Thammasat Medical Journal - 10 vol 3

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û °√°Æ“§¡-°—𬓬π ÚııÛ

ISSN 1513-5241

ªï∑’Ë Ò ©∫—∫∑’Ë Û °√°Æ“§¡-°—𬓬π ÚııÛ

Volume 10 Number 3 July-September 2010

∫∑∫√√≥“∏‘°“√ ❍ µà“ߧ«“¡§‘¥-µà“ßÕÿ¥¡°“√≥å

Thammasat Medical Journal Vol. 10 No. 3 July-September 2010

π‘æπ∏åµâπ©∫—∫ ❍ ªí®®—¬‡ ’ˬ߄π°“√‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥¥”™—Èπ≈÷°Õÿ¥µ—π„π‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘ ❍ §«“¡ “¡“√∂¢ÕßÕ—µ√“ à«π pulsatility index ¢Õß°“√µ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß middle cerebral °—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ „π°“√∑”π“¬∑“√°‚µ™â“„π§√√¿å √–¥—∫√ÿπ·√ß ❍ °“√µ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ°„πÀ≠‘ßµ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿµ—Èß·µà Ûı ªï ¢÷Èπ‰ª ¢≥–¡’Õ“¬ÿ§√√¿å Ò˜-ÚÙ —ª¥“Àå ❍ º≈°“√§≈Õ¥¢Õß µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å‡°‘π ÒÚ ™—Ë«‚¡ß ❍ ª√– ∫°“√≥å‡∫◊ÈÕßµâπ„π°“√ºà“µ—¥¡¥≈Ÿ°™π‘¥ª√“»®“°·º≈‡ªìπ∫πÀπâ“∑âÕߺŸâªÉ«¬·≈–°“√ºà“µ—¥∑“ßπ√’‡«™∑’Ë ≈ÿ°≈È”πâÕ¬„π‚√ß欓∫“≈πæ√—µπ√“™∏“π’ ❍ º≈°“√‡ª≈’ˬπ·ª≈ß·∫∫‡©’¬∫æ≈—πµàÕ°“√¢¬“¬¢Õß∑√«ßÕ°¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬„πºŸâÀ≠‘ß∑’Ë„ à‡ ◊ÈÕ√—¥√Ÿª ❍ ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ∫∑§«“¡ª√‘∑—»πå ❍ §«“¡™√“√–¥—∫‡´≈≈å ❍ °“√ÕÕ°°”≈—ß°“¬„ππÈ”‡æ◊ËÕΩñ°°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ ❍ »“ π“°—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ❍ °“√µ√«®«‘π‘®©—¬‚√§¡“≈“‡√’¬¥â«¬‡∑§π‘§™’««‘∑¬“√–¥—∫‚¡‡≈°ÿ≈ ∫∑§«“¡øóôπ«‘™“ ❍ ¿“«–æ‘…®“°¬“™“ ª°‘≥°– ❍ æ®π“πÿ°√¡»—æ∑å·æ∑¬å Õ—°…√ E (µàÕ) ❍ »—æ∑å —∫ π : species: ™π‘¥ À√◊Õ™π‘¥æ—π∏ÿå? ❍ ∫—≠™’‡Õ° “√ ‘Ëßæ‘¡æå∑“ß«‘™“°“√ ‡√◊ËÕß ç¿“«–‚≈°√âÕπé „πª√–‡∑»‰∑❍ æ≈—ßß“π· ßÕ“∑‘µ¬å≈¥¿“«–‚≈°√âÕπ ❍ °“√∑¥ Õ∫≈¡À“¬„® ❍ Õππ—°»÷°…“·æ∑¬å¬ÿ§„À¡àÕ¬à“߉√¥’ ❍ π«—µ°√√¡ : ‡§√◊ËÕß∂à“ߪ“°™àÕߧ≈Õ¥ ´’ Õ“√å «’ √ÿàπ∑’Ë Ò (CRV V.1) ®¥À¡“¬∂÷ß∫√√≥“∏‘°“√

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û °√°Æ“§¡-°—𬓬π ÚııÛ

“√∫—≠ ∫√√≥“∏‘°“√·∂≈ß

Contents

250 Editor’s Note Editorial

∫∑∫√√≥“∏‘°“√ µà“ߧ«“¡§‘¥-µà“ßÕÿ¥¡°“√≥å °âÕ߇°’¬√µ‘ °Ÿ≥±å°—π∑√“°√

π‘æπ∏åµâπ©∫—∫ ªí®®—¬‡ ’ˬ߄π°“√‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥¥”™—Èπ≈÷°Õÿ¥µ—π „π‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘ Õ— π’ ∑ÕßÕ¬Ÿà «’√¬– ‡¿“‡®√‘≠

