛ.Û ¿“«–¬“‰¡àÕÕ°ƒ∑∏‘Ï (dose failure) √âÕ¬≈– Ú. ·≈–¿“«– unpredictable off √âÕ¬≈– ˆ.˜ (μ“√“ß∑’Ë Ú) ªí≠À“Õ◊ËπÊ∑’ËπÕ°‡Àπ◊Õ®“°°“√‡§≈◊ËÕπ‰À«∑’ËºŸâ‡¢â“√à«¡°“√ »÷°…“√–∫ÿ·°à·æ∑¬å ‰¥â·°à Õ“°“√∑âÕßºŸ°®”π«π Ùˆ √“¬ (√âÕ¬≈– ˆÚ.Ú) ªí≠À“¥â“π°“√πÕπ·≈–πÕπ‰¡àÀ≈—∫ ÛÒ √“¬ (√âÕ¬≈– ÙÒ.˘) Õ“°“√Àπâ“¡◊¥‡«’¬π»’√…–‡«≈“‡ª≈’Ë¬π ∑à“∑“ß Úı √“¬ (√âÕ¬≈– ÛÛ.¯) (μ“√“ß∑’Ë Û)

168 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ μ“√“ß∑’Ë Ú ¢âÕ¡Ÿ≈°“√√—°…“‚√§æ“√å°‘π —π¢ÕßºŸâ‡¢â“√à«¡°“√»÷°…“ §ÿ≥ ¡∫—μ‘

®”π«π (√âÕ¬≈–)

ºŸâªÉ«¬„À¡à √—°…“¥â«¬¬“‡æ’¬ßÀπ÷Ëß™π‘¥ ¬“√—°…“‚√§æ“√å°‘π —π∑’Ë√—∫ª√–∑“π - Levodopa

ÒÛ (Ò˜.ˆ) Ú˘ (Û˘.Ú)

- Dopamine agonists - COMT inhibitors - MAOB inhibitor (Selegiline) - Anticholinergics ¬“Õ◊ËπÊ - Anti dementia drugs - Sedating agents º≈¢â“ß‡§’¬ß∑“ß°“√‡§≈◊ËÕπ‰À« - Wearing off - Peak dose dyskinesia - Dose failure - Unpredictable off

ÚÒ (Ú¯.Ù) ÒÒ (ÒÙ.˘) Ò (Ò.Ù) ˜ (˘.ı)

ˆ (¯Ò.Ò)

˜ (˘.ı) Ò (ÒÛ.ı) Òı (Ú) Ò (ˆˆ.˜) ı (ÛÛ.Û) Û (Ú.) Ò (ˆ.˜)

μ“√“ß∑’Ë Û Õ“°“√πÕ°‡Àπ◊Õ®“°Õ“°“√∑“ß°“√‡§≈◊ËÕπ‰À«∑’ËºŸâªÉ«¬À√◊Õ≠“μ‘√“¬ß“π·æ∑¬å Õ“°“√ ∑âÕßºŸ° πÕπ‰¡àÀ≈—∫ μ◊Ëπßà“¬ Àπâ“¡◊¥ ‡«’¬π»’√…–‡«≈“‡ª≈’Ë¬π∑à“∑“ß ªí≠À“‡√◊ËÕß§«“¡®” ÕàÕπ‡æ≈’¬ ‡Àπ◊ËÕ¬ßà“¬ §≈◊Ëπ‰ â Õ“‡®’¬π °“√√—∫§«“¡√Ÿâ ÷°∑’Ëº‘¥ª√°μ‘ ´÷¡‡»√â“ ¿“æÀ≈Õπ Õ“°“√∑“ß®‘μª√– “∑ Õ“°“√Õ◊ËπÊ

®”π«π (√âÕ¬≈–) Ùˆ (ˆÚ.Ú) ÛÒ (ÙÒ.˘) Úı (ÛÛ.¯) ÒÙ (Ò¯.˘) ÒÒ (ÒÙ.˘) ¯ (Ò.¯) ˜ (˘.ı) Ù (ı.Ù) Ù (ı.Ù) Ú (Ú.¯)

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

º≈ ”√«®·∫∫ Õ∫∂“¡ªí≠À“°“√πÕπÀ≈—∫¢Õß ºŸâªÉ«¬‚√§æ“√å°‘π —π MPDSS ¡’ºŸâμÕ∫·∫∫ Õ∫∂“¡§√∫∑—Èß Ò˘ ¢âÕ∑—Èß ‘Èπ ˜Û §π §‘¥‡ªìπ√âÕ¬≈– ˘¯.ˆ ®“°º≈μÕ∫·∫∫ Õ∫∂“¡æ∫«à“¡’ ºŸªâ «É ¬∑’¡Ë ª’ ≠ í À“‡√◊ÕË ß°“√πÕπÀ≈—∫Õ¬à“ßπâÕ¬ Ò ª√–‡¿∑∂÷ß ˜Ò √“¬ (√âÕ¬≈– ˘˜.Û) ªí≠À“°“√πÕπÀ≈—∫∑’Ëæ∫¡“°∑’Ë ÿ¥ ı

169

Õ—π¥—∫·√° ‰¥â·°à ªí≠À“‡√◊ËÕß°“√ª«¥ªí “«–°≈“ß¥÷° √âÕ¬≈– ˆÛ ªí≠À“πÕπ‰¡àÀ≈—∫ μ◊πË ßà“¬ √âÕ¬≈– ıÛ.Ù ªí≠À“ °“√πÕπ°√π √âÕ¬≈– Ùˆ.ˆ ªí≠À“∑“ß°“√‡§≈◊ËÕπ‰À«™à«ß μ◊ËππÕπ √âÕ¬≈– Ùı.Ú ·≈–ªí≠À“Õ“°“√°√– —∫°√– à“¬ √–À«à“ß°“√πÕπÀ≈—∫√âÕ¬≈– ÙÚ.ı (√Ÿª∑’Ë Ò)

√Ÿª∑’Ë Ò ·ºπ¿Ÿ¡‘·∑àß· ¥ß§«“¡™ÿ°‡ªìπ√âÕ¬≈–¢ÕßºŸâªÉ«¬∑’Ë¡’ªí≠À“∑“ß°“√πÕπÀ≈—∫„π·μà≈–À—«¢âÕ

√Ÿª∑’Ë Ú °√“ø‡ âπ· ¥ß§–·ππ‡©≈’Ë¬ PDSS / MPDSS „π·μà≈–À—«¢âÕ°—∫°“√»÷°…“„πª√–‡∑»Õ◊ËπÊ

170 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ §–·ππ√«¡¢Õß·∫∫ Õ∫∂“¡ PDSS ·≈– MPDSS ®“°°“√»÷°…“π’È‡∑à“°—∫ ˘˘.ˆ˜ ± Úˆ.ˆÚ ·≈– ÒÛÒ.˜ ± ÛÒ.Ò §–·ππ PDSS ‡©≈’Ë¬„π·μà≈–¢âÕ¡’§à“ „°≈â‡§’¬ß°—∫°“√°“√»÷°…“„πª√–‡∑»Õ◊ËπÊ¯-ÒÒ ´÷Ëß¡’§«“¡ ·μ°μà “ ß®“°§–·ππ√«¡·≈–§–·ππ„π·μà ≈ –¢â Õ ¢Õß ·∫∫ Õ∫∂“¡ PDSS „πºŸâ ŸßÕ“¬ÿ∑—Ë«‰ªÒ (√Ÿª∑’Ë Ú) ‡¡◊ËÕ ∑”°“√»÷°…“À“§«“¡ —¡æ—π∏å√–À«à“ßªí≠À“°“√πÕπÀ≈—∫ ®“°·∫∫ Õ∫∂“¡ MPDSS °—∫ªí®®—¬μà“ßÊ æ∫«à“ §«“¡ “¡“√∂„π°“√∑”ß“π¢ÕßºŸªâ «É ¬ (§à“æ’ = .ÒÚ, r = .Ú˘)

¿“«–¬“À¡¥ƒ∑∏‘Ï°àÕπ‡«≈“ (wearing off) (§à“æ’ = .ÙÙ, r = -.ÚÛ) ·≈–§–·ππ§ÿ≥¿“æ™’«μ‘ ®“°·∫∫ Õ∫∂“¡ PDQ8 (§à“æ’ <.Ò, r = -.ıÚ) ¡’§«“¡ —¡æ—π∏å°—∫§–·ππ ®“°·∫∫ Õ∫∂“¡ MPDSS Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ ·≈– ‡¡◊ËÕπ”§«“¡ —¡æ—π∏å¡“«‘‡§√“–Àå‚¥¬√«¡ ¥â«¬«‘∏’ Multiple linear regression æ∫«à“¡’‡æ’¬ß§–·ππ§ÿ≥¿“æ™’«‘μ®“° ·∫∫ Õ∫∂“¡ PDQ-8 ·≈–§«“¡ “¡“√∂„π°“√∑”ß“π¢Õß ºŸâªÉ«¬∑’Ë¬—ß§ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘

μ“√“ß∑’Ë Ù ªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏å§–·ππ¢Õß·∫∫ Õ∫∂“¡ MPDSS ªí®®—¬ Õ“¬ÿ ‡æ»À≠‘ß §«“¡ “¡“√∂„π°“√∑”ß“πª√–®” √—°…“¥â«¬ Levodopa √—°…“¥â«¬ Dopamine agonist √–¬–‡«≈“∑’ËªÉ«¬‡ªìπ‚√§æ“√å°‘π —π ¿“«– Motor complications ¡’ªí≠À“ wearing off ¡’ªí≠À“ peak dose dyskinesia Schwab & England ADL Modified Hoehn & Yahr PDQ-8 score

Simple linear regression Coefficients P-value .Ûˆ .ÒÛÒ .Ú˘Ò .ıÒ -.ˆ -.ı˘ -.Ò˜ˆ -.ÚÛ˜ -.ÒÒ .ÒÛÙ -.Ò¯ı -.ıÚÛ

Õ¿‘ª√“¬º≈ ®“°º≈°“√«‘®—¬· ¥ß„Àâ‡ÀÁπ«à“ ªí≠À“°“√πÕπ À≈—∫„πºŸâªÉ«¬‚√§æ“√å°‘π —π‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬ ·≈– æ∫‰¥â¡“°°«à“ªí≠À“°“√πÕπÀ≈—∫„πºŸâ ŸßÕ“¬ÿ∑—Ë«‰ª ¡’ §«“¡ —¡æ—π∏å°∫— √–¥—∫§ÿ≥¿“æ™’«μ‘ ªí≠À“∑“ß°“√‡§≈◊ÕË π‰À« ·≈–§«“¡ “¡“√∂„π°“√∑”ß“π¢ÕßºŸâªÉ«¬ ·∫∫ Õ∫∂“¡ MPDSS ‡ªìπ·∫∫ Õ∫∂“¡∑’Ë§√Õ∫§≈ÿ¡∂÷ßªí≠À“°“√πÕπ À≈—∫‰¥â∑ÿ°ª√–‡¿∑ „™â«‘∏’°“√«—¥¥â«¬ visual analogue scale ´÷Ëß¡’§«“¡≈–‡Õ’¬¥ Ÿß ®÷ß∑”„Àâ “¡“√∂§—¥°√Õß·≈–μ√«®æ∫ §«“¡™ÿ°¢Õßªí≠À“°“√πÕπÀ≈—∫„πºŸâªÉ«¬‚√§æ“√å°‘π —π ®“°°“√»÷°…“π’È‰¥â∂÷ß√âÕ¬≈– ˘˜.Û

.˜ˆÚ .Úˆ¯ .ÒÚ .ˆ˜Ò .˘ˆÛ .ˆ˘Ò .ÒÛ˜ .ÙÙ .Û˘Ù .Úı˜ .ÒÒ˜ <.Ò

Multiple linear regression Coefficients P-value

.ÚÙÚ

.Ò˜

-.ÒıÛ

.ÒÛ˜

-.ÙıÙ

<.Ò

ªí≠À“ª«¥ªí “«–°≈“ß¥÷°‡ªìπªí≠À“∑’Ëæ∫‰¥â ∫à Õ¬∑’Ë ÿ ¥ æ∫‰¥â √â Õ¬≈– ˆÛ „πºŸâªÉ «¬‚√§æ“√å °‘π — π Õ¥§≈âÕß°—∫º≈°“√»÷°…“„πª√–‡∑»μà“ßÊ√«¡∂÷ß„πºŸâªÉ«¬ Ÿ ß Õ“¬ÿ ∑—Ë « ‰ª¯-ÒÒ Õ“°“√ª«¥ªí “«–∫àÕ¬°≈“ß¥÷°Õ“®¡’ “‡Àμÿ ¡ “®“°√–¥— ∫ “√‚¥ª“¡’ π ´÷Ë ß ¡’ à « π™à « ¬„π°“√ §«∫§ÿ¡°“√∑”ß“π¢Õß°√–‡æ“–ªí “«–∑’Ë≈¥≈ßÒÚ §«“¡ √Ÿâ ÷°ªí “«–‰¡à ÿ¥¢≥–∑’ËºŸâªÉ«¬¡’Õ“°“√·¢Áß‡°√Áß ¿“«– √–∫∫ª√– “∑‡ √’∑”ß“π∫°æ√àÕß ´÷Ëß¡—°æ∫„πºŸâªÉ«¬‚√§ æ“√å°‘π —π∑’Ë¡’√–¬–‡«≈“¥”‡π‘π‚√§¡“π“πÒÛ,ÒÙ À√◊ÕÕ“®‡°‘¥ ®“° “‡ÀμÿÕ◊ËπÊ ∑’Ëæ∫√à«¡‰¥â„πºŸâ ŸßÕ“¬ÿ ‡™àπ ¿“«–μàÕ¡≈Ÿ° À¡“°‚μ ¿“«–°≈â“¡‡π◊ÈÕ™àÕß‡™‘ß°√“πÀ¬àÕπ¬“π ¿“«–μ‘¥ ‡™◊ÈÕ„π∑“ß‡¥‘πªí “«– ‚√§‡∫“À«“π ‡ªìπμâπ

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ªí≠À“πÕπ‰¡àÀ≈—∫ μ◊Ëπßà“¬‡ªìπªí≠À“∑’Ëæ∫‰¥â ∫àÕ¬‡ªìπ≈”¥—∫∑’Ë Õß æ∫‰¥â√âÕ¬≈– ıÛ.Ù ‡ª√’¬∫‡∑’¬∫°—∫ √âÕ¬≈– Ù.ˆ „πºŸâ ŸßÕ“¬ÿ∑—Ë«‰ªÒı ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§«“¡‰« ¢Õßªí≠À“°“√πÕπ‰¡àÀ≈—∫ μ◊Ëπßà“¬ ∑’Ë‰¥â®“°°“√ Õ∫∂“¡ ºŸâ ªÉ « ¬‡¡◊Ë Õ ºŸâ ªÉ « ¬æ∫·æ∑¬å ·≈–·∫∫ Õ∫∂“¡ MPDSS æ∫«à“·∫∫ Õ∫∂“¡ MPDSS “¡“√∂· ¥ßªí≠À“¿“«– πÕπ‰¡àÀ≈—∫ μ◊Ëπßà“¬‰¥â¡“°¢÷Èπ∂÷ß√âÕ¬≈– ÒÒ.ı · ¥ß„Àâ ‡ÀÁπ«à“·∫∫ Õ∫∂“¡ MPDSS ¡’§«“¡‰«„π°“√√–∫ÿ¿“«– πÕπ‰¡à À ≈— ∫ μ◊Ë π ßà “ ¬‰¥â ¥’ ° «à “ ®“°°“√ Õ∫∂“¡ºŸâ ªÉ « ¬ ‚¥¬μ√ß πÕ°®“°ªí≠À“°“√πÕπÀ≈—∫∑’Ëæ∫¡“°„πºŸâªÉ«¬ ‚√§æ“√å°‘π —π·≈â« ®“°·∫∫ Õ∫∂“¡¢âÕ∑’Ë Ò · ¥ß„Àâ‡ÀÁπ «à“ ºŸâªÉ« ¬‚√§æ“√å °‘π — π √âÕ ¬≈– Û˘.˜ ¬— ß ¡’ªí ≠ À“¥â “ π §ÿ≥¿“æ°“√πÕπÀ≈—∫‚¥¬√«¡√à«¡¥â«¬ ªí≠À“°“√πÕπ°√π ‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬‡ªìπ ≈”¥—∫∑’ Ë “¡ æ∫‰¥â√Õâ ¬≈– Ùˆ.ˆ ‡ª√’¬∫‡∑’¬∫°—∫√âÕ¬≈– ÚÙ.ˆ „πºŸâ Ÿ ß Õ“¬ÿ ∑—Ë « ‰ªÒı Õ“°“√πÕπ°√π¡’§«“¡ —¡æ—π∏å°—∫ ¿“«–À¬ÿ¥À“¬„®¢≥–πÕπÀ≈—∫ (obstructive sleep apnea) ªí®®ÿ∫—π¬—ß‰¡à∑√“∫∂÷ß°≈«‘∏“π∑’Ë™—¥‡®π¢ÕßÕ“°“√πÕπ°√π „πºŸâªÉ«¬‚√§æ“√å°‘π —π ·μà‡™◊ËÕ«à“‡°‘¥®“°°“√·¢Áß‡°√Áß¢Õß °≈â “ ¡‡π◊È Õ ∫√‘ ‡ «≥∑“ß‡¥‘ π À“¬„® à « π∫π ·≈–¡’ § «“¡ — ¡ æ— π ∏å °— ∫ √–¥— ∫ ¢Õß “√‚¥ª“¡’ π ·≈–‡´‚√‚∑π‘ π „π √–∫∫ª√– “∑ à«π°≈“ßÒˆ,Ò˜ ¿“«–πÕπ°√π ·≈–À¬ÿ¥ À“¬„®√–À«à“ßπÕπÀ≈—∫‡ªìπ “‡ÀμÿÀπ÷Ëß´÷Ëßπ”¡“ Ÿà§«“¡º‘¥ ª√°μ‘¢Õß°“√πÕπÀ≈—∫ª√–‡¿∑μà“ßÊ μ“¡¡“ ‡¡◊Ë Õ æ‘ ® “√≥“º≈°“√«‘ ‡ §√“–Àå § «“¡ — ¡ æ— π ∏å ‚ ¥¬ √«¡¢Õßªí®®—¬μà“ßÊ μàÕ§–·ππ¢Õß·∫∫ Õ∫∂“¡ MPDSS æ∫«à “ §«“¡ “¡“√∂„π°“√∑”ß“πª√–®” ·≈–√–¥— ∫ §ÿ≥¿“æ™’«‘μ∑’Ë«—¥®“°§–·ππ·∫∫ Õ∫∂“¡ PDQ-8 ‡ªìπ ªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠ ‚¥¬ºŸâªÉ«¬∑’Ë∑”ß“π ‡ªìπª√–®”·≈–ºŸâªÉ«¬∑’Ë¡’§ÿ≥¿“æ™’«‘μ∑’Ë¥’ ®–¡’ªí≠À“°“√ πÕπÀ≈—∫∑’ËπâÕ¬°«à“ “‡Àμÿ§«“¡ —¡æ—π∏å¢Õß°“√∑”ß“πμàÕ °“√πÕπÀ≈—∫ Õ“®Õ∏‘∫“¬‰¥â®“°°≈ÿà¡ºŸâªÉ«¬∑’Ë “¡“√∂∑”ß“π ª√–®”‰¥â ¡’Õ“¬ÿ Õ“°“√·≈–§«“¡√ÿπ·√π¢Õß‚√§∑’ËπâÕ¬°«à“ πÕ°®“°π’ºÈ ªŸâ «É ¬∑’¬Ë ß— ∑”ß“πÕ¬Ÿ¡à °— ®–μâÕß∑”ß“π„π‡«≈“°≈“ß«—π ·≈–‡¢â“πÕπ„π‡«≈“°≈“ß§◊π ∑”„Àâ¡°’ “√πÕπÀ≈—∫∑’‡Ë ªìπ‡«≈“ ¡Ë”‡ ¡Õ¡“°°«à“ºŸâªÉ«¬∑’Ë‰¡à‰¥â∑”ß“π ‡¡◊ËÕæ‘®“√≥“·∫∫ Õ∫∂“¡§ÿ≥¿“æ™’«‘μ PDQ-8 æ∫«à“‰¡à¡§’ ”∂“¡„¥∑’‡Ë °’¬Ë «¢âÕß°—∫ªí≠À“°“√πÕπÀ≈—∫‚¥¬μ√ß §”∂“¡ à«π„À≠à¡ÿàß‡πâπ‰ª∑’Ëªí≠À“∑“ß°“√‡§≈◊ËÕπ‰À«‡ªìπ ”§—≠ ¥—ßπ—Èπ°“√∑’Ëº≈°“√«‘®—¬æ∫§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠√–À«à“ß·∫∫ Õ∫∂“¡∑—Èß Õß · ¥ß„Àâ‡ÀÁπ«à“ªí®®—¬

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∑—Èß Õß¡’§«“¡ —¡æ—π∏å´÷Ëß°—π·≈–°—π πÕ°®“°ªí≠À“°“√ πÕπÀ≈—∫·≈â« ¬—ßæ∫«à“ºŸâª«É ¬√âÕ¬≈– ˆÚ ¡’ªí≠À“‡√◊ËÕß∑âÕß ºŸ° ∂à“¬Õÿ®®“√–≈”∫“° ·≈–ºŸâªÉ«¬√âÕ¬≈– ÛÛ ¡’ªí≠À“‡√◊ËÕß Àπâ“¡◊¥ ‡«’¬π»’√…–¢≥–‡ª≈’Ë¬π∑à“∑“ß√à«¡¥â«¬ ´÷Ëßªí≠À“ ‡À≈à“π’È· ¥ß∂÷ß°“√∑”ß“π¢Õß√–∫∫ª√– “∑‡ √’∑’Ë∫°æ√àÕß ¥—ßπ—Èπ·æ∑¬å§«√„Àâ§«“¡ ”§—≠°—∫ªí≠À“∑’ËπÕ°‡Àπ◊Õ®“° ªí≠À“∑“ß°“√‡§≈◊ÕË π‰À« ‡™àπªí≠À“°“√πÕπÀ≈—∫∑’ºË ¥‘ ª√°μ‘ ªí≠À“∑âÕßºŸ° ªí≠À“Õ“°“√Àπâ“¡◊¥ ‡«’¬π»’√…– √à«¡¥â«¬ ‡π◊ËÕß®“°‡ªìπªí≠À“∑’Ë¡’§«“¡ —¡æ—π∏å°—∫§ÿ≥¿“æ™’«‘μ¢Õß ºŸâªÉ«¬‚√§æ“√å°‘π —π∑’Ë ”§—≠

√ÿª ªí ≠ À“°“√πÕπÀ≈— ∫ æ∫‰¥â ∫à Õ ¬„πºŸâ ªÉ « ¬‚√§ æ“√å°‘π —π ·≈–¡’§«“¡ —¡æ—π∏å°—∫√–¥—∫§ÿ≥¿“æ™’«‘μ ¿“«– ª«¥ªí “«–°≈“ß¥÷°‡ªìπªí≠À“∑’Ëæ∫‰¥â∫àÕ¬∑’Ë ÿ¥ ºŸâªÉ«¬ §«√‰¥â√∫— °“√ª√–‡¡‘πªí≠À“°“√πÕπÀ≈—∫¥â«¬·∫∫ Õ∫∂“¡ MPDSS ‡π◊ËÕß®“°¡’§«“¡‰«·≈–§«“¡≈–‡Õ’¬¥μàÕªí≠À“°“√ πÕπÀ≈—∫„π≈—°…≥–μà“ßÊ¡“°°«à“ ºŸâªÉ«¬∑’Ë¡’§ÿ≥¿“æ„π°“√ πÕπÀ≈— ∫ ∑’Ë ¥’ ® – à ß ‡ √‘ ¡ „Àâ ¡’ §ÿ ≥ ¿“æ™’ «‘ μ ∑’Ë ¥’ ¢÷È π √à « ¡¥â « ¬ ¥—ßπ—πÈ °“√„Àâ§«“¡ ”§—≠μàÕ§ÿ≥¿“æ¢Õß°“√πÕπÀ≈—∫ √—°…“ ¿“«–°“√πÕπÀ≈—∫∑’Ëº‘¥ª√°μ‘ ·≈– àß‡ √‘¡ ÿ¢≈—°…≥–¢Õß °“√πÕπÀ≈—∫∑’Ë¥’ ®– “¡“√∂™à«¬‡æ‘Ë¡√–¥—∫§ÿ≥¿“æ™’«‘μ„Àâ °—∫ºŸâªÉ«¬‰¥â πÕ°®“°π’È ·æ∑¬åºŸâ¥Ÿ·≈√—°…“§«√„Àâ§«“¡ ”§—≠μà Õªí≠À“∑’ËπÕ°‡Àπ◊Õ‰ª®“°ªí≠À“∑“ß°“√‡§≈◊ËÕπ ‰À«Õ◊ËπÊ ·≈–μ—Èß‡ªìπ‡ªÑ“À¡“¬∑’Ë ”§—≠„π°“√√—°…“ºŸâªÉ«¬ ‚√§æ“√å°‘π —πμàÕ‰ª

172 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ¿“§ºπ«° °. ·∫∫ Õ∫∂“¡ PDQ-8 ©∫—∫¿“…“‰∑¬ ®“°°“√ªÉ«¬‡ªìπ‚√§æ“√å°‘π —π §ÿ≥ª√– ∫°—∫ªí≠À“μàÕ‰ªπ’È∫àÕ¬·§à‰Àπ„π™à«ßÀπ÷Ëß‡¥◊Õπ∑’Ëºà“π¡“ ? §”∂“¡ Ò. ¡’§«“¡¬“°≈”∫“°„π°“√‰ª‰Àπ¡“‰Àπ„π∑’Ë “∏“√≥–? Ú. ¡’§«“¡¬“°≈”∫“°„π°“√·μàßμ—« ? Û. √Ÿâ ÷°‡»√â“ ? Ù. ¡’ªí≠À“°—∫ºŸâ¡’§«“¡ —¡æ—π∏å„°≈â™‘¥°—∫§ÿ≥ ? ı. ¡’ªí≠À“‡°’Ë¬«°—∫ ¡“∏‘¢Õß§ÿ≥‡™àπ ‡«≈“Õà“πÀπ—ß ◊ÕÀ√◊Õ¥Ÿ‚∑√∑—»πå ? ˆ. √Ÿâ ÷°‰¡à “¡“√∂ ◊ËÕ “√°—∫ºŸâ§π‰¥âÕ¬à“ß‡À¡“– ¡ ? ˜. ¡’Õ“°“√‡®Á∫ª«¥®“°°≈â“¡‡π◊ÈÕ‡ªìπμ–§√‘«À√◊Õ‡°√Áßμ—« ? ¯. √Ÿâ ÷°Õ—∫Õ“¬„π∑’Ë “∏“√≥–‡π◊ËÕß®“°‡ªìπ‚√§æ“√å°‘π —π ?

ªí≠À“ Mobility ADL Emotional well-being Social support Cognitions Communication Bodily discomfort Stigma

¢. ·∫∫ Õ∫∂“¡ MPDSS ·≈–§«“¡ —¡æ—π∏å°—∫ªí≠À“°“√πÕπÀ≈—∫™π‘¥μà“ßÊ §”∂“¡

ªí≠À“°“√πÕπÀ≈—∫

Ò. §ÿ≥¿“æ°“√πÕπÀ≈—∫μÕπ°≈“ß§◊π‚¥¬√«¡¢Õß∑à“π ‡ªìπÕ¬à“ß‰√ ? Overall quality of sleep Ú. ∑à“π¡’°“√πÕπÀ≈—∫¬“°μÕπ°≈“ß§◊πÀ√◊Õ‰¡à? Sleep onset and maintenance Û. ∑à“π¡’Õ“°“√πÕπÀ≈—∫‰¡à π‘∑ μâÕßμ◊Ëπ¢÷Èπ¡“°≈“ß¥÷°∫àÕ¬À√◊Õ‰¡à? Sleep onset and maintenance Ù. ∑à“π¡’Õ“°“√·¢π¢“Õ¬Ÿà‰¡àπ‘Ëß™Õ∫¢¬—∫‰ª¡“À√◊Õ°√–μÿ°®π∑”„ÀâÀ≈—∫‰¡à π‘∑À√◊Õ‰¡à? Nocturnal restlessness ı. ¢≥–Õ¬Ÿà∫π‡μ’¬ß§ÿ≥√Ÿâ ÷°ßÿàπßà“π °√– —∫°√– à“¬À√◊Õ‰¡à? Nocturnal restlessness ˆ. ∑à“π√Ÿâ ÷°∑√¡“π°—∫°“√Ωíπ√â“¬μÕπ°≈“ß§◊π®πμâÕßμ◊Ëπ°≈“ß¥÷°À√◊Õ‰¡à? Nocturnal psychosis ˜. ∑à“π√Ÿâ ÷°∑√¡“π°—∫°“√‰¥â¬‘πÀ√◊Õ‡ÀÁπ„π ‘Ëß∑’Ë§πÕ◊Ëπ‰¡à‡ÀÁπÀ√◊Õ‰¡à‰¥â¬‘π? Nocturnal psychosis ¯. ∑à“πμâÕßμ◊Ëπ¡“ªí “«–°≈“ß¥÷°À√◊Õ‰¡à? Nocturia ˘. ∑à“π¡’°“√°≈—Èπªí “«–‰¡àÕ¬Ÿà‡æ√“–‰¡à “¡“√∂‡§≈◊ËÕπ‰À«‰ª‡¢â“ÀâÕßπÈ”‰¥âÀ√◊Õ‰¡à? Nocturia Ò. ∑à“π¡’Õ“°“√™“À√◊Õ√Ÿâ ÷°√–¬‘∫√–¬—∫μ“¡·¢π¢“ ∑”„ÀâμâÕßμ◊Ëπ°≈“ß¥÷°À√◊Õ‰¡à? Nocturnal motor symptoms ÒÒ. ∑à“π¡’°“√ª«¥‡°√Áß°≈â“¡‡π◊ÈÕ·¢πÀ√◊Õ™“¢≥–πÕπÀ≈—∫À√◊Õ‰¡à? Nocturnal motor symptoms ÒÚ.∑à“π¡’°“√μ◊ËπμÕπ‡™â“„π∑à“∑’Ëª«¥·¢πÀ√◊Õ¢“À√◊Õ‰¡à? Nocturnal motor symptoms ÒÛ. ¢≥–μ◊ËπμÕπ‡™â“∑à“π¡’Õ“°“√ —ËπÀ√◊Õ‰¡à? Nocturnal motor symptoms ÒÙ. ∑à“π√Ÿâ ÷°ÕàÕπ‡æ≈’¬·≈–ßà«ßπÕπ‰¡à ¥™◊ËπÀ≈—ßμ◊ËππÕπμÕπ‡™â“À√◊Õ‰¡à? Sleep refreshment Òı. ∑à“π‡§¬À≈—∫‚¥¬‰¡à¡’Õ“°“√ßà«ßπ”¡“°àÕπ√–À«à“ß«—πÀ√◊Õ‰¡à? Daytime dozing Òˆ. ∑à“π¡’°“√πÕπ≈–‡¡Õ∑’ËÕ“®∑”√â“¬À√◊Õ‡ªìπÕ—πμ√“¬μàÕμπ‡ÕßÀ√◊ÕºŸâ¥Ÿ·≈À√◊Õ‰¡à? REM behavioral disorder* REM behavioral disorder* Ò˜. ∑à“πæ∫∫“¥·º≈À√◊Õ√Õ¬ø°™È”À≈—ßμ◊ËππÕπ‚¥¬‰¡à∑√“∫ “‡ÀμÿÀ√◊Õ‰¡à? Ò¯. ∑à“π‡§¬πÕπÀ≈—∫¢≥–∑”°‘®°√√¡∑’ËμâÕß„™â ¡“∏‘ ‡™àπ¢—∫√∂ À√◊Õ‰¡à? Sudden onset of sleep* Ò˘. ∑à“ππÕπ°√πÀ√◊Õ‰¡à? Snoring* * §”∂“¡∑’Ë‡æ‘Ë¡‡μ‘¡¡“®“°·∫∫ Õ∫∂“¡ PDSS

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‡Õ° “√Õâ“ßÕ‘ß Ò. de Rijk MC, Breteler MM, Graveland GA, et al. Prevalence of Parkinson's disease in the elderly: the Rotterdam Study. Neurology 1995;45:2143-6. Ú. Sukying C, Bhokakul V, Udomsubpayakul U. An epidemiological study on insomnia in an elderly Thai population. J Med Assoc Thai 2003;86:316-24. Û. Kumar S, Bhatia M, Behari M. Sleep disorders in Parkinson's disease. Mov Disord 2002;17:775-81. Ù. Tandberg E, Larsen JP, Karlsen K. A communitybased study of sleep disorders in patients with Parkinson's disease. Mov Disord 1998;13:895-9. ı. van Hilten JJ, Weggeman M, van der Velde EA, Kerkhof GA, van Dijk JG, Roos RA. Sleep, excessive daytime sleepiness and fatigue in Parkinson's disease. J Neural Transm Park Dis Dement Sect 1993;5:235-44. ˆ. Tanasanvimon S, Ayuthaya NI, Phanthumchinda K. Modified Parkinson's Disease Sleep Scale (MPDSS) in Thai Parkinson's disease patients. J Med Assoc Thai 2007;90:2277-83. ˜. Chaudhuri KR, Martinez-Martin P. Clinical assess ment of nocturnal disability in Parkinson's disease: the Parkinson's Disease Sleep Scale. Neurology 2004;63:S17-20. ¯. Wang G, Cheng Q, Zeng J, et al. Sleep disorders in Chinese patients with Parkinson's disease: validation study of a Chinese version of Parkinson's disease sleep scale. J Neurol Sci 2008;271:153-7. ˘. Suzuki K, Okuma Y, Hattori N, et al. Characteris tics of sleep disturbances in Japanese patients with Parkinson's disease. A study using Parkinson's disease sleep scale. Mov Disord 2007;22:1245-51.

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Ò. Chaudhuri KR, Pal S, DiMarco A, et al. The Parkinson's disease sleep scale: a new instrument for assessing sleep and nocturnal disability in Parkinson's disease. J Neurol Neurosurg Psychiatry 2002;73:629-35. ÒÒ. Martinez-Martin P, Salvador C, Menendez-Guisasola L, et al. Parkinson's Disease Sleep Scale: validation study of a Spanish version. Mov Disord 2004;19:122632. ÒÚ. Yoshimura N, Mizuta E, Yoshida O, Kuno S. Therapeutic effects of dopamine D1/D2 receptor agonists on detrusor hyperreflexia in 1-methyl4-phenyl-1,2,3,6-tetrahydropyridine-lesioned parkinsonian cynomolgus monkeys. J Pharmacol Exp Ther 1998;286:228-33. ÒÛ. Singer C, Weiner WJ, Sanchez-Ramos JR. Auto nomic dysfunction in men with Parkinson's disease. Eur Neurol 1992;32:134-40. ÒÙ. Araki I, Kuno S. Assessment of voiding dysfunction in Parkinson's disease by the international prostate symptom score. J Neurol Neurosurg Psychiatry 2000;68:429-33. Òı. Tubtimtes S, Sukying C, Prueksaritanond S. Sleep problems in out-patient of primary care unit. J Med Assoc Thai 2009;92:273-8. Òˆ. Veasey SC, Panckeri KA, Hoffman EA, Pack AI, Hendricks JC. The effects of serotonin antagonists in an animal model of sleep-disordered breathing. Am J Respir Crit Care Med 1996;153:776-86. Ò˜. Braga-Neto P, da Silva-Junior FP, Sueli Monte F, de Bruin PF, de Bruin VM. Snoring and excessive daytime sleepiness in Parkinson's disease. J Neurol Sci 2004;217:41-5.

174 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ Abstract Quality of life and sleep-related problems in patients with Parkinsonûs disease at Thammasat University Hospital Praween Lolekha, Kongkiat Kulkantrakorn Department of Internal Medicine, Faculty of Medicine, Thammasat University Background:

Parkinson's disease (PD) is a neurobehavioral disorder defined clinically by its motor symp toms alone. Sleep disorders are behavioral problems that are common and under recognized. In addition, these problems have impact on patient well being and quality of life.

Objective:

To evaluate the prevalence of sleep-related problems in patient with PD and its association with the quality of life.

Material and Method: A cross sectional study in 74 PD patients was conducted at Thammasat University Hospital. Sleep problems and quality of life were assessed by the Modified Parkinson's Disease Sleep Scale (MPDSS) and Parkinson's Disease Questionnaire (PDQ-8) Results:

Sleep-related problems were found in 97% of PD patients. Nocturia, sleep initiation and maintenance problem and snoring were common. Sleep-related problems detected by MPDSS had significant correlation with PDQ-8 scores (p <0.001, r = -0.52), history of wearing off (p = 0.044, r = -0.23) and (p = 0.012, r = 0.29).

Conclusion:

Sleep-related problems are frequent in PD patients and associated with the patient's quality of life. The improvement of sleep and other non-motor aspects of PD should become an important target in the treatment of PD.

Key words:

Quality of life, Sleep disorders, Parkinson's disease

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∫∑§«“¡ª√‘∑—»πå

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177

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ŒÕ√å‚¡π‡æ» ·≈– æƒμ‘°√√¡∑“ß‡æ», ¢π“¥Õ«—¬«–‡æ»

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°“√ —¡º— “√‡®π‘ ∑’π·≈–‡¥¥´’π„π™à«ß μ—Èß§√√¿å¡’º≈∑”„Àâ‡°‘¥°“√Õ—°‡ ∫‡æ‘Ë¡¢÷Èπ

Yi et al., 2002Ò¯

Jefferson et al., 2002ÚÚ

Seibel et al., 2008ÚÙ

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√ÿª °“√√—∫ª√–∑“πÕ“À“√∑’Ë¡’ “√°≈ÿà¡‰Õ‚´ø≈“‚«π Ÿß¡’º≈∑“ß§≈‘π‘°∑—Èß„π·ßà¥’·≈–·ßà≈∫ ‚¥¬º≈∑“ß§≈‘π‘° „π·ßà¥’®“°°“√√—∫ª√–∑“πÕ“À“√∑’Ë¡’ “√°≈ÿà¡‰Õ‚´ø≈“‚«π Ÿß ®–æ∫¡“°„π«—¬ºŸâ ŸßÕ“¬ÿ „π∑“ß°≈—∫°—π º≈∑“ß§≈‘π‘° „π·ßà≈∫®“°°“√√—∫ª√–∑“πÕ“À“√∑’¡Ë ’ “√°≈ÿ¡à ‰Õ‚´ø≈“‚«π Ÿß ®–æ∫¡“°„π«—¬‡®√‘≠æ—π∏ÿå ‚¥¬ à«π¡“°®–‡ªìπº≈°“√ «‘®—¬„π —μ«å∑¥≈Õß ¥—ßπ—Èπº≈∑“ß‡«™°√√¡¢÷Èπ°—∫™à«ß«—¬¢Õß °“√‰¥â√∫— “√°≈ÿ¡à ‰Õ‚´ø≈“‚«π ‚¥¬ “√°≈ÿ¡à ‰Õ‚´ø≈“‚«π „πÕ“À“√¡’ª√–‚¬™πå°—∫ºŸâ ŸßÕ“¬ÿ ‚¥¬‡©æ“–À≠‘ß«—¬À¡¥ ª√–®”‡¥◊Õπ‡ªìπÕ¬à“ß¡“° ∑—Èßπ’ÈÕ“®‡π◊ËÕß®“°ºŸâ ŸßÕ“¬ÿ¡’ °“√º≈‘μ ŒÕ√å‚¡π‡æ»≈¥≈ß °“√√—∫ª√–∑“π “√‰ø‚μ‡Õ ‚μ√‡®π §≈â“¬°—∫‡ªìπ°“√ª√—∫ ¡¥ÿ≈¬å¢ÕßŒÕ√å‚¡π‡æ»„π√à“ß°“¬ ·≈–‡ªì π °“√‰¥â √— ∫ ŒÕ√å ‚ ¡π‡Õ ‚μ√‡®π®“°∏√√¡™“μ‘ ¡ “ ∑¥·∑πŒÕ√å‚¡π‡æ»„π√à“ß°“¬∑’Ë¢“¥À“¬‰ª Õ¬à“ß‰√°Áμ“¡ ª√–‚¬™πå¢Õß “√°≈ÿà¡‰Õ‚´ø≈“‚«π„π°≈ÿà¡Õ“¬ÿÕ◊Ëπ¬—ß‰¡à ™—¥‡®ππ—° ´÷Ëß§«√‰¥â√—∫°“√»÷°…“«‘®—¬„πª√–‡¥Áππ’È¡“°¢÷Èπ ‡æ◊ËÕ„Àâ‰¥â√—∫§”μÕ∫∑’Ë™—¥‡®π¢÷Èπ

°‘μμ‘°√√¡ª√–°“» ¢Õ¢Õ∫æ√–§ÿ≥»“μ√“®“√¬å ¥√.‰¡μ√’ ÿ∑∏®‘μμå ∑’Ë‰¥â ≈–‡«≈“„Àâ§”·π–π”„π°“√‡¢’¬π∫∑§«“¡

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

Siemonı, Art Therapy: Theory and Practice ‚¥¬ Paola Luzzattoˆ, »‘≈ª–‡æ◊ËÕ°“√∫”∫—¥ Ú : ¿“§∑ƒ…Æ’ ‚¥¬ ‡≈‘»»‘√‘√å ∫«√°‘μμ‘˜.

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

¢âÕæ÷ß —ß«√ Ò. π—°»‘≈ª°√√¡∫”∫—¥§«√‡≈◊Õ°„™â»‘≈ª«— ¥ÿ·≈– «‘∏’°“√∑’Ë‡À¡“– ¡°—∫Õ“¬ÿ·≈–§«“¡ “¡“√∂¢ÕßºŸâ√—∫∫√‘°“√ Ú. ª√–™“°√∑’Ë¡’°“√∫“¥‡®Á∫√ÿπ·√ß∑’Ë ¡Õß À√◊Õ ‚√§ª√– “∑Õ“®¡’§«“¡¬“°≈”∫“°„π°“√§âπÀ“ ¿“æ®‘μ„® ¢Õßμπ‡Õß‚¥¬°√–∫«π°“√»‘≈ª°√√¡∑’ËÕ“»—¬æ◊Èπ»—°¬¿“æ °“√∑”ß“π Õ¬à “ ß‰√°Á μ “¡ ª√–™“°√‡À≈à “ π’È ® –‰¥â √— ∫ ª√–‚¬™πå ® “°»‘ ≈ ª°√√¡∫”∫— ¥ „π¥â “ π∑’Ë ‡ °‘ ¥ °“√°√–μÿâ π Õ“√¡≥å§«“¡√Ÿâ ÷° ·≈–§«“¡‡æ≈‘¥‡æ≈‘π„®∑’Ë‰¥â√—∫®“°°“√ √—ß √√§åß“π»‘≈ª– Û. ¢≥–∑’ËºŸâ√—∫°“√∫”∫—¥∑”ß“π»‘≈ª–‚¥¬¡’À√◊Õ ‰¡à ¡’ π— ° ∫”∫— ¥ §Õ¬·π–°“√∑”ß“π ·μà ¢—È π μÕπ¢Õß°“√ μ’ § «“¡∫Õ°π— ¬ °“√· ¥ßÕÕ°∑“ß ¿“æ®‘ μ ∂◊ Õ ‡ªì π °√–∫«π°“√∑’ËμâÕß¡’π—°∫”∫—¥§Õ¬°”°—∫¥Ÿ·≈ Ù. π— ° ∫”∫— ¥ §«√„™â ° √–∫«π°“√»‘ ≈ ª°√√¡ ‡ªìπ°“√∫”∫—¥‡ √‘¡‡¡◊ËÕ„™â√à«¡°“√∫”∫—¥√—°…“¿“«–‡®Á∫ªÉ«¬ ∑“ß°“¬ ·≈–§«√‡¢â“„®«à“»‘≈ª°√√¡∫”∫—¥‡ªìπ®‘μ∫”∫—¥∑“ß ‡≈◊Õ° ∑’Ë‰¡à„™à°“√∫”∫—¥∑“ß‡≈◊Õ° ”À√—∫Õ“¬ÿ√°√√¡∑—Ë«‰ª

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®‘μ∫”∫—¥‚¥¬®‘μ·æ∑¬å‡¡◊ËÕÕ“¬ÿ ÚÙ ªï ¿“æ®‘μ‡æâÕΩíπ ·μ°·¬° — ∫ π¢Õß‡∏Õ ◊ ∫ ‡π◊Ë Õ ß®“°ª√– ∫°“√≥å ∑’Ë πà“¢¬–·¢¬ß„π«—¬‡¥Á° ·≈–¥â«¬§«“¡‡©≈’¬«©≈“¥‰¥â™à«¬„Àâ ‡∏Õ„™â°“√«“¥‡¢’¬π‡√’¬∫‡√’¬ß§«“¡‡æâÕΩíππÕ°®‘μ ”π÷°·≈– Õ—πμ√“¬μàÕ®‘μ„®®“°§«“¡∑√ß®”μ—Èß·μà°àÕπ«—¬æŸ¥ ®‘μ·æ∑¬å ‰¥â™à«¬ π—∫ πÿπ°“√μàÕ Ÿâ¢Õß‡∏Õ„Àâ “¡“√∂ª√—∫μ—«‡¢â“ Ÿà ‚≈°·Ààß§«“¡ªìπ®√‘ß Õ’«“‡ªìπ≈Ÿ°≈—∫Ê ¢Õß™“¬Õ◊Ëπ∑’Ë‰¡à„™à∫‘¥“ ‡∏Õ∂Ÿ° ¬Ë”¬’∑“ß‡æ»‚¥¬¡“√¥“μ‘¥¬“ ∫‘¥“·≈–‡æ◊ËÕπ¢Õß§√Õ∫§√—« ‡ªìπª√–®”μ—Èß·μà®”§«“¡‰¥â ·≈–¢“¥§«“¡ π„®¥Ÿ·≈®“° §√Õ∫§√—« Õ’«“‡¢’¬π¿“æ¡“μ≈Õ¥μ—Èß·μà‡ªìπ‡¥Á°‡≈Á° ∫—π∑÷° ª√– ∫°“√≥å¢Õß‡∏Õ‰«â„π¿“æ ‡∏Õ‡¢’¬π‰«âÀ≈“¬√âÕ¬¿“æ °à Õ πÀπâ “ ‡¢â “ √— ∫ ®‘ μ ∫”∫— ¥ ´÷Ë ß ‰¥â ™à « ¬ªÑ Õ ß°— π ‰¡à „ Àâ ∂Ÿ ° ª√– ∫°“√≥å„πÕ¥’μ§√Õ∫Õ¬à“ßÀ¡¥®¥ ‡¡◊ËÕÕ’«“π”¿“æ ‡¢’¬π¡“· ¥ß„π™—«Ë ‚¡ß∫”∫—¥ ‡∏Õ¬—ß‰¡à√§Ÿâ «“¡À¡“¬¢Õß¿“æ ®π°√–∑—Ëß‰¥âæŸ¥§ÿ¬ª√–μ‘¥ª√–μàÕ°—∫‡Àμÿ°“√≥å∑’Ë‡°‘¥¢÷Èπ ‡ªìπ‡√◊ÕË ß∑’πË “à ∑÷ßË ∑’ÕË «’ “À“¬ªÉ«¬∑—ßÈ ∑“ß°“¬·≈–®‘μ„® ‡π◊ÕË ß®“°æ√ «√√§å‚¥¬π—¬ —≠≈—°…≥å»≈‘ ª°√√¡¢Õß°“√¡’™«’ μ‘ °“√«“¥‡¢’¬π¿“æ‰¥â‡ªìπ∑’ËÕ“»—¬ ◊ËÕ “√°—∫μπ‡Õß ‡ªìπ∑’Ë ”À√—∫ºŸâ∑’Ë‰¡à§“¥§‘¥·≈–æŸ¥‰¡à‰¥â “¡“√∂‡ªìπμ—«μπ‰¥â ¿“æ«“¥¢Õß‡∏Õ √â“ß§«“¡ª√–∑—∫„®„π ‘Ëßº ¡º “π∑’Ë·¬° °—π‰¡àÕÕ° √–À«à“ß®‘πμ∑—»πå°“√√à«¡‡æ» §«“¡À¡°¡ÿπà °“√ ∫—ß§—∫„Àâ°√–∑”´È”Ê °—∫Õß§åª√–°Õ∫§«“¡∫√‘ ÿ∑∏‘Ïºÿ¥ºàÕß ª√“°Ø√à«¡°—π ß“π»‘≈ª°√√¡∑’Ë¡’√Ÿª≈—°…≥å´È”Ê °—π· ¥ß ∂÷ßÕÿ∫“¬°“√À≈∫À≈’°§«“¡‡®Á∫ª«¥∑’‡Ë ∏Õ§âπæ∫„π«—¬‡¥Á° ™à«¬ „Àâ‡∏Õ “¡“√∂∑π§«“¡‡®Á∫ª«¥·≈–§«“¡ –Õ‘¥ –‡Õ’¬π ¢≥–∂Ÿ°°√–∑”¬Ë”¬’ °√≥’¢ÕßÕ’«“™’È„Àâ‡ÀÁπ§«“¡®”‡ªìπ∑’Ëπ—°∫”∫—¥μâÕß „Àâ§«“¡ ”§—≠μàÕ‡π◊ÈÕÀ“∑—Èß∑’Ë‡°‘¥¢≥– ”π÷°·≈–πÕ° ”π÷° ∑’Ëª√“°Ø„πß“π»‘≈ª–¢ÕßºŸâªÉ«¬ ´÷Ëß‡ªìπ ‘Ëß‡™◊ËÕ¡‚¬ßÕ¬à“ß ‡¥’¬«°—∫§«“¡∑√ß®”„π«—¬‡¥Á°°àÕπæŸ¥ „πß“π»‘≈ª–Õ“®¡’ ¿“…“∑’Ë “¡“√∂∫àß∫Õ°∂÷ß ‘Ëß∑’Ë‡°‘¥¢÷Èπ∑—Èß∑’Ë·ª≈°ª√–À≈“¥ ªÉ“‡∂◊ËÕπ ‚À¥√â“¬∑“√ÿ≥ ‡ªìπ§«“¡º‘¥∑’ËÀ«ßÀâ“¡‰¡à„Àâ “¡“√∂¡’ μ‘ — ¡ ª™— ≠ ≠–∑’Ë ® –æŸ ¥ ß“π»‘ ≈ ª–®÷ ß ™à « ¬„Àâ “¡“√∂ª≈¥°“√ –°¥°—πÈ ∑–≈“¬°”·æß∑’ªË °ªÑÕß·≈–μàÕμâ“π ·≈–™à«¬‡ªî¥‡º¬§«“¡√Ÿâ ÷°ª«¥√â“«·≈–§«“¡∑√ß®”∑’Ë¢—¥·¬âß ∑”„Àâ “¡“√∂∫”∫—¥·°â‰¢„Àâ‡¢â“ Ÿà ÿ¢¿“æ®‘μ∑’Ë¥’‰¥â ·≈– »‘ ≈ ª°√√¡∫”∫— ¥ ¬— ß “¡“√∂‡ªì π ‘Ë ß ™à « ¬∑’Ë ∑ √ßæ≈— ß „π°“√ §«∫§ÿ ¡ ¡¥ÿ ≈ ∑“ßÕ“√¡≥å ∑’Ë “¡“√∂π”‰ª„™â ‡ √‘ ¡ ß“π ®‘μ∫”∫—¥·∫∫ π∑π“‰¥â¥â«¬

186 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ √“¬∑’Ë Û °≈ÿà¡‡¥Á°‡À¬◊ËÕπÈ”À≈“°¥‘π∂≈à¡˘ ‡¡◊ËÕ‡¥◊Õπæƒ…¿“§¡ æ.». ÚıÙ˘ ‡°‘¥Õÿ∫—μ‘¿—¬ ∏√√¡™“μ‘ √ÿ π ·√ß∑’Ë Õ”‡¿Õ≈— ∫ ·≈ ®— ß À«— ¥ Õÿ μ √¥‘ μ ∂å ¡’ ª√–™“™π∑âÕß∂‘Ëπ®”π«π¡“°‰¥â√—∫º≈°√–∑∫¥â“π∑√—æ¬å ‘π ∑’ËÕ¬ŸàÕ“»—¬ √à“ß°“¬·≈–®‘μ„® ®÷ß¡’Àπà«¬ß“πμà“ßÊ ‡¢â“‰ª „Àâ°“√™à«¬‡À≈◊Õ π—°«‘™“°“√π—°«‘®—¬®“°¡À“«‘∑¬“≈—¬∫Ÿ√æ“ ·≈–®“° ∂“∫—πæ—≤π“°“√‡¥Á°√“™π§√‘π∑√ °√¡ ÿ¢¿“æ®‘μ °√–∑√«ß “∏“√≥ ÿ ¢ ‰¥â √à « ¡°— π »÷ ° …“·≈–„™â ‡ ∑§π‘ § »‘ ≈ ª°√√¡∫”∫— ¥ ‡¥Á ° „π∑â Õ ß∑’Ë ∑’Ë ‰ ¥â √— ∫ º≈°√–∑∫∑“ß ®‘μ„®®“°‡Àμÿ°“√≥åπ—Èπ ¯ √“¬ (™“¬ ı §π, À≠‘ß Û §π) Õ“¬ÿ ˜ - ÒÙ ªï ∑’Ë¡’Õ“°“√∑“ß®‘μ·μà‰¡à√ÿπ·√ß¡“° ¬—ß‰¡à ®”‡ªìπμâÕß√—∫°“√√—°…“∑“ß®‘μ‡«™ √–‡∫’¬∫«‘∏’»÷°…“ª√–°Õ∫¥â«¬°“√μ√«®‡¬’Ë¬¡§√—Èß ·√°·≈–μ‘ ¥ μ“¡¥Ÿ ¿“æ®‘ μ ‚¥¬∫ÿ § ≈“°√®‘ μ ·æ∑¬å · ≈– π—°®‘μ«‘∑¬“ —ª¥“Àå≈–§√—Èß√«¡ ÒÚ §√—Èß √à«¡°—∫§≥– π—°«‘®‘μ√»‘≈ªá·≈–π—° “∏“√≥ ÿ¢∑’Ë™—°π”„Àâ‡¥Á°™ÿ¥‡¥’¬«°—π «“¥¿“æ‚¥¬Õ‘ √–„π™à«ß‡«≈“‡¥’¬«°—π ®“°º≈°“√»÷°…“ · ¥ß«à“°“√«“¥¿“æ¢Õß‡¥Á°‰¥â∑”„Àâ‡°‘¥º≈∫√√‡∑“Õ“°“√ ∑“ß®‘μ‰¥â™—¥‡®π„π‡¥Á°∑’Ë»÷°…“ ˜ √“¬®“° ¯ √“¬ §‘¥‡ªìπ √âÕ¬≈– ¯˜.ı

‡Õ° “√Õâ“ßÕ‘ß Ò. Ganim B. Art and healing: Using expressive art to heal your body, mind, and spirit. New York: Three Rivers Press; 1999. Ú. McNiff S. Art as medicine: creating a therapy of the imagination. Boston: Shambhala; 1992. Û. Kramer E. Art as therapy. Collected papers. Edited by Gerity LA. London and Philadelphia: Jessica Kingsley Publishers; 2000. Ù. Ulman E, Dachinger P, editors. Art therapy in theory and practice. New York: Schocken Books; 1975. ı. Franklin M, Siemon T. Toward an understanding of the fundamental healing and therapeutic qualities of Art. J Thai Tradit Alternat Med 2008;6:269-74. ˆ. Luzzatto P. Art therapy: theory and practice. A Brief Overview. J Health Systems Res 2009;3:292-6. ˜. ‡≈‘»»‘√√‘ å ∫«√°‘μμ‘. »‘≈ª–‡æ◊ÕË °“√∫”∫—¥ Ú : ¿“§∑ƒ…Æ’. «“√ “√«‘®—¬√–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ıÒÚ-¯. ¯. ‡≈‘»»‘√‘√å ∫«√°‘μμ‘ (ºŸâ·ª≈·≈–‡√’¬∫‡√’¬ß). »‘≈ª–‡æ◊ËÕ °“√∫”∫—¥ ‚¥¬ Õ’¥‘∏ ‡•√‡¡Õ√å. °√ÿß‡∑æœ : ”π—° æ‘¡æå°√ÿß‡∑æ‡«™ “√; ÚııÚ: ÛÛÒ Àπâ“. ˘. ‡≈‘»»‘√‘√å ∫«√°‘μμ‘, ª√–¿“ ‚ Ã ®‘π¥“-π—π∑«√»‘≈ªá, ¡—¬ ‘√∑‘ Õß∂“«√. »‘≈ª°√√¡∫”∫—¥‡¥Á°‡À¬◊ÕË πÈ”À≈“° ¥‘π∂≈à¡ ∑’ËÕ”‡¿Õ≈—∫·≈ ®—ßÀ«—¥Õÿμ√¥‘μ∂å. «“√ “√ «‘®—¬√–∫∫ “∏“√≥ ÿ¢ Úıı;Ò:ÛÒ˘-ÛÚ.

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Abstract Art Therapy in Practice Lertsiri Bovornkitti Faculty of Fine Art, Srinakharinwirot University Art Therapy has long been practiced in many countries, especially in the West, as an alternative means for treating mentally traumatized persons. However, it is not yet implemented rutinely in Thailand. Literally, it denotes the practice of utilizing art materials in the treatment of patients; the current term refers to the specific use of art creation in psychotherapy (莽art psychotherapy茅). The main objectives of treatment are the strengthening of indivdual creativity and the expression and elaboration of the patients没 thoughts and emotions. The visual art of drawing and painting are the most commonly practiced: sculpturing is a practical therapeutic form for dealing with blind patients. Patients没 creation of visual art, leading to non-verbal self disclosure,helps them get in touch with thoughts and feelings that are hidden from the conscious mind, the discipline of so-called expressive art therapy. This chapter furnishes a brief overview of art therapy practice in achieving therapeutic results. In practice, there are three main types of art therapy interventions: open studio, group art therapy, and individual art therapy. In order to facillitate the expression of the internal world, art therapy practice involves offering the patient a white page and the freedom to choose any art material, and to work within a silent and peaceful environment. Regarding the art therapeutic process, the three elements, namely, image-making, the elaboration of images, and the relationship with the art therapist, are inferconnected. They should never be used in isolation, and none of them should be forgotten in clinical practice. At this point, it must be stressed that the results of treatment rely upon the process of creation and not the finished art product

188 .

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∫∑π” °“√∑“√ÿ≥°√√¡‡¥Á°¡’ Ù √Ÿª·∫∫‰¥â·°à °“√∑”√â“¬ √à“ß°“¬ °“√∑”√â“¬®‘μ„® °“√∑”√â“¬∑“ß‡æ» ·≈–°“√≈–‡≈¬ ∑Õ¥∑‘Èß ‚¥¬∑—Ë«‰ªæ∫«à“‡¥Á°¡—°∂Ÿ°°√–∑”¥â«¬À≈“¬√Ÿª·∫∫ ª–ªπ°—π º≈¢Õß°“√∂Ÿ°°√–∑”‡À≈à“π’È °àÕ„Àâ‡°‘¥Õ—πμ√“¬ À√◊Õº≈‡ ’¬μàÕ√à“ß°“¬·≈–®‘μ„®¢Õß‡¥Á°∑—Èß„π√–¬– —Èπ·≈– √–¬–¬“« ·≈– àßº≈„Àâ‡°‘¥‡ªìπªí≠À“ —ß§¡μ“¡¡“Õ¬à“ß ¡“°¡“¬ ‡¥Á°∑’∂Ë °Ÿ ∑“√ÿ≥°√√¡ à«π„À≠à¡“æ∫·æ∑¬å∑·’Ë ºπ° ©ÿ°‡©‘π¥â«¬Õ“°“√∫“¥‡®Á∫∑“ß°“¬ ´÷Ëß‡ªìπº≈‚¥¬μ√ß®“° °“√∂Ÿ°∑”√â“¬√à“ß°“¬·≈–/À√◊Õ∑“ß‡æ» °“√∫“¥‡®Á∫π—ÈπÕ“® ¡’§«“¡√ÿπ·√ß∂÷ß¢—Èπ‡ ’¬™’«‘μ‰¥â À“°‰¡à‰¥â√—∫°“√√—°…“Õ¬à“ß ∑—π∑à«ß∑’ ¥—ßπ—Èπ °“√∑“√ÿ≥°√√¡‡¥Á°®÷ß®—¥‡ªìπ¿“«–©ÿ°‡©‘π Õ¬à“ßÀπ÷Ëß∑“ß®‘μ‡«™‡¥Á°·≈–«—¬√ÿàπÒ πÕ°‡Àπ◊Õ®“°°“√ „Àâ°“√√—°…“¿“«–‡√àß¥à«π∑“ß°“¬·≈â« ·æ∑¬å∑’ËªØ‘∫—μ‘ß“π„π ·ºπ°©ÿ°‡©‘π¬—ß‡ªìπºŸ¡â ’ «à π ”§—≠„π°“√™à«¬‡À≈◊Õ‡¥Á°„Àâ‡¢â“

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

Ú. ¡’ ° “√ à ß μà Õ ∑’ ¡ À«‘ ™ “™’ æ‚¥¬‡√Á « ∑’Ë ÿ ¥‚¥¬ ≈¥°√–∫«π°“√¢—ÈπμÕπ´—∫´âÕπ∑’Ë∑”„Àâ‡ ’¬‡«≈“ √«¡∂÷ß μâÕß¡’°“√™’È·®ß°—∫‡¥Á°∂÷ß§«“¡ ”§—≠ §«“¡®”‡ªìπ ·≈–¢—Èπ μÕπ¢Õß°“√„Àâ§«“¡™à«¬‡À≈◊Õ Û. „Àâ°“√ª√–§—∫ª√–§Õß¥â“π®‘μ„® ”À√—∫°“√ª√–§—∫ª√–§Õß¥â“π®‘μ„® ·æ∑¬å·≈– ∑’¡ºŸ√â °— …“μâÕß¡’∑»— π§μ‘·≈–∑à“∑’‡™‘ß∫«°√«¡∂÷ß°“√‰¡àμ¥— ‘π (non-judgmental) μàÕ‡¥Á°·≈–≠“μ‘ ª√–°Õ∫°—∫¡’∑—°…– °“√ ◊ËÕ “√∑’Ë¥’ ‚¥¬‡π◊ÈÕÀ“°“√´—°ª√–«—μ‘§«√¡ÿàß‡πâπ‰ª∑’Ë ‡Àμÿ°“√≥å °“√°√–∑” º≈∑’Ë‡°‘¥¢÷Èπ°—∫‡¥Á° ·≈–·π«∑“ß°“√ ™à«¬‡À≈◊Õ‡ªìπÀ≈—° ¡“°°«à“°“√æ¬“¬“¡ ◊∫ «π Õ∫ «π ‡æ◊ËÕÀ“μ—«ºŸâ°√–∑”¡“≈ß‚∑…‚¥¬‡√Á« ´÷Ëß°√–∫«π°“√¥—ß°≈à“« §«√‡ªìπÀπâ“∑’ËÀ≈—°¢Õßμ”√«® °“√æ¬“¬“¡§“¥§—Èπ À√◊Õ¡ÿàß ‡πâπ‡æ’¬ß·μà®–À“ºŸâ°√–∑”º‘¥‚¥¬∑’¡ºŸâ∫”∫—¥√—°…“‡Õß ®– àßº≈‡ ’¬μàÕ°“√ √â“ß —¡æ—π∏¿“æ·≈–°“√‰¥â¢âÕ¡Ÿ≈∑’Ë·∑â®√‘ß ´÷Ëß®–°√–∑∫μàÕ§«“¡√à«¡¡◊Õ·≈–º≈°“√∫”∫—¥√—°…“‡¥Á° ·≈–§√Õ∫§√—«„π‡«≈“μàÕ¡“ ∑—°…–°“√øíßÕ¬à“ßμ—Èß„® ‡™àπ ¡’°“√ ∫μ“‡ªìπ√–¬– æ¬—°Àπâ“ àß‡ ’¬ßμÕ∫ πÕßÕ¬à“ß‡À¡“– ¡ ‡ªî¥‚Õ°“ „Àâ ‡¥Á°‰¥â‡≈à“Õ¬à“ßÕ‘ √– ‰¡à∂“¡π”·≈–‰¡àæŸ¥¢—¥®—ßÀ«–‡¥Á° ‡ªìπ ∑—°…–°“√ ◊ËÕ “√Õ¬à“ßÀπ÷Ëß∑’Ë ”§—≠·≈–·æ∑¬å®”‡ªìπμâÕß¡’ ‡æ◊Ë Õ ™à « ¬„Àâ‡¥Á°‡°‘¥§«“¡√Ÿâ ÷°ª≈Õ¥¿—¬ ‰«â«“ß„® ·≈–¡’ ‚Õ°“ ‰¥â√–∫“¬§«“¡√Ÿâ ÷°Ò ´÷ËßÕ“®∂◊Õ‰¥â«à“‡ªìπ™à«ß‡«≈“ ¢Õß°“√∫”∫—¥√—°…“ (therapeutic session) ‰ª„πμ—«¥â«¬ πÕ°®“°π’È°“√æŸ¥‡æ◊ËÕª√–§—∫ª√–§Õß®‘μ„®®–™à«¬ „Àâ‡¥Á° “¡“√∂ ß∫ §≈“¬§«“¡À«“¥°≈—« «‘μ°°—ß«≈ À√◊Õ ‰¡à ∫“¬„®‰¥â ·æ∑¬å§«√„Àâ§«“¡¡—Ëπ„®°—∫‡¥Á°‚¥¬¡’‡π◊ÈÕÀ“ „π°“√ ◊ËÕ “√ ¥—ßμàÕ‰ªπ’ÛÈ ● ‡ªìπ‡√◊ËÕß∑’Ë¥’¡“°∑’Ë‡¥Á°‰¥â‡≈à“‡√◊ËÕß°“√∂Ÿ°∑”√â“¬ „Àâøíß ● ‡™◊Õ Ë „π ‘ßË ∑’‡Ë ¥Á°‡≈à“®√‘ßÊ (‰¡à§¥‘ «à“‡ªìπ‡√◊ÕË ß‚°À° §‘¥‰ª‡Õß À√◊Õ‰√â “√–) ● ®–æ¬“¬“¡„Àâ ¡ “°∑’Ë ÿ ¥ ∑’Ë ® –™à « ¬ªÑ Õ ß°— π‰¡à „ Àâ °“√∑”√â“¬π’È‡°‘¥¢÷Èπ°—∫‡¥Á°Õ’° ● °“√∑”√â “ ¬∑’Ë ‡ °‘ ¥ ¢÷È π‰¡à‰¥â‡ªìπ§«“¡º‘¥¢Õß‡¥Á° ·≈–∫Õ°‡¥Á°¥â«¬«à“ ·¡â§π‡√“®–‚μ‡ªìπºŸâ„À≠à·≈â« ∫“ß§√—Èß °Á¬—ß∑”º‘¥ ∑”‰¡à¥’‰¥â (°“√∫Õ°‡™àππ’È‡æ◊ËÕ„Àâ‡¥Á°≈¥§«“¡ √Ÿâ ÷°º‘¥ ‰¡à§‘¥‚∑…μπ‡Õß «à“μπ‡Õß‡ªìπ§π‡≈« ∑”º‘¥ ®÷ß ¡§«√∂Ÿ°≈ß‚∑…√ÿπ·√ß)

¡’‡¥Á°§πÕ◊ËπÊ ∑’Ë‡§¬∂Ÿ°°√–∑”‡™àπ°—π ·μà„π ∑’ Ë ¥ÿ æ«°‡¢“°Áº“à π‡√◊ÕË ß√“«√â“¬Ê π—πÈ ‰ª‰¥â (‡æ◊ÕË ∑”„Àâ‡¥Á°‡°‘¥ °”≈—ß„®·≈–Õÿàπ„®«à“§πÕ◊Ëπ°Á‡§¬‡®ÕÕ¬à“ßμ—«‡Õß·≈– “¡“√∂ ºà“π¡—π‰ª‰¥â) ● ®”‡ªìπ∑’Ë®–μâÕß∫Õ°°—∫ºŸâ„À≠à∫“ß§π‡æ◊ËÕ∑’Ë‡¢“ ‡À≈à“π—Èπ®–‰¥â™à«¬„Àâ‡¥Á°ª≈Õ¥¿—¬ ∑—ßÈ π’°È “√„Àâ§«“¡¡—πË „®„π‡√◊ÕË ß¥—ß°≈à“«μâÕß∑”‰ª¥â«¬ §«“¡ª√“√∂π“¥’Õ¬à“ß®√‘ß„® ‡ªìπ‰ªμ“¡∏√√¡™“μ‘ Õ¥§≈âÕß °—∫∫ÿ§≈‘° ∑à“∑’ ¿“…“æŸ¥ ·≈– ¿“…“°“¬ ¢Õß·æ∑¬å¥â«¬ ‡ªÑ“À¡“¬ Ÿß ÿ¥¢Õß°“√¥Ÿ·≈‡¥Á°∑’Ë∂Ÿ°∑“√ÿ≥°√√¡ ‚¥¬∑’¡ À«‘™“™’æμâÕßÕ“»—¬°√–∫«π°“√§ÿ¡â §√Õß ™à«¬‡À≈◊Õ ·≈–∫”∫—¥øóπô øŸ Õ¬à“ß‡ªìπÕß§å√«¡·≈–§√Õ∫§≈ÿ¡∑ÿ°¡‘μ‘ ‡æ◊ÕË π”‰ª Ÿà Ò) °“√„Àâ‡¥Á°‰¥â√—∫§«“¡ª≈Õ¥¿—¬ ‰¡à∂Ÿ°°√–∑”´È” Ú) ‰¥â√—∫°“√«‘π‘®©—¬·≈–√—°…“¿“«–§«“¡º‘¥ª√°μ‘∑“ß°“¬ ·≈–®‘μ„® ∑’‡Ë °‘¥¢÷πÈ À√◊Õ‡ªìπº≈°√–∑∫®“°°“√∂Ÿ°∑“√ÿ≥°√√¡ π—Èπ ·≈– Û) ‡æ◊ËÕ„Àâ‡¥Á°‰¥â¡’æ—≤π“°“√∑ÿ°Ê ¥â“π‰ªμ“¡∑’Ë §«√®–‡ªìπ‡μÁ¡»—°¬¿“æ¢Õßμπ‡ÕßÚ ¥—ßπ—Èπ ·æ∑¬å·≈–∑’¡ ºŸâ√—°…“∑’Ë·ºπ°©ÿ°‡©‘π ´÷Ëß¡—°‡ªìπª√–μŸ¥à“π·√°¢Õß°“√ §âπæ∫ªí≠À“·≈–„Àâ°“√™à«¬‡À≈◊Õ‡∫◊ÈÕßμâπ ®÷ß¡’∫∑∫“∑ ”§— ≠ ¬‘Ë ß ∑’Ë ® –™à « ¬ à ß ‡ √‘ ¡„Àâ ° “√¥Ÿ · ≈‡¥Á ° ∂Ÿ ° ∑“√ÿ ≥ °√√¡ “¡“√∂∫√√≈ÿ‡ªÑ“À¡“¬¥—ß°≈à“«‰¥â ●

√ÿª ·æ∑¬å∑’ËªØ‘∫—μ‘ß“π„π·ºπ°©ÿ°‡©‘π¡’ à«π ”§—≠„π °√–∫«π°“√™à«¬‡À≈◊Õ·≈–§ÿâ¡§√Õß‡¥Á°∂Ÿ°∑“√ÿ≥°√√¡ ‚¥¬ ¡’∫∑∫“∑À≈—° Ú ª√–°“√§◊Õ „Àâ°“√«‘π‘®©—¬Õ¬à“ß√«¥‡√Á« (early detection) ·≈– „Àâ°“√√—°…“‡∫◊ÕÈ ßμâπ (initial management) ·°à‡¥Á°∑—Èß¥â“π °“¬ ®‘μ —ß§¡ „π·ßà°“√¥Ÿ·≈ ¥â“π®‘μ —ß§¡ ·æ∑¬å§«√‰¥â¢âÕ¡Ÿ≈®“° °“√´—°ª√–«—μ‘ °“√ μ√«®ª√–‡¡‘π≈—°…≥– æàÕ·¡à/ºŸâª°§√Õß ·≈–°“√μ√«® ª√–‡¡‘π≈—°…≥–°“√· ¥ßÕÕ° √«¡∂÷ß ¿“æ®‘μ„®¢Õß‡¥Á° ·≈â«π”‰ªª√–°Õ∫°—∫À≈—°∞“π°“√μ√«®√à“ß°“¬ ‡æ◊ËÕ™à«¬„π °“√«‘π‘®©—¬¿“«–∑“√ÿ≥°√√¡‡¥Á° à«π°“√„Àâ§«“¡™à«¬‡À≈◊Õ ‡∫◊ÈÕßμâπ ª√–°Õ∫¥â«¬ °“√„Àâ°“√√—°…“Õ“°“√∑“ß®‘μ‡«™ °“√ àßμàÕ∑’¡ À«‘™“™’æ‚¥¬‡√Á« ·≈–°“√ª√–§—∫ª√–§Õß ¥â“π®‘μ„® ´÷ËßμâÕßÕ“»—¬∫√√¬“°“»∑’Ë‡À¡“– ¡ ∑—»π§μ‘∑’Ë¥’ μàÕ‡¥Á°·≈–§√Õ∫§√—« μ≈Õ¥®π¡’∑—°…–°“√ ◊ËÕ “√∑’Ë¡’ ª√– ‘∑∏‘¿“æ

192 .

‡Õ° “√Õâ“ßÕ‘ß Ò. ª√“‚¡∑¬å ÿ§π‘™¬å. ¿“«–©ÿ°‡©‘π∑“ß®‘μ‡«™‡¥Á°. „π: «‘π—¥¥“ ªî¬–»‘≈ªá, æπ¡ ‡°μÿ¡“π, ∫√√≥“∏‘°“√. μ”√“®‘μ‡«™‡¥Á°·≈–«—¬√ÿàπ. °√ÿß‡∑æ¡À“π§√: ∫’¬Õπ¥å ‡Õπ‡∑Õ√å‰æ√´å, ÚıÙı:ÛÒ˘-Ú¯. Ú. »√’‡«’¬ß ‰æ‚√®πå°≈ÿ . °“√æ‘ ®Ÿ πå°“√∑“√ÿ≥°√√¡·≈–∑Õ¥∑‘ßÈ ‡¥Á°. „π: ¡Ÿ≈π‘∏‘»Ÿπ¬åæ‘∑—°…å ‘∑∏‘‡¥Á°. §Ÿà¡◊ÕªØ‘∫—μ‘ß“π ¢Õß∑’¡ À«‘™“™’æ„π°√–∫«π°“√§ÿ¡â §√Õß‡¥Á°. °√ÿß‡∑æ¡À“π§√: ¡Ÿ≈π‘∏»‘ πŸ ¬åæ∑‘ °— …å ∑‘ ∏‘‡¥Á°, ÚıÙ˜:Û-ÒÛ. Û. Lask B, Taylor S and Nunn KP. The maltreated child. In: Lask B, Taylor S and Nunn KP eds. Practical Child Psychiatry: The clinicianûs guide. London: BMJ Publishing, 2003:209-23. Ù. ª√‘™«—π ®—π∑√å»‘√‘. Child Maltreatment. „π: «‘π—¥¥“ ªî¬–»‘≈ªá, æπ¡ ‡°μÿ¡“π. ∫√√≥“∏‘°“√. μ”√“®‘μ‡«™ ‡¥Á°·≈–«—¬√ÿàπ ‡≈à¡ Ú. °√ÿß‡∑æ¡À“π§√: ∫’¬Õπ¥å ‡Õπ‡∑Õ√å‰æ√´å, Úıı:Òı-ˆˆ. ı. Õ—¡æ≈ ŸÕ”æ—π. °“√°√–∑”∑“√ÿ≥·≈–∑Õ¥∑‘Èß‡¥Á°. „π: «—≥‡æÁ≠ ∫ÿ≠ª√–°Õ∫, Õ—¡æ≈ ŸÕ”æ—π, πßæß“ ≈‘¡È ÿ«√√≥ ∫√√≥“∏‘°“√. ®‘μ‡«™‡¥Á° ”À√—∫°ÿ¡“√·æ∑¬å (©∫—∫ ª√—∫ª√ÿß). °√ÿß‡∑æ¡À“π§√: ™«πæ‘¡æå, Ò˘˘-ÚÒ.