Thammasat Medical Journal Vol. 10 No. 3 July-September 2010

251

Kongkiat Kulkantrakorn Original Articles

252 The risk factors of deep vein thrombosis in Thammasat University Hospital Assanee Tongyoo Veeraya Paocharoen

§«“¡ “¡“√∂¢ÕßÕ—µ√“ à«π pulsatility index ¢Õß 264 The value of middle cerebral artery-umbillical °“√µ√«®¥â « ¬§≈◊Ë π ‡ ’ ¬ ߧ«“¡∂’Ë Ÿ ß ¥Õæ‡≈Õ√å À ≈Õ¥ artery pulsatility index ratio in prediction ‡≈◊Õ¥·¥ß middle cerebral °—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß of severe fetal growth restriction ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ „π°“√∑”π“∑“√°‚µ™â“„π§√√¿å√–¥—∫√ÿπ·√ß µâÕßµ“ π—π∑‚°¡≈ Tongta Nanthakomon ®√‘π∑√å∑‘æ¬å ¡ª√– ‘∑∏‘Ï Charintip Somprasit °“√µ√«®¥â « ¬§≈◊Ë π ‡ ’ ¬ ߧ«“¡∂’Ë Ÿ ß ¥Õæ‡≈Õ√å À ≈Õ¥ 271 Uterine artery Doppler flow in advanced ‡≈◊Õ¥·¥ß¡¥≈Ÿ°„πÀ≠‘ßµ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿµ—Èß·µà Ûı ªï maternal age at 17-24 weeks of gestation ¢÷Èπ‰ª ¢≥–¡’Õ“¬ÿ§√√¿å Ò˜-ÚÙ —ª¥“Àå µâÕßµ“ π—π∑‚°¡≈ Tongta Nanthakomon Õ∏‘µ“ ®—π∑‡ π“ππ∑å Athita Chanthasenanont ®√‘π∑√å∑‘æ¬å ¡ª√– ‘∑∏‘Ï Charintip Somprasit º≈°“√§≈Õ¥¢Õß µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«–∂ÿßπÈ”§√Ë”·µ° 282 Outcomes of pregnancy with premature rupture °àÕπ°“√‡®Á∫§√√¿å‡°‘π ÒÚ ™—Ë«‚¡ß of membranes more than 12 hours §”π«√ ®‘µ√¡≥’«√√≥ Khamnuan Jitmaneewan

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û °√°Æ“§¡-°—𬓬π ÚııÛ

“√∫—≠ π‘æπ∏åµâπ©∫—∫

Thammasat Medical Journal Vol. 10 No. 3 July-September 2010

Contents

Original Articles

ª√– ∫°“√≥å‡∫◊ÈÕßµâπ„π°“√ºà“µ—¥¡¥≈Ÿ°™π‘¥ª√“»®“° 290 Scarless hysterectomy and minimally invasive gynecologic operations in Nopparat Rajathani ·º≈‡ªìπ∫πÀπâ“∑âÕߺŸâªÉ«¬·≈–°“√ºà“µ—¥∑“ßπ√’‡«™∑’Ë Hospital : initial experience ≈ÿ°≈È”πâÕ¬„π‚√ß欓∫“≈πæ√—µπ√“™∏“π’ Chalermpol Assawatheerangkoon ‡©≈‘¡æ≈ Õ—»«∏’√“ß°Ÿ√ º≈°“√‡ª≈’ˬπ·ª≈ß·∫∫‡©’¬∫æ≈—πµàÕ°“√¢¬“¬¢Õß 294 Immediate effect of chest expansion after exercise in women wearing tight-shirt ∑√«ßÕ°¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬„πºŸÀâ ≠‘ß∑’„Ë à‡ ◊ÕÈ √—¥√Ÿª Bromwadee Asachereewattana æ√À¡«¥’ Õ—»‡®√’¬å«—≤π“ Suwimol Damrongseen ÿ«‘¡≈ ¥”√ß»’≈ Noppawan Charususin πæ«√√≥ ®“√ÿ ÿ ‘π∏å Patcharee Kooncumchoo æ—™√’ §ÿ≥§È”™Ÿ ªí®®—¬∑’¡Ë Õ’ ∑‘ ∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈ÕŸ∑à Õß 302 Factors influencing on use of herbal medicinal products in U-Thong hospital, Suphanburi ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ province Naphatsaran Roekruangrit π¿— √—≠™πå ƒ°…å‡√◊Õ߃∑∏‘Ï Kaysorn Sumpaothong ‡°…√ ”‡¿“∑Õß Arunporn Itharat Õ√ÿ≥æ√ Õ‘∞√—µπå