ˆ. Goodman R, Scott S. Child maltreatment. In: Goodman R, Scott S editors. Child psychiatry. Oxford: Blackwell Science, 2005:169-84. ˜. Robert E, Laumann-Billings E&L. Child Abuse. In: Rutter M, Taylor E, editors. Child and Adolescent Psychiatry. 4th ed. Oxford: Blackwell Science, 2002:325-39. ¯. Budd KS. Assessing parenting competence in child protection cases: a clinical practice model. Clin Child Fam Psychol Rev, 2001;4:1-18. ˘. Glaser D. Child Sexual Abuse. In: Rutter M, Taylor E, editors Child and Adolescent Psychiatry. 4th ed. Oxford: Blackwell Science, 2002: 340-58. Ò. ≥—∑∏√ æ‘∑¬√—μπå‡ ∂’¬√. Counseling. „π: «‘π—¥¥“ ªî¬–»‘≈ªá, æπ¡ ‡°μÿ¡“π. ∫√√≥“∏‘°“√. μ”√“®‘μ‡«™ ‡¥Á°·≈–«—¬√ÿàπ ‡≈à¡ Ú. °√ÿß‡∑æ¡À“π§√: ∫’¬Õπ¥å ‡Õπ‡∑Õ√å‰æ√´å, Úıı:ÚÙ˘-ıÙ.

Abstract Role of general practitioner for psychosocial intervention in maltreated child Supara Chaopricha Department of Psychiatry, Faculty of Medicine, Thammasat University Child maltreatment is a main social and public health concern. It is accounted for a child psychiatric emergency. General practitioner working in an emergency department plays a key role in early detection and initial psychosocial management for this problem besides of treating a childûs physical condition. In terms of early detection, evidence of child maltreatment could be based on history taking, child and parent assessment. Psychosocial intervention includes initial management of child psychiatric problems, urgent referral to multidisciplinary team and giving psychological support to the affected child. Positive attitude and competent communication skills are required for the general practitioner to work with the child and family effectively. Therefore, proper management in the emergency room is a holistic part of the child protective process. Key words: Psychosocial intervention, Child maltreatment

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§«“¡À¡“¬¢Õß¿“«–ª√’Õ’·§≈¡‡´’¬ (Pre-eclampsia)

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μ√«®æ∫§«“¡¥—π‚≈À‘μ Ÿß·≈–°“√√—Ë«¢Õß‚ª√μ’π „πªí “«–∑’‡Ë °‘¥¢÷πÈ „À¡à „π μ√’μß—È §√√¿å ∑’¡Ë Õ’ “¬ÿ§√√¿å‡°‘π Ú —ª¥“Àå‰ª·≈â«·≈–¡’ ‘ËßμàÕ‰ªπ’È Õ¬à“ßπâÕ¬ Ò ¢âÕ Ò. Õ“°“√¢Õß√–∫∫ª√– “∑°≈“ß (symptoms of central nervous system): ¡Õß‡ÀÁπ¿“æ‰¡à™—¥ (blurred vision) ‡ÀÁπ¿“æ ¡’‡ß“¡◊¥ (scotomata) ª«¥»’√…–√ÿπ·√ßÕ¬à“ß∑’Ë ‰¡à‡§¬‡ªìπ¡“°àÕπ À√◊Õª«¥μ≈Õ¥‡«≈“∑—Èß∑’Ë ‰¥â¬“·°ª«¥·≈â« (severe headache; i.e., incapacitating, ùthe worst headache I have ever hadû or headache that persists and progress despite analgesic therapy) Ú. Õ“°“√¢Õß°“√¢¬“¬μ—«¢Õß‡¬◊ÕË Àÿ¡â μ—∫ (symptoms of liver capsule distension): ª«¥∑â Õ ß„μâ ™ “¬‚§√ß¢«“À√◊ Õ ≈‘È π ªïò (right upper quadrant of epigastric pain) §≈◊Ëπ‰ â/Õ“‡®’¬π (nausea, vomiting) Û. ¢â Õ ∫à ß · ¥ß«à “ ¡’ ° “√∫“¥‡®Á ∫ ¢Õß‡´≈≈å μ— ∫ (hepatocellular injury): ¡’°“√‡æ‘Ë¡¢÷Èπ¢Õß‡Õπ‰´¡åμ—∫¡“°°«à“ Ú ‡∑à“ ¢Õßª√°μ‘ (serum transaminase concentration at least twice normal) Ù. §«“¡¥—π‚≈À‘μ Ÿß„π√–¥—∫√ÿπ·√ß (severe blood pressure elevation):

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§«“¡¥—π‚≈À‘μ√–¥—∫´‘ ‚μ≈‘§ * Òˆ ¡‘≈≈‘‡¡μ√ ª√Õ∑ À√◊Õ§«“¡¥—π‚≈À‘μ√–¥—∫‰¥·Õ ‚μ≈‘§ * ÒÒ ¡‘≈≈‘‡¡μ√ª√Õ∑ ‚¥¬«—¥´È” Õß§√—ÈßÀà“ß °—πÕ¬à“ßπâÕ¬ ˆ ™—Ëß‚¡ß ‡°≈Á¥‡≈◊Õ¥μË” (thrombocytopenia) ) Ò,  μ—«/ ≈Ÿ°∫“»°å¡‘≈≈‘‡¡μ√ ‚ª√μ’π√—Ë«„πªí “«– (proteinuria) * ı °√—¡ ¢Õßªí “«– ÚÙ ™—Ë«‚¡ß ªí “«–πâÕ¬ (oliguria) < ı ¡‘≈≈‘≈μ‘ √¿“¬„π ÚÙ ™—Ë«‚¡ß ¿“«–°“√‡®√‘ ≠ ‡μ‘ ∫ ‚μ™â “ ¢Õß∑“√°„π§√√¿å (severe fetal growth restriction) ªÕ¥∫«¡πÈ” (pulmonary edema) ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (cerebrovascular accident)

Õÿ∫—μ‘°“√≥å §«“¡¥—π‚≈À‘μ Ÿß„π√–À«à“ß°“√μ—Èß§√√¿å (gestational hypertension) ∂◊Õ«à“‡ªìπ¿“«–·∑√°´âÕπ∑’Ë ”§—≠„π ∑“ß Ÿμ»‘ “ μ√å ‚¥¬æ∫Õÿ∫μ— °‘ “√≥åª√–¡“≥√âÕ¬≈– ı-Ò ¢Õß °“√μ—Èß§√√¿åÒ,Ú,Û,Ù à«π¿“«–ª√’Õ’·§≈¡‡´’¬æ∫‰¥â√âÕ¬≈– ı-ˆ ¢Õß°“√μ—Èß§√√¿åÚ ´÷Ëß‡ªìπ “‡Àμÿ°“√μ“¬∑’Ë ”§—≠ Õ—π¥—∫ Õß¢Õß¡“√¥“„π À√—∞Õ‡¡√‘°“Ò,Ú „πª√–‡∑»‰∑¬¡’ °“√»÷°…“∑’Ë¡À“«‘∑¬“≈—¬¢Õπ·°àπ„πªï æ.». ÚıÙÒ æ∫«à“ Õÿ∫—μ‘°“√≥å¢Õßª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß√âÕ¬≈– .˘ˆ μàÕ °“√§≈Õ¥ı „π‚√ßæ¬“∫“≈¡À“«‘∑¬“≈—¬∫Ÿ√æ“ ®“°°“√ ◊∫§âπ ∞“π¢âÕ¡Ÿ≈‚√ßæ¬“∫“≈®“°ªï æ.». ÚıÙ¯ ∂÷ß ÚııÚ æ∫ Õÿ∫—μ‘°“√≥å¢Õßª√’Õ’·§≈¡‡´’¬‡∑à“°—∫√âÕ¬≈– .Û μàÕ°“√ §≈Õ¥·≈–‡ªìπ™π‘¥√ÿπ·√ß√âÕ¬≈– .Ò μàÕ°“√§≈Õ¥ˆ

“‡Àμÿ “‡Àμÿ¢Õßª√’Õ’·§≈¡‡´’¬„πªí®®ÿ∫—π¬—ß‰¡à‡ªìπ∑’Ë °√–®à“ß™—¥π—° ·μàæ∫«à“À≈—ß®“°ºŸâªÉ«¬‰¥â§≈Õ¥∫ÿμ√·≈â« Õ“°“√À√◊ Õ §«“¡º‘ ¥ ª√°μ‘ ¥— ß °≈à “ « “¡“√∂À“¬‰ª‰¥â ‡ Õß ´÷Ëß‡ªìπ«‘∏’°“√√—°…“‚√§À√◊Õ¿“«–¥—ß°≈à“«„πªí®®ÿ∫—πÒ,Ú,Û ¿“«–ª√’Õ’·§≈¡‡´’¬‰¡à‰¥â¡’Õ“°“√· ¥ß‡æ’¬ß·§à§«“¡¥—π ‚≈À‘μ Ÿß·≈–‚ª√μ’π√—Ë«„πªí “«–‡∑à“π—Èπ ·μà¬—ß¡’§«“¡ ·ª√ª√«π¢Õß√–∫∫μà“ßÊ „π√à“ß°“¬À≈“¬√–∫∫ª√–°Õ∫°—π (multisystem disorder) ‚¥¬∑’Ë‰¡à∑√“∫μâπ‡Àμÿ·πà™—¥˜,¯,˘

ªí®®—¬‡ ’Ë¬ß ®“°°“√»÷°…“‡¡◊ËÕ‡√Á«Ê π’È‡°’Ë¬«°—∫ªí®®—¬‡ ’Ë¬ß¢Õß °“√‡°‘¥¿“«–ª√’Õ·’ §≈¡‡´’¬æ∫«à“ºŸ∑â ¡’Ë §’ «“¡¥—π‚≈À‘μ ŸßÕ¬Ÿ‡à ¥‘¡ ‚√§‡∫“À«“π §«“¡Õâ«π·≈–§√√¿å·Ω¥¡’§«“¡ —¡æ—π∏å°—∫ ¿“«–ª√’Õ’·§≈¡‡´’¬√âÕ¬≈– ÚÚ.Û „πºŸâªÉ«¬§√√¿å·√°∑’Ë‡ªìπ ª√’Õ’·§≈¡‡´’¬·≈–À“°‡§¬‡°‘¥ª√’Õ’·§≈¡‡´’¬„π§√√¿å°àÕπ ®–æ∫§«“¡ — ¡ æ—π ∏å √ –À«à “ ßªí® ®—¬ ¥— ß °≈à“ «°—∫ °“√‡°‘¥ ª√’ Õ’·§≈¡‡´’¬„π§√√¿åÀ≈—ß∂÷ß√âÕ¬≈– ıÚ.ÚÒ à«π°“√»÷°…“ „πª√–‡∑»‰∑¬„π‡√◊Ë Õ ßªí ® ®— ¬ ‡ ’Ë ¬ ß°Á „ Àâ º ≈°“√»÷ ° …“ §≈â“¬§≈÷ß°—πı

°“√√—°…“ °“√∑”„Àâ§√√¿å ‘Èπ ÿ¥À√◊Õ°“√§≈Õ¥∫ÿμ√¬—ß∂◊Õ«à“ ‡ªì π «‘ ∏’ ° “√√— ° …“ ÿ ¥ ∑â “ ¬∑’Ë ¥’ ∑’Ë ÿ ¥ „πªí ® ®ÿ ∫— π ”À√— ∫ ¿“«– ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ßÒ,Ú,Û Õ¬à“ß‰√°Áμ“¡°Á¬—ß¡’¢âÕ°—ß¢“ ‡ ¡Õ„π‡«≈“∑’ËμâÕßμ—¥ ‘π„®‡æ◊ËÕ¬ÿμ‘°“√μ—Èß§√√¿å ”À√—∫ºŸâ∑’Ë ‡ªìπª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß ‚¥¬‡©æ“–„π√“¬∑’Ë¡’Õ“¬ÿ §√√¿åπâÕ¬°«à“ ÛÙ —ª¥“Àå ‡π◊ËÕß°“√∑”ß“π¢Õß∂ÿß≈¡„π ªÕ¥∑“√°¬—ß‰¡àæ√âÕ¡ ¥—ßπ—Èπ°“√«“ß·ºπ°“√√—°…“®÷ß®”‡ªìπ μâÕß¡’§«“¡≈–‡Õ’¬¥√Õ∫§Õ∫ ·≈–æ‘‡§√“–Àå∂÷ß¢âÕ¥’¢âÕ‡ ’¬ ¢Õß°“√√—°…“π—ÈπÊ ‡π◊ËÕß®“°¡’‚Õ°“ ‡°‘¥¿“«–·∑√°´âÕπ∑’Ë √ÿπ·√ßμàÕ¡“√¥“·≈–∑“√°„π§√√¿å °“√√— ° …“·∫∫ª√–§— ∫ ª√–§Õß (expectant management) ”À√—∫ª√’Õ’·§≈¡‡´’¬π—∫‡ªìπ«‘∏’°“√√—°…“Õ’° √Ÿª·∫∫Àπ÷ËßπÕ°®“°°“√∑”„Àâ§√√¿å ‘Èπ ÿ¥∑—π∑’ ‚¥¬‡©æ“– „π μ√’ μ—È ß §√√¿å ∑’Ë ¡’ ¿ “«–ª√’ Õ’ · §≈¡‡´’ ¬ ™π‘ ¥ √ÿ π ·√ß·μà ¡’ Õ“¬ÿ§√√¿åπâÕ¬°«à“ ÛÙ —ª¥“Àå ´÷Ëß°“√√—°…“¥â«¬«‘∏’°“√ ¥—ß°≈à“«¬—ß‡ªìπªí≠À“‚μâ·¬âß°—π„πÀ≈“¬Ê ª√–‡¥Áπ ·μàÀ“° ®–¡’°“√√—°…“¥â«¬«‘∏’¥—ß°≈à“«§«√μâÕß√—∫‰«â„π‚√ßæ¬“∫“≈ ‚¥¬‚√ßæ¬“∫“≈¥— ß °≈à “ «μâ Õ ß¡’ »— ° ¬¿“æ Ÿ ß ¥â “ π∫ÿ § ≈“°√ ‡§√◊ËÕß¡◊Õ ¬“·≈–‡«™¿—≥±åÒÒ À≈— °°“√∑—Ë«‰ª„π°“√√—°…“¿“«–ª√’ Õ’·§≈¡‡´’¬ ‰¥â · °à °“√§«∫§ÿ ¡ ¿“æ§«“¡ªÉ « ¬‡®Á ∫ ¢Õß¡“√¥“ (maternal stabilization) ‚¥¬¡“°¡— ° ‡ªì π °“√§«∫§ÿ ¡ §«“¡¥— π ‚≈À‘ μ ·≈–°“√ªÑ Õ ß°— π Õ“°“√™— ° ª√–‡¡‘ π ·≈– ªÑÕß°—π¿“«–·∑√°´âÕπ √«¡∂÷ß„Àâ°“√ª√–§—∫ª√–§Õß¥â“π Õ◊ËπÊ ∑“ß°“√æ¬“∫“≈ √«¡∑—Èß°“√ª√–‡¡‘π ÿ¢¿“æ∑“√°„π §√√¿å‡ªìπ√–¬–‰ªæ√âÕ¡Ê °—π ‡™àπ °“√μ√«®π—∫°“√¥‘Èπ ¢Õß∑“√° °“√μ√«®§≈◊πË ‰øøÑ“À—«„®∑“√°„π§√√¿å (non-stress test) °“√μ√«® ÿ¢¿“æ∑“√°¥â«¬«‘∏’™’«øî ‘° å‚¥¬„™â§≈◊Ëπ ‡ ’¬ß§«“¡∂’Ë Ÿß (biophysical profiles) ‡ªìπμâπ

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

‡Àμÿ º ≈Àπ÷Ë ß „π°“√„Àâ ° “√√— ° …“·∫∫ª√–§— ∫ ª√–§Õß„π√“¬∑’ËÕ“¬ÿ§√√¿å¬—ß‰¡à§√∫°”Àπ¥§◊Õ ‡æ◊ËÕ√Õ √–¬–‡«≈“‡æ◊ËÕ„ÀâªÕ¥∑“√°∑”ß“π‰¥â ¡∫Ÿ√≥å¢÷Èπ‚¥¬°“√„Àâ ¬“ ‡μÕ√Õ¬¥å (steroids) ´÷Ëß¬“®–¡’ª√– ‘∑∏‘¿“æ‡μÁ¡∑’Ë‡¡◊ËÕ ÚÙ ™—Ë«‚¡ßÀ≈—ß°“√©’¥¬“§√∫§√—Èß ÿ¥∑â“¬ ´÷Ëßªí®®ÿ∫—π‡ªìπ∑’Ë ¬Õ¡√—∫°—π∑—Ë«‰ª·≈â««à“ ¿“«–ª√’Õ’·§≈¡‡´’¬‰¡à¡’ à«π„π °“√°√–μÿâπ„Àâ§«“¡ ¡∫Ÿ√≥å (maturation) ¢ÕßªÕ¥∑“√° ‡®√‘≠‡√Á«¢÷Èπ·μàÕ¬à“ß„¥ πÕ°®“°π’È¬—ß¡’°“√»÷°…“∑’Ë„Àâº≈ Õ¥§≈âÕß°—π«à“ °“√„Àâ “√ ‡μÕ√Õ¬¥å„π μ√’μ—Èß§√√¿å ª√’Õ’·§≈¡‡´’¬‡¡◊ËÕÕ“¬ÿ§√√¿å¬—ß‰¡à§√∫°”Àπ¥¡’ª√–‚¬™πå Õ¬à“ß™—¥‡®π„π°“√°√–μÿâπ°“√æ—≤π“¢Õß‡´≈≈å∂ÿß≈¡ªÕ¥ ¢Õß∑“√°„π§√√¿å Û,ÒÒ,ÒÚ Õ¬à “ ß‰√°Á μ “¡°“√„Àâ “√ ‡μÕ√Õ¬¥å °à Õ π§≈Õ¥‰¡à “¡“√∂≈¥§«“¡√ÿ π ·√ß¢Õß ¿“«–ª√’Õ’·§≈¡‡´’¬·μàÕ¬à“ß„¥ÒÛ °“√„Àâ ° “√√— ° …“·∫∫ª√–§— ∫ ª√–§Õß ”À√— ∫ ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß¡’ºŸâ∑”°“√»÷°…“«‘®—¬æ∫«à“¡’º≈¥’ °«à“°“√μ—¥ ‘π„®„Àâ§≈Õ¥„π Õß°√≥’‡¥àπÊ ‰¥â·°à °√≥’∑’Ë °“√«‘π‘®©—¬«à“¡’¿“«–ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß®“°‡°≥±å °“√√—Ë«¢Õß‚ª√μ’π„πªí “«–Õ¬à“ß‡¥’¬« ·≈–°√≥’∑’Ë Õß§◊Õ °“√«‘π‘®©—¬«à“¡’¿“«–ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß®“°‡°≥±å °“√‡®√‘ ≠ ‡μ‘ ∫ ‚μ™â “ ¢Õß∑“√°„π§√√¿å Õ ¬à “ ß‡¥’ ¬ «„π μ√’ μ—Èß§√√¿å∑’Ë¡’Õ“¬ÿ§√√¿åπâÕ¬°«à“ ÛÚ —ª¥“Àå‚¥¬°“√μ√«® ÿ¢¿“æ∑“√°„π§√√¿å·≈â«æ∫«à“ ÿ¢¿“æ∑“√°„π§√√¿å¬—ßÕ¬Ÿà „π‡°≥±åª√°μ‘ ´÷Ëß∑—Èß Õß°√≥’ “¡“√∂¬◊¥Õ“¬ÿ§√√¿å ‚¥¬ ‡©≈’Ë¬‰¥âÕ’° Û «—ππ—∫®“°«—π‡¢â“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈ ·≈–æ∫«à“√âÕ¬≈– ¯ı ¢Õß μ√’μ—Èß§√√¿åª√’Õ·’ §≈¡‡´’¬™π‘¥ √ÿπ·√ß¡—°μâÕß§≈Õ¥¿“¬„π Ò —ª¥“Àåπ—∫·μà‡√‘Ë¡μ√«®æ∫ ¿“«–ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ßÒÒ

¢âÕæ‘®“√≥“μ“¡‡°≥±å°“√«‘π‘®©—¬¿“«– ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß°—∫°“√„Àâ°“√√—°…“·∫∫ ª√–§—∫ª√–§Õß‰¥â·°à°√≥’¥—ßμàÕ‰ªπ’È Ò. §«“¡º‘¥ª√°μ‘¢Õßº≈∑“ßÀâÕßªØ‘∫—μ‘°“√‡æ’¬ß ™—Ë«§√“« ‰¥â·°à À≠‘ß∑’Ë¡’¿“«–ª√’Õ’·§≈¡‡´’¬‰¡à¡’Õ“°“√∑“ß §≈‘π‘°·μà¡’º≈°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√∑’Ëº‘¥ª√°μ‘‡æ’¬ß ™—«Ë §√“«·≈â«°≈—∫¡“‡ªìπª√°μ‘‰¥â¿“¬„π ÚÙ-Ù¯ ™—«Ë ‚¡ß ‡™àπ ALT, AST, ‡°√Á¥‡≈◊Õ¥μË” À√◊Õ¡’°“√·¢Áßμ—«¢Õß‡≈◊Õ¥º‘¥ª√°μ‘ (coagulopathy) ‡ªìπμâπ ‚¥¬∑’Ë¡’§«“¡¥—π‚≈À‘μª√°μ‘À√◊Õ Ÿß ‡≈Á°πâÕ¬ ºŸâªÉ«¬≈—°…≥–π’È “¡“√∂‡≈◊Õ°„™â°“√√—°…“·∫∫ ª√–§—∫ª√–§Õß‰¥âÒÙ Ú. ¡’°“√√—Ë«¢Õß‚ª√μ’π„πªí “«–Õ¬à“ß‡¥’¬« §◊Õ

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¡“°°«à“ ı °√—¡μàÕ«—π®“°ªí “«–∑’Ë‡°Á∫ – ¡ ÚÙ ™—Ë«‚¡ß ´÷Ëßªí®®ÿ∫—π‰¥â¡’°“√∑∫∑«πß“π«‘®—¬¥â“π°“√√—°…“ª√–§—∫ ª√–§ÕßºŸâªÉ«¬≈—°…≥–π’È®π‡ªìπ∑’Ë¬Õ¡√—∫°—π·≈â««à“ “¡“√∂ „Àâ ° “√√— ° …“·∫∫ª√–§— ∫ ª√–§Õß‚¥¬∑’Ë ‰ ¡à æ ∫«à “ ¡’ ¿ “«– ·∑√°´âÕπ‡æ‘Ë¡¢÷Èπ πÕ°®“°π’È¬—ßæ∫«à“°“√„™â‡°≥±å¥—ß°≈à“« „π°“√∑”π“¬§«“¡√ÿπ·√ß¢Õß‚√§¡—°„Àâº≈‰¡à·πàπÕπÒı Û. °“√‡®√‘≠‡μ‘∫‚μ™â“¢Õß∑“√°„π§√√¿åÕ¬à“ß‡¥’¬« Õ“®„Àâ°“√√—°…“‡™àππ’È‰¥â„π°√≥’μà“ßÊ‡À≈à“π’È ‰¥â·°à °“√ ‡®√‘≠‡μ‘∫‚μ™â“„π§√√¿å™π‘¥‰¡à√ÿπ·√ß (πÈ”Àπ—°∑“√°Õ¬Ÿà„π ™à«ß‡ªÕ√å‡´Áπμå‰∑≈å∑’Ë ı ·μà‰¡à∂ß÷ ‡ªÕ√å‡´Áπμå‰∑≈å∑’Ë Ò ”À√—∫ Õ“¬ÿ§√√¿åπ—Èπ) Õ“¬ÿ§√√¿åπâÕ¬°«à“ ÛÚ —ª¥“Àå °“√μ√«® ÿ¢¿“æ∑“√°¥â«¬°“√μ√«®§≈◊Ëπ‰øøÑ“À—«„®∑“√° (nonstress test) ¬—ßª√°μ‘ ¥—™π’ª√‘¡“≥πÈ”§√Ë” (amniotic fluid index: AFI) ¡“°°«à“ ı ‡´πμ‘‡¡μ√ À√◊Õ™àÕßπÈ”§√Ë”∑’Ë¡“°∑’Ë ÿ¥®“° °“√μ√«®«—¥¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¡“°°«à“ Ú ‡´πμ‘‡¡μ√ μ“¡·π«¥‘Ëß (maximum vertical pocket) ·≈–°“√μ√«® §≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß·∫∫¥Õª‡≈Õ√å (Doppler velocimetry ultrasonography) ‰¡àæ∫≈—°…≥– persistent absent À√◊Õ reversed diastolic flow ¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß¢Õß “¬ –¥◊Õ (umbilical artery) Õ¬à“ß‰√°Áμ“¡¬—ß‰¡à¡’À≈—°∞“π π—∫ πÿπ ∂÷ßª√–‚¬™πåμàÕ∑“√°¡“°π—°„π°√≥’¥—ß°≈à“«‚¥¬°“√„Àâ°“√ √—°…“·∫∫ª√–§—∫ª√–§ÕßÒÒ,Òˆ,Ò˜ Ù. §«“¡¥—π‚≈À‘μ ŸßÕ¬à“ß‡¥’¬«‚¥¬∑’Ë‰¡à¡’¿“«– ·∑√°´âÕπÕ◊Ëπ„π√“¬∑’ËÕ“¬ÿ§√√¿åπâÕ¬°«à“ ÛÙ —ª¥“Àå Õ“® æ‘®“√≥“„Àâ°“√√—°…“·∫∫ª√–§—∫ª√–§Õß‰¥â ®“°°“√»÷°…“ ∑’Ë ºà “ π¡“æ∫«à “ °“√√— ° …“·∫∫ª√–§— ∫ ª√–§Õß‚¥¬°“√ „Àâ¬“≈¥§«“¡¥—π‚≈À‘μ„π√“¬∑’Ë¡’§«“¡¥—π‚≈À‘μ Ÿß„π√–¥—∫ μâπ (mild degree hypertension) ®–‰¡à‡ª≈’¬Ë π·ª≈ß°“√¥”‡π‘π ‚√§À√◊Õ™à«¬≈¥Õ—μ√“°“√μ“¬∑“√°ª√‘°”‡π‘¥ (perinatal morbidity and mortality) ·≈–¬— ß ‡ªì π °“√≈¥°“√‰À≈ ‡«’¬π‡≈◊Õ¥∑’Ë‰ª¬—ß√° Õ’°∑—Èß¬—ß‡ªìπ°“√∫¥∫—ßÕ“°“√· ¥ß ¢Õß¿“«–ª√’ Õ’ · §≈¡‡´’ ¬ Õ’ ° ¥â « ¬ ¥— ß π—È π ®÷ ß ‰¡à π‘ ¬ ¡„Àâ ¬“≈¥§«“¡¥—π‚≈À‘μ„π¿“«–ª√’Õ’·§≈¡‡´’¬√–¥—∫μâπ ·μà„π °√≥’ª√’Õ·’ §≈¡‡´’¬™π‘¥√ÿπ·√ß¡—°¡’°“√„Àâ¬“≈¥§«“¡¥—π‚≈À‘μ √à « ¡¥â « ¬ ‡æ◊Ë Õ ªÑ Õ ß°— π °“√‡°‘ ¥ ‚√§À≈Õ¥‡≈◊ Õ ¥ ¡Õß (cerebrovascular accident) ¡“°°«à“°“√ªÑÕß°—π°“√¥”‡π‘π‚√§ÒÙ,Ò˜,Ò¯

¢âÕÀâ“¡„π°“√„Àâ°“√√—°…“·∫∫ª√–§—∫ª√–§ÕßÒ˘ ‰¥â·°à ●

μ√’μ—Èß§√√¿åÕ¬Ÿà„π ¿“«–°“√‰À≈‡«’¬π‚≈À‘μ ‰¡à‡ ∂’¬√ (hemodynamic instability) À√◊Õ™ÁÕ§

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(shock) º≈°“√μ√«® ÿ¢¿“æ∑“√°„π§√√¿åº¥‘ ª√°μ‘ ‡™àπ §«“¡º‘¥ª√°μ‘¢Õß°√“ø· ¥ßº≈°“√∫—π∑÷° °“√‡μâπ¢ÕßÀ—«„®∑“√°°—∫°“√ πÕßμÕ∫°“√ ¥‘Èπ∑“√° (non-reactive NST) §–·ππ°“√ μ√«® ÿ¢¿“æ∑“√°∑“ß™’«øî ‘° å¥â«¬§≈◊Ëπ‡ ’¬ß §«“¡∂’ Ë ßŸ (biophysical profiles) ‰¥â§–·πππâÕ¬ ‡™àπ πâÕ¬°«à“ Ù „π Ò §–·ππ· ¥ß«à“∑“√°¡’ ¿“«–¢“¥ÕÕ°´‘‡®π √à«¡°—∫¿“«–πÈ”§√Ë”πâÕ¬ (oligohydramnios) ‚¥¬¥Ÿ ® “°¥— ™ π’ πÈ” §√Ë” (amniotic fluid index) ®–πâÕ¬°«à“ ı ‡´πμ‘‡¡μ√ À√◊ÕπâÕ¬°«à“ Ú ‡´πμ‘‡¡μ√μ“¡·π«¥‘Ëß¢Õß ™àÕß«à“ß∑’¡Ë π’ È”§√Ë”Õ¬Ÿà (maximum vertical pocket) §«“¡¥—π‚≈À‘μ Ÿß¢—Èπ√ÿπ·√ß∑’Ë‰¡àμÕ∫ πÕßμàÕ °“√√—°…“¥â«¬¬“ (non-responsive hypertension) ª«¥»’ √ …–√ÿ π ·√ßÕ¬à “ ß∑’Ë ‰ ¡à ‡ §¬‡ªì π ¡“°à Õ π (incapacitating headache) °“√¡Õß‡ÀÁπ¿“æº‘¥ ª√°μ‘‰ª (blurred vision or scotoma) À√◊Õ¡’ Õ“°“√ª«¥®ÿ°·πàπ√ÿπ·√ß∫√‘‡«≥≈‘ÈπªïòÀ√◊Õ„μâ ™“¬‚§√ß¢«“ Õ“°“√™—°√–À«à“ß°“√μ—Èß§√√¿å (eclampsia) ªÕ¥∫«¡πÈ” (pulmonary edema) ‰μ«“¬ (renal failure) ¡’ √ –¥— ∫ §√’ ‡ Õμ‘ π‘ π (creatinine) ‡æ‘¡Ë ¡“°°«à“ Ò ¡‘≈≈‘°√—¡μàÕ‡¥´‘≈μ‘ √ ·≈–À√◊Õªí “«–ÕÕ°πâÕ¬°«à“ .ı ¡‘≈≈‘≈‘μ√ μàÕπÈ”Àπ—°¡“√¥“ Ò °‘‚≈°√—¡μàÕ™—Ë«‚¡ß‡ªìπ ‡«≈“μàÕ‡π◊ËÕß°—π Ú ™—Ë«‚¡ß (severe oliguria) ‚¥¬‰¡à πÕßμÕ∫μàÕ°“√„Àâ “√πÈ”∑“ßÀ≈Õ¥ ‡≈◊Õ¥¥” ı ¡‘≈≈‘≈‘μ√ º≈°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√º‘¥ª√°μ‘ ‰¥â·°à AST ALT ¡“°°«à “ Õß‡∑à“ ¢Õß§à “ ª√°μ‘ ®”π«π‡°≈Á¥‡≈◊Õ¥πâÕ¬°«à“ Ò, ‡´≈≈åμàÕ ‰¡‚§√≈‘ μ √·≈–À√◊ Õ ¡’ ° “√·¢Á ß μ— « ¢Õß‡≈◊ Õ ¥ º‘¥ª√°μ‘ (coagulopathy) ‚¥¬¡’Õ“°“√‡≈«≈ß ¿“¬„π ˆ-ÒÚ ™—Ë«‚¡ßÀ≈—ß°“√«‘π‘®©—¬ √°≈Õ°μ—«°àÕπ§≈Õ¥ (placental abruption) ‡¢â“ Ÿà√–¬–‡®Á∫§√√¿å®√‘ß (true labor pain) À√◊Õ ¡’°“√·μ°√—Ë«¢Õß∂ÿßπÈ”§√Ë”°àÕπ°“√‡®Á∫§√√¿å (premature rupture of membrane) Õ“¬ÿ§√√¿åμ—Èß·μà ÛÙ —ª¥“Àå‡ªìπμâπ‰ª À√◊Õ πâÕ¬°«à“ ÚÙ —ª¥“Àå

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¡“√¥“μâÕß°“√§≈Õ¥∫ÿμ√ ª√’Õ·’ §≈¡‡´’¬¢—πÈ √ÿπ·√ß™π‘¥ HELLP syndrome ‡π◊Ë Õß®“°°“√»÷ ° …“∑’Ë ºà “ π¡“æ∫«à “ ª√–‚¬™πå ¢Õß°“√√—°…“·∫∫ª√–§—∫ª√–§Õß„π°≈ÿ¡à Õ“°“√ HELLP ¬— ß ‰¡à ™— ¥ ‡®ππ— ° „π·ßà º ≈≈— æ ∏å ¢ Õß ∑“√°√–¬–ª√‘°”‡π‘¥ (perinatal outcome) ·≈– Õ—μ√“ªÉ«¬·≈–μ“¬¢Õß∑“√°·√°‡°‘¥ Ú¯ «—π·√° (neonatal morbidity and mortality)Ò˘,Ú,ÚÒ

°“√√—°…“·∫∫ª√–§—∫ª√–§Õß ”À√—∫ μ√’μ—Èß§√√¿å ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß∑”Õ¬à“ß‰√∫â“ß ‚¥¬À≈—°¢Õß°“√„Àâ°“√∫√‘∫“≈≈—°…≥–π’È¡’§«“¡ ¡ÿßà À«—ß‡æ◊ÕË ≈¥À√◊ÕªÑÕß°—π¿“«–·∑√°´âÕπ„π¡“√¥“·≈–∑“√° ‚¥¬¡’√“¬≈–‡Õ’¬¥¥—ßπ’Ò,ÒÚ,ÚÚ È ● μâÕß√—∫‰«â√—°…“„π‚√ßæ¬“∫“≈®π°√–∑—Ëß§≈Õ¥ ● ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ„π¡“√¥“‚¥¬ o °“√μ√«®«—¥§«“¡¥—π‚≈À‘μ∑ÿ° Ù ™—Ë«‚¡ß §«∫§ÿ¡§«“¡¥—π‚≈À‘μ´‘ ‚μ≈‘§„ÀâÕ¬Ÿ√à –À«à“ß ÒÛ-Òı ¡‘≈≈‘‡¡μ√ª√Õ∑·≈–‰¥·Õ ‚μ≈‘§ ¯-Ò ¡‘≈≈‘‡¡μ√ª√Õ∑ o À“°§«“¡¥— π ‚≈À‘ μ ´‘ ‚μ≈‘ § * Òˆ ¡‘≈≈‘‡¡μ√ª√Õ∑À√◊Õ‰¥·Õ ‚μ≈‘§ * Ò ¡‘ ≈ ≈‘ ‡ ¡μ√ª√Õ∑ „Àâ √— ° …“¥â « ¬¬“≈¥ §«“¡¥—π‚≈À‘μ ‡™àπ nifedipine À√◊Õ labetalol À√◊Õ nicardipine À√◊Õ hydralazine o μ√«®§«“¡ ¡∫Ÿ√≥å¢Õß‡≈◊Õ¥ (complete blood count) ®”π«π‡°≈Á¥‡≈◊Õ¥ √–¥—∫ §√’‡Õμ‘π‘π„ππÈ”‡À≈◊Õß (serum creatinine) ‡Õπ‰´¡å aspartate aminotransferase ‡Õπ‰´¡å lactate dehydrogenase: LDH √–¥—∫∫‘≈≈‘√∫Ÿ π‘ (bilirubin) ‰ø∫√‘‚π‡®π (fibrinogen) ‡«≈“ ‚ª√∏√Õ¡∫‘π (prothrombin time) ·≈– æ“√å ‡ ™’ ¬ ≈ ∏√Õ¡‚∫æ≈“ μ‘ π (partial thromboplastin time) ∑ÿ°«—πÀ√◊Õ«—π‡«âπ«—π μ√«®À“‚ª√μ’π®“°ªí “«– – ¡ ÚÙ ™—Ë«‚¡ß∑ÿ°«—πÀ√◊Õ«—π‡«âπ«—π ¬°‡«âπ‡¡◊ËÕ‡¢â“ ‡°≥±å¢Õßª√’Õ’·§≈¡‡´’¬¢—Èπ√ÿπ·√ß·≈â« o ´—°∂“¡Õ“°“√¢Õßª√’Õ·’ §≈¡‡´’¬√–¥—∫√ÿπ·√ß ‡™àπ Õ“°“√ª«¥»’√…– °“√¡Õß‡ÀÁπ¿“æ∑’Ë º‘ ¥ ª√°μ‘ (scotomata) Õ“°“√ª«¥∑âÕ ß ∫√‘‡«≥≈‘ÈπªïòÀ√◊Õ„μâ™“¬‚§√ß¢«“ ‡ªìπμâπ

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

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o ™—ËßπÈ”Àπ—°∑ÿ°«—π ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ„π∑“√° ‰¥â·°à °“√ „Àâ¡“√¥“∫—π∑÷°°“√¥‘Èπ¢Õß∑“√° °“√μ√«® Õ∫ ÿ¢¿“æ∑“√°„π§√√¿å¥â«¬°“√μ√«®§≈◊Ëπ ‰øøÑ “ À— « „®∑“√°∑ÿ ° «— π °“√μ√«®∑“ß ™’«øî ‘° å∑ÿ° —ª¥“Àå ·≈–°“√μ√«®§≈◊Ëπ‡ ’¬ß §«“¡∂’ Ë ßŸ ¥Õª‡≈Õ√å (Doppler ultrasonography) —ª¥“Àå≈– Ú §√—Èß °“√„Àâ ‡μÕ√Õ¬¥å ‡™à π ‡∫μ“‡¡∑∏“‚´π (betamethasone) ©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥” ÒÚ ¡‘≈≈‘°√—¡/«—ππ“π Ú «—π À√◊Õ ‡¥°´“‡¡∏“‚´π (dexamethasone) ˆ ¡‘≈≈‘°√—¡∑ÿ° ÒÚ ™—Ë«‚¡ß *Ù §√—ÈßÀ√◊Õ ÒÚ ¡‘≈≈‘°√—¡∑ÿ° ÒÚ ™—Ë«‚¡ß *Ú §√—Èß „π°√≥’∑’ËÕ“¬ÿ§√√¿å¬—ß‰¡à§√∫°”Àπ¥ °“√„Àâ·¡°π’‡´’¬¡ (magnesium) „π À√—∞ Õ‡¡√‘ ° “ „Àâ ‡ æ◊Ë Õ ªÑ Õ ß°— π °“√™— ° (seizure prophylaxis) „π√–¬–·√°¢Õß°“√√—∫‰«â√—°…“ „π‚√ßæ¬“∫“≈ À“°μ—¥ ‘π„®®–„Àâ°“√√—°…“ ·∫∫ª√–§—∫ª√–§ÕßμàÕ„ÀâÀ¬ÿ¥·¡°π’‡´’¬¡‰¥â ·μà„πΩ√—Ëß‡» ¡—°„Àâ·¡°π’‡´’¬¡ ‡¡◊ËÕμ—¥ ‘π„® „Àâ μ√’μ—Èß§√√¿å§≈Õ¥∫ÿμ√ÒÚ °“√√— ° …“¥â « ¬«‘ ∏’ ° “√‡æ‘Ë ¡ “√πÈ” „π√à “ ß°“¬ (plasma volume expansion) ®“°·π«§‘¥∑’Ë«à“ „π μ√’ μ—È ß §√√¿å ∑’Ë ¡’ ¿ “«–ª√’ Õ’ · §≈¡‡´’ ¬ ®–¡’ ª√‘¡“≥¢Õß‡À≈«„πÀ≈Õ¥‡≈◊Õ¥πâÕ¬®“°°“√ À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥∑—Ë«√à“ß°“¬ (systemic vasospasm) ¥—ßπ—Èπ°“√‡æ‘Ë¡ “√πÈ”„π√à“ß°“¬ πà“®–‡°‘¥ª√–‚¬™πåμàÕºŸâªÉ«¬ ®“°°“√»÷°…“„πª√–‡¥Áππ’Èæ∫«à“ °“√„Àâ “√πÈ”‡æ‘Ë¡‰¡à§àÕ¬¡’º≈μàÕ§«“¡¥—π‚≈À‘μ‡¥‘¡ ¡“°π—° ‚¥¬Õ“®™à«¬∑”„Àâ°“√‰À≈‡«’¬π‡≈◊Õ¥ ‰ª¬—ß√°¥’¢÷Èπ ·μàμâÕß„Àâ¥â«¬§«“¡√–¡—¥√–«—ß ‡æ√“–ºŸâ ªÉ « ¬‡À≈à “ π’È ‡ ’Ë ¬ ßμà Õ °“√‡°‘ ¥ ¿“«– ª√‘¡“≥πÈ”„π√à“ß°“¬‡°‘π‰¥âßà“¬ ‡π◊ËÕß®“°¡’ √–¥—∫§«“¡¥—π colloid osmotic μË”Õ¬Ÿà¥â«¬ ®÷ß Õ“®‡°‘¥¿“«–·∑√°´âÕπÀ≈—ß§≈Õ¥‰¥âÛˆ ¢âÕ √ÿª„πªí®®ÿ∫—π®“°°“√»÷°…“√–¬–‡¡◊ËÕ‰¡àπ“π ¡“π’Èæ∫«à“ «‘∏’°“√¥—ß°≈à“«‰¡à§àÕ¬‰¥âª√–‚¬™πå ™—¥‡®ππ—°„π°“√√—°…“¿“«–ª√’Õ’·§≈¡‡´’¬ÒÚ

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«‘∏’°“√§≈Õ¥ “¡“√∂™—°π”„Àâ§≈Õ¥‰¥â‡¡◊ËÕÕ“¬ÿ§√√¿åμ—Èß·μà ÛÙ —ª¥“Àå¢÷Èπ‰ª ‚¥¬§”π÷ß∂÷ß ¿“æª“°¡¥≈Ÿ° ∑à“¢Õß∑“√° (fetal position) ·≈– à«ππ” (fetal presentation) ¢Õß∑“√° „π§√√¿å‡À¡◊Õπ°“√μ—Èß§√√¿å∑—Ë«Ê ‰ª ·≈–ºà“μ—¥§≈Õ¥‡¡◊ËÕ¡’ ¢âÕ∫àß™’È∑“ß°“√·æ∑¬åÚÚ

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°“√¥Ÿ·≈À≈—ß§≈Õ¥ °“√„Àâ§”ª√÷°…“ „πÀ≠‘ß∑’Ëμ—Èß§√√¿åª√’Õ’·§≈¡‡´’¬¬—ß§ßμâÕß¡’°“√‡ΩÑ“ √–«— ß „π‡√◊Ë Õ ß¢Õß¿“«–·∑√°´â Õ π∑’Ë Õ “®‡°‘ ¥ ¢÷È π ‰¥â ‡™à π ªÕ¥∫«¡πÈ” ¿“«–Õ’·§≈¡‡´’¬¡ (eclampsia) ‰ª®π∂÷ß°≈ÿà¡ Õ“°“√ HELLP ¥—ßπ—Èπ§«√„Àâ°“√¥Ÿ·≈‡√◊ËÕß ¡¥ÿ≈¢Õß “√ πÈ”‡¢â“·≈–ÕÕ°®“°√à“ß°“¬ °“√´—°∂“¡Õ“°“√¢Õßª√’Õ’·§≈¡

198 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ‡´’¬™π‘¥√ÿπ·√ß ‡™àπ Õ“°“√ª«¥»’√…– °“√¡Õß‡ÀÁπ¿“æ∑’Ë º‘¥ª√°μ‘ Õ“°“√ª«¥∑âÕß∫√‘‡«≥≈‘ÈπªïòÀ√◊Õ„μâ™“¬‚§√ß¢«“ ‡ªìπμâπ à«π°“√„Àâ¬“≈¥§«“¡¥—π‚≈À‘μ·≈–¬“°—π™—°μâÕß „ÀâμàÕ®π§√∫ Ù¯ ™—Ë«‚¡ßÀ≈—ß§≈Õ¥ ºŸâªÉ«¬∫“ß√“¬Õ“®μâÕß „Àâ¬“≈¥§«“¡¥—π‚≈À‘μ‰ª√—∫ª√–∑“πμàÕ®π§√∫ Ú —ª¥“Àå À≈—ß§≈Õ¥·≈â«π—¥μ‘¥μ“¡Õ“°“√Õ’°§√—Èß „πºŸâªÉ«¬∫“ß√“¬∑’Ë ¬—ß¡’§«“¡¥—π‚≈À‘μ Ÿß·≈–¡’°“√√—Ë«¢Õß‚ª√μ’π„πªí “«– ‡¡◊ËÕμ‘¥μ“¡°“√√—°…“À≈—ß§≈Õ¥·≈â« Û ‡¥◊Õπ∫àß«à“ πà“®–¡’ ‚√§Õ◊Ëπ·∑√°Õ¬Ÿà‡¥‘¡πÕ°®“°¿“«–ª√’Õ’·§≈¡‡´’¬Ò °“√„Àâ§”ª√÷°…“ ”À√—∫°“√μ—ßÈ §√√¿å§√—ßÈ ∂—¥‰ª ®“° °“√»÷°…“∑’Ëºà“π¡“æ∫«à“‚Õ°“ ∑’Ë®–‡°‘¥¿“«–ª√’Õ’·§≈¡‡´’¬ ´È”¡’·π«‚πâ¡ Ÿß¢÷Èπ ∑—Èßπ’Èæ∫«à“À“°¿“«–ª√’Õ’·§≈¡‡´’¬„π §√√¿å·√°‡°‘¥°àÕπÕ“¬ÿ§√√¿å Û —ª¥“Àå ‚Õ°“ ‡°‘¥´È”„π §√√¿åμàÕ¡“®– Ÿß∂÷ß√âÕ¬≈– ÙÒ πÕ°®“°π’È¬—ßæ∫«à“¡’§«“¡ ·μ°μà“ß∑“ß¥â“π‡™◊ÕÈ ™“μ‘ ‚¥¬æ∫«à“„π§πº‘«¥” (negroid) ®– æ∫Õ—μ√“°“√‡ªìπ´È”¡“°°«à“§πº‘«¢“« (caucasian) à«π °≈ÿà¡Õ“°“√ HELLP æ∫°“√‡°‘¥´È”ª√–¡“≥√âÕ¬≈– ıÒ §«“¡‡ ’Ë¬ß°—∫°“√‡°‘¥‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥°—∫ ¿“«–ª√’Õ’·§≈¡‡´’¬æ∫«à“ ª√’Õ’·§≈¡‡´’¬„π§√√¿å·√°‰¡à ‡æ‘Ë¡§«“¡‡ ’Ë¬ßμàÕ‚√§À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ·μà∂â“‡ªìπ´È”„π §√√¿å∂—¥¡“‚¥¬¡’°“√¥”‡π‘π‚√§‡√‘Ë¡μâπ„πÕ“¬ÿ§√√¿åπâÕ¬Ê ºŸâªÉ«¬‡À≈à“π’È®–¡’§«“¡‡ ’Ë¬ß‡æ‘Ë¡¡“°¢÷ÈπÒ ¡’°“√»÷°…“æ∫«à“ ª√’ Õ’ · §≈¡‡´’ ¬ ‡æ‘Ë ¡ §«“¡‡ ’Ë ¬ ßμà Õ ¿“«–‰¢¡— π „π‡≈◊ Õ ¥ Ÿ ß (dyslipidemia) ·≈–°“√¥◊ÈÕμàÕÕ‘π´Ÿ≈‘π (insulin resistance) ∑”„ÀâÕ“®‡æ‘Ë¡§«“¡‡ ’Ë¬ßμàÕ°“√‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥À—«„® ‚§‚√π“√’ (coronary artery disease) ‰¥âÚÙ

º≈≈—æ∏å¢Õß°“√√—°…“·∫∫ª√–§—∫ª√–§Õß „π¿“«–ª√’Õ’·§≈¡‡´’¬™π‘¥√ÿπ·√ß „πÕ“¬ÿ§√√¿å ÚÙ-ÛÙ —ª¥“Àå ®“°°“√»÷ ° …“∑’Ë ºà “ π¡“æ∫«à “ ¡’ Õ— μ √“°“√μ“¬ ª√‘°”‡π‘¥μ—Èß·μà√âÕ¬≈– -Òˆ.ˆ ´÷Ëßº—π·ª√μ“¡Õ“¬ÿ§√√¿å °“√‡®√‘≠‡μ‘∫‚μ™â“„π§√√¿å §«“¡√ÿπ·√ß¢Õß‚√§ (HELLP syndrome À√◊Õ eclampsia) §ÿ≥¿“æ¢Õß°“√∫√‘∫“≈∑“√° ·√°‡°‘¥ ·μà¢âÕ¡Ÿ≈„π À√—∞Õ‡¡√‘°“ ·§π“¥“·≈–Ω√—Ëß‡» æ∫«à“Õ—μ√“°“√μ“¬∑“√°ª√‘°”‡π‘¥‡∑à“°—∫√âÕ¬≈–  À“°Õ“¬ÿ §√√¿å‡°‘π Û —ª¥“ÀåÒ˘

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μ“¬∑’Ë ”§—≠¢Õß¡“√¥“·≈–∑“√°∑—Ë«‚≈° °“√μ—¥ ‘π„®¢Õß ·æ∑¬å„π°“√„Àâ§≈Õ¥„π√–¬–‡«≈“∑’Ë‡À¡“– ¡ ®÷ß¡’ à«π ”§—≠„π°“√≈¥Õ—μ√“°“√ªÉ«¬·≈–μ“¬¢Õß∑“√° ªí ® ®ÿ ∫— π ¬— ß ‰¡à ¡’ «‘ ∏’ ° “√„¥∑’Ë ¡’ § «“¡·¡à π ¬”‡æ◊Ë Õ ∑”π“¬‚√§À√◊Õ§âπÀ“‚√§∑’¡Ë ª’ √– ‘∑∏‘¿“æ‡æ’¬ßæÕ ‡π◊ÕË ß®“° ‡ªìπ‚√§∑’Ë‰¡à∑√“∫ “‡Àμÿ·πà™—¥ ·≈–¬—ß‰¡à∑√“∫∂÷ß°≈‰° °“√‡°‘¥‚√§ °“√√—°…“¿“«–ª√’Õ’·§≈¡‡´’¬¢—Èπ√ÿπ·√ß‚¥¬°“√ ∑”„Àâ§√√¿å ‘Èπ ÿ¥∑ÿ°√“¬¬—ß§ß‡ªìπ·π«∑“ß∑’Ë∂◊ÕªØ‘∫—μ‘°—πÕ¬Ÿà Õ¬à“ß‰√°Áμ“¡ºŸâ‡¢’¬π¡’§«“¡‡ÀÁπ«à“„π∫“ß°√≥’∑’Ë ‡°‘¥¿“«–ª√’Õ’·§≈¡‡´’¬‡¡◊ËÕÕ“¬ÿ§√√¿åπâÕ¬°«à“ ÛÙ —ª¥“Àå ‚¥¬„™â‡°≥±å°“√«‘π‘®©—¬∫“ß¢âÕ∑’ËÕ“®¡’º≈°√–∑∫μàÕ¡“√¥“ ·≈–∑“√°πâ Õ ¬ Õ“®„Àâ ∑ “ß‡≈◊ Õ °°— ∫ ºŸâ ªÉ « ¬·≈–≠“μ‘ ∑’Ë ® – „Àâ°“√√—°…“·∫∫ª√–§—∫ª√–§Õß‰¥â Õ¬à“ßπâÕ¬‡æ◊ÕË ‡ªìπ°“√„Àâ “√ ‡μÕ√Õ¬¥å‡æ◊ËÕ°√–μÿâπ°“√æ—≤π“°“√„π°“√∑”ß“π¢Õß ‡´≈≈å∂ÿß≈¡ªÕ¥∑“√° ·≈–¬◊¥Õ“¬ÿ§√√¿åÕÕ°‰ª‡æ◊ËÕ„Àâ∑“√° ¡’Õ—μ√“°“√ªÉ«¬‡®Á∫À√◊Õμ“¬≈¥≈ß®“°°“√§≈Õ¥°àÕπ°”Àπ¥ ∑—È ß π’È ∑—È ß π—È π §ßÕ¬Ÿà ∑’Ë «‘ ® “√≥≠“≥¢Õß·æ∑¬å · μà ≈ –∑à “ π·≈– ∑’¡ß“π À “¢“ μ≈Õ¥®π°“√ª√–‡¡‘π ¿“«–¢ÕßºŸâªÉ«¬ ·μà≈–√“¬„π¢≥–π—Èπ «à“ ¡§«√„Àâ°“√√—°…“„π√Ÿª·∫∫„¥ ®÷ß®–¡’ª√–‚¬™πå Ÿß ÿ¥ ¿“¬„μâ°“√‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ ¢Õß¡“√¥“·≈–∑“√°Õ¬à“ß‡¢â¡ß«¥

‡Õ° “√Õâ“ßÕ‘ß Ò. National high blood pressure education program working group on high blood pressure in pregnancy. Report of the national high blood pressure education program working group on high blood pressure in pregnancy. Am J Obstet Gynecol 2000;183:S1-S22. Ú. American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia: ACOG Practice Bulletin No.:33. Obstet Gynecol 2002;99:159-67. Û. Wagner LK. Diagnosis and management of preeclampsia. Am Fam Physician 2004;70:2317-24. Ù. Samadi AR, Mayberry RM, Zaidi AA, Plesant JC, McGhee N Jr, Rice RJ. Maternal hypertension and associated pregnancy complications among AfricanAmerican and other women in the United States. Obstet Gynecol 1996;87:557-63. ı. √—μπ“ §”«‘≈—¬»—°¥‘Ï, √“¬‘π Õ‚√√à“, °π° ’®√. ¿“«– §«“¡¥— π ‚≈À‘ μ Ÿ ß ®“°°“√μ—È ß §√√¿å ™ π‘ ¥ √ÿ π ·√ß„π

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‚√ßæ¬“∫“≈»√’π§√‘π∑√å. »√’π§√‘π∑√å‡«™ “√ 2541;13 :137-44. ß“π‡«™ ∂‘μ‘·≈– “√ π‡∑». ∞“π¢âÕ¡Ÿ≈‚√ßæ¬“∫“≈ ¡À“«‘ ∑ ¬“≈— ¬ ∫Ÿ √ æ“ ªï æ.». 2548-2552. §≥– ·æ∑¬»“ μ√å¡À“«‘∑¬“≈—¬∫Ÿ√æ“ Anim-Nyame N, Gamble J, Soonranna SR, Johnson MR, Steer PJ. Microvascular permeability is related to circulating levels of tumour necrosis factor-alpha in pre-eclampsia. Cardiovasc Res 2003;58:162-9. Saibai BM, Mabie WC. Hemodynamics of preeclampsia. Clin Perinatol 1991;18:727-47. Brown MA, Zammit VC, Lowe SA. Capillary permeability and extracellular fluid volumes in pregnancy-induced hypertension. Clin Sci 1989;77: 599-604. Saibi BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009;200:481.e1-481.e7. Norwitz ER, Funai EF. Expectant management of severe preeclampsia remote from term: hope for the best, but expectant the worst. Am J Obstet Gynecol 2008;199:209-12. Haddad B, Sibai BM. Expectant management in pregnancies with severe pre-eclampsia. Semin Perinatol. 2009;33:143-51. Fonseca JE, Mendez F, Catano C, Arias F. Dexamethasone treatment does not improve the outcome of women with HELLP syndrome: a doubleblind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol 2005;193:1591-8. Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeksû gestation: A randomized controlled trial. Am J Obstet Gynecol 1994;171:818-22. Thangaratinam S, Coomarasamy A, OûMahony F, Sharp S, Zamora J, Khan KS, et al. Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systemic review. BMC Med 2009;7:10. Chammas MF, Nguyen TM, Li MA, Nuwayhid BS, Castro LC. Expectant management of severe preterm

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preeclampsia: is intrauterine growth restriction an indication for immediate delivery? Am J Obstet Gynecol 200;183:853-8. Chari RS, Friedman SA, OûBrien JM, Sibai BM. Daily antenatal testing in women with severe preeclampsia. Am J Obstet Gynecol 1995;173:1207-10. Sibai BM. Treatment of hypertension in pregnant women. N Engl J Med 1996;335:257-65. Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007;196:514e1-e9. Visser W, Wallenburg HCS. Temporising management of severe pre-eclampsia with and without the HELLP syndrome. Br J Obstet Gynaecol 1995;102:111-7. van Pampus MG, Wolf H, Westenberg SM, Post JA, Bonsel GJ, Treffers PE . Maternal and perinatal outcome after expectant management of the HELLP syndrome compared with pre-eclampsia without HELLP syndrome. Eur J Obstet Gynecol Reprod Biol 1998;76:31-6. Bolte AC, van Geijn HP, Dekker GA. Management and monitoring of severe preeclampsia. Eur J Obstet Gynecol Reprod Biol 2001;96:8-20. Anthony J, Johanson RB. Critical care in pregnancy. Curr Obstet Gynecol 1996;6:98-104. Park M, Brewster UC. Management of preeclampsia. Hospital physician 2007;43:35-32.

200 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ Abstract Expectant management of severe pre-eclampsia Kitti Krungkraipetch Faculty of Medicine, Burapha University Pre-eclampsia is a form of hypertension that is usual to human pregnancy. The clinical findings can manifest as either a maternal syndrome (hypertension and proteinuria with or without the others multisystem abnormalities) or as a fetal syndrome (intrauterine growth retardation of fetus, oligohydramnios and abnormal oxygenation supply). Preeclampsia is clearly a heterogeneous condition for which the pathogenesis could be different in women with various risk factors. The pathogenesis of disease among women may be different vary from healthy nulliparous women to women with preexisting vascular disease or multiple pregnancies. More over the pathophysiology of preeclampsia with early onset may be different than that of preeclampsia developing at term, during labor, or postpartum stage. Pre-eclampsia complicates around 6 to 8 % of all pregnancies and is the common cause of maternal mortality. Although the etiology is unknown, it is clear that the design for the development of this condition is placed down early in pregnancy period. Once the diagnosis of pre-eclampsia has been made, treatment options are limited. The delivery of the fetus remains the only effective treatment. But sometime it is difficult to make the decision especially in the pregnancies that remote from term. According to criteria of diagnosis of severe preeclampsia, some criteria may not be proper used for making decision to termination of pregnancy, i.e., heavy proteinuria, intrauterine fetal growth retardation (IUGR) only. If possible in specific conditions for example; only proteinuria or IUGR, it may be considered for expectant management for prolongation of pregnancy whose gestation remote from term. The expectant management goal is to reduce the perinatal morbidity and mortality in the premature infants by steroid treatment. The topic will discuss issues that should be considered in selecting women with severe preeclampsia for prompt delivery against expectant management. Key words : Severe pre-eclamsia, Expectant management

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°≈ÿà¡Õ“°“√Œ’‚¡ø“‚°‰´μ‘° ≈‘¡‚øŒ’ μ‘‚Õ‰´‚μ´‘ æ™√æ√√≥ ÿ√æ≈™—¬

∫∑§—¥¬àÕ °≈ÿà¡Õ“°“√Œ’‚¡ø“‚°‰´μ‘° ≈‘¡‚øŒ’ μ‘‚Õ‰´‚μ´‘ (Hemophagocytic lymphohistiocytosis; HLH) ‡ªìπ°≈ÿ¡à Õ“°“√∑’‡Ë °‘¥®“°§«“¡∫°æ√àÕß„π°“√∑”ß“π¢Õß‡´≈≈å„π√–∫∫¿Ÿ¡§‘ ¡ÿâ °—π∑’¡Ë À’ πâ“∑’°Ë ”®—¥‡™◊ÕÈ ‚√§·≈– ‘ßË ·ª≈°ª≈Õ¡ ‰¥â·°à cytotoxic T-lymphocyte ·≈– natural killer ∑”„Àâ‡°‘¥°“√°√–μÿâπ°“√À≈—Ëß “√ cytokine À≈“¬™π‘¥ ´÷Ëß¡’º≈∑”„Àâ‡´≈≈å„π°≈ÿà¡Œ‘ μ‘‚Õ‰´∑å (histiocyte ·≈– macrophage) ‡æ‘Ë¡®”π«π·≈–·æ√à°√–®“¬Õ¬à“ß√ÿπ·√ß àßº≈„Àâ‡°‘¥°“√∑”≈“¬‡π◊ÈÕ‡¬◊ËÕ·≈–Õ«—¬«– ”§—≠∑—Ë«√à“ß°“¬ ¡—°μ√«®æ∫ ‘Ëß°√–μÿâπ„Àâ‡°‘¥°≈ÿà¡Õ“°“√π’È ‰¥â·°à °“√ μ‘¥‡™◊ÕÈ , ‚√§¡–‡√Áß, ‚√§ autoimmune, ¿“«–¿Ÿ¡§‘ ¡ÿâ °—π∫°æ√àÕß∑’∂Ë “à ¬∑Õ¥∑“ßæ—π∏ÿ°√√¡ ≈—°…≥–Õ“°“√∑“ß§≈‘π°‘ ∑’ Ë ”§—≠ §◊Õ ¡’‰¢â μ—∫¡â“¡‚μ ¡’ cytopenia Õ¬à“ßπâÕ¬Ê Ú √–∫∫¢÷Èπ‰ª √à«¡°—∫°“√μ√«®æ∫ hemophagocytosis „π √–¬–∑’Ë‚√§≈ÿ°≈“¡®–¡’°“√∑”ß“π¢ÕßÕ«—¬«– ”§—≠≈â¡‡À≈«·≈–ºŸâªÉ«¬Õ“®¡’Õ—πμ√“¬∂÷ß™’«‘μ∂â“‰¡à‰¥â√—∫°“√√—°…“∑’Ë ·¡àπ¬”·≈–√«¥‡√Á« ·π«∑“ß°“√√—°…“ª√–°Õ∫¥â«¬°“√«‘π‘®©—¬Õ¬à“ß∂Ÿ°μâÕß „Àâ°“√√—°…“‚√§‚¥¬Õâ“ßÕ‘ßμ“¡ Ÿμ√ °“√√—°…“®”‡æ“– (HLH-2004) ·≈–°”®—¥ªí®®—¬°√–μÿâπ„Àâ‡°‘¥‚√§§«∫§Ÿà°—π‰ª √«¡∑—Èß√—°…“·∫∫ª√–§—∫ª√–§Õß ·≈–‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπμà“ßÊ °“√‡ª≈’Ë¬π∂à“¬‰¢°√–¥Ÿ°Õ“®®”‡ªìπ„π√“¬∑’Ë¡’Õ“°“√√ÿπ·√ß ¡’°“√∂à“¬∑Õ¥∑“ß æ—π∏ÿ°√√¡À√◊Õμ√«®æ∫¬’π∑’Ëº‘¥ª√°μ‘ §” ”§—≠:

Œ’‚¡ø“‚°‰´μ‘° ≈‘¡‚øŒ’ μ‘‚Õ‰´‚μ´‘ , ‡´≈≈åŒ‘ μ‘‚Õ‰´∑å, HLH-2004

‚§√ß°“√®—¥μ—Èß¿“§«‘™“°ÿ¡“√‡«™»“ μ√å §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ μ√å

202 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ °≈ÿ¡à Õ“°“√Œ’‚¡ø“‚°‰´μ‘° ≈‘¡‚øŒ’ μ‘‚Õ‰´‚μ´‘ À√◊Õ Hemophagocytic lymphohistiocytosis (HLH; D76.1) „πÕ¥’μ‡§¬‡√’¬°«à“ °≈ÿ¡à Õ“°“√Œ’‚¡ø“‚°‰´μ‘° (Hemophagocytic syndrome) ‡ªìπ°≈ÿ¡à Õ“°“√∑“ß§≈‘π°‘ ∑’ªË √–°Õ∫¥â«¬‰¢â, μ—∫¡â“¡‚μ, pancytopenia, ·≈–μ√«®∑“ßæ¬“∏‘«‘∑¬“æ∫ ≈— ° …≥–∑’Ë ‡ √’ ¬ °«à “ hemophagocytosis (‡´≈≈å „ π°≈ÿà ¡ macrophage ®—∫°‘π‡´≈≈å‡¡Á¥‡≈◊Õ¥¢“«, ‡¡Á¥‡≈◊Õ¥·¥ß·≈– ‡°≈Á¥‡≈◊Õ¥¢Õßμ—«‡Õß) ‚¥¬¡’æ¬“∏‘ ¿“æ‡°‘¥¢÷Èπ‰¥â∑—Èß„π ‰¢°√–¥Ÿ°, μ—∫, ¡â“¡, μàÕ¡πÈ”‡À≈◊Õß ·≈–√–∫∫ª√– “∑ ‡°‘ ¥ ®“°§«“¡º‘ ¥ ª√°μ‘ ¢ Õß°≈‰°°“√∑”ß“π„π√–∫∫ ¿Ÿ¡‘§ÿâ¡°—π¢Õß√à“ß°“¬ æ∫‰¥âπâÕ¬„π‡¥Á° ·μà‰¥â√—∫§«“¡ π„®„π°“√»÷°…“§âπ§«â“‡æ‘¡Ë ¡“°¢÷πÈ „π™à«ß∑»«√√…∑’ºË “à π¡“ °≈ÿ¡à Õ“°“√π’¡È º’ √Ÿâ “¬ß“π‰«â§√—ßÈ ·√°„πªï æ.». ÚÙ¯Ú ‚¥¬ Scott ·≈– Robb-SmithÒ ´÷Ëß√“¬ß“π¿“«–∑’Ë¡’°“√‡®√‘≠ ¢Õß‡´≈≈åŒ‘ μ‘‚Õ‰´∑å (histiocyte) º‘¥ª√°μ‘·≈–μ√«®æ∫ hemophagocytosis ‡√’¬°«à“ çHistiocytic medullary reticulosisé „πªï æ.». ÚÙ˘ı ‚¥¬ Farquhar ·≈– ClaireauxÚ ‰¥â √“¬ß“πºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘°“√‡°‘¥°≈ÿà¡Õ“°“√π’È„π§√Õ∫§√—« ‡¥’¬«°—π ‡√’¬°«à“ çFamilial haemophagocytic reticulosisé „π ªï æ.». ÚıÒ¯ ‚¥¬ Chandra ·≈–§≥–Û ‰¥â√“¬ß“π ºŸâªÉ«¬ Ú √“¬∑’Ëμ√«®æ∫§«“¡º‘¥ª√°μ‘¢Õß‡´≈≈å„π√–∫∫‡√μ‘§Ÿ‚≈Œ’ μ‘‚Õ‰´μ‘°¢Õß‰¢°√–¥Ÿ°∑’Ë¡’°“√®—∫°‘π‡¡Á¥‡≈◊Õ¥¢Õßμ—«‡Õß ∑”„Àâ‡°‘¥°≈ÿà¡Õ“°“√‰¢â ´’¥ ·≈–μ—∫¡â“¡‚μ ·μà‡°‘¥¢÷Èπ ™—Ë«§√“«√à«¡°—∫°“√μ‘¥‡™◊ÈÕ∫“ß™π‘¥ ´÷Ëß‡√’¬°«à“ çTransient histiocytosisé À≈—ß®“°π—Èπ°Á¡’°“√√“¬ß“π®“°À≈“¬ª√–‡∑» ‡°’Ë¬«°—∫¿“«– hemophagocytosis ∑’Ë‡°‘¥√à«¡°—∫§«“¡º‘¥ ª√°μ‘¢Õß√à“ß°“¬∑’ËÀ≈“°À≈“¬ ‰¥â·°à °“√μ‘¥‡™◊ÈÕ‰«√— , ·∫§∑’‡√’¬, ‡™◊ÕÈ √“·≈–ª√ ‘μ √«¡∑—ßÈ ‚√§ autoimmuneÙ-˜ ·≈– ‚√§¡–‡√Áß‚¥¬‡©æ“– T-cell lymphoma¯-Ò ‡ªìπμâπ

°“√‡√’¬°™◊ËÕ‚√§·≈–°“√·∫àß°≈ÿà¡‚√§ „πªï æ.». ÚıÚ¯ ‰¥â¡’°“√°àÕμ—Èß ¡“§¡Œ‘ μ‘‚Õ‰´∑å (The Histiocyte Society) ¢÷È π à ß º≈„Àâ · æ∑¬å ®”π«π¡“°®“°∑—«Ë ‚≈°¡’§«“¡ π„®„π°“√»÷°…“‡°’¬Ë «°—∫‡´≈≈å Œ‘ μ‘‚Õ‰´∑å ·≈–‚√§∑’Ë¡’§«“¡º‘¥ª√°μ‘‡°’Ë¬«¢âÕß°—∫‡´≈≈åπ’È ¡“°¢÷Èπ ·≈–„πªï æ.». ÚıÛ ‰¥â¡’°“√ª√–™ÿ¡‡æ◊ËÕ·∫àß °≈ÿà¡‚√§∑’Ë¡’§«“¡º‘¥ª√°μ‘‡°’Ë¬«¢âÕß°—∫‡´≈≈åŒ‘ μ‘‚Õ‰´∑å ‡ªìπ Û °≈ÿà¡ (classes)ÒÒ,ÒÚ ‰¥â·°à Ò) Langerhans cell histiocytosis (LCH) (class I) Ú) Non-Langerhans cell histiocytosis (class II) Û) Malignant histiocytic disorders (class III)

μàÕ¡“‰¥â¡’°“√‡ª≈’Ë¬π™◊ËÕ‡√’¬°‡æ◊ËÕ„Àâ —¡æ—π∏å°—∫ °≈‰°°“√‡°‘¥‚√§¡“°¢÷Èπ ‰¥â·°à Ò) Dendritic cell-related disorders Ú) Macrophage-related disorders Û) Malignant disorders ‚¥¬ HLH ®—¥Õ¬Ÿà„π°≈ÿà¡∑’Ë Ú (macrophage-related disorders) ·≈–‡ªìπ‚√§∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥„π°≈ÿà¡π’È À≈—ß®“° π—È π ‰¥â ¡’ § «“¡æ¬“¬“¡„π√–¥— ∫ π“π“™“μ‘ „ π°“√®— ¥ °“√ ª√–™ÿ¡‡æ◊ËÕ√«∫√«¡À≈—°∞“π°“√»÷°…“·≈–°”Àπ¥·π«∑“ß °“√√—°…“‚√§∑’¡Ë §’ «“¡º‘¥ª√°μ‘‡°’¬Ë «¢âÕß°—∫‡´≈≈å Œ‘ μ‘‚Õ‰´∑å π’ÈÕ¬à“ß‡À¡“– ¡ „πªï æ.». ÚıÛ˜ ‰¥â¡’°“√ª√–°“»„™â LCH-I ·≈– HLH-94ÒÛ μàÕ¡“‰¥â¡’°“√ª√—∫ª√ÿß·°â‰¢Õ¬à“ß μàÕ‡π◊ËÕß ®π¡’∑’Ë„™â·æ√àÀ≈“¬„πªí®®ÿ∫—π ‰¥â·°à LCH-III ·≈– HLH-2004ÒÙ

«‘∑¬“°“√√–∫“¥ ‡°‘¥¢÷Èπ„π‡¥Á°¡“°°«à“ºŸâ„À≠à ∂â“‡ªìπ Familial haemophagocytic lymphohistiocytosis (FHL) ¡—°· ¥ß Õ“°“√μ—Èß·μà«—¬∑“√° ·μà∫“ß√“¬Õ“®«‘π‘®©—¬‰¥â‡√Á«μ—Èß·μàÕ¬Ÿà „π§√√¿å¡“√¥“ À√◊Õ‡√‘Ë¡¡’Õ“°“√™â“„π‡¥Á°‚μ „πÕ¥’μ¡’ √“¬ß“πÕÿ∫—μ‘°“√≥å„π‡¥Á°ª√–¡“≥ Ò.Ú μàÕ Ò,,Òı ·μà¡’°“√§“¥°“√≥å«à“πà“®–¡’®”π«πºŸâªÉ«¬ Ÿß∂÷ß Ò √“¬μàÕ ‡¥Á°‡°‘¥¡’™’æ ı, √“¬Òˆ ‚¥¬‰¡àæ∫§«“¡·μ°μà“ß°—π ¢Õß°“√‡°‘¥‚√§„π·μà≈–‡æ» ‡·≈–‡™◊ÈÕ™“μ‘ √“¬ß“πºŸâªÉ«¬®“°ª√–‡∑»‰∑¬¡’Õ¬Ÿàª√–ª√“¬ Õ’° ∑—Èß¬—ß¡’®”π«πºŸâªÉ«¬Õ’°¡“°∑’Ë¬—ß‰¡à‰¥â¡’°“√√“¬ß“π °«‘«—≥≥å «’√°ÿ≈·≈–§≥–Ò˜ ‰¥â√“¬ß“πºŸªâ «É ¬‡¥Á°®”π«π ıÚ √“¬ (æ.». ÚıÛÒ-ÚıÙ) ∑’Ë‡ªìπ‚√§ HLH ‚¥¬ à«π„À≠à°«à“√âÕ¬≈– Ù ‡°‘¥√à«¡°—∫ non-Hodgkin lymphoma √Õß≈ß¡“ §◊Õ ‚√§μ‘¥‡™◊ÈÕ ·≈–‰¡à∑√“∫ “‡Àμÿ∑’Ë·πà™—¥ «—π¥’ π‘ß “ππ∑åÒ¯ √“¬ß“πºŸâªÉ«¬‡¥Á°®”π«π ı √“¬ (æ.». ÚıÛÚ-ÚıÙÒ) ∑’Ë‡ªìπ‚√§ HLH ´÷Ëß‡°‘¥√à«¡°—∫‚√§μ‘¥‡™◊ÈÕ æ∫«à“¡’Õ—μ√“°“√ ‡ ’¬™’«‘μ Ÿß∂÷ß√âÕ¬≈– ˜ ‚¥¬¡’ “‡Àμÿ°“√‡ ’¬™’«‘μ à«π „À≠à‡ªìπ°“√μ‘¥‡™◊ÈÕ·∑√°´âÕπ ·≈–Õ«—¬«–¿“¬„π≈â¡‡À≈« ·μà √ “¬ß“π„πºŸâ „ À≠à ‡ °◊ Õ ∫∑—È ß À¡¥‡°‘ ¥ √à « ¡°— ∫ ‚√§¡–‡√Á ß ‚¥¬‡©æ“– T-cell lymphomaÒ˘-ÚÚ

æ¬“∏‘ √’√«‘∑¬“ ‡´≈≈åŒ‘ μ‘‚Õ‰´∑å ®—¥‡ªìπ‡´≈≈å‡¡Á¥‡≈◊Õ¥™π‘¥Àπ÷Ëß ‡°‘¥®“°‡´≈≈åμ—«ÕàÕπ„π‰¢°√–¥Ÿ°™π‘¥ myelomonocytic stem cell ∑’Ë‡ªìπμâπ°”‡π‘¥¢Õß “¬ monohistiocytic ·≈–

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

myelocytic ´÷Ë ß º≈‘ μ monocyte/ macrophage ·≈– granulocyte μ“¡≈”¥—∫ ‡´≈≈åπ’È∂Ÿ° √â“ß„π‰¢°√–¥Ÿ°°àÕπ®– ª≈àÕ¬ÕÕ°¡“ Ÿà°√–· ‚≈À‘μ·≈–°√–®“¬‰ª¬—ß‡π◊ÈÕ‡¬◊ËÕμà“ßÊ ‚¥¬·∫àß™π‘¥μ“¡Àπâ“∑’Ë‰¥â‡ªìπ Ú °≈ÿà¡ ‰¥â·°à Ò. Ordinary histiocyte À√◊Õ antigen processing cell ∑”Àπâ“∑’Ë∑”≈“¬ ‘Ëß·ª≈°ª≈Õ¡ Ú. Dendritic cell À√◊Õ antigen presenting cell ∑”Àπâ “ ∑’Ë μà Õ Ÿâ °— ∫ ‡™◊È Õ ‚√§ ‚¥¬∑”ß“π√à « ¡°— ∫ B ·≈– T-lymphocytes (À√◊Õ‡ªìπ immunoregulatory effector cells) ‡¡◊ËÕ¡’‡™◊ÈÕ‚√§‡¢â“ Ÿà√à“ß°“¬¡πÿ…¬å ®–¡’‡´≈≈å®”π«π ¡“°„π√–∫∫¿Ÿ ¡‘ §ÿâ ¡ °— π √«¡∑—È ß ‡´≈≈å ≈‘ ¡ ‚ø‰´∑å ·≈– Œ‘ μ‘‚Õ‰´∑å ∑’Ë∂Ÿ°°√–μÿâπ‡æ◊ËÕμàÕ Ÿâ°—∫‡™◊ÈÕ‚√§ ‚¥¬ª√°μ‘ ‡¡◊ËÕ‡™◊ÈÕ‚√§∂Ÿ°°”®—¥‰ª·≈â«®–¡’°≈‰°¬âÕπ°≈—∫¡“¬—∫¬—Èß°“√ ∑”ß“π¢Õß‡´≈≈å‡À≈à“π’È ·≈–∑”„Àâ√–∫∫¿Ÿ¡‘§ÿâ¡°—π°≈—∫ Ÿà ¿“«–ª√°μ‘ÚÛ-Úı §«“¡º‘¥ª√°μ‘„πºŸâªÉ«¬ HLH ‡°‘¥ ‡π◊ËÕß®“°¡’§«“¡∫°æ√àÕß¢Õß√–∫∫¿Ÿ¡‘§ÿâ¡°—π∑’Ë∑”„ÀâÕ¬Ÿà„π ¿“«–∂Ÿ°°√–μÿâπÕ¬Ÿàμ≈Õ¥ (immune dysregulation) ∑”„Àâ ‡°‘¥°≈ÿà¡Õ“°“√ HLH „π∑’Ë ÿ¥ ∑ƒ…Æ’∑’Ë¬Õ¡√—∫„πªí®®ÿ∫—π¢Õß HLH ‡°’Ë¬«¢âÕß °—∫§«“¡∫°æ√àÕß„π°“√∑”ß“π¢Õß‡´≈≈å cytotoxic Tlymphocyte (CTL) ·≈– natural killer (NK) „π°“√°”®—¥ ‡™◊ÕÈ ‚√§·≈– ‘ßË ·ª≈°ª≈Õ¡ ∑”„Àâ‡°‘¥°“√°√–μÿπâ °“√À≈—ßË “√ cytokine À≈“¬™π‘¥ÕÕ°¡“¡“°º‘¥ª√°μ‘ ‰¥â·°à interferongamma (IFN-a), soluble interleukin-2 receptor (sIL-2R), tumor necrosis factor-alpha (TNF-_) ·≈– granulocyte macrophage colony-stimulating factor (GM-CSF) ´÷Ëß ¡’º≈¬—∫¬—Èß°“√‡°‘¥ apoptosis ¢Õß macrophage ∑”„Àâ¡’ °“√‡æ‘¡Ë ®”π«π¢Õß‡´≈≈åπ’È ·≈–·æ√à°√–®“¬Õ¬à“ß√ÿπ·√ß √«¡

∑—Èß¡’°“√º≈‘μ interleukin-1 (IL-1) ·≈– interleukin-6 (IL-6) àßº≈„Àâ‡°‘¥°“√∑”≈“¬‡π◊ÈÕ‡¬◊ËÕ·≈–Õ«—¬«– ”§—≠∑—Ë« √à“ß°“¬Úˆ,Ú˜

°“√·∫àß™π‘¥μ“¡ “‡Àμÿ Ò) Primary À√◊Õ Familial hemophagocytic lymphohistiocytosis (FHL À√◊Õ FHLH) ‡ªìπ∂à“¬∑Õ¥∑“ß æ—π∏ÿ°√√¡‚¥¬¬’π¥âÕ¬ ·∫àß‡ªìπ ı ™π‘¥¬àÕ¬μ“¡™π‘¥¢Õß ¬’π∑’Ë‡°’Ë¬«¢âÕß ‰¥â·°à FHL1 - ‰¡à∑√“∫™π‘¥ FHL2 - PRF1 FHL3 - UNC13D (™◊ËÕ‡¥‘¡ §◊Õ MUNC13-4) FHL4 - STX11 FHL5 - STXBP2 §«“¡º‘¥ª√°μ‘∑“ß¬’π¥—ß°≈à“«π’ÈÚ¯-Ûı “¡“√∂ Õ∏‘ ∫ “¬°“√‡°‘ ¥ ‚√§„π§√Õ∫§√— « ºŸâ ªÉ « ¬‚√§ FHL ‰¥â ª√–¡“≥√âÕ¬≈– ı-¯ ¢÷ÈπÕ¬Ÿà°—∫≈—°…≥–ª√–™“°√∑’Ëæ∫ ¥— ß π—È π ®÷ ß ¡’ ºŸâ ªÉ « ¬Õ’ ° ®”π«π¡“°∑’Ë √ Õ°“√μ√«®æ∫¬’ π ∑’Ë ‡°’¬Ë «¢âÕß∑’¬Ë ß— ‰¡à‡ªìπ∑’√Ë ®Ÿâ °— ¬’π∑’μË √«®æ∫∫àÕ¬∑’ Ë ¥ÿ §◊Õ PRF1 ·≈– UNC13D ´÷Ëß§«∫§ÿ¡°“√ —ß‡§√“–Àå‚ª√μ’π™◊ËÕ perforin ·≈– Munc13-4 μ“¡≈”¥—∫ ´÷Ëß‚ª√μ’π∑—Èß Õßπ’È¡’ «à π√à«¡ „π°“√°”®—¥‡™◊ÈÕ‚√§‚¥¬‡´≈≈å CTL ·≈– NK ·≈–‡™◊ËÕ«à“ ¡’Àπâ“∑’Ë„π°“√¬—∫¬—Èß‰¡à„Àâ√–∫∫¿Ÿ¡‘§ÿâ¡°—π∑”ß“π¡“°‡°‘π ™π‘¥ FHL5 ‡æ‘Ëß¡’√“¬ß“π°“√μ√«®æ∫≈à“ ÿ¥„π™π™“μ‘ ·∂∫μ–«—πÕÕ°°≈“ß·≈–¬ÿ‚√ªμÕπ°≈“ß ‡°‘¥®“°°“√¢“¥ ‚ª√μ’π Munc18-2 ∑’Ë§«∫§ÿ¡°“√ √â“ß‚¥¬¬’π STXBP2 ¡’ º≈∑”„Àâ‡°‘¥§«“¡∫°æ√àÕß„π°“√ª≈àÕ¬ cytotoxic granules (degranulation) ¢Õß‡´≈≈å NK

μ“√“ß∑’Ë Ò · ¥ß™◊ËÕ·≈–μ”·Àπàß¢Õß¬’π∑’Ë —¡æ—π∏å°—∫™π‘¥¢Õß‚√§ FHL ™π‘¥ ¬’π μ”·Àπàß∫π‚§√‚¡‚´¡ FHL1 FHL2

NA PRF1

9q21.3-22 10q21-22

FHL3

17q25.1

FHL4

UNC13D (MUNC13-4) STX11

FHL5

STXBP2

19p13.2-13.3

6q24

¥—¥·ª≈ß®“°: Cetica V, 2010Ûı ·≈– Zhang K, 2006Û¯ NA=No data available

203

ºŸâªÉ«¬‚√§ HLH ∑’Ëμ√«®æ∫¬’π

¡’√“¬ß“π‡©æ“–™“«ª“°’ ∂“π Ù §√Õ∫§√—« ‚¥¬‡©≈’Ë¬√âÕ¬≈– Ú-Û ®“°∑—Ë«‚≈° >√âÕ¬≈– ı ¢Õß§√Õ∫§√—«™“«·Õø√‘°—π-Õ‡¡√‘°—π ‚¥¬‡©≈’Ë¬√âÕ¬≈– Ú-Û ®“°∑—Ë«‚≈° √âÕ¬≈– Ú ¢Õß§√Õ∫§√—«™“«μÿ√°’ æ∫πâÕ¬¡“°„π™π™“μ‘Õ◊Ëπ ‡æ‘Ëß¡’√“¬ß“π‡©æ“–∫“ß™π™“μ‘ (™“«´“Õÿ¥‘Õ“√–‡∫’¬, μÿ√°’, ª“°’ ∂“π, ¬ÿ‚√ª)

204 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ (μ“√“ß∑’Ë Ò) μ“¡‡°≥±å∑’Ë°”Àπ¥‰«â “¡“√∂„Àâ°“√ «‘π‘®©—¬ FHL ‡¡◊ËÕμ√«®æ∫¬’π∑’Ë —¡æ—π∏å°—∫°“√‡°‘¥ FHL ‚¥¬ ‰¡à®”‡ªìπμâÕß¡’≈—°…≥–∑“ß§≈‘π‘°§√∫μ“¡‡°≥±å ·μà§«√ ß —¬‚√§π’È ∂â“¡’‡¥Á°‡ªìπ‚√§π’È¡“°°«à“Àπ÷Ëß§π„π§√Õ∫§√—« ·≈–„π°√≥’∑’Ë√—°…“·≈â«‰¡à¥’¢÷Èπ À√◊ÕÀ¬ÿ¥°“√√—°…“·≈â«‚√§ °≈—∫‡ªìπ´È” °“√‡ª≈’Ë¬π∂à“¬‰¢°√–¥Ÿ° ‡ªìπ«‘∏’‡¥’¬«∑’Ë∑”„Àâ À“¬¢“¥®“°‚√§‰¥â Ú) Secondary À√◊Õ Acquired À√◊Õ Reactive HLH ‡°‘¥√à«¡°—∫§«“¡º‘¥ª√°μ‘∑’Ë‡°‘¥¢÷Èπ„π√à“ß°“¬ ‰¥â·°à - ‚√§μ‘¥‡™◊ÈÕ (Infection-associated hemophagocytic syndrome; IAHS)Ù,ı ‰¥â·°à °“√μ‘¥‡™◊ÈÕ‰«√— , ·∫§∑’‡√’¬, ‡™◊ÈÕ√“·≈–ª√ ‘μ - ‚√§∑“ß autoimmuneˆ,˜ ‰¥â·°à Rheumatoid arthritis, Macrophage activation syndrome (MAS) ∑’Ëæ∫„πºŸâ ªÉ«¬‚√§ Juvenile idiopathic arthritis - ‚√§¡–‡√Áß (Malignancy-associated hemophagocytic syndrome; MAHS) ‚¥¬‡©æ“– T - cell lymphoma¯,˘,Ò Û) Inherited immune disorderÛˆ ‡ªìπ‚√§¿Ÿ¡‘§ÿâ¡°—π ∫°æ√àÕß∑’Ë∂à“¬∑Õ¥∑“ßæ—π∏ÿ°√√¡ ∑’Ë¡’§«“¡∫°æ√àÕß„π°“√ ∑”ß“π¢Õß‡´≈≈å∑’Ë¡’Àπâ“∑’Ë„π°“√°”®—¥‡™◊ÈÕ‚√§·≈– ‘Ëß·ª≈° ª≈Õ¡ ·≈–¡’§«“¡‡ ’Ë¬ßμàÕ°“√‡°‘¥ hemophagocytosis ∑’Ë √ÿπ·√ß√à«¡¥â«¬ ‰¥â·°à - X-linked lymphoproliferative disease (XLP) ‡°‘¥ ®“°°“√¢“¥‚ª√μ’π SAP ·≈– XIAP ∑’Ë§«∫§ÿ¡°“√ √â“ß‚¥¬ ¬’π SH2D1A ·≈– BIRC4 μ“¡≈”¥—∫ ¡—°· ¥ßÕ“°“√μ“¡ À≈—ß°“√μ‘¥‡™◊ÈÕ Epstein-Barr virus (EBV) ∑’Ë√ÿπ·√ß ∫“ß√“¬ Õ“®æ∫√à«¡°—∫ hypogammaglobulinemia - Chediak-Higashi syndrome ‡°‘¥®“°°“√¢“¥ ‚ª√μ’π CHS1 ∑’Ë§«∫§ÿ¡°“√ √â“ß‚¥¬¬’π LYST ¡—°®–μ√«® æ∫ albinism, ‡°≈Á¥‡≈◊Õ¥∑”ß“π∫°æ√àÕß ·≈–¡’ granules ¢π“¥ „À≠à (secretory lysosomes) „π‡´≈≈åπ‘«‚∑√øî≈≈å/ ≈‘¡‚ø‰´∑å

- Griscelli syndrome type 2 (GS2) ‡°‘¥®“°°“√ ¢“¥‚ª√μ’π Rab27a ∑’Ë§«∫§ÿ¡°“√ √â“ß‚¥¬¬’π RAB27A ¡’§«“¡º‘¥ª√°μ‘¢Õß√–∫∫ª√– “∑√à«¡°—∫ ’º«‘ / ’º¡º‘¥ª√°μ‘ (partial albinism with silvery-grey hair)

°“√«‘π‘®©—¬ Õâ “ ßÕ‘ ß μ“¡‡°≥±å ° “√«‘ π‘ ® ©— ¬ ‚¥¬ Histiocyte Society ´÷ËßÕ“»—¬Õ“°“√∑“ß§≈‘π‘°√à«¡°—∫°“√μ√«®∑“ß ÀâÕßªØ‘∫—μ‘°“√‡©æ“–‚√§ ‚¥¬æ∫¢âÕ„¥¢âÕÀπ÷Ëß°Á “¡“√∂ „Àâ°“√«‘π‘®©—¬‰¥â Ò) μ√«®æ∫¬’π∑’Ë —¡æ—π∏å°—∫°“√‡°‘¥ FHL (diseasecausing mutation) ‰¥â·°à PRF1, UNC13D (™◊ËÕ ‡¥‘¡ §◊Õ MUNC13-4), STX11 À√◊Õ Ú) ¡’≈—°…≥–∑“ß§≈‘π‘°∑’Ëæ∫Õ¬à“ßπâÕ¬ ı ¢âÕ®“° ∑—ÈßÀ¡¥ ¯ ¢âÕ ¥—ßπ’È - Prolonged fever: ‰¢â¡“°°«à“ ˜ «—π - Splenomegaly - Cytopenia: Õ¬à“ßπâÕ¬ Ú lineages μàÕ‰ªπ’È Absolute neutrophils πâÕ¬°«à“ Ò,/μL ‡°≈Á¥‡≈◊Õ¥πâÕ¬°«à“ Ò,/μL Œ’‚¡‚°≈∫‘ππâÕ¬°«à“ ˘. g/dL (πâÕ¬°«à“ Ò. g/dL ”À√—∫∑“√° <Ù —ª¥“Àå) - Hypofibrinogenemia: √–¥—∫ Fibrinogen πâÕ¬°«à“ Ò.ı g/L À√◊Õ Hypertriglyceridemia: √–¥—∫ triglycerideÀ≈—ßÕ¥Õ“À“√¡“°°«à“ Ú. mmol/L (Úˆı mg/dL) À√◊Õ Ÿß°«à“ Û ‡∑à“¢Õß à«π ‡∫’Ë¬ß‡∫π¡“μ√∞“π¢Õß§à“Õâ“ßÕ‘ß·μà≈–Õ“¬ÿ - Hemophagocytosis: μ√«®æ∫„πμàÕ¡πÈ”‡À≈◊Õß, ¡â“¡, πÈ”‰¢ —πÀ≈—ß À√◊Õ‰¢°√–¥Ÿ° ‚¥¬‰¡à¡’ À≈—°∞“π¢Õß‚√§¡–‡√Áß (√Ÿª¿“æ∑’Ë Ò) ÒÙ

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√Ÿª¿“æ∑’Ë Ò · ¥ßµ—«Õ¬à“ß¿“æ‰¢°√–¥Ÿ°ºŸâªÉ«¬‚√§ HLH ∑’Ë¡’‡´≈≈å Œ‘ µ‘‚Õ‰´∑å ®—∫°‘π‡¡Á¥‡≈◊Õ¥·¥ß ‡¡Á¥‡≈◊Õ¥¢“« ·≈–‡°≈Á¥‡≈◊Õ¥ (¿“æ °. ·≈– ¢.)

°.

¢.

- Low or absent natural killer (NK) cell activity: °“√∑”ß“π¢Õß‡´≈≈å NK ∑’Ë ¡’ ª √– ‘∑ ∏‘ ¿ “æ ≈¥≈ß —¡æ—π∏å°—∫√–¬–¢Õß‚√§∑’Ë¡’Õ“°“√≈ÿ°≈“¡

- Hyperferritinemia: √–¥—∫ Ferritin ≥ı µg/L - High plasma concentrations of soluble CD25: √–¥—∫ soluble IL2R ≥2,400 U/mL

· ¥ßÕ“°“√∑“ß§≈‘π‘°·≈–º≈°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√∑’Ëæ∫‰¥â∫àÕ¬„πºŸâªÉ«¬‚√§ HLH ≈—°…≥– Õ“°“√∑“ß§≈‘π‘° ‰¢â ¡â“¡‚μ μ—∫‚μ μàÕ¡πÈ”‡À≈◊Õß‚μ º◊πË Õ“°“√∑“ß√–∫∫ª√– “∑ º≈°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√ Anemia* Thrombocytopenia* Neutropenia* Hypertriglyceridemia* Hypofibrinogenemia* Hyperbilirubinemia

√âÕ¬≈– ˆ-Ò Ûı-Ò Û˘-˘˜ Ò˜-ıÚ Û-ˆı ˜-Ù˜ ¯˘-Ò ¯Ú-Ò ı¯-¯˜ ı˘-Ò Ò˘-¯ı ˜Ù

¥—ß· ¥ß„πμ“√“ß∑’Ë Ú æ∫«à“ºŸâªÉ«¬„π°≈ÿà¡Õ“°“√ HLH ¡—°®–¡“¥â«¬‰¢â‡ªìπÕ“°“√À≈—° √à«¡°—∫Õ“°“√·≈– Õ“°“√· ¥ßÕ◊Ëπ Ê ‡™àπ μ—∫ ¡â“¡ ·≈–μàÕ¡πÈ”‡À≈◊Õß‚μ, ´’¥, ‡≈◊Õ¥ÕÕ°º‘¥ª√°μ‘, º◊Ëπ (erythroderma, macules, purpuric spots, papules, morbilliform eruptions), Õ“°“√∑“ß √–∫∫ª√– “∑ (™—°, ataxia, Õ—¡æ“μ§√÷Ëß´’°, ‡ª≈’Ë¬π·ª≈ß ∂“π–∑“ß®‘μ) °“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√Õ◊ËπÊ πÕ° ‡Àπ◊Õ®“°‡°≥±å°“√«‘π‘®©—¬¥—ß°≈à“« ∑’Ë¡’ª√–‚¬™πå„π°“√ π—∫ πÿπ°“√«‘π‘®©—¬ ‰¥â·°à - °“√μ√«®πÈ”‰¢ —πÀ≈—ßæ∫ pleocytosis, √–¥—∫ ‚ª√μ’π Ÿß - °“√μ√«®™‘Èπ‡π◊ÈÕμ—∫æ∫≈—°…≥–¢Õß chronic persistent hepatitis

°“√¥Ÿ·≈√—°…“ ¡’®ÿ¥¡ÿàßÀ¡“¬‡æ◊ËÕ Ò. √—°…“‚√§∑’Ë‡ªìπ “‡ÀμÿÀ√◊Õ‚√§∑’Ë‡°‘¥√à«¡ ´÷ËßμâÕß§âπÀ“ ·≈–„Àâ°“√√—°…“®”‡æ“–

Ú. §«∫§ÿ¡‡´≈≈å∑’Ë∑”ß“πº‘¥ª√°μ‘ ·≈–≈¥√–¥—∫ inflammatory cytokines ∑’Ë¡’°“√À≈—ËßÕÕ°¡“¡“°º‘¥ª√°μ‘ °“√√—°…“ μ“¡·π«∑“ß¢Õß Histiocyte Society ∑’Ëª√—∫ª√ÿß≈à“ ÿ¥ §◊Õ HLH-2004ÒÙ ¢÷Èπ°—∫ “‡Àμÿ·≈–§«“¡√ÿπ·√ß¢Õß‚√§ ‰¥â·°à Ò) ºŸâªÉ«¬∑’Ë‰¡à¡’ª√–«—μ‘‚√§ HLH „π§√Õ∫§√—« ·≈–μ√«®‰¡àæ∫¬’π∑’Ë‡°’Ë¬«¢âÕß √à«¡°—∫¡’Õ“°“√ ‰¡à√ÿπ·√ß “¡“√∂™—°π”„Àâ‚√§ ß∫‰¥â „Àâ ° “√√— ° …“‡©æ“–„π√–¬–‡∫◊È Õ ßμâ π (Initial therapy) ¯ —ª¥“Àå ‚¥¬μ‘¥μ“¡°“√¥”‡π‘π‚√§À≈—ßÀ¬ÿ¥°“√√—°…“ ∂â“ ‚√§°≈—∫‡ªìπ´È”°Á„Àâ‡√‘Ë¡°“√√—°…“„À¡à·≈–‡ª≈’Ë¬π·ºπ°“√ √—°…“‡ªìπ·∫∫∑’Ë Ú Ú) ºŸâªÉ«¬∑’Ë ß —¬‡ªìπ FHL (ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘ §√Õ∫§√—«À√◊Õμ√«®æ∫¬’π∑’Ë‡°’Ë¬«¢âÕß) À√◊Õ Õ“°“√√ÿπ·√ß ‰¡à “¡“√∂™—°π”„Àâ‚√§ ß∫‰¥â/ ¡’°“√°≈—∫‡ªìπ´È” „Àâ°“√√—°…“„π√–¬–‡∫◊ÈÕßμâπ (Initial therapy) ¯ —ª¥“Àå ·≈â«„ÀâμàÕ„π√–¬–μàÕ‡π◊ËÕß (Continuation therapy) ‡æ◊ËÕ√Õ °“√‡ª≈’Ë¬π∂à“¬‰¢°√–¥Ÿ°‡¡◊ËÕæ√âÕ¡

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μ“√“ß∑’Ë Û ·π«∑“ß°“√√—°…“‚√§ HLH μ“¡·π«∑“ß¢Õß Histiocyte Society √–¬–¢Õß°“√√—°…“

·π«∑“ß°“√¥Ÿ·≈√—°…“

√–¬–‡∫◊ÈÕßμâπ (Initial therapy) —ª¥“Àå∑’Ë Ò-¯

- Dexamethasone („ÀâμàÕ‡π◊ËÕß ‡√‘Ë¡®“°¢π“¥¬“ Ÿß ·≈–ª√—∫≈¥≈ß) 10 mg/m2 „Àâ∑ÿ°«—π ( —ª¥“Àå∑’Ë Ò-Ú) 5 mg/m2 „Àâ∑ÿ°«—π ( —ª¥“Àå∑Û-Ù) 2.5 mg/m2 „Àâ∑ÿ°«—π ( —ª¥“Àå∑’Ë ı-ˆ) 1.25 mg/m2 „Àâ∑ÿ°«—π ( —ª¥“Àå∑’Ë ˜-¯) ·≈–≈¥¢π“¥¬“≈ß®πÀ¬ÿ¥¬“ - VP-16 („ÀâμàÕ‡π◊ËÕß Ò-Ú §√—ÈßμàÕ —ª¥“Àå) 150 mg/m2 iv „Àâ Ú §√—ÈßμàÕ —ª¥“Àå ( —ª¥“Àå∑’Ë Ò-Ú) 150 mg/m2 iv „Àâ Ò §√—ÈßμàÕ —ª¥“Àå ( —ª¥“Àå∑’Ë Û-¯) - Cyclosporine A („ÀâμàÕ‡π◊ËÕß ·≈–ª√—∫¢π“¥μ“¡√–¥—∫¬“„π‡≈◊Õ¥) 6 mg/kg „Àâ∑ÿ°«—π (·∫àß„Àâ Ú §√—ÈßμàÕ«—π) √—°…“√–¥—∫¬“„π‡≈◊Õ¥ª√–¡“≥ 200 microgram/L ‚¥¬μ‘¥μ“¡ º≈¢â“ß‡§’¬ßμàÕ°“√∑”ß“π¢Õß‰μ·≈–μ—∫

√–¬–μàÕ‡π◊ËÕß (Continuation therapy) —ª¥“Àå∑’Ë ˘-Ù

- Dexamethasone (∑ÿ° Ú —ª¥“Àå) 10 mg/m2 „ÀâμàÕ‡π◊ËÕß Û «—πμàÕ√Õ∫ ≈—∫°—∫ - VP-16 (∑ÿ° Ú —ª¥“Àå) 150 mg/m2 iv Ò §√—ÈßμàÕ√Õ∫

√–¬–§ÿ°§“¡/ ‡¡◊ËÕ‚√§°≈—∫‡ªìπ´È” (Reactivation therapy)

‡√‘Ë¡„Àâ°“√√—°…“√–¬–‡∫◊ÈÕßμâπ„À¡à (Intensification of initial therapy)

°“√√—°…“‡¡◊ËÕ¡’Õ“°“√∑“ß√–∫∫ ª√– “∑ (CNS reactivation)

„Àâ¬“ methotrexate ©’¥‡¢â“∑“ß‰¢ —πÀ≈—ß (Intrathecal methotrexate therapy) - Methotrexate: <Ò ªï-6 mg, Ò-Ú ªï-8 mg, Ú-Û ªï-10 mg, >Û ªï-12 mg

¢âÕ∫àß™’È„π°“√‡ª≈’Ë¬π∂à“¬‰¢°√–¥Ÿ°

Ò) ‚√§ FHL Ú) ‡¡◊ËÕ‰¡à “¡“√∂™—°π”„Àâ‚√§ ß∫‰¥â/ ‡¡◊ËÕ‚√§°≈—∫‡ªìπ´È” ·≈–À“ºŸâ ∫√‘®“§‡´≈≈åμâπ°”‡π‘¥‰¥â ´÷ËßÕ“®‡ªìπ matched donor, mis-matched donor, family haploidentical donor, cord blood

À¬ÿ¥°“√√—°…“

‡¡◊ËÕÕ“°“√ª√°μ‘/ ‚√§ ß∫ (Complete resolution of the disease)

¥—¥·ª≈ß®“°: Henter JI, 2007ÒÙ

μ“¡·π«∑“ß°“√√—°…“¢Õß HLH-2004 (μ“√“ß∑’Ë Û) °“√√—°…“‡∫◊ÈÕßμâπ (Initial therapy) „πºŸâªÉ«¬ HLH ª√–°Õ∫ ¥â«¬°“√„Àâ¬“ etoposide, dexamethasone ·≈– cyclosporine π“π ¯ —ª¥“Àå Intrathecal methotrexate ®–„™â‡©æ“–√“¬ μ√«®æ∫§«“¡º‘¥ª√°μ‘¢ÕßπÈ”‰¢ —πÀ≈—ß À√◊Õ¡’Õ“°“√∑“ß √–∫∫ª√– “∑ °“√√—°…“μàÕ‡π◊ÕË ß (Continuation therapy) „π —ª¥“Àå∑’Ë ˘ ‡ªìπμâπ‰ª ª√–°Õ∫¥â«¬°“√„Àâ¬“ etoposide

≈—∫°—∫ dexamethasone ‡ªìπ√–¬– ´÷Ëß®–„Àâ‡©æ“–ºŸâªÉ«¬ FHL À√◊Õ √“¬∑’ËÕ“°“√√ÿπ·√ß/ ¡’°“√°≈—∫‡ªìπ´È” ‡æ◊ËÕ√Õ °“√‡ª≈’Ë¬π∂à“¬‰¢°√–¥Ÿ° °“√„Àâ immunoglobulin Õ“® ¡’ª√–‚¬™πå„π°“√§«∫§ÿ¡°“√À≈—ßË proinflammatory cytokines ·≈–¬—∫¬—Èß‡´≈≈å macrophage, T ·≈– B-lymphocyte ∑’Ë∂Ÿ° °√–μÿâπ

208 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ °“√μ‘¥μ“¡Õ“°“√À≈—ß„Àâ°“√√—°…“ Õ“°“√∑“ß§≈‘π‘°∑’Ë∫àß™’È°“√μÕ∫ πÕßμàÕ°“√√—°…“ (Clinical response) - ‰¡à¡’‰¢â - ¢π“¥¡â“¡§≈”‰¥â‡≈Á°≈ß - ‡°≈Á¥‡≈◊Õ¥ * Ò, /μL - √–¥—∫ fibrinogen ª√°μ‘ - √–¥—∫ ferritin ≈¥≈ß (Õ¬à“ßπâÕ¬√âÕ¬≈– Úı) ‚√§ ß∫ (Non-active disease; resolution) - ‰¡à¡’‰¢â - ‰¡à¡’¡â“¡‚μ - ‰¡à¡’ cytopenia - ‰¡à¡’ hypertriglyceridemia - ‰¡à¡’ hyperferritinemia - °“√μ√«®πÈ”‰¢ —πÀ≈—ßª√°μ‘ ‚√§°≈—∫ªìπ´È” (Reactivation of disease) - ‡°≈Á¥‡≈◊Õ¥ < Ò, μL - √–¥—∫ fibrinogen ) Òı mg/dL - √–¥—∫ triglyceride * Úˆı mg/dL - μ√«®æ∫ hemophagocytosis - √–¥—∫ ferritin ‡æ‘Ë¡¢÷Èπ - √–¥—∫ Soluble CD25 (soluble IL-2 receptor) > 2,400 U/mL

(primary À√◊Õ secondary HLH) ·≈–°“√«‘π‘®©—¬‚√§√à«¡ °—∫°“√„Àâ°“√√—°…“Õ¬à“ß∂Ÿ°μâÕß ¥—ßπ—Èπ·æ∑¬åºŸâ√—°…“®–μâÕß μ√–Àπ—°∂÷ß‚√§∑’Ë¡’Õ—πμ√“¬ Ÿß·≈–§ÿ°§“¡™’«‘μ¥—ß‡™àπ‚√§ HLH „π°“√„Àâ√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√·≈–Õ“°“√· ¥ß∑’Ë‡¢â“ ‰¥âμ“¡‡°≥±å°“√«‘π‘®©—¬ ‚¥¬μâÕß«‘π‘®©—¬·¬°‚√§Õ◊ËπÕÕ° ‰ª°àÕπ·≈–„Àâ °“√√—°…“Õ¬à“ß‡μÁ¡∑’Ëμ—Èß·μàμâπ°àÕπ®–¡’°“√ ∑”ß“π¢ÕßÕ«—¬«–¿“¬„π≈â¡‡À≈« ´÷Ëß®–™à«¬‡æ‘Ë¡‚Õ°“ √Õ¥ ™’«‘μ·≈–°“√À“¬¢“¥®“°‚√§‰¥â

‡Õ° “√Õâ“ßÕ‘ß Ò. Ú. Û.

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Abstract Hemophagocytic lymphohistiocytosis Pacharapan Surapolchai Department of Pediatrics, Faculty of Medicine, Thammasat University Hemophagocytic lymphohistiocytosis (HLH) is a syndrome characterized by inappropriately activated lymphocytes and natural killer cells that produce high concentrations of cytokines. It is evidenced that "hypercytokinemia" and subsequently uncontrolled activation of histiocytes/ macrophages and T-lymphocytes underline the progressive organ dysfunction which leads to death in affected patients. The predominant clinical findings of HLH are persistent fever, cytopenias, hepato-splenomegaly and hemophagocytosis. Diagnosing HLH is extremely challenging and HLH is usually fatal if untreated. The Histiocyte Society treatment study (HLH-2004) outlines diagnostic criteria and treatment protocol, based on chemo-immunotherapy, as well as treatment of underlying conditions and supportive care. Subsequent hematopoietic stem cell transplantation is recommended for patients with familial disease or molecular diagnosis, and patients with severe and persistent, or reactivated disease. Key words: Hemophagocytic lymphohistiocytosis, Histiocyte, HLH-2004

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

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¡—Ëπ§ßÀ√◊Õ Ÿ≠‡ ’¬°“√∑√ßμ—«„π√–À«à“ß‡¥‘πÒÛ,Òı °“√À°≈â¡®– àßº≈°√–∑∫μàÕ√à“ß°“¬·≈â«π—Èπ ¬—ß àßº≈°√–∑∫μàÕ ¿“æ®‘μ„® ∑’Ë‡√’¬°«à“ ç°≈ÿà¡Õ“°“√¿“¬À≈—ß °“√À°≈â¡é (post-fall syndrome) √à«¡¥â«¬ ´÷Ëß∑”„Àâ‡°‘¥ §«“¡√Ÿâ ÷°°≈—«°“√≈â¡ (fear of falling)Ò¯ ‚¥¬®“°°“√»÷°…“ ∑’Ëºà“π¡“æ∫«à“Õ—μ√“°“√‡°‘¥¿“«–§«“¡√Ÿâ ÷°°≈—«°“√≈â¡Õ¬Ÿà „π™à«ß√âÕ¬≈– Ù - ˜Û „πºŸâ ŸßÕ“¬ÿ∑’Ë‡§¬≈â¡ ´÷Ëß‡ªìπ Õ—μ√“∑’Ë Ÿß πÕ°®“°π’È¬—ßæ∫«à“ºŸâ ŸßÕ“¬ÿ∑’Ë‰¡à‡§¬¡’ª√–«—μ‘°“√ ≈â¡°Á¡’¿“«–°“√°≈—«°“√≈â¡„πÕ—μ√“∑’Ë ŸßÒ˘ °“√‡°‘¥°“√°≈—« °“√≈â¡∑”„ÀâºŸâ ŸßÕ“¬ÿ®–‰¡à°≈â“∑’Ë®–¡’°“√‡§≈◊ËÕπ‰À« À√◊Õ ≈¥°“√‡§≈◊ËÕπ‰À«„π°“√∑”°‘®°√√¡μà“ßÊ „π™’«‘μª√–®”«—π ´÷Ë ß ®– à ß º≈μà Õ ·≈–‡æ‘Ë ¡ §«“¡‡ ’Ë ¬ ß„π°“√À°≈â ¡ ´È” ‰¥â „ π Õπ“§μÚ,ÚÒ

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

Delbaere ·≈–§≥–„πªï §.». ÚÙ ‰¥â∑”°“√»÷°…“ º≈¢Õß°“√≈â¡∑’Ë¡’μàÕ°“√∑”°‘®«—μ√ª√–®”«—πæ∫«à“º≈¢Õß °“√≈â¡∑”„ÀâºŸâ ŸßÕ“¬ÿ¡’°“√À≈’°‡≈’Ë¬ß°“√∑”°‘®«—μ√ª√–®”«—π ‚¥¬°‘®°√√¡∑’ËºŸâ ŸßÕ“¬ÿÀ≈’°‡≈’Ë¬ß¡“°∑’Ë ÿ¥§◊Õ °“√‡Õ◊ÈÕ¡¡◊Õ À¬‘∫ ‘Ëß¢Õß ·≈–°“√‡¥‘π πÕ°®“°π’È·≈â«®“°°“√∑’ËºŸâ ŸßÕ“¬ÿ ¡’ § «“¡°≈— « ∑’Ë ‡ °‘ ¥ °“√≈â ¡ à ß º≈μà Õ §«“¡·¢Á ß ·√ß¢Õß °≈â “ ¡‡π◊È Õ ´÷Ë ß ®– à ß º≈°√–∑∫μà Õ §«“¡ “¡“√∂„π°“√ ‡§≈◊ËÕπ‰À«·≈–°“√∑√ßμ—« ®“° “‡Àμÿ¥—ß°≈à“«®–∑”„Àâ‡°‘¥ º≈„π∑“ß≈∫μàÕºŸâ ŸßÕ“¬ÿ ‚¥¬ºŸâ ŸßÕ“¬ÿ®–‰¡à¡—Ëπ„®μàÕ°“√ ‡§≈◊ËÕπ‰À«∑”„Àâ‡°Á∫μ—« ·≈–·¬°μ—«ÕÕ°®“°§√Õ∫§√—«À√◊Õ ®“° —ß§¡¡“°¢÷πÈ ÚÚ ´÷ßË Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß Brouwer ·≈–§≥–„πªï §.». ÚÙ æ∫«à“ºŸâ ŸßÕ“¬ÿ∑’Ë¡’¿“«–°“√°≈—« °“√≈â¡®–¡’§à“§–·ππ¢Õß·∫∫ª√–‡¡‘π Activities-specific balance confidence ∑’Ë∑¥ Õ∫‡°’Ë¬«°—∫§«“¡¡—Ëπ„®„π°“√ ∑”°‘®«—μ√ª√–®”«—π πâÕ¬°«à“°≈ÿà¡ºŸâ ŸßÕ“¬ÿ∑’Ë‰¡à¡’¿“«–°≈—« °“√≈â¡ √«¡∑—Èß„π°≈ÿà¡∑’Ë°≈—«°“√≈â¡®–¡’°“√ÕàÕπ·√ß¢Õß °≈â “ ¡‡π◊È Õ ¢“·≈–¡’ ¿ “«–®”°— ¥ ¢Õß§«“¡ “¡“√∂„π°“√ ∑√ßμ—«√à«¡¥â«¬ÚÛ °“√∑’ËºŸâ ŸßÕ“¬ÿ¡’§«“¡°≈—«∑’Ë‡°‘¥®“°°“√≈â¡®– àßº≈ °√–∑∫μà Õ §«“¡¡—Ë π „®„π°“√∑”°‘ ® °√√¡μà “ ßÊ „π™’ «‘ μ ª√–®”«—π ·≈–§ÿ≥¿“æ™’«μ‘ √«¡∑—ßÈ ºŸ â ßŸ Õ“¬ÿ∑¡’Ë °’ “√≈â¡„π™à«ß Ò ªï ®–¡’·π«‚πâ¡∑’Ë®–¡’°“√®”°—¥°“√‡§≈◊ËÕπ‰À«∑’Ë∑” °‘®°√√¡„π™’«‘μª√–®”«—πÚÛ Reelick ·≈–§≥–„πªï §.». Ú˘ æ∫«à“ºŸâ ŸßÕ“¬ÿ∑’Ë¡’ª√–«—μ‘°“√≈â¡·≈–¡’¿“«–§«“¡ √Ÿâ ÷°°≈—«°“√≈â¡®–¡’§«“¡‡√Á«„π°“√‡¥‘π≈¥≈ß √«¡∑—Èß¡’ √–¬–‡«≈“„π°“√°â“«‡¥‘π„π·μà≈–§√—Èß‡æ‘Ë¡¡“°¢÷Èπ ´÷Ëß‡ªìπº≈ ¡“®“°ºŸâ ŸßÕ“¬ÿμâÕß°“√≈¥°“√√∫°«π ¡¥ÿ≈„π¢≥–‡¥‘π„Àâ ¡“°∑’Ë ÿ ¥ÚÙ πÕ°®“°°“√≈â¡·≈–°“√°≈—«°“√≈â¡®– àßº≈ °√–∑∫μàÕ§«“¡ “¡“√∂„π°“√‡§≈◊ËÕπ‰À« ¬—ß®– à ßº≈ °√–∑∫μàÕ ¿“æ®‘μ„®¢ÕßºŸ â ßŸ Õ“¬ÿ ‡™àπ °“√‡°‘¥¿“«–´÷¡‡»√â“ À√◊Õ«‘μ°°—ß«≈®π∑”„ÀâºŸâ ŸßÕ“¬ÿÀ≈’°‡≈’Ë¬ß°“√∑”°‘®°√√¡ ¥â«¬μπ‡ÕßÀ√◊Õ‰¡à¡’°“√∑”°‘®°√√¡‡≈¬Úı, Úˆ ®“°∑’Ë°≈à“«¡“¢â“ßμâπ°“√≈â¡¢ÕßºŸâ ŸßÕ“¬ÿ®–∑”„Àâ ‡°‘¥º≈‡ ’¬À≈“¬ª√–°“√ ‡™àπ °“√∫“¥‡®Á∫ °“√°≈—«°“√≈â¡ °“√®”°—¥°“√‡§≈◊ËÕπ‰À«„π°“√∑”°‘®°√√¡μà“ßÊ „π™’«‘μ ª√–®”«—π √«¡∑—Èß àßº≈μàÕ ¿“æ®‘μ„®¢ÕßºŸâ ŸßÕ“¬ÿ ¥—ßπ—Èπ °“√≈¥Õ—μ√“‡ ’¬Ë ß∑’®Ë –∑”„Àâ‡°‘¥°“√≈â¡„πºŸ â ßŸ Õ“¬ÿ‡ªìπ ‘ßË ”§—≠ ´÷ËßμâÕß‡¢â“„®∂÷ßªí®®—¬∑’Ë∑”„Àâ‡°‘¥°“√≈â¡∑—Èß Õßª√–°“√μ“¡ ∑’Ë ° ≈à “ «¡“¢â “ ßμâ π ∑’Ë ª √–°Õ∫¥â « ¬ªí ® ®— ¬ ¿“¬„π·≈–ªí ® ®— ¬ ¿“¬πÕ° ”À√—∫ªí®®—¬∑’Ë∑”„Àâ‡°‘¥°“√≈â¡¿“¬„π√à“ß°“¬π—Èπ

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‡ªìπ‡√◊ËÕß∑’Ë·°â‰¢‰¥â≈”∫“°‡π◊ËÕß®“°√à“ß°“¬¢ÕßºŸâ ŸßÕ“¬ÿ¡’ °“√‡ ◊ËÕ¡μ“¡«—¬ ´÷Ëß°“√≈¥ªí®®—¬‡ ’Ë¬ß∑’Ë¥’∑’Ë ÿ¥ §◊Õ °“√ÕÕ° °”≈—ß°“¬ ‚¥¬™π‘¥¢Õß°“√ÕÕ°°”≈—ß°“¬∑’Ë‡À¡“– ¡ ”À√—∫ ºŸ â ßŸ Õ“¬ÿππÈ— §«√‡ªìπ°“√ÕÕ°°”≈—ß°“¬∑’‰Ë ¡à‡§≈◊ÕË π‰À«√«¥‡√Á« ·≈–√ÿπ·√ß®π‡°‘π‰ª „πªí®®ÿ∫—π°“√ÕÕ°°”≈—ß°“¬∑’Ë‰¥â√—∫ °“√¬Õ¡√—∫«à“ ™à«¬ àß‡ √‘¡§«“¡ “¡“√∂„π°“√∑√ßμ—« ¡’ §«“¡‡À¡“– ¡μàÕºŸâ ŸßÕ“¬ÿ §◊Õ ‰∑‡°ä° ´÷Ëß‡ªìπ°“√ÕÕ° °”≈—ß°“¬∑’Ë™à«¬ àß‡ √‘¡„Àâ¡’§«“¡·¢Áß·√ß¢Õß°≈â“¡‡π◊ÈÕ≈¥ §«“¡μ÷ß‡§√’¬¥ ¿“«–«‘μ°°—ß«≈ æ√âÕ¡∑—Èß™à«¬„Àâ‡°‘¥§«“¡ √Ÿâ ÷°ºàÕπ§≈“¬ ‚¥¬¡’≈—°…≥–À√◊Õ√Ÿª·∫∫°“√‡§≈◊ËÕπ‰À« Õ¬à“ß™â“Ê ¥â«¬∑à«ß∑à“∑’Ë¡’§«“¡μàÕ‡π◊ËÕß μ≈Õ¥°“√Ωñ°®–¡’ °“√∂à “ ¬πÈ” Àπ— ° ®“°¢“¢â “ ßÀπ÷Ë ß ‰ª¬— ß ¢“Õ’ ° ¢â “ ßÀπ÷Ë ß ´÷Ë ß ‡ªìπ°“√§«∫§ÿ¡°“√‡ª≈’Ë¬π·ª≈ß®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬„Àâ Õ¬Ÿà„π¢Õ∫‡¢μ¢Õß∞“π√—∫πÈ”Àπ—°∑’Ë¡’Õ¬ŸàÕ¬à“ß®”°—¥·μà≈–∑à“ ¢Õß‰∑‡°ä°®–‡πâπ„π≈—°…≥–¢Õß°“√∫‘¥À¡ÿπ à«πμà“ßÊ ¢Õß √à“ß°“¬ ∑—Èß„π à«π¢Õß≈”μ—« ·¢π·≈–¢“ √à«¡°—∫°“√ §«∫§ÿ¡≈¡À“¬„®Õ¬à“ßª√– “π —¡æ—π∏å°—π æ√âÕ¡∑—Èß°“√∑’Ë „™â§«“¡‡√Á«„π°“√‡§≈◊ËÕπ∑’ËμË”´÷Ëß∑”„Àâ¡’·√ß°√–·∑°μàÕ¢âÕ μàÕπâÕ¬ ®÷ß‰¡à°àÕ„Àâ‡°‘¥Õ—πμ√“¬·≈–¡’§«“¡ª≈Õ¥¿—¬μàÕºŸâ ŸßÕ“¬ÿ ŸßÚ˜, ÛÒ πÕ°®“°π’È ‰∑‡°ä° ¬—ß‡ªìπ°“√ÕÕ°°”≈—ß°“¬∑’Ë„™â ‡∑§‚π‚≈¬’„π√–¥—∫μË” ‰¡àμâÕß°“√Õÿª°√≥å·≈–§à“„™â®à“¬„¥Ê “¡“√∂Ωñ°‰¥âßà“¬·≈– –¥«° ®÷ß‡À¡“– ”À√—∫π”‰ª„™â ‡ªìπ°“√ÕÕ°°”≈—ß°“¬ ‡æ◊ËÕ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâ ŸßÕ“¬ÿ„π ™ÿ¡™π ºŸâ ŸßÕ“¬ÿ∑’ËΩñ°‰∑‡°ä° ‡ªìπª√–®”®–¡’§«“¡¡—Ëπ§ß„π °“√∑√ß∑à“¢≥–∑”°‘®°√√¡‰¥â¥’°«à“ºŸâ∑’Ë‰¡à‰¥âΩñ°‰∑‡°ä°ÛÚ Wong ·≈–§≥–„πªï §.». ÚÒ ‰¥â°≈à“«‰«â«à“ ‰∑‡°ä° ‡ªìπ°“√ÕÕ°°”≈—ß°“¬·∫∫ª√– “π —¡æ—π∏å (coordination exercise) ∑’Ë “¡“√∂™à«¬≈¥ªí®®—¬‡ ’Ë¬ß„π°“√À°≈â¡Û ®“°°√–∫«π°“√°“√√—°…“§«“¡ “¡“√∂„π°“√ §«∫§ÿ¡∑à“∑“ß„πºŸâ ŸßÕ“¬ÿ‰¥â „π¢≥–‡¥’¬«°—π Li ·≈–§≥– ‰¥âª√–‡¡‘πª√– ‘∑∏‘¿“æ¢Õß‚ª√·°√¡°“√Ωñ°‰∑‡°ä° „πºŸâ ªÉ«¬∑’Ë¡’Õ“¬ÿ¡“°°«à“ ˜ ªï ‚¥¬æ∫«à“ °“√Ωñ°‰∑‡°ä° Û §√—Èß μàÕ —ª¥“Àå ‡ªìπ‡«≈“ ˆ ‡¥◊Õπ ¡’ª√– ‘∑∏‘¿“æ„π°“√≈¥ ®”π«π§√—È ß ¢Õß°“√≈â ¡ §«“¡‡ ’Ë ¬ ß ·≈–§«“¡°≈— « ´÷Ë ß “¡“√∂‡æ‘Ë¡§«“¡ “¡“√∂„π°“√∑√ßμ—«·≈–°“√∑”°‘®«—μ√ ª√–®”«—π‰¥âÛÛ ”À√—∫°“√·°â‰¢ªí®®—¬∑’Ë∑”„Àâ‡°‘¥°“√≈â¡¿“¬πÕ° √à“ß°“¬ ‡ªìπ ‘ËßÀπ÷Ëß∑’Ë “¡“√∂∑”‰¥â ‚¥¬‡πâπ„π‡√◊ËÕß¢Õß °“√®—¥ ¿“æ·«¥≈âÕ¡∑’ËÕ¬Ÿà√Õ∫μ—«ºŸâ ŸßÕ“¬ÿÕ¬à“ß‡À¡“– ¡ ª√–°Õ∫¥â«¬ ‘Ëß·«¥≈âÕ¡¿“¬„π∫â“π ‚¥¬°“√®—¥‡§√◊ËÕß‡√◊Õπ

216 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ∑’ËÕ¬Ÿà¿“¬„π∫â“π„Àâ‡ªìπ√–‡∫’¬∫‰¡à«“ß ‘Ëß¢Õß∑’Ëæ◊Èπ μâÕß √–«—ß°“√«“ß “¬‰øøÑ“À√◊Õ„™â«— ¥ÿ∑”æ◊Èπ∫â“π∑’Ë≈◊Ëπ´÷Ëß‡ªìπ ªí®®—¬∑’Ë∑”„ÀâºŸâ ŸßÕ“¬ÿ –¥ÿ¥≈â¡‰¥âßà“¬ °“√®—¥· ß «à“ß„π μ—«Õ“§“√·≈–πÕ°Õ“§“√„Àâ‡À¡“– ¡„π∫√‘‡«≥∑’ËºŸâ ŸßÕ“¬ÿ μâÕß„™â‡ªìπª√–®” √«¡∑—Èß§«√μ‘¥μ—ÈßªÿÉ¡‡ªî¥„ÀâÕ¬Ÿà„π√–¥—∫∑’Ë ºŸâ ŸßÕ“¬ÿ°¥‰¥âÕ¬à“ß –¥«° πÕ°®“°π’È§«√μâÕß¡’°“√®—¥ Õÿ ª °√≥å ™à « ¬‡À≈◊ Õ ‡æ‘Ë ¡ ‡μ‘ ¡ „π à « π¢Õß∫â “ π∑’Ë ¡’ ‚ Õ°“ ∑’Ë ºŸ â ßŸ Õ“¬ÿ®–≈◊πË ≈â¡‰¥âß“à ¬ ‡™àπ„πÀâÕßπÈ”§«√μâÕß¡’√“«®—∫ ·ºàπ °—π≈◊Ëπ À√◊Õ‡°â“Õ’È‡æ◊ËÕ„ÀâºŸâ ŸßÕ“¬ÿπ—Ëß„π¢≥–Õ“∫πÈ” √“« ∫— π ‰¥§«√¡’ § «“¡·¢Á ß ·√ß ”À√— ∫ ‡§√◊Ë Õ ß·μà ß °“¬¢Õß ºŸâ ŸßÕ“¬ÿμâÕß‰¡à√ÿà¡√à“¡·≈–√Õß‡∑â“∑’ËºŸâ ŸßÕ“¬ÿ «¡„ à§«√¡’ ¢π“¥∑’Ë‡À¡“– ¡ °“√‡¥‘π ”À√—∫ºŸâ ŸßÕ“¬ÿ∫“ß√“¬§«√μâÕß ·π–π”„Àâ¡’°“√„™âÕÿª°√≥å™à«¬æ¬ÿß ‡™àπ ‰¡â‡∑â“ À√◊Õ‚§√ß ™à«¬‡¥‘π ‡æ◊ËÕ§«“¡¡—Ëπ§ß„π¢≥–‡§≈◊ËÕπ‰À« √«¡∑—ÈßμâÕß¡’ °“√·π–π”°“√∑”°‘®«—μ√ª√–®”«—πμà“ßÊ ‡æ◊ËÕ„ÀâºŸâ ŸßÕ“¬ÿ¡’ §«“¡¡—Ëπ„®„π°“√∑”°‘®°√√¡¡“°¢÷ÈπÛÙ, Ûı

‡Õ° “√Õâ“ßÕ‘ß Ò. Alexandra S, Brain RD, Philip JR, John PP. What is balance. Clin Rehabil 2000;14:402-6. Ú. Shumway-Cook, A. Woollacot M. Motor control: Translating research into clinical practice. 3th ed 2007; Philadelphia: Lippincott Williams & Wilkins. Û. Gauchard G, Jeandel C, Tessier A, Perrin PP. Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects. Neuroscience Letters 1999;273:81-4. Ù. Hughes V, Frontera WR, Wood M, Evans WJ, Dallal GE, et al. Longitudinal muscle strength changes in older adults: influence of muscle mass, physical activity, and health. J Gerontol A Biol Sci Med Sci 2001; 56:209-17. ı. Verhagen AP, Immink M, Van der meulen A, Bierma-Zeinstra SMA. The effect of Tai Chi Chuan in older adults: a systemic review. Family Practice 2004;21:107-13. ˆ. Woollacott M, Shumway-Cook A. Attention and the control of posture and gait: a review of and emerging area of research. Gait and posture 2002; 16:1-14. ˜. Bryant E. Gender difference at the time of

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retirement. Clinical Biomechanics. 2005;20:330-35. Judge J, King MB, Whipple R, Clive J, Wolfson L. Dynamic balance in older persons: effects of reduced visual and proprioceptive input. Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 1995;50:263-70. Mahboobin A, Loughlin P Redfern M. A modelbased approach and sensory integregation in posture control of older adults. Neuroscience Letters 2007; 492:147-51. Hangeman P, Leibowitz J, Blanke D. Age and gender effects on posture control measures. Arch Phys Med Rehabil 1995;76:961-65. Van Iersel MB, Ribbers H, Munneke M, Borm GF, Olde Rikkert MG. The effect of cognitive dual tasks on balance during walking in physically fit elderly prople. Arch Phys Med Rehabil 2007;88:187-91. Chou L.-S, Kaufman KR, Brey RH, Draganish LF. Motion of the whole bodyûs center of mass when steping over obstacles of different heights. Gait and posture 2000;13:17-26 Hahn M, Michael CL. Age- realated reduction in sagittal plane center of mass motion during obstacle crossing. Journal of biomechanics 2004;37:837-44 Laufer Y, Barak Y, Chemel I. Age-related differences in the effect of a perceived threat to stability on postural control. J Gerontology 2006;61:500-4 «‘ ¿ “«’ °‘ ® °”·Àß, π‘ æ— ∏ °‘ μ μ‘ ¡ “ππ∑å , »ÿ ¿ ‘ ∑ ∏‘Ï æ√√≥π“√ÿ ‚ ≥∑— ¬ . ªí ® ®— ¬ ‡ ’Ë ¬ ßμà Õ °“√À°≈â ¡ ¢Õß ºŸ â ßŸ Õ“¬ÿ„π™ÿ¡™π. «“√ “√«‘™“°“√ “∏“√≥ ÿ¢ ÚıÙ˘; Òı:˜¯˜-˘˘. Runyan CW. Unintentional injuries in the home in the United States: Part II: Morbidity. Am J Pre Med 2005;281:80-7. Melzer I, Benjuya N, Kaplanski J. Postural stability in the elderly: a comparison between fallers and non-fallers. Age and Ageing 2004;33:602-7. Tinetti M. Speechley M. Prevention of falls among the elderly. New England journal of medicine 1989; 320:1055-59.

218 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ Abstract Falls in elderly Noppol Pramodhyakul Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University Balance is a complex function that requires the integration of information from the sensory system and the organization of sensory inputs. Sensory input organization is useful for planning and executing movement in order to achieve a goal requiring upright posture. However, this process was interrupted in older people leading to falls problem. Falls have been reported as a major cause of injury, morbidity and long term in rehabilitation in older people. Two factors related to falls are intrinsic and extrinsic factors. Intrinsic factors are gender, sensory impairment, muscle weakness, poor physical fitness, acute illness, vertigo, hearing impairment, balance and gait impairment, depression, anxiety and use of more than four items of medicine. Extrinsic factors or environmental factors are unfit shoes, long dress, obstacle and slippery floor. Falling caused physical injury, bone fracture and fear of falling in older people. Many older people had fear of falling syndrome after falling leading to further restricted movement and limited activities of daily living. As a result, falls have an impact on both their physical and psychological function. Therefore, fall prevention is greatly necessary for older people, for example, exercise or home rearrangement. Key words: Fall, Elderly

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220 .

¡’√“¬ß“π«à“ ºŸâªÉ«¬‰ø‚∫√¡—¬Õ—≈‡®’¬¡’√–¥—∫ serum cytokine ∫“ß™π‘¥ Ÿß¢÷Èπ ‡™àπ interleukin-6(IL-6)Ú ·≈–μ√«®æ∫ inflammatory cytokines ‡™àπ interleukin1beta, interleukin-6 ·≈– tumor necrosis factoralpha ∑’Ëº‘«Àπ—ß¢ÕßºŸâªÉ«¬ÚÒ ´÷Ëß∫àß™’È∂÷ß¿“«– neurogenic inflammation ·≈–Õ“®‡ªìπμâπ‡ÀμÿÀπ÷Ëß¢Õß§«“¡‡®Á∫ª«¥ ¢ÕßºŸâªÉ«¬ ‡π◊ÕË ß®“°ºŸªâ «É ¬‰ø‚∫√¡—¬Õ—≈‡®’¬¡—°¡’§«“¡º‘¥ª√°μ‘ ¢Õß°“√πÕπÀ≈—∫ À≈—∫‰¡à π‘∑ À≈—∫‰¡à≈°÷ °≈à“«§◊Õ ‰¡à “¡“√∂ ‡¢â“ Ÿà°“√πÕπÀ≈—∫™à«ß stage IV non REM sleep ‰¥â ·≈– ¡—°¡’ alpha-delta EEG patternÚÚ,ÚÛ ª√–°Õ∫°—∫¡’ °“√∑¥≈Õß ∑”„Àâ‡°‘¥ alpha-delta sleep „π§πª√°μ‘·≈â« æ∫«à“∑”„Àâ‡°‘¥Õ“°“√ª«¥°≈â“¡‡π◊ÈÕ Ωó¥μ÷ß ·≈–¡’®ÿ¥°¥‡®Á∫ °≈â“¡‡π◊ÕÈ ‰¥â ®÷ß‡ªìπ‰ª‰¥â«“à §«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ Õ“®‡ªìπÕ’° “‡ÀμÿÀπ÷ßË ¢ÕßÕ“°“√ª«¥„πºŸªâ «É ¬‰ø‚∫√¡—¬Õ—≈‡®’¬ ªí®®ÿ∫π— ·π«§‘¥∑’¡Ë °’ “√π”‡ πÕ·≈–‰¥â√∫— °“√¬Õ¡√—∫ ¡“°§◊Õ·π«§‘¥‡√◊ËÕß central sensitization ‚¥¬ Yunus ‡ πÕ„Àâ„™â§”«à“ Central Sensitivity SyndromesÚÙ,Úı ´÷ËßÀ¡“¬√«¡∂÷ß‰ø‚∫√¡—¬Õ—≈‡®’¬·≈–Õ“°“√À√◊Õ°≈ÿà¡Õ“°“√ √à«¡Õ◊ËπÊ ¥â«¬ ‡™àπ °≈ÿà¡Õ“°“√≈”‰ â·ª√ª√«π (irritable bowel syndrome) °≈ÿà¡Õ“°“√ÕàÕπ≈â“‡√◊ÈÕ√—ß (chronic fatigue syndrome)

¿“«–ª«¥À≈—ß‡√◊ÈÕ√—ß °√–‡æ“–ªí “«–Õ—°‡ ∫‡√◊ÈÕ√—ß™π‘¥ interstitial cystitis πÕ°®“°π’È „πºŸâªÉ«¬‰ø‚∫√¡—¬Õ—≈‡®’¬ ¬—ßæ∫ªí≠À“ ∑“ß®‘μ‡«™·≈–®‘μ —ß§¡‰¥â∫àÕ¬Ê ‰¥â·°à bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders ·≈– panic disorderÚˆ,Ú˜,Ú¯ ªí®®—¬‡ ’Ë¬ß∑“ß®‘μ —ß§¡∑’Ëæ∫√à«¡°—π ∫àÕ¬Ê §◊Õ somatizationÚ˘, increased negative life events, psychological distress, hypochondriases, posttraumatic stress disorder

°“√μ√«®√à“ß°“¬ ®–æ∫«à“ºŸâªÉ«¬¡’ pain threshold μË”°«à“ª√°μ‘ °≈à“«§◊Õ∂â“À¬‘°À√◊Õ®—∫º‘«Àπ—ß„π∫√‘‡«≥∑’Ëª«¥‡∫“Ê °Á®– æ∫«à“¡’Õ“°“√ª«¥¡“°°«à“ª√°μ‘ ®–μ√«®æ∫®ÿ¥°¥‡®Á∫μ“¡ °≈â“¡‡π◊ÈÕμà“ßÊ ∑—Ë«√à“ß°“¬ ·μà‰¡àæ∫Õ“°“√ÕàÕπ·√ß¢Õß °≈â“¡‡π◊ÕÈ æ‘ ¬— °“√‡§≈◊ÕË π∑’¢Ë Õß¢âÕ¡—°ª√°μ‘ ‰¡àæ∫°“√∫«¡ À√◊ÕÕ—°‡ ∫¢Õß¢âÕμàÕμà“ßÊ °“√μ√«®√à“ß°“¬∑“ß√–∫∫ ª√– “∑¡—°‰¡àæ∫§«“¡º‘¥ª√°μ‘„¥Ê Õ¬à“ß‰√°Á¥’Õ“®μ√«® √à“ß°“¬æ∫§«“¡º‘¥ª√°μ‘∑’Ë‡°’Ë¬«¢âÕß°—∫‚√§À√◊Õ¿“«–∑’Ëæ∫ √à«¡°—∫‰ø‚∫√¡—¬Õ—≈‡®’¬‰¥â

°“√μ√«®∑“ßÀâÕßªØ‘∫—μ‘°“√ ≈—°…≥–‡«™°√√¡ ºŸâ ªÉ « ¬¡— ° ¡“æ∫·æ∑¬å ¥â « ¬Õ“°“√ª«¥‡°◊ Õ ∫∑—Ë « √à“ß°“¬À√◊Õ∑—Ë«√à“ß°“¬Õ¬à“ß‡√◊ÈÕ√—ß·≈–μàÕ‡π◊ËÕß ‚¥¬Õ“® ¡’ Õ “°“√ª«¥≈— ° …≥–·ºà ° √–®“¬ ª«¥≈÷ ° Ê ª«¥μ◊È Õ Ê ª«¥μÿ∫Ê À√◊Õª«¥§≈â“¬∂Ÿ°∑‘Ë¡·∑ß√à«¡°—∫Õ“°“√™“‡ÀπÁ∫ À√◊Õ§«“¡√Ÿâ ÷° —¡º— º‘¥·º°‰ª®“°ª√°μ‘ (dysesthesia) ·≈–Õ“°“√‡®Á∫ª«¥∑’Ë‡°‘¥®“°μ—«°√–μÿâπ∑’Ë‚¥¬ª√°μ‘‰¡à°àÕ„Àâ ‡°‘¥§«“¡‡®Á∫ª«¥ (allodynia) ºŸâªÉ«¬¡—°¡’Õ“°“√¢Õß §«“¡«‘μ°°—ß«≈ ´÷¡‡»√â“ °“√πÕπÀ≈—∫º‘¥ª√°μ‘ «‘ß‡«’¬π ¡÷πßß Õ“°“√¢âÕΩó¥·¢Áß„πμÕπ‡™â“ Õ“°“√ÕàÕπ≈â“ °“√∑”ß“π ¢Õß≈”‰ â·ª√ª√«π (irritable bowel syndrome) ·≈– °√–‡æ“–ªí “«–Õ—°‡ ∫‡√◊ÈÕ√—ß™π‘¥ interstitial cystitis ‰ø‚∫√¡—¬Õ—≈‡®’¬¬—ßÕ“®æ∫√à«¡°—∫‚√§À√◊Õ¿“«–Õ◊πË Ê ¥â«¬‰¥â·°à °≈ÿà¡Õ“°“√ÕàÕπ≈â“‡√◊ÈÕ√—ß (chronic fatigue syndrome) °≈ÿà¡Õ“°“√≈”‰ â·ª√ª√«π (irritable bowel syndrome) §«“¡º‘¥ª√°μ‘¢Õß¢âÕμàÕ¢“°√√‰°√ (temporomandibular disorder) ¿“«–ª«¥»’√…–‡√◊ÈÕ√—ß ‚√§¿Ÿ¡‘·æâ ®“°°≈ÿà¡ “√‡§¡’ (multiple chemical sensitivities)

‚¥¬∑—«Ë ‰ª °“√μ√«®∑“ßÀâÕßªØ‘∫μ— °‘ “√æ◊πÈ ∞“π‰¥â·°à CBC, ESR, Urine Analysis, Blood chemistry, ANA, RF ¡—°‰¡àæ∫§«“¡º‘¥ª√°μ‘

°“√«‘π‘®©—¬ ‡ªìπ°“√«‘π‘®©—¬®“°°≈ÿà¡Õ“°“√‚¥¬Õ“»—¬°“√´—° ª√–«—μ·‘ ≈–°“√μ√«®√à“ß°“¬ ‚¥¬Õ“®„™â‡°≥±å°“√«‘π®‘ ©—¬¢Õß American College of Rheumatology 1990 CriteriaÛ ´÷Ëß„™â·æ√àÀ≈“¬„π°“√»÷°…“«‘®—¬ À√◊Õ‡°≥±å°“√«‘π‘®©—¬¢Õß YunusÛÒ ´÷Ëß‡À¡“– ¡°—∫°“√„™âß“π∑“ß§≈‘π‘° ¥—ßπ’È °. ‡°≥±å°“√«‘π‘®©—¬¢Õß American College of Rheumatology 1990 Criteria Ò) ¡’Õ“°“√ª«¥∑—Ë«√à“ß°“¬ ´’°´â“¬¢Õß√à“ß°“¬ ´’°¢«“¢Õß√à“ß°“¬ à«π∑’ËÕ¬Ÿà‡Àπ◊Õ‡Õ« ·≈– à«π∑’ËÕ¬Ÿà„μâ‡Õ« √«¡∂÷ßμâÕß¡’Õ“°“√ª«¥ à«π·°π°≈“ß¢Õß√à“ß°“¬‰¥â · °à °√–¥Ÿ° —πÀ≈—ß à«π§Õ À√◊Õ°√–¥Ÿ° —πÀ≈—ß à«πÕ° À√◊Õ Àπâ“Õ° à«πÀπâ“ À√◊ÕÀ≈—ß à«π≈à“ß Õ“°“√ª«¥‡À≈à“π’ÈμâÕß ‡ªìπ¡“Õ¬à“ßπâÕ¬ Û ‡¥◊Õπ √à«¡°—∫

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

Ú) °“√μ√«®√à“ß°“¬æ∫®ÿ¥°¥‡®Á∫‡©æ“– Õ¬à“ßπâÕ¬ ÒÒ μ”·Àπàß„π Ò¯ μ”·Àπàß ‚¥¬„™â·√ß°¥‰¡à‡°‘π Ù °‘‚≈°√—¡ „π∑“ßªØ‘ ∫— μ‘ §◊ Õ ·√ß°¥¥â « ¬π‘È « ¡◊ Õ ∑’Ë ∑”„Àâ ‡ ≈Á ∫ à « πª≈“¬

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¢“¥‡≈◊Õ¥À√◊Õ´’¥¢“« ®ÿ¥°¥‡®Á∫∑—Èß Ò¯ μ”·Àπàßπ—Èπ· ¥ß ¥—ßμ“√“ß∑’Ë Ò ·≈– ¿“æ∑’Ë Ò

μ“√“ß∑’Ë Ò ®ÿ¥°¥‡®Á∫ Ò¯ μ”·Àπàß¢Õß√à“ß°“¬μ“¡‡°≥±å°“√«‘π‘®©—¬¢Õß American College of Rheumatology 1990 CriteriaÛ Occiput Low cervical Trapezius Supraspinatus Second rib Lateral epicondyle Gluteal Greater trochanter Knee

bilateral, at the suboccipital muscle insertions. bilateral, at the anterior aspects of the intertransverse spaces at C5-C7. bilateral, at the midpoint of the upper border. bilateral, at origins, above the scapula spine near the medial border. bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces. bilateral, 2 cm distal to the epicondyles. bilateral, in upper outer quadrants of buttocks in anterior fold of muscle. bilateral, posterior to the trochanteric prominence. bilateral, at the medial fat pad proximal to the joint line.

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¢. ‡°≥±å°“√«‘π‘®©—¬¢Õß Yunus Ò. μâÕß¡’Õ“°“√ª«¥À√◊ÕΩó¥μ÷ßÕ¬à“ßπâÕ¬ Û ·Ààß ·≈–‰¡à¡’ “‡ÀμÿÕ◊Ëπ∑’Ë‡ªìπμâπ‡Àμÿ¢ÕßÕ“°“√ Ú. μ√«®æ∫®ÿ¥ª«¥ ı ®ÿ¥ √à«¡°—∫Õ“°“√√à«¡ Û Õ“°“√ À√◊Õ ®ÿ¥ª«¥ Û ®ÿ¥ √à«¡°—∫Õ“°“√√à«¡ Û Õ“°“√ Û. Õ“°“√√à«¡μà“ßÊ ¥—ßπ’È Û.Ò °‘®°√√¡∑“ß°“¬¡’º≈μàÕÕ“°“√ Û.Ú ¿“æ¿Ÿ¡‘Õ“°“»¡’º≈μàÕÕ“°“√ Û.Û §«“¡°—ß«≈À√◊Õ§«“¡‡§√’¬¥¡’º≈μàÕÕ“°“√ Û.Ù °“√πÕπÀ≈—∫‰¡à¥’ Û.ı ¡’Õ“°“√ÕàÕπ≈â“À√◊Õ‡Àπ◊ÕË ¬ ‡æ≈’¬ ∑—«Ë μ—« Û.ˆ «‘μ°°—ß«≈ Û.˜ ª«¥»’√…–‡√◊ÈÕ√—ß Û.¯ °≈ÿà¡Õ“°“√≈”‰ â·ª√ª√«π Û.˘ √Ÿâ ÷°«à“∫«¡ Û.Ò Õ“°“√™“

°“√√—°…“ °“√√—°…“‰ø‚∫√¡—¬Õ—≈‡®’¬π—ÈπμâÕß‡ªìπ°“√√—°…“∑—Èß ∑“ß√à“ß°“¬ ®‘μ„® ·≈– —ß§¡ ´÷Ëß‰¥â·°à °“√„Àâ§«“¡√Ÿâ °“√ √—°…“¥â«¬¬“ ·≈–°“√√—°…“∑’‰Ë ¡à„™à¬“ ‡æ◊ÕË ≈¥Õ“°“√ª«¥ °“√ ÕàÕπ≈â“ ·°â‰¢§«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ √—°…“®‘μ„® ·≈–Õ“√¡≥å¢ÕßºŸâªÉ«¬ °“√„Àâ§«“¡√Ÿâ ‡°’Ë¬«°—∫‰ø‚∫√¡—¬Õ—≈‡®’¬·°àºŸâªÉ«¬ ·≈–§√Õ∫§√—«‡ªìπ ‘Ëß∑’Ë ”§—≠·≈–μâÕß∑”‡ªìπ ‘Ëß·√° ‡æ◊ËÕ„Àâ ºŸâªÉ«¬·≈–§√Õ∫§√—«∑√“∫«à“‚√§π’È ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬ ‰¡à‡ªìπ Õ—πμ√“¬μàÕ™’«‘μ ‰¡à∑”„Àâæ‘°“√ §«“¡º‘¥ª√°μ‘∑“ß®‘μ„®¡’ à«π ”§—≠„π°“√°√–μÿâπÕ“°“√ ·μà‰¡à„™à “‡Àμÿ‚¥¬μ√ß¢Õß ‚√§π’È ‡æ◊ËÕ„ÀâºŸâªÉ«¬·≈–§√Õ∫§√—«≈¥§«“¡«‘μ°°—ß«≈ ·≈– ª√—∫æƒμ‘°√√¡„Àâ‡À¡“– ¡ ‡™àπ √—∫°“√√—°…“Õ¬à“ßμàÕ‡π◊ËÕß ¡Õß‚≈°„π·ßà¥’ æ—°ºàÕπ·≈–πÕπμ√ß‡«≈“ À≈’°‡≈’Ë¬ßμ—« °√–μÿâπ∑’Ë®–∑”„ÀâπÕπ‰¡àÀ≈—∫ ‡™àπ °“·ø §«√ÕÕ°°”≈—ß°“¬ Õ¬à“ß ¡Ë”‡ ¡Õ „π à«π¢Õß§√Õ∫§√—«§«√¡’∫∑∫“∑„π°“√ ª√–§—∫ª√–§Õß‚¥¬°“√‡¢â“„® ‡ÀÁπÕ°‡ÀÁπ„® „Àâ°”≈—ß„® √—∫ øíßºŸâªÉ«¬ ·≈–°√–μÿâπ„ÀâºŸâªÉ«¬ªØ‘∫—μ‘μπ„Àâ‡À¡“– ¡ πÕ° ®“°π’È · æ∑¬å ¬— ß §«√Õ∏‘ ∫ “¬∂÷ ß «‘ ∏’ ° “√·≈–μ— « ‡≈◊ Õ °„π°“√ √—°…“μà“ßÊ μ≈Õ¥®π°“√æ¬“°√≥å‚√§ °“√√—°…“¥â«¬¬“ „πªí®®ÿ∫—π¡’°“√»÷°…“«‘®—¬‡°’Ë¬« °—∫¬“∑’Ë„Àâº≈„π°“√√—°…“‡æ‘Ë¡¡“°¢÷Èπ ®÷ß¡’¬“∑’Ë„™â·≈–Õ¬Ÿà √–À«à“ß°“√»÷°…“Õ¬ŸàÀ≈“¬°≈ÿà¡ ¥—ßπ’È

¬“μâ“π´÷¡‡»√â“™π‘¥ tricyclic (Tricyclic antidepressants, TCAs) ‡ªìπ¬“∑’Ë¡’°“√»÷°…“°—∫‰ø‚∫√¡—¬Õ—≈‡®’¬¡“°∑’Ë ÿ¥ ¡’°≈«‘‘∏“π‚¥¬¬—∫¬—Èß°“√™—°°≈—∫¢Õß serotonin ·≈– norepinephrine ¡’º≈°“√»÷°…“·∫∫ ÿà¡·≈– §«∫§ÿ¡∑’Ë π—∫ πÿπ¬“ amitryptyline „π°“√∫√√‡∑“ª«¥ §«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ ·≈–°“√ÕàÕπ≈â“„πºŸâªÉ«¬ ‰ø‚∫√¡—¬Õ—≈‡®’¬ÛÚ,ÛÛ,ÛÙ ¢π“¥∑’„Ë ™â§Õ◊ Ò-ı ¡°. °àÕπ πÕπ ¬“°≈ÿà¡ selective serotonin reuptake inhibitors (SSRIs) ‰¥â·°à fluoxetineÛı,Ûˆ, sertralineÛ˜, citalopramÛ¯ ·≈– paroxetineÛ˘ ¬“„π°≈ÿ¡à π’¥È °’ «à“ TCAs „π‡√◊ËÕß¢Õßƒ∑∏‘Ï¢â“ß‡§’¬ß∑’ËπâÕ¬°«à“ ·μà°Á¡’ª√– ‘∑∏‘º≈∑’Ë ¥âÕ¬°«à“¥â«¬‡™àπ°—π ¬“°≈ÿà¡ serotonin-norepineprine reuptake inhibitors (SNRIs) ‡ªìπ¬“∑’ËÕÕ°ƒ∑∏‘Ï¬—∫¬—Èß°“√‡°Á∫ °≈—∫¢Õß∑—Èß serotonin ·≈– norepineprine „Àâº≈§≈â“¬ TCAs ·μà¡’ƒ∑∏‘Ï¢â“ß‡§’¬ß∑’ËπâÕ¬°«à“ ºŸâªÉ«¬∑π¬“‰¥â¥’°«à“ ‰¥â·°à venlafaxine ˜ı ¡°./«—πÙ,ÙÒ, milnacipran ÒÚ ¡°./«—πÙÚ,ÙÛ,ÙÙ, duloxetine ˆ-ÒÚ ¡°./ «—πÙı,Ùˆ,Ù˜ ´÷Ëß¬“ Ú ™π‘¥À≈—ß§◊Õ milnacipran ·≈– duloxetine π—πÈ ¡’º≈°“√»÷°…“·∫∫ ÿ¡à ·≈–§«∫§ÿ¡ π—∫ πÿπ ∂÷ßª√– ‘∑∏‘º≈·≈–§«“¡ª≈Õ¥¿—¬„πºŸâªÉ«¬‰ø‚∫√¡—¬Õ—≈‡®’¬ ‚¥¬∑’Ëª√– ‘∑∏‘º≈®– Ÿß°«à“°≈ÿà¡ TCAsÙ¯ ¬“°≈ÿà¡ §≈“¬°≈â“¡‡π◊ÈÕ (muscle relaxants) §◊Õ ¬“ cyclobenzaprine ´÷Ëß¡’‚§√ß √â“ß§≈â“¬ amitriptyline æ∫«à“¡’ª√– ‘∑∏‘¿“æ„π°“√√—°…“‰ø‚∫√¡—¬Õ—≈‡®’¬ ‚¥¬¡’º≈ °“√»÷°…“·∫∫ ÿà¡·≈–§«∫§ÿ¡ÛÙ,Ù˘,ı π—∫ πÿπ¢π“¥∑’Ë „™â§◊Õ Ò-Û ¡°. °àÕππÕπıÒ æ∫«à“ ¡’º≈™à«¬≈¥ Õ“°“√ª«¥®”π«π®ÿ¥ª«¥ §«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ °“√ÕàÕπ≈â“ §«“¡«‘μ°°—ß«≈ Õ“°“√¢âÕΩó¥·¢Áß ·≈–≈”‰ â ·ª√ª√«π≈¥≈ß ¬“°—π™—° (anticonvulsants) ¬“°≈ÿà¡π’È¡’°“√„™â „π°“√√—°…“Õ“°“√ª«¥‡√◊ÕÈ √—ß ‡™àπ ª«¥°√–¥Ÿ°·≈–°≈â“¡‡π◊ÕÈ Õ“°“√ª«¥®“°√–∫∫ª√– “∑¡“π“π·≈â« ”À√—∫‰ø‚∫√¡—¬Õ—≈‡®’¬π—Èπ¡’°“√»÷°…“·∫∫ ÿà¡, ª°ªî¥∑—Èß ÕßΩÉ“¬‚¥¬‡ª√’¬∫ ‡∑’¬∫°—∫¬“À≈Õ° æ∫«à“ pregabalin ¢π“¥ Û-ˆ ¡°./«—π ¡’ª√– ‘∑∏‘º≈„π°“√≈¥Õ“°“√ª«¥ °“√ÕàÕπ≈â“ ·≈–§«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ıÚ,ıÛ,ıÙ ¬“Õ’°μ—« Àπ÷Ëß§◊Õ gabapentin ¢π“¥ Ò,Ú-Ú,Ù ¡°./«—π ‚¥¬ °“√»÷°…“·∫∫ ÿà¡, ª°ªî¥∑—Èß ÕßΩÉ“¬‚¥¬‡ª√’¬∫‡∑’¬∫°—∫ ¬“À≈Õ° æ∫«à“¡’ª√– ‘∑∏‘º≈„π°“√≈¥Õ“°“√ª«¥·≈–§«“¡ º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ıı

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010

¬“·°âª«¥ (analgesics): tramadol ‡ªìπ¬“·°â ª«¥∑’Ë¡’°“√¬◊π¬—πª√– ‘∑∏‘º≈„π°“√√—°…“‰ø‚∫√¡—¬-Õ—≈‡®’¬ ‚¥¬º≈°“√»÷°…“·∫∫ ÿ¡à ¡’°≈ÿ¡à §«∫§ÿ¡ıˆ,ı˜ ¢π“¥∑’„Ë ™â§Õ◊ ı-Ù ¡°./«—π °≈«‘∏“πÕÕ°ƒ∑∏‘Ï§◊Õ‡ªìπ weak mu opioid receptor agonist √à«¡°—∫°“√¬—∫¬—Èß°“√™—°°≈—∫¢Õß serotonin ·≈– norepinephrine °“√„™â¬“ tramadol Õ“® „™â„π√Ÿª¬“‡¥’Ë¬«À√◊Õ„π√Ÿªº ¡°—∫ acetaminophen °Á‰¥â ı¯,ı˘ à«π¬“°≈ÿà¡ NSAIDs ·≈– opioids π—ÈπÕ“®‰¡à§àÕ¬ ‰¥âº≈·≈–‰¡à¡’À≈—°∞“π π—∫ πÿπ ¬“°≈ÿà¡ alpha2-adrenergic agonist §◊Õ tizanidine ´÷Ëß„™â„π°“√√—°…“Õ“°“√‡°√Áß¢Õß°≈â“¡‡π◊ÈÕ(spasticity) ·≈–Õ“°“√ª«¥‡√◊ÈÕ√—ß ÕÕ°ƒ∑∏‘Ï∑’Ë‰¢ —πÀ≈—ß ‚¥¬¬—∫¬—Èß spinal polysynaptic pathways ≈¥°“√À≈—ßË “√ aspatate, glutamate, substance P ‡æ‘Ë¡ nociceptive threshold Õ“®¡’º≈™à«¬≈¥§«“¡ª«¥·≈–™à«¬„ÀâπÕπ‰¥â¥’¢÷Èπ ·μà¬—ß‰¡à ¡’º≈°“√»÷°…“„πºŸâªÉ«¬‰ø‚∫√¡—¬Õ—≈‡®’¬ ¬“°≈ÿà¡ sedative-hypnotics ‰¥â·°à¬“ zopiclone ·≈– zolpidem Õ“®™à«¬„π°“√√—°…“§«“¡º‘¥ª√°μ‘„π°“√ πÕπÀ≈—∫·≈–°“√ÕàÕπ≈â“·μà‰¡à™à«¬„π‡√◊ËÕß§«“¡‡®Á∫ª«¥ˆ ¬“ pramipexole ™à«¬≈¥Õ“°“√ª«¥·≈–°“√ÕàÕπ≈â“ˆÒ ¬“

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sodium oxybate ™à«¬≈¥Õ“°“√ª«¥·≈–∑”„ÀâπÕπÀ≈—∫¥’ ¢÷ÈπˆÚ ¬“Õ◊ËπÊ ‰¥â·°à ¬“ tropisetron ´÷Ëß‡ªìπ¬“μâ“π 5hydroxytryptamine-3 receptor (5-HT3 receptor antagonist) ¡’º≈°“√»÷°…“·∫∫ ÿà¡¡’°≈ÿà¡§«∫§ÿ¡ˆÛ,ˆÙ æ∫«à“™à«¬≈¥Õ“°“√ª«¥·≈–™à«¬„ÀâπÕπÀ≈—∫‰¥â¥’¢÷Èπ ¬“ nabilone ´÷Ëß‡ªìπ cannabinoids ™π‘¥Àπ÷Ëß°Á¡’º≈°“√»÷°…“ ·∫∫ ÿà¡¡’°≈ÿà¡§«∫§ÿ¡ «à“™à«¬≈¥Õ“°“√ª«¥‰¥âˆı °“√„Àâ growth hormone „πºŸâªÉ«¬‰ø‚∫√¡—¬Õ—≈‡®’¬∑’Ë¡’¿“«–æ√àÕß growth hormone √à«¡¥â«¬™à«¬≈¥Õ“°“√ª«¥·≈–®”π«π ®ÿ¥ª«¥≈ßˆˆ ¬“„π°≈ÿà¡π’È¬—ßμâÕß°“√º≈°“√»÷°…“‡æ‘Ë¡‡μ‘¡ ·≈–Õ“®‡ªìπª√–‚¬™πå„πÕπ“§μ ‡æ◊ËÕ„Àâßà“¬„π°“√æ‘®“√≥“„™â¬“∑’Ë¡’®”π«π¡“° Õ“® æ‘®“√≥“„™â¬“μ“¡Õ“°“√À≈—°μ“¡§”·π–π”¢Õß ¡“§¡°“√ »÷°…“‡√◊ËÕß§«“¡ª«¥·Ààßª√–‡∑»‰∑¬ˆ˜ ¥—ßμ“√“ß∑’Ë Ú °“√√—°…“∑’Ë‰¡à„™à¬“ °“√√—°…“∑’Ë‰¡à„™à¬“∑’Ë ”§—≠¡“° ”À√—∫‰ø‚∫√¡—¬Õ—≈‡®’¬§◊Õ °“√ÕÕ°°”≈—ß°“¬ˆ¯ ·≈–°“√∫”∫—¥¥â«¬°“√ª√—∫ ‡ª≈’Ë¬π§«“¡§‘¥·≈–æƒμ‘°√√¡ (cognitive behavioral therapy)

μ“√“ß∑’Ë Ú §”·π–π”°“√æ‘®“√≥“„™â¬“μ“¡Õ“°“√À≈—°¢Õß‰ø‚∫√¡—¬Õ—≈‡®’¬ ¢Õß ¡“§¡°“√»÷°…“‡√◊ËÕß§«“¡ª«¥·Ààß ª√–‡∑»‰∑¬ˆ˜ Õ“°“√À≈—° ¬“ ª«¥ πÕπ‰¡àÀ≈—∫ ´÷¡‡»√â“/«‘μ°°—ß«≈ ¬“¢π“π·√° - Amitryptyline ++ ++ ++ - Nortryptyline + ++ ++ - Fluoxetine + ++ - Pregabalin ++ ++ + ¬“¢π“π∑’Ë Õß - Gabapentin ++ ++ NA - Tramadol ++ NA NA - Duloxetine ++ ++ - Milnacipran ++ + - Venlafaxine + ++ - Mirtazapine + ++ ++ ++ = ¡’º≈¥’¡“° + = ¡’º≈¥’ NA = ¬—ß‰¡à¡’¢âÕ¡Ÿ≈ - = ‰¡à‰¥âº≈À√◊Õ·¬à≈ß

224 .

°“√ÕÕ°°”≈—ß°“¬∑’Ë¡’ª√– ‘∑∏‘¿“æ„πºŸâ ªÉ « ¬‰ø‚∫√¡—¬Õ—≈‡®’¬§◊Õ°“√ÕÕ°°”≈—ß°“¬∑’Ë‡πâπ°“√‡æ‘Ë¡ ¡√√∂π– ¢Õß√à“ß°“¬‰¥â·°à °“√ÕÕ°°”≈—ß°“¬·∫∫·Õ‚√∫‘°ˆ˘,˜,˜Ò °“√ÕÕ°°”≈—ß°“¬∑’‡Ë πâπ§«“¡·¢Áß·√ß¢Õß°≈â“¡‡π◊ÕÈ ˜Ò,˜Ú,˜Û ·≈–°“√ÕÕ°°”≈—ß°“¬„ππÈ” (pool exercise)˜Ù,˜ı °“√ ÕÕ°°”≈—ß°“¬‡À≈à“π’È¡’º≈™à«¬≈¥Õ“°“√ª«¥ °“√ÕàÕπ≈â“≈ß ‰¥â °“√∫”∫— ¥ ¥â « ¬°“√ª√— ∫ ‡ª≈’Ë ¬ π§«“¡§‘ ¥ ·≈– æƒμ‘°√√¡˜ˆ,˜˜,˜¯ ™à«¬„ÀâºŸâªÉ«¬πÕπÀ≈—∫‰¥â¥’¢÷Èπ Õ“°“√ ª«¥ ·≈–°“√ÕàÕπ≈â“≈¥≈ß ‚¥¬®–„Àâº≈¥’¡“°¢÷Èπ‡¡◊ËÕ√à«¡ °—∫°“√ÕÕ°°”≈—ß°“¬ °‘®°√√¡°“√≈¥§«“¡‡§√’¬¥ (stress reduction) ‡™àπ °“√Ωñ° ¡“∏‘À√◊Õ°“√Ωñ° μ‘˜˘ ‚¬§– ¡«¬®’π ß“πÕ¥‘‡√° μà“ßÊ ™à«¬≈¥§«“¡‡§√’¬¥ Õ“°“√´÷¡‡»√â“·≈–Õ“°“√ª«¥≈ß‰¥â °“√√—°…“Õ◊ËπÊ ‰¥â·°à °“√Ωíß‡¢Á¡ (acupuncture) ™à«¬≈¥Õ“°“√ª«¥ °“√ÕàÕπ≈â“ §«“¡«‘μ°°—ß«≈¯,¯Ò ·≈– ≈¥®”π«π ®ÿ¥ª«¥¯Ú,¯Û °“√©’¥¬“™“∑’Ë®ÿ¥ª«¥°≈â“¡‡π◊ÈÕ (trigger point injection) “¡“√∂≈¥Õ“°“√ª«¥„πºŸâªÉ«¬ ‰ø‚∫√¡—¬Õ—≈‡®’¬∑’¡Ë Õ’ “°“√ª«¥°≈â“¡‡π◊ÕÈ (myofascial pain) √à«¡¥â«¬‰¥â¯Ù °“√π«¥™à«¬≈¥Õ“°“√ª«¥„π√–¬– —Èπ¯ı,¯ˆ °“√π«¥‡π◊ÈÕ‡¬◊ËÕ‡°’Ë¬«æ—π (connective tissue massage) ™à«¬≈¥Õ“°“√ª«¥·≈–¿“«–´÷¡‡»√â“¯˜ °“√π«¥·ºπ‰∑¬ ™à«¬≈¥Õ“°“√ª«¥·≈–√–¥—∫ substance-P „πºŸâªÉ«¬ª«¥ À≈—ß‡√◊ÕÈ √—ß¯¯ ®÷ßÕ“®¡’ª√–‚¬™πå„πºŸªâ «É ¬‰ø‚∫√¡—¬Õ—≈‡®’¬¥â«¬ à«π°“√√—°…“¥â«¬°“√®—¥°√–¥Ÿ° —πÀ≈—ß (chiropractic manipulation) π—Èπ¡’º≈°“√»÷°…“πâÕ¬¡“°¯˘ ®÷ß¬—ß √ÿª º≈‰¡à‰¥â

√ÿª ‰ø‚∫√¡—¬Õ—≈‡®’¬‡ªìπ°≈ÿà¡Õ“°“√ª«¥‡√◊ÈÕ√—ß ∑—Ë « √à“ß°“¬ ∑’Ëæ∫∫àÕ¬„πÀ≠‘ß«—¬°≈“ß§π √à«¡°—∫Õ“°“√ÕàÕπ≈â“ ·≈–§«“¡º‘¥ª√°μ‘¢Õß°“√πÕπÀ≈—∫ ‚√§π’¬È ß— ‰¡à∑√“∫ “‡Àμÿ ∑’·Ë πàπÕπ ·≈–¬—ß‰¡à¡°’ “√√—°…“∑’‰Ë ¥âº≈¥’∑ ’Ë ¥ÿ „πªí®®ÿ∫π— ·¡â«“à ®–¡’§«“¡°â“«Àπâ“„π°“√»÷°…“‡°’Ë¬«°—∫‰ø‚∫√¡—¬Õ—≈‡®’¬¡“° ¢÷πÈ °Áμ“¡ °“√√—°…“®÷ßμâÕß∫Ÿ√≥“°“√∑—ßÈ °“√√—°…“∑“ß√à“ß°“¬ ®‘μ„® ·≈– —ß§¡ ¥â«¬°“√„Àâ§«“¡√Ÿâ °“√„Àâ¬“μà“ßÊ √à«¡°—∫ °“√√—°…“∑’Ë‰¡à„™à¬“ ‡æ◊ËÕ¡ÿàß∫√√‡∑“Õ“°“√μà“ßÊ ≈¥§«“¡ ∑ÿ°¢å∑√¡“π ·≈–‡æ‘Ë¡§ÿ≥¿“æ™’«‘μ¢ÕßºŸâªÉ«¬

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æ®π“πÿ°√¡»—æ∑å·æ∑¬å Õ—°…√ E (μàÕ) §≥–°√√¡°“√®—¥∑”æ®π“πÿ°√¡»—æ∑å·æ∑¬»“ μ√å √“™∫—≥±‘μ¬ ∂“π* electropherogram ¿“æ∫—π∑÷°·∂∫·¬°«— ¥ÿ¥â«¬‰øøÑ“ π. ¿“æ∫—π∑÷°·∂∫·¬° “√ª√–®ÿ„π°√–∫«π°“√·¬° “√ª√–®ÿ¥â«¬‰øøÑ“ §¡¡. electrophoretogram electrophoregram §¡¡. electropherogram, electrophoretogram electrophoresis °“√·¬° “√ª√–®ÿ¥â«¬‰øøÑ“ π. °“√·¬°μ—« ∂Ÿ ° ≈–≈“¬∑’Ë ¡’ ª √–®ÿ ‚ ¥¬Õ“»— ¬ §«“¡·μ°μà “ ß¢Õß Õ—μ√“°“√‡§≈◊ËÕπ∑’Ë„π π“¡‰øøÑ“ºà“πμ—«°≈“ß ‡™àπ «ÿâπÕ–°“‚√ ‡´≈≈Ÿ‚≈ ·Õ´’‡∑μ agarose gel electrophoresis °“√·¬° “√ª√–®ÿ ¥â«¬‰øøÑ“„π«ÿâπÕ–°“‚√ π. °“√·¬°μ—« ∂Ÿ°≈–≈“¬‡™‘ß ‰øøÑ“„π«ÿâπ ‚¥¬¡’Õ–°“‚√ ‡ªìπμ—«°≈“ß „™â·¬°‚ª√μ’π, ‚ª√μ’π‰¢¡—π, °√¥π‘«‡§≈’¬ ·≈– “√Õ◊Ëπ Ê cellulose acetate electrophoresis °“√·¬° “√ ª√–®ÿ¥â«¬‰øøÑ“ºà“π‡´≈≈Ÿ‚≈ ·Õ´’‡∑μ π. ™π‘¥¢Õß°“√·¬° μ—«∂Ÿ°≈–≈“¬‡™‘ß‰øøÑ“„π«ÿâπ ‚¥¬¡’Õ–°“‚√ ‡ªìπμ—«°≈“ß gel electrophoresis °“√·¬° “√ª√–®ÿ¥â«¬‰øøÑ“„π «ÿâπ π. °“√·¬°μ—«∂Ÿ°≈–≈“¬‡™‘ß‰øøÑ“„π«ÿâπÕ–°“‚√ ¡’ ·∫∫À≈Õ¥ ·≈–·ºàπ∫“ß paper electrophoresis °“√·¬° “√ª√–®ÿ¥â«¬‰øøÑ“ ∫π°√–¥“… π. °“√·¬°μ— « ∂Ÿ ° ≈–≈“¬¥â « ¬‰øøÑ “ ‚¥¬¡’ °√–¥“…‡ªìπμ—«°≈“ß „™â·¬°‚ª√μ’π„π´’√—¡ polyacrylamide gel electrophoresis °“√·¬° “√

ª√–®ÿ¥â«¬‰øøÑ“„π«ÿâπæÕ≈’·Õ§√‘≈“‰¡¥å π. °“√·¬°μ—«∂Ÿ° ≈–≈“¬¥â«¬‰øøÑ“‚¥¬¡’«ÿâπæÕ≈’·Õ§√‘≈“‰¡¥å‡ªìπμ—«°≈“ß „™â ·¬°‚¡‡≈°ÿ≈μ“¡¢π“¥, ª√–®ÿ, À√◊Õ∑—Èß ÕßÕ¬à“ß starch gel electrophoresis °“√·¬° “√ª√–®ÿ¥â«¬ ‰øøÑ“„π·ªÑß π. °“√·¬°μ—«∂Ÿ°≈–≈“¬¥â«¬‰øøÑ“‚¥¬·ªÑß ‡ªìπμ—«°≈“ß „™â·¬°‚¡‡≈°ÿ≈¢π“¥„À≠à ‚¥¬‡©æ“–æ«° ‚ª√μ’π two-dimensional gel electrophoresis °“√·¬° “√ ª√–®ÿ¥â«¬‰øøÑ“„π·ªÑß·∫∫ Õß¡‘μ‘ π. «‘∏’·¬°μ—«∂Ÿ°≈–≈“¬ ¥â «¬‰øøÑ“„πμ—«°≈“ß‡æ◊Ë Õ·¬° “√ª√–®ÿ ‚¥¬„Àâ°√–· ‰øøÑ“‰À≈„π∑‘»∑“ß∑’Ëμ—Èß©“°°—π electrophoretic -·¬° “√ª√–®ÿ¥â«¬‰øøÑ“ «. ‡°’Ë¬«°—∫°“√ ·¬°μ—«∂Ÿ°≈–≈“¬∑’Ë¡’ª√–®ÿ¥â«¬‰øøÑ“ electrophoretogram §¡¡. electropherogram, electrophoregram electrophotometer ¡“μ√· ß‰øøÑ“ π. ‡§√◊ËÕß¡◊Õª√–°Õ∫ ¥â«¬μ—«√—∫√Ÿâ§«“¡‡¢â¡· ß„™âμ√«®‡∑’¬∫ ’ electrophysiologic - √’√«‘∑¬“‰øøÑ“ «. ‡°’Ë¬«°—∫ √’√«‘∑¬“ ‰øøÑ“ electrophysiology √’√«‘∑¬“‰øøÑ“ π. (Ò) °“√»÷°…“ °≈«‘∏“π°“√‡°‘¥ª√“°Ø°“√≥å‰øøÑ“∑“ß√–∫∫ª√– “∑ ·≈–º≈„π ‘Ëß¡’™’«‘μ; (Ú) °“√»÷°…“º≈¢Õß‰øøÑ“μàÕ ª√“°Ø°“√≥å∑“ß √’√«‘∑¬“

».πæ.Õ√√∂ ‘ ∑ ∏‘Ï ‡«™™“™’ « – ∑’Ë ª √÷ ° …“, ».¥√.πæ. ¡™— ¬ ∫«√°‘ μ μ‘ ª√–∏“π°√√¡°“√, √».πæ.°â Õ ß‡°’ ¬ √μ‘ °Ÿ ≥ ±å °— π ∑√“°√ °√√¡°“√, √».æ≠.®—π∑æß…å «– ’ °√√¡°“√, ».∑æ≠.„®πÿ™ ®ß√—°…å °√√¡°“√, ».æ≠.©«’«√√≥ ∫ÿ≠π“§ °√√¡°“√, πæ.∑Õß¥’ ™—¬æ“π‘™, ».§≈‘π‘§ æ≠.§ÿ≥‰∏«¥’ ¥ÿ≈¬®‘π¥“ °√√¡°“√, π“ßπ—¬π“ «√“Œ—»«ªμ‘ °√√¡°“√, ».πæ.π‘æπ∏å æ«ß«√‘π∑√å °√√¡°“√, ».πæ.∫√√®ß ¡‰À «√‘¬– °√√¡°“√, ».πæ.ª√–‡ √‘∞ ∑Õß‡®√‘≠ °√√¡°“√, √».¥√.ª√’¬“ ≈’ÃÀ°ÿ≈ °√√¡°“√, πæ.‰æ±Ÿ√¬å ¡ÿ∑√ ‘π∏å °√√¡°“√, ».πæ.¥√.‡√◊Õπ ¡≥– °√√¡°“√, √».æ≠.«“≥’ «‘ ÿ∑∏å‡ √’«ß»å °√√¡°“√, ».¥√.æ≠.»»‘∏√ ºŸâ°ƒμ¬“§“¡’ °√√¡°“√, ».πæ. ¡æ≈ æß»å‰∑¬ °√√¡°“√, ».πæ. —≠≠“ ÿ¢æ“≥‘™π—π∑å °√√¡°“√, ».πæ. “‚√®πå «√√≥æƒ°…å °√√¡°“√, æÕ.πæ. ÿ√®‘μ ÿπ∑√∏√√¡ °√√¡°“√, √».¿≠.Õ√≈—°…≥“ ·æ√—μ°ÿ≈ °√√¡°“√, √».¥√.πæ.Õ‘»√“ß§å πÿ™ª√–¬Ÿ√ °√√¡°“√, π. . ¡∑√ß »°ÿππ“§ °√√¡°“√, π. .≈—°¢≥“«√√≥ Õπ—π∏«—™ °√√¡°“√.

232 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ electropositive -ª√–®ÿ‰øøÑ“∫«° «. ¡’ª√–®ÿ‰øøÑ“∫«° electroradiometer ¡“μ√√—ß ’‰øøÑ“ π. Õ‘‡≈Á°‚∑√ ‚§ª „™â«—¥æ≈—ßß“π°“√·ºà√—ß ’ electroresection °“√μ—¥¥â«¬‰øøÑ“ π. °“√μ—¥ÕÕ°‚¥¬„™â Õÿª°√≥å‰øøÑ“ electroretinogram ¿“æ∫—π∑÷°»—°¬å‰øøÑ“®Õμ“ π. ¿“æ ∫—π∑÷°∑’Ë‰¥â®“°°“√μ√«®»—°¬å‰øøÑ“¢Õß®Õμ“‡¡◊ËÕ∂Ÿ° °√–μÿâπ¥â«¬· ß electroretinograph ‡§√◊ËÕß∫—π∑÷°»—°¬å‰øøÑ“®Õμ“ π. ‡§√◊ËÕß¡◊Õμ√«®∫—π∑÷°°“√μÕ∫ πÕß∑“ß‰øøÑ“¢Õß ®Õμ“‡¡◊ËÕ∂Ÿ°°√–μÿâπ¥â«¬· ß electroretinography °“√∫—π∑÷°»—°¬å‰øøÑ“®Õμ“ π. °“√∫—π∑÷°°“√‡ª≈’Ë¬π·ª≈ß»—°¬å‰øøÑ“¢Õß®Õμ“‡¡◊ËÕ °√–μÿâπ¥â«¬· ß electrosalivogram ¿“æ∫—π∑÷°»—°¬å‰øøÑ“μàÕ¡πÈ”≈“¬ π. ¿“æ∫—π∑÷°· ¥ß»—°¬¿“æ¢ÕßμàÕ¡πÈ”≈“¬‚¥¬‡§√◊ËÕß μ√«®¥â«¬‰øøÑ“ electroscission °“√μ—¥¥â«¬‰øøÑ“ π. °“√®’Èμ—¥¥â«¬‰øøÑ“ electroscope °≈âÕß«—¥‰øøÑ“ ∂‘μ π. ‡§√◊ËÕß¡◊Õ«—¥§«“¡ ‡¢â¡¢Õß°“√·ºà√—ß ’‚¥¬μ√«®®—∫°“√‡§≈◊ËÕπ®“°·ºàπ μ—«π”

electrosynthesis °“√ —ß‡§√“–Àå¥â«¬‰øøÑ“ π. ªØ‘°‘√‘¬“‡§¡’ ∑’Ë‡ªìπº≈®“°°“√„™â‰øøÑ“ electrotherapist ‡«™∫”∫—¥

π—°∫”∫—¥¥â«¬‰øøÑ“ π. ºŸâ„™â‰øøÑ“‡æ◊ËÕ

electrotherapy °“√∫”∫—¥¥â«¬‰øøÑ“ π. °“√„™â‰øøÑ“‡æ◊ËÕ ‡«™∫”∫—¥ electrotome ¡’¥‰øøÑ“ π. Õÿª°√≥å‰øøÑ“„™âºà“μ—¥ electrotomy °“√μ—¥¥â«¬‰øøÑ“ π. °“√μ— ¥ ÕÕ°¥â « ¬ ‰øøÑ“°√–· μË” ∑’Ë¡’§«“¡μà“ß»—°¬å·≈–§«“¡∂’Ë Ÿß ´÷Ëß‰¡à∑”„Àâ‡π◊ÈÕ‡¬◊ËÕ®—∫‡ªìπ°âÕπ electrotropism °“√μÕ∫ πÕß‰øøÑ“ π. ·π«‚πâ¡∑’Ë‡´≈≈å À√◊ Õ ‘Ë ß ¡’ ™’ «‘ μ μÕ∫ πÕß„π≈— ° …≥–®”‡æ“–μà Õ ‘Ë ß °√–μÿâπ‰øøÑ“ negative electrotropism °“√μÕ∫ πÕß‰øøÑ“‡™‘ß ≈∫ π. ·π«‚πâ¡∑’Ë‡´≈≈å∂Ÿ°‰≈à‚¥¬ ‘Ëß°√–μÿâπ‰øøÑ“ positive electrotropism °“√μÕ∫ πÕß‰øøÑ“‡™‘ß ∫«° π. ·π«‚πâ¡∑’Ë‡´≈≈å∂Ÿ°¥÷ß¥Ÿ¥‚¥¬ ‘Ëß°√–μÿâπ‰øøÑ“ electroureterogram ¿“æ∫—π∑÷°§≈◊Ëπ‰øøÑ“∑àÕ‰μ π. ¿“æ ∫—π∑÷°®“°°“√∫—π∑÷°§≈◊Ëπ‰øøÑ“∑àÕ‰μ electroureterography °“√∫—π∑÷°§≈◊Ëπ‰øøÑ“∑àÕ‰μ π. °“√ ∫—π∑÷°§≈◊Ëπ‰øøÑ“°≈â“¡‡π◊ÈÕ∑àÕ‰μ· ¥ß»—°¬å‰øøÑ“ ‡¡◊ËÕ°√–μÿâπ°“√∫’∫μ—«¢Õß°≈â“¡‡π◊ÈÕ∑àÕ‰μ

electrosection °“√ºà“¥â«¬‰øøÑ“ π. °“√ºà“μ—¥¥â«¬‡§√◊ËÕß®’È ‰øøÑ“

electrovagogram ¿“æ∫—π∑÷°§≈◊Ëπ‰øøÑ“ª√– “∑‡«°— π. ¿“æ∫—π∑÷°· ¥ß°“√º—π·ª√‰øøÑ“¢Õßª√– “∑‡«°—

electroshock °“√∑”™ÁÕ°‰øøÑ“ π. °“√∫”∫—¥‚¥¬°“√ºà“π °√–· ‰øøÑ“‰ª∑’Ë ¡ÕßÕ¬à“ß·√ß·≈–‡√Á«

electroversion °“√°≈—∫§≈◊Ëπ‰øøÑ“ π. °“√¬ÿμ‘°“√‡μâπº‘¥ ®—ßÀ«–¢ÕßÀ—«„®¥â«¬‰øøÑ“

electrospectrogram ¿“æ∫—π∑÷°·¬°§≈◊Ëπ‰øøÑ“ π. ¿“æ ∫—π∑÷° ®“°°“√μ√«®·¬°Õß§åª√–°Õ∫§≈◊Ëπ‰øøÑ“ ¡Õß

electrovert °≈—∫§≈◊Ëπ‰øøÑ“ °. àß°√–· ‰øøÑ“‡¢â“ ŸàÀ—«„® À√◊Õ∑’Ë∫√‘‡«≥Àπâ“À—«„®‡æ◊ËÕ¬ÿμ‘°“√‡μâπº‘¥®—ßÀ«–

electrospectrography °“√∫—π∑÷°·¬°§≈◊Ëπ‰øøÑ“ π. °“√ ∫—π∑÷°·¬°Õß§åª√–°Õ∫§≈◊Ëπ‰øøÑ“∑’Ë√«¡°—π„π¿“æ §≈◊Ëπ‰øøÑ“ ¡Õß electrospinogram ¿“æ∫—π∑÷°§≈◊Ëπ‰øøÑ“‰¢ —πÀ≈—ß π. ¿“æ∫—π∑÷°»—°¬åß“π‰øøÑ“¢Õß‰¢ —πÀ≈—ß electrostatic -‰øøÑ“ ∂‘μ «. ‡°’Ë¬«°—∫‰øøÑ“ ∂‘μ electrostimulation °“√°√–μÿâπ¥â«¬‰øøÑ“ π. °“√°√–μÿâπ ‡π◊ÈÕ‡¬◊ËÕ¥â«¬‰øøÑ“ ‡æ◊ËÕ°“√∫”∫—¥ À√◊Õ°“√«‘®—¬

electrovibratory - —Ëπ√—«¥â«¬‰øøÑ“ «. ‡°’Ë¬«°—∫°“√∑”„Àâ —Ëπ√—«¥â«¬‰øøÑ“ electuary ¬“°«π π. √Ÿª·∫∫¬“ª√–°Õ∫¥â«¬ºß¬“º ¡ πÈ”º÷ÈßÀ√◊ÕπÈ”‡™◊ËÕ¡ ·≈â«ªíôπ‡ªìπ°âÕπ eledoisin ‡Õ‡≈¥Õ¬´‘π π. ‡ÕÁπ‡¥§“‡æª‰∑¥å®“°μàÕ¡ πÈ”≈“¬À¡÷°¬—°…å™π‘¥‡≈Á° ‡ªìπ “√μ—Èßμâπ¢Õß‡æª ‰∑¥å™’«¿“æÀ≈“¬™π‘¥ ¡’ƒ∑∏‘Ï¢¬“¬À≈Õ¥‡≈◊Õ¥ ≈¥·√ß¥—π‡≈◊Õ¥ ·≈–°√–μÿâπ°≈â“¡‡π◊ÈÕ‡√’¬∫πÕ° À≈Õ¥‡≈◊Õ¥

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

eleidin ‡Õ‰≈¥‘π π. ‚ª√μ’π‚§√ß √â“ß —¡æ—π∏å°—∫‡§Õ√“∑‘π æ∫„π‡´≈≈åÀπ—ß™—Èπ μ√“μ—¡≈Ÿ´‘¥—¡

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element ∏“μÿ π. (Ò) à«π¡Ÿ≈∞“πÀ√◊ÕÕß§åª√–°Õ∫¢Õß ·μà≈– ‘ßË ; (Ú) “√‡π◊ÕÈ ‡¥’¬«∑’‰Ë ¡àÕ“® ≈“¬‚¥¬«‘∏‡’ §¡’; (Û) ª√—™≠“„π‡«™»“ μ√å∑“ß‡≈◊Õ° °≈ÿà¡ “√æ◊Èπ∞“π ª√–°Õ∫¥â«¬ ı ∏“μÿ §◊Õ ¥‘π πÈ” ≈¡ ‰ø ·≈– Õ«°“»

‡π◊ÈÕ‡¬◊ËÕÀπ“¢÷Èπ¡—°‡ªìπ∑’Ë¢“ ‡°‘¥®“°‚√§‰ø≈“¡∑ÿàß‡ªìπ´È” Ê À√◊Õ‡π◊ÈÕ‡¬◊ËÕ„μâÀπ—ß™—Èπ≈÷° Õ—°‡ ∫‡√◊ÈÕ√—ß‡ªìπ´È” Ê elephantiasis oculi ¿“«–Àπ—ßμ“™â“ß π. ¿“«–‡π◊ÈÕ Àπ—ßμ“Àπ“·≈–¬◊ËππŸπ elephantiasis scroti ¿“«–∂ÿßÕ—≥±–Àπ—ß™â“ß π. ¿“«–‡π◊ÈÕ‡¬◊ËÕ·≈–Àπ—ß∂ÿßÕ—≥±–‚μÀπ“ ‡Àμÿ∫«¡πÈ”‡À≈◊Õß §¡¡. chylocele, lymph scrotum

elementary -¡Ÿ≈∞“π «. ‰¡àÀ¡¥‰ªÀ√◊Õ·∫àß·¬°‡ªìπ à«π ¬àÕ¬À√◊ÕÕß§åª√–°Õ∫‰¡à‰¥â

elephantoid §≈â“¬‚√§‡∑â“™â“ß «. ‡°’Ë¬«°—∫À√◊Õ≈—°…≥– §≈â“¬‚√§‡∑â“™â“ß

elevator ‡§√◊ËÕß¬° π. Õÿª°√≥å„™âß—¥¬°‡π◊ÈÕ‡¬◊ËÕ ¬°™‘Èπ °√–¥Ÿ°ÕÕ° À√◊Õ∂Õπ√“°øíπ ‡™àπ ‡§√◊ËÕß¬° ‡ª≈’Ë¬π¡ÿ¡ ‡§√◊ËÕß¬°‡¬◊ËÕÀÿâ¡°√–¥Ÿ° ‡§√◊ËÕß¬°√“°øíπ angular elevator ‡§√◊ËÕß¬°‡ª≈’Ë¬π¡ÿ¡ π. ‡§√◊ËÕß ¬°∑’Ëª≈“¬„∫∑”¡ÿ¡∑“ß¢«“À√◊Õ´â“¬°—∫¥â“¡ periosteum elevator ‡§√◊ËÕß¬°‡¬◊ËÕÀÿâ¡°√–¥Ÿ° π. ·ºàπ‚≈À–·∫π„™â‡≈“–‡¬◊ËÕÀÿâ¡°√–¥Ÿ° root elevator ‡§√◊ËÕß¬°√“°øíπ π. ‡§√◊ËÕß¬°∑“ß ∑—πμ°√√¡ ”À√—∫∂Õπ√“°øíπ∑’ËÀ—°μ‘¥

eleotherapy ‡μ≈∫”∫—¥ π. °“√∫”∫—¥¥â«¬πÈ”¡—π ‚¥¬‡©æ“– ‚¥¬°“√©’¥πÈ”¡—π elephantiasic -‚√§‡∑â“™â“ß «. ‡°’Ë¬«°—∫‚√§‡∑â“™â“ß, À√◊Õ º‘«Àπ—ßÀπ“À¬“∫§≈â“¬Àπ—ß™â“ß elephantiasis Ò. ‚√§‡∑â“™â“ß π. ‚√§Àπ—ß·≈–‡π◊ÈÕ‡¬◊ËÕ„μâÀπ—ß∫«¡ πÈ”‡À≈◊Õß∑ÿμ‘¬¿Ÿ¡‘√ÿπ·√ß‡Àμÿ∑àÕπÈ”‡À≈◊Õß‡®√‘≠ º‘¥ª√°μ‘Õÿ¥μ—π à«π¡“°‡ªìπ∑’Ë¢“À√◊Õ∂ÿßÕ—≥±– ‡°‘¥®“°ÀπÕπæ¬“∏‘øî≈“‡√’¬ Ú. ¿“«–Àπ—ß™â“ß π. ¿“«–‡π◊ÈÕ‡¬◊ËÕ‚μ·≈–Àπ“‡°‘π ®“° “‡Àμÿμà“ß Ê elephantiasis chirurgica ¿“«–Àπ—ß™â“ß‡Àμÿ »—≈¬°√√¡ π. ‡π◊ÈÕ‡¬◊ËÕ∫«¡πÈ”‡À≈◊Õß√ÿπ·√ßÀ≈—ßºà“μ—¥‡μâ“π¡ congenital elephantiasis ¿“«–Àπ—ß™â“ß·μà°”‡π‘¥ π. ‡π◊ÈÕ‡¬◊ËÕ∫«¡πÈ”‡À≈◊Õßª∞¡¿Ÿ¡‘ ‡°‘¥À≈—ß§≈Õ¥À√◊ÕÀ≈—ß §≈Õ¥‰¡àπ“π elephantiasis gingivae ¿“«–‡Àß◊Õ°Àπ—ß™â“ß π. ‡Àß◊Õ°Àπ“‚¥¬∑—Ë«‰ªÀ√◊ÕÀπ“‡ªìπÀ¬àÕ¡∑’Ë¡’‡¬◊ËÕ‡ âπ„¬‡®√‘≠ ‡°‘π ∂à“¬∑Õ¥∑“ßæ—π∏ÿ°√√¡‡¥àπ ®“°¬“ À√◊Õ‰¡à∑√“∫ “‡Àμÿ lymphangiectatic elephantiasis ‚√§‡∑â“™â“ß ‡ÀμÿÀ≈Õ¥πÈ”‡À≈◊Õß‚ªÉßæÕß π. ‚√§‡∑â“™â“ß™π‘¥∑’Ë‡°‘¥®“° À≈Õ¥ πÈ”‡À≈◊Õß‚ªÉßæÕß¡“°„πÕ«—¬«–∑’Ë‡ªìπ‚√§ elephantiasis neuromatosa ¿“«–Àπ—ß™â“ß∑â“« · πª¡ π. ‡π◊ÈÕßÕ°„¬ª√– “∑μ“¡μ√–°Ÿ≈ ¡’æ—≤π“°“√ ‡ª≈’Ë¬π·ª≈ß„π√–∫∫ª√– “∑ °≈â“¡‡π◊ÈÕ °√–¥Ÿ° ·≈–Àπ—ß ∑”„Àâ‡π◊ÈÕ‡¬◊ËÕ‚μÀπ“‡ªìπªÿÉ¡ª¡¡’°â“πμ–ªÿÉ¡μ–ªò”∑—Ë«√à“ß°“¬ √à«¡°—∫∫√‘‡«≥Àπ—ß ’‡¢â¡ §¡¡.‚√§∑â“«· πª¡ elephantiasis nostras ¿“«–Àπ—ß™â“ß∑ÿμ‘¬¿Ÿ¡‘ π.

eliminant ¬“°”®—¥ π. ¬“∑’Ë°”®—¥ ‘Ëß§â“ß„πÕ«—¬«–μà“ß Ê ‡™àπ ¬“√ÿ ¬“°√–μÿâπÕ“‡®’¬π ¬“¢—∫ªí “«– elimination °“√°”®—¥ π. (Ò) °“√°√–∑”∑’Ë¢—∫ÕÕ°‚¥¬ ‡©æ“–°“√¢—∫ÕÕ°®“°√à“ß°“¬; (Ú) °“√≈–‡«âπ immune elimination °“√°”®—¥¥â«¬¿Ÿ¡‘§ÿâ¡°—π π. °“√∑”≈“¬ “√°àÕ¿Ÿ¡‘§ÿâ¡°—π¥â«¬ “√¿Ÿ¡‘§ÿâ¡°—π elinin ‡Õ≈‘π‘π π. ≈‘‚æ‚ª√μ’π¢Õß‡¡Á¥‡≈◊Õ¥·¥ß∑’Ë¡’ªí®®—¬ °≈ÿà¡‡≈◊Õ¥ Õ“√å‡Õ™, ‡Õ ·≈– ∫’ elixir πÈ”ª√ÿß π. “√≈–≈“¬„ √ À«“π ¡’πÈ”‡™◊ËÕ¡º ¡ ·Õ≈°ÕŒÕ≈å „ à “√·μàß°≈‘Ëπ Õ“®¡’μ—«¬“‰¥â elliptocytary -‡¡Á¥‡≈◊Õ¥·¥ß√’ «. ‡°’Ë¬«°—∫‡´≈≈å‡¡Á¥‡≈◊Õ¥ ·¥ß√Ÿª√’ elliptocyte ‡¡Á¥‡≈◊Õ¥·¥ß√’ «. ‡´≈≈å‡¡Á¥‡≈◊Õ¥·¥ß√Ÿª‰¢àÀ√◊Õ√’ æ∫„π¿“«–‡´≈≈å√Ÿª√’ elliptocytosis ¿“«–‡´≈≈å√Ÿª√’ π. °“√¡’‡¡Á¥‡≈◊Õ¥·¥ß‡´≈≈å √Ÿª√’®”π«π¡“°„π‡≈◊Õ¥ hereditary elliptocytosis ¿“«–‡¡Á¥‡≈◊Õ¥·¥ß√’ æ—π∏ÿ°√√¡ π. ‚√§∑“ßæ—π∏ÿ°√√¡∑’Ë¡’‡¡Á¥‡≈◊Õ¥·¥ß√’μ—Èß·μà √âÕ¬≈– Û›Ò ºŸâªÉ«¬ à«π¡“°‰¡à¡’Õ“°“√ ·μà∫“ß§π¡’°“√ ∑”≈“¬‡¡Á¥‡≈◊Õ¥·¥ß·≈–‡≈◊Õ¥®“ß®“°¡’‡¡Á¥‡≈◊Õ¥·¥ß·μ° ≈“¬

234 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ spherocytic elliptocytosis ¿“«–‡¡Á¥‡≈◊Õ¥·¥ß√’ ‡´≈≈å°≈¡ π. ‚√§∑“ßæ—π∏ÿ°√√¡∑’Ë¡’‡¡Á¥‡≈◊Õ¥·¥ß°≈¡ ´÷Ëß ‡´≈≈å®–·μ°ßà“¬·≈–‰¡à∑πμàÕ·√ß¥—πÕÕ ‚¡´‘ ºŸâªÉ«¬ à«π„À≠à¡’¿“«–‡≈◊Õ¥®“ß®“°‡¡Á¥‡≈◊Õ¥·¥ß·μ° ≈“¬ ·≈– ¡’§«“¡‡ ’Ë¬ßμàÕ°“√‡°‘¥¿“«–«‘°ƒμ‘‰¡à √â“ß‡¡Á¥‡≈◊Õ¥ elliptocytotic -¿“«–‡¡Á¥‡≈◊Õ¥·¥ß√’ «. ‡°’Ë¬«°—∫¿“«–‡¡Á¥ ‡≈◊Õ¥·¥ß‡´≈≈å√Ÿª√’ elongation °“√¬◊π¬“« π. (Ò) °“√°√–∑”, °√–∫«π°“√ À√◊Õ¿“«–∑’Ë‡æ‘Ë¡§«“¡¬“«; (Ú) °“√‡§≈◊ËÕπ´÷Ëß‡ªìπ æ¬“∏‘ ¿“æ¢Õßøíπ„π∑‘»∑“ß∫¥‡§’È¬«À√◊Õ°—¥μ—¥ π.; (Û) °“√∑’Ë¿“æ√—ß ’¢ÕßÕ«—¬«–‡ÀÁπ¬“«°«à“®√‘ß π. eluate μ–°Õπ™– π. ‘Ëß∑’Ë™–ÕÕ°¡“ À√◊Õ ‘Ëß∑’Ë‡À≈◊Õ‡ªìπ º≈®“°°“√™– À√◊Õ°“√·¬°ºß¥â«¬πÈ” eluent μ—«™– π. “√≈–≈“¬À√◊Õ¢Õß‡À≈«∑’Ë„™â„π°“√™– elution °“√™– π. °“√∑”„Àâ ‘Ëß∑’Ëμ‘¥Õ¬ŸàÀ≈ÿ¥‰ªÀ√◊ÕÀ¡¥ ‰ª¥â«¬ “√≈–≈“¬ À√◊Õ·√ßª–∑– elutriation °“√ªÉ π ·¬°¥â « ¬πÈ” π. °“√·¬° “√‚¥¬ °“√ªÉπ·≈â«º ¡πÈ” ‡æ◊ËÕ·¬°μ–°Õπ¢Õß ‘Ëß∑’ËÀπ—° °«à“ÕÕ°®“° ‘Ëß∑’Ë‡∫“°«à“ emaciation ¿“«–ºÕ¡·Àâß π. ¿“«–ºÕ¡Õ¬à“ß¡“° ‰¡à¡’ ‰¢¡—π„μâÀπ—ß ‡ªìπ ¿“æ‡ ◊ËÕ¡‚∑√¡¢Õß√à“ß°“¬ emasculate μÕπ π. μ—¥À√◊Õ∑”≈“¬Õ«—¬«– ◊∫æ—π∏ÿå‡æ»™“¬ ‡æ◊ËÕ‰¡à„Àâ‡°‘¥≈Ÿ° emasculation °“√μÕπ π. °“√μ—¥≈Ÿ°Õ—≥±–ÕÕ°∑—ßÈ Õß¢â“ß embalming °“√∂πÕ¡»æ π. °“√‡°Á∫√—°…“»æ¥â«¬πÈ”¬“ √–ß—∫‡™◊ÈÕ·≈– “√°—π‡ ’¬‡æ◊ËÕªÑÕß°—π°“√‡πà“ ≈“¬ embedding °“√Ωíßμ√÷ß π. °“√μ√÷ß‡π◊ÈÕ‡¬◊ËÕ àßμ√«®„π «— ¥ÿμ—«°≈“ß‡æ◊ËÕ‰¡à„Àâ‡ ’¬√Ÿª¢≥–∂Ÿ°μ—¥‡ªìπ·ºàπ ∫“ß¡“° embolalia ¿“«–æŸ¥·∑√°§”‰√â§«“¡ π. °“√ Õ¥·∑√°§” ‰√â§«“¡À¡“¬À√◊Õ§”∑’‰Ë ¡à “¡“√∂‡¢â“„®‰¥â„π¢âÕ§«“¡ ∑’ËæŸ¥ embolectomy °“√ºà“ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. »—≈¬°√√¡ ºà“μ—¥‡Õ“ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ÕÕ° embolic - ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ «. ‡°’Ë¬«°—∫ ‘ËßÀ≈ÿ¥Õÿ¥ À≈Õ¥‡≈◊Õ¥

emboliform §≈â“¬ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ «. §≈â“¬°—∫ ‘Ëß À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥; ‡Õ¡‚∫≈‘øÕ√å¡π‘«‡§≈’¬ π. ™◊ËÕπ‘«‡§≈’¬ „π°â“π∫π ¢Õß ¡ÕßπâÕ¬ Õ¬Ÿà√–À«à“ß‡¥π‡∑μπ‘«‡§≈’¬ °—∫‚°≈‚∫ π‘«‡§≈’¬ embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. °“√Õÿ¥À≈Õ¥ ‡≈◊Õ¥©—∫æ≈—π‚¥¬≈‘Ë¡‡≈◊Õ¥À√◊Õ ‘Ëß·ª≈°ª≈Õ¡ ‡™àπ øÕßÕ“°“» πÈ”§√Ë” ·∫§∑’‡√’¬ ´÷Ëßπ”‰ª∑“ß°√–· ‡≈◊Õ¥ Ÿà®ÿ¥∑’ËÕÿ¥ air embolism ‚√§À≈Õ¥‡≈◊Õ¥Õÿ¥¥â«¬Õ“°“» π. ‚√§À≈Õ¥‡≈◊Õ¥‡©’¬∫æ≈—π‡Àμÿ¡’øÕßÕ“°“»À≈ÿ¥‡¢â“À≈Õ¥ ‡≈◊Õ¥¥” ®“°¿¬—πμ√“¬, ®“°°“√ºà“μ—¥ À√◊Õ ®“°°“√≈¥·√ß ¥—π∫√√¬“°“»©—∫æ≈—π amniotic fluid embolism ¿“«–À≈Õ¥‡≈◊Õ¥Õÿ¥ ¥â«¬πÈ”§√Ë” π. ‚√§À≈Õ¥‡≈◊Õ¥‡©’¬∫æ≈—π‡ÀμÿπÈ”§√Ë”‡¢â“ Ÿà °√–· ‰À≈‡«’¬π‡≈◊Õ¥¢Õß·¡à bacillary embolism ¿“«–À≈Õ¥‡≈◊Õ¥Õÿ¥¥â«¬ ·∫§∑’‡√’¬ π. ‚√§À≈Õ¥‡≈◊Õ¥Õÿ¥°—Èπ‡©’¬∫æ≈—π‚¥¬°√–®ÿ° ·∫§∑’‡√’¬∑√ß·∑àß bland embolism ¿“«–À≈Õ¥‡≈◊Õ¥Õÿ¥°—Èπ¥â«¬ ‘Ëß ‰√â‡™◊ÈÕ π. ‚√§À≈Õ¥‡≈◊Õ¥Õÿ¥°—Èπ‡©’¬∫æ≈—π‚¥¬ ‘Ëß‰¡àμ‘¥‡™◊ÈÕ bone marrow embolism ¿“«–À≈Õ¥‡≈◊Õ¥Õÿ¥°—Èπ §â«¬‰¢°√–¥Ÿ° π. ‚√§À≈Õ¥‡≈◊Õ¥‡©’¬∫æ≈—π¡’‰¢°√–¥Ÿ° À≈ÿ¥‡¢â“°√–· ‡≈◊Õ¥®“°·∑àß°√–¥Ÿ°¬“«À—° capillary embolism ¿“«–À≈Õ¥‡≈◊Õ¥ΩÕ¬Õÿ¥°—Èπ π. À≈Õ¥‡≈◊Õ¥ΩÕ¬Õÿ¥°—Èπ‚¥¬·∫§∑’‡√’¬ cerebral embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ ¡Õß π. ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß©—∫æ≈—π‡Àμÿ ‘ËßÀ≈ÿ¥Õÿ¥ cholesterol embolism ¿“«–À≈Õ¥‡≈◊Õ¥¡’§Õ‡≈ ‡μÕ√Õ≈Õÿ¥ π. °“√¡’™‘Èπ§Õ‡≈ ‡μÕ√Õ≈∑’ËÀ≈ÿ¥®“°ºπ—ß∑àÕ‡≈◊Õ¥ ·¥ß‰ªÕÿ¥À≈Õ¥‡≈◊Õ¥©—∫æ≈—π §¡¡. cholesterol crystal embolism coronary embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ À—«„® π. °“√¡’ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥À—«„®‡©’¬∫æ≈—π crossed embolism ¿“«– ‘ßË À≈ÿ¥Õÿ¥‰¢«âÀ≈Õ¥‡≈◊Õ¥ π. ¿“«–≈‘Ë¡‡≈◊Õ¥„πÀ≈Õ¥‡≈◊Õ¥¥”‡§≈◊ËÕπ‰ªÕÿ¥À≈Õ¥‡≈◊Õ¥ ·¥ß ‚¥¬ºà“π™àÕß‚À«àºπ—ß°—ÈπÀ—«„®®“°ÀâÕß∫π¢«“‰ª´â“¬ §¡¡. paradoxical embolism direct embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ ‚¥¬μ√ß π. °“√¡’ ß‘Ë À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥„π∑‘»∑“ß°√–· ‡≈◊Õ¥

Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

fat embolism ¿“«–‰¢¡—πÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. °“√¡’‰¢¡—πÀ≈ÿ¥‡¢â“‰ªÕÿ¥À≈Õ¥‡≈◊Õ¥‡©’¬∫æ≈—π ¿“¬À≈—ß °√–¥Ÿ°¬“«À—° À√◊Õ¿“¬À≈—ß‰¥â√—∫§Õ√å∑‘‚§ ‡μ’¬√Õ¬¥å‡ªìπ ‡«≈“π“π infective embolism ¿“«– ‘ËßÀ≈ÿ¥μ‘¥‡™◊ÈÕÕÿ¥À≈Õ¥ ‡≈◊Õ¥ π. °“√¡’ ‘ËßÀ≈ÿ¥∑’Ëμ‘¥‡™◊ÈÕÕÿ¥À≈Õ¥‡≈◊Õ¥ lymph embolism; lymphogenous embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥πÈ”‡À≈◊Õß π. °“√¡’ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥ πÈ”‡À≈◊Õß miliary embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ ‡≈Á°À≈“¬·Ààß π. °“√¡’ ‘ËßÀ≈ÿ¥¢π“¥‡≈Á°®”π«π¡“°√–®“¬ Õÿ¥À≈Õ¥‡≈◊Õ¥¢π“¥‡≈Á°„π‡«≈“‡¥’¬«°—π multiple embolism ¿“«– ‘ËßÀ≈ÿ¥À≈“¬™‘ÈπÕÿ¥ À≈Õ¥‡≈◊Õ¥ π. °“√¡’ ‘ËßÀ≈ÿ¥¢π“¥‡≈Á°À≈“¬™‘ÈπÕÿ¥À≈Õ¥ ‡≈◊Õ¥ oil embolism ¿“«–‰¢¡—πÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. §¡¡. fat embolism pantaloon embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥§√àÕ¡ßà“¡ ∑àÕ‡≈◊Õ¥·¥ß π. °“√¡’ ‘ËßÀ≈ÿ¥Õÿ¥§√àÕ¡ßà“¡∑àÕ‡≈◊Õ¥·¥ß ‡°‘¥ Õ“°“√ª«¥∑âÕß ª«¥À≈—ß ·≈–ª«¥¢“∑—Èß Õß¢â“ß√à«¡°—∫ √Ÿâ ÷°™“·≈–‡¬Áπ §¡¡. saddle embolism paradoxical embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ ªØ‘∑√√»πå π. §¡¡. crossed embolism pulmonary embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ ªÕ¥ π. °“√¡’ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥À√◊Õ·¢πßÀπ÷Ëß·¢πß„¥ Ÿªà Õ¥ retinal embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥®Õ μ“ π. °“√¡’ ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥·¥ß®Õμ“ saddle embolism ¿“«– ‘ßË À≈ÿ¥Õÿ¥§√àÕ¡·∫∫Õ“π¡â“ π. §¡¡. pantaloon embolism spinal embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ ‰¢ —πÀ≈—ß π. °“√¡’ ß‘Ë À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥·¥ß Ÿ‰à ¢ —πÀ≈—ß tumor embolism ¿“«–‡π◊ÈÕßÕ°À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. °“√¡’™‘Èπ‡π◊ÈÕßÕ°À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ venous embolism ¿“«– ‘ËßÀ≈ÿ¥Õÿ¥¡“®“°À≈Õ¥ ‡≈◊Õ¥¥” π. °“√¡’ ‘ËßÀ≈ÿ¥∑’Ë‡°‘¥„πÀ≈Õ¥‡≈◊Õ¥¥” embolization Ò. °“√‡°‘ ¥ ‘Ë ß À≈ÿ ¥ „πÀ≈Õ¥‡≈◊ Õ ¥ π. °√–∫«π°“√À√◊Õ ¿“æ∑’Ë‡°‘¥ ‘ËßÀ≈ÿ¥„πÀ≈Õ¥‡≈◊Õ¥ ; Ú. °“√Õÿ¥À≈Õ¥‡≈◊Õ¥‡æ◊ËÕ∫”∫—¥ π. °“√„ à«—μ∂ÿ ‡¢â“‰ªÕÿ¥À≈Õ¥‡≈◊Õ¥‡æ◊ËÕ°“√∫”∫—¥

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embololalia °“√·∑√°§”‰√â§«“¡ π. §¡¡. embolalia embolomycotic - ‘Ëßμ‘¥‡™◊ÈÕÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. ‡°’Ë¬« °—∫°“√¡’ ‘ËßÀ≈ÿ¥μ‘¥‡™◊ÈÕÕÿ¥À≈Õ¥‡≈◊Õ¥ embolophrasia °“√·∑√°§”‰√â§«“¡ π. §¡¡. embololalia embolotherapy °“√∫”∫—¥‚¥¬Õÿ¥À≈Õ¥‡≈◊Õ¥ π. §¡¡. embolization §«“¡À¡“¬∑’Ë Ú embolus ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. °âÕπ«— ¥ÿÀ√◊Õ≈‘Ë¡‡≈◊Õ¥ ∑’Ë∂Ÿ°°√–· ‡≈◊Õ¥æ“‰ªÕÿ¥À≈Õ¥‡≈◊Õ¥ air embolus øÕßÕ“°“»À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. øÕßÕ“°“»À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ bullet embolus °√– ÿπÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. ‘ËßÀ≈ÿ¥∑’Ë‡ªìπ°√– ÿπÕÿ¥À≈Õ¥‡≈◊Õ¥ cancer embolus ¡–‡√ÁßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. ‘Ëß À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥∑’Ë‡ªìπ™‘Èπ‡π◊ÈÕ¡–‡√Áß fat embolus ‰¢¡—πÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. ‘ËßÀ≈ÿ¥ Õÿ¥À≈Õ¥‡≈◊Õ¥∑’Ë‡ªìπ‰¢¡—π foam embolus øÕß‡≈◊Õ¥À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. ‘ËßÀ≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥∑’Ë‡ªìπøÕßÕ“°“»ªπ°âÕπ‡≈◊Õ¥ obturating embolus ‘ËßÀ≈ÿ¥Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥ π. ‘ËßÀ≈ÿ¥∑’ËÕÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥ riding embolus; saddle embolus; straddling embolus ‘ËßÀ≈ÿ¥Õÿ¥§√àÕ¡ßà“¡À≈Õ¥‡≈◊Õ¥ π. ‘ËßÀ≈ÿ¥∑’Ëμ‘¥Õ¬Ÿà μ√ß®ÿ¥·¬°·¢πß¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß ∑”„ÀâÕÿ¥‡≈◊Õ¥∑’Ë®– ‰ª¬—ßª≈“¬·¢πßÀ≈Õ¥‡≈◊Õ¥ tumor embolus ‡π◊ÈÕßÕ°À≈ÿ¥Õÿ¥À≈Õ¥‡≈◊Õ¥ π. §¡¡. cancer embolus embouchement √Ÿ‡ªî¥À≈Õ¥‡≈◊Õ¥ π. √Ÿ‡ªî¥¢ÕßÀ≈Õ¥ ‡≈◊Õ¥Àπ÷Ëß‰ª ŸàÕ’°À≈Õ¥‡≈◊Õ¥Àπ÷Ëß embrasure ™àÕß ∫øíπ π. ™àÕß√–À«à“ß‚§âß ∫øíπ ‡ªìπ ™àÕß∑“ß„ÀâÕ“À“√À≈ÿ¥®“°°“√ ∫øíπ√–À«à“ß°“√ ‡§’È¬«Õ“À“√ buccal embrasure ™àÕß ∫øíπ¥â“π·°â¡ π. ™àÕß∑“ß¥â“π·°â¡∑’Ë‡°‘¥®“°°“√ ∫øíπ√–À«à“ßøíπ°√“¡°—∫ øíπ°√“¡πâÕ¬ incisal embrasure ™àÕß ∫øíπμ—¥ π. ™àÕß«à“ß √–À«à“ß —π¢Õ∫øíπ∑’Ë ∫°—∫ —πª≈“¬øíπμ—¥ §¡¡. occlusal embrasuve labial embrasure ™àÕßÀ«à“ßøíπ¥â“π√‘¡Ωïª“° π. ™àÕß∑’Ë‡ªî¥°«â“ß∑“ß¥â“π√‘¡Ωïª“°√–À«à“ßøíπ‡¢’È¬«°—∫øíπμ—¥

236 ____________________________________∏√√¡»“ μ√å‡«™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Ú ª√–®”‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ lingual embrasure ™àÕßÀ«à“ßøíπ¥â“π≈‘πÈ π. ™àÕß ∑’Ë‡ªî¥°«â“ß∑“ß¥â“π≈‘Èπ√–À«à“ßøíπ‡¢’È¬«°—∫øíπμ—¥ occlusal embrasure ™à Õ ß ∫øí π π. §¡¡. incisal embrasure embrocation Ò. °“√∑“¬“ π. °“√„™â ¬ “‡À≈«∑“∫π º‘ « °“¬; Ú. ¬“∑“ π. ¬“∑’Ë º ¡„π¢Õß‡À≈« ”À√—∫„™â∑“¿“¬πÕ° embryectomy °“√ºà“μ—¥‡ÕÁ¡∫√‘‚Õ π. °“√ºà “ μ— ¥ ‡Õ“ ‡ÕÁ¡∫√‘‚Õ„π§√√¿åπÕ°¡¥≈Ÿ°ÕÕ° embryo ‡ÕÁ¡∫√‘‚Õ π. (Ò) μ—«ÕàÕπ —μ«å∑’Ë‡®√‘≠®“°‰¢à∑’Ë º ¡·≈â« ´÷Ëß®–‡®√‘≠‡ªìπ —μ«åμàÕ‰ª; (Ú) μ—«ÕàÕπ „π§π∑’Ëæ—≤π“®“°‡√‘Ë¡ªØ‘ π∏‘®π¡’Õ“¬ÿ ¯ —ª¥“Àå; (Û) ™‘È π ª√–°Õ∫¢Õß‡¡≈Á ¥ æ— π ∏ÿå æ◊ ™ ∑’Ë æ— ≤ π“‰ª ‡ªìπμâπ Jano`lk embryo ‡ÕÁ¡∫√‘‚Õ®“πÕ¬§å π. μ—«ÕàÕπ ¢Õß§π∑’Ë¡’‚§âß‡ÕÕÕ√åμ“ Û Õ—π ·≈–™àÕß§ÕÀÕ¬ Ú Õ—π presomite embryo ‡ÕÁ¡∫√‘‚Õ°àÕπ√–¬–ª≈âÕß π. ‡ÕÁ¡∫√‘‚Õ„π√–¬–°àÕπ¡’ª≈âÕß§Ÿà·√° previllous embryo ‡ÕÁ¡∫√‘‚Õ°àÕπ¡’√° π. μ—« ÕàÕπ√–¬–°àÕπ∑’Ë√°¡’§Õ√‘‚Õπ‘°«‘≈‰≈ somite embryo ‡ÕÁ¡∫√‘‚Õ√–¬–ª≈âÕß π. μ—«ÕàÕπ √–¬–√–À«à“ß°“√ª√“°Øμ—«¢Õßª≈âÕß§Ÿà·√°°—∫§Ÿà ÿ¥∑â“¬ embryoblast ‡ÕÁ¡∫√‘‚Õ∫≈“ μå π. °≈ÿà¡‡´≈≈å∑’Ë‡®√‘≠μàÕ ‰ª‡ªìπ‡ÕÁ¡∫√‘‚Õ

embryology «‘∑¬“‡ÕÁ¡∫√‘‚Õ π. «‘∑¬“»“ μ√å¢Õßμâπ°”‡π‘¥ ·≈–æ—≤π“°“√¢Õß∫ÿ§§≈®“°°“√ªØ‘ π∏‘®π∂÷ß√–¬– ¯ —ª¥“Àå ·≈–æ—≤π“°“√„π™’æ®—°√∑ÿ°√–¬– comparative embryology «‘∑¬“‡ÕÁ¡∫√‘‚Õ‡ª√’¬∫ ‡∑’¬∫ π. °“√»÷°…“‡ÕÁ¡∫√‘‚Õ‡ª√’¬∫‡∑’¬∫„π ‘Ëß¡’™’«‘μÀ≈“¬ ™π‘¥æ—π∏ÿå descriptive embryology «‘∑¬“‡ÕÁ¡∫√‘‚Õæ√√≥π“ π. °“√»÷°…“‡ÕÁ¡∫√‘‚Õ·≈–≈Ÿ°„π∑âÕß ·≈–Õß§åª√–°Õ∫ √à«¡∑“ß°“¬«‘¿“§μ“¡≈”¥—∫‡«≈“¢Õß√–¬–·≈–«‘∂’∑“ß°“√ æ—≤π“ experimental embryology «‘∑¬“‡ÕÁ¡∫√‘‚Õ∑¥≈Õß π. °“√«‘‡§√“–Àåªí®®—¬·≈–§«“¡ —¡æ—π∏å„πæ—≤π“°“√‚¥¬ „™â‡ÕÁ¡∫√‘‚Õ„π°“√∑¥≈Õß embryoma ‡π◊ÈÕßÕ°‡´≈≈å‡ÕÁ¡∫√‘‚Õ π. ‡π◊ÈÕßÕ°∑’Ë§“¥«à“¡“ ®“°‡´≈≈åÀ√◊Õ‡π◊ÈÕ‡¬◊ËÕ‡ÕÁ¡∫√‘‚Õ ‡™àπ ∂ÿß‡¥Õ√å¡Õ¬¥å ‡∑Õ√“‚∑¡“ embryomorphous - —≥∞“π‡ÕÁ¡∫√‘‚Õ «. ¡’√Ÿª≈—°…≥å àÕ«à“ ‡ªì π ‡ÕÁ ¡ ∫√‘ ‚ Õ; ¡’ ‡ π◊È Õ ‡¬◊Ë Õ º‘ ¥ ª√°μ‘ ‡ À¡◊ Õ π‡ªì π à«π§â“ß¢Õß‡ÕÁ¡∫√‘‚Õ embryonal -‡ÕÁ¡∫√‘‚Õ «. ‡°’Ë¬«°—∫‡ÕÁ¡∫√‘‚Õ embryonate Ò. -¥ÿ®‡ÕÁ¡∫√‘‚Õ «. ‡°’Ë¬«°—∫À√◊Õ§≈â“¬μ—« ‡ÕÁ¡∫√‘‚Õ Ú. -¡’‡ÕÁ¡∫√‘‚Õ «. ¡’μ—«‡ÕÁ¡∫√‘‚ÕÕ¬Ÿà Û. -μ—Èß§√√¿å «. ‡°’Ë¬«°—∫°“√ªØ‘ π∏‘

embryoctony °“√∑”≈“¬‡ÕÁ¡∫√‘‚Õ π. °“√∑”≈“¬ ‡ÕÁ¡∫√‘‚ÕÀ√◊Õ≈Ÿ°„π∑âÕß∑’Ë¬—ß¡’™’«‘μ

embryonic -‡ÕÁ¡∫√‘‚Õ «. ‡°’Ë¬«°—∫‡ÕÁ¡∫√‘‚Õ

embryogenesis °”‡π‘¥‡ÕÁ¡∫√‘‚Õ π. (Ò) °“√º≈‘μ‡ÕÁ¡∫√‘‚Õ; (Ú) °“√æ—≤π“„Àâ‡°‘¥‡ÕÁ¡∫√‘‚Õ‚¥¬°“√ ◊∫æ—π∏ÿå ·∫∫Õ“»—¬‡æ»

embryonism ¿“æ‡ÕÁ¡∫√‘‚Õ «. §¡¡. embryoism

embryogenetic -°”‡π‘¥‡ÕÁ¡∫√‘‚Õ «. §¡¡. embryogenic

embryony °“√‡°‘¥‡ÕÁ¡∫√‘‚Õ π. §¡¡. embryogenesis

embryogenic -°”‡π‘¥‡ÕÁ¡∫√‘‚Õ «. (Ò) ‡°’Ë¬«°—∫æ—≤π“°“√ ¢Õß‡ÕÁ¡∫√‘‚Õ; (Ú) ‡°’Ë¬«°—∫°“√∑”„Àâ¡’‡ÕÁ¡∫√‘‚Õ

embryopathology æ¬“∏‘«‘∑¬“‡ÕÁ¡∫√‘‚Õ π. °“√»÷°…“ §«“¡º‘¥ª√°μ‘À√◊Õæ—≤π“°“√º‘¥ª√°μ‘¢Õß‡ÕÁ¡∫√‘‚Õ

embryogeny °”‡π‘¥‡ÕÁ¡∫√‘‚Õ π. §¡¡. embryogenesis

embryopathy æ¬“∏‘ ¿“æ‡ÕÁ¡∫√‘‚Õ π. ¿“«–À√◊Õ‚√§ ¢Õß‡ÕÁ¡∫√‘‚Õ∑’Ë‡ªìπº≈®“°æ—≤π“°“√º‘¥ª√°μ‘

embryoniform -·∫∫‡ÕÁ¡∫√‘‚Õ «. §¡¡. embryoid

embryonoid -¥ÿ®‡ÕÁ¡∫√‘‚Õ «. §¡¡. embryoid

embryoid -§≈â“¬‡ÕÁ¡∫√‘‚Õ «. ¡’≈—°…≥–§≈â“¬μ—«‡ÕÁ¡∫√‘‚Õ embryoplastic -°”‡π‘¥‡ÕÁ¡∫√‘‚Õ «. §¡¡. embryogenic embryoism ¿“æ‡ÕÁ¡∫√‘‚Õ π. ¿“æ∑’Ë‡ªìπ‡ÕÁ¡∫√‘‚Õ embryologist π—°«‘∑¬“‡ÕÁ¡∫√‘‚Õ π. ºŸâ‡™’Ë¬«™“≠‡√◊ËÕß ‡ÕÁ¡∫√‘‚Õ

embryoscope °≈âÕßμ√«®‡ÕÁ¡∫√‘‚Õ π. Õÿª°√≥å„™â àÕß μ√«®‡ÕÁ¡∫√‘‚Õ

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embryotome ¡’¥μ—¥‡ÕÁ¡∫√‘‚Õ π. Õÿª°√≥å„™â„π°“√μ—¥ ‡ÕÁ¡∫√‘‚Õ

anterior embryotoxon «ß¢“«¢Õ∫°√–®°μ“ ¥â“πÀπâ“ π. «ß ’‡∑“¢“«∑’Ë¥â“ππÕ°¢Õ∫°√–®°μ“

embryotomy °“√ºà“‡ÕÁ¡∫√‘‚Õ π. (Ò) °“√μ—¥·¢π¢“ ‡ÕÁ ¡ ∫√‘ ‚ Õ„π¡¥≈Ÿ ° À√◊ Õ „π™à Õ ß§≈Õ¥‡æ◊Ë Õ ™à « ¬ §≈Õ¥„π°√≥’ ∑’Ë ‰ ¡à “¡“√∂§≈Õ¥‰¥â μ “¡ª√°μ‘ ; (Ú) °“√™”·À≈–‡ÕÁ¡∫√‘‚ÕÀ√◊Õ≈Ÿ°„π∑âÕß

posterior embryotoxon «ß¢“«¢Õ∫°√–®°μ“ ¥â“πÀ≈—ß π. «ß ’‡∑“¢“«∑’Ë¥â“π„π¢Õ∫°√–®°μ“ ·≈–À“°¡’ æ—≤π“°“√º‘¥ª√°μ‘ ¢Õ∫®–πŸπ¬◊Ëπ¡“μ‘¥∑’Ë‡π◊ÈÕ‡¬◊ËÕ¡à“πμ“ §¡¡. Axenfeld anomaly

embryotoxon «ß¢“«¢Õ∫°√–®°μ“ π. «ß ’‡∑“¢“«∑’Ë ¢Õ∫°√–®°μ“·μà °”‡π‘ ¥ À√◊ Õ ‡°‘ ¥ „π¿“¬À≈— ß ‡Àμÿ¡§’ Õ‡≈ ‡μÕ√Õ≈ – ¡∑’ Ë «à πæ¬ÿß¢Õß°√–®°μ“ ¡—°æ∫‡¡◊ËÕÕ“¬ÿ¡“°°«à“ ı ªï À√◊Õæ∫√à«¡°—∫μ“ æ‘°“√∫“ß‚√§

embryotroph Õ“À“√‡ÕÁ¡∫√‘‚Õ π. Õ“À“√¢Õß‡ÕÁ¡∫√‘‚Õ embryotrophy ‚¿™π“°“√‡ÕÁ¡∫√‘‚Õ π. Õ“À“√‡ÕÁ¡∫√‘‚Õ

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Thammasat Medical Journal, Vol. 10 No. 2, April-June 2010____________________________________

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