∫∑§«“¡ª√‘∑»— πå

Review Articles

§«“¡™√“√–¥—∫‡´≈≈å æ‘π∑ÿ √ À“≠ °ÿ≈

311 Cellular aging Pintusorn Hansakul

°“√ÕÕ°°”≈—ß°“¬„ππÈ”‡æ◊ËÕΩñ°°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ

320 Aquatic exercise to improve balance in the elderly Piyapa Keawutan

ªî¬“¿“ ·°â«Õÿ∑“π »“ π“°—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ¢«—≠®‘µ »»‘«ß»“‚√®πå

327 Religion and health in the elderly Kwanchit Sasiwongsaroj

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û °√°Æ“§¡-°—𬓬π ÚııÛ

“√∫—≠ ∫∑§«“¡ª√‘∑»— πå °“√µ√«®«‘π‘®©—¬‚√§¡“≈“‡√’¬¥â«¬‡∑§π‘§™’««‘∑¬“ √–¥—∫‚¡‡≈°ÿ≈ «’√–™—¬ ‡Õ◊ÈÕ ‘∑∏‘™—¬

∫∑§«“¡øóπô «‘™“ ¿“«–æ‘…®“°¬“™“ ª√’¬æ√√≥ Õ√ÿ≥“°Ÿ√

ª°‘≥°– æ®π“πÿ°√¡»—æ∑å·æ∑¬å Õ—°…√ E (µàÕ)

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

Thammasat Medical Journal Vol. 10 No. 3 July-September 2010

Contents

Review Articles 335 Molecular diagnosis of malaria

Veerachai Eursitthichai Refresher Course 345 Local anesthetic toxicity Preeyaphan Arunakul Miscellaneous 352 English Dictionary of Medical Terms : The Letter E (contd) The Royal Instituteûs Medical Dictionary Committer

»—æ∑å —∫ π : species: ™π‘¥ À√◊Õ ™π‘¥æ—π∏ÿå? ¡™—¬ ∫«√°‘µµ‘ æ√√…“ ‰∑√ß“¡

362 Species

∫—≠™’‡Õ° “√ ‘Ëßæ‘¡æå∑“ß«‘™“°“√ ‡√◊ËÕß ç¿“«–‚≈°√âÕπé „πª√–‡∑»‰∑§≥–°√√¡°“√®—¥∑”æ®π“πÿ°√¡»—æ∑å ‘Ëß·«¥≈âÕ¡ √“™∫—≥±‘µ¬ ∂“π

364 Thai Publication in çGlobal warmingé

æ≈—ßß“π· ßÕ“∑‘µ¬å≈¥¿“«–‚≈°√âÕπ ‰æ±Ÿ√¬å «√√≥æß…å

368 Solar energy reduces global warming Paitoon Wanapongse

°“√∑¥ Õ∫≈¡À“¬„® Õ√√∂æ≈ ™’æ —µ¬“°√ ‡√◊Õß√Õß ™’æ —µ¬“°√

371 Breath test Attapon Cheepsattayakorn Ruangrong Cheepsattayakorn

Somchai Bavornkitti Phansa Sai-Ngam

The Royal Instituteûs Medical Dictionary Committer

How to instruct the Generation Y medical stydebts?

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û °√°Æ“§¡-°—𬓬π ÚııÛ

“√∫—≠ ª°‘≥°–

Thammasat Medical Journal Vol. 10 No. 3 July-September 2010

Contents

Miscellaneous

Õππ—°»÷°…“·æ∑¬å¬ÿ§„À¡àÕ¬à“߉√¥’ «‘π‘∑√“ π«≈≈–ÕÕß

381 How to instruct the Generation Y medical students Winitra Nuallaong

π«—µ°√√¡ : ‡§√◊ËÕß∂à“ߪ“°™àÕߧ≈Õ¥ ´’ Õ“√å «’ √ÿàπ∑’Ë Ò (CRV V.1) ‡©≈‘¡æ≈ Õ—»«∏’√“ß°Ÿ√

387 The Innovation : CRV V.1 Chalermpol Assawatheerangkoon

®¥À¡“¬∂÷ß∫√√≥“∏‘°“√

390 Letter to the Editor

∫√√≥“∏‘°“√·∂≈ß «— ¥’ ¡“™‘°·≈–ºŸâÕà“π∑ÿ°∑à“π «“√ “√©∫—∫π’Ȫ√–°Õ∫¥â«¬‡√◊ËÕß∑“ß°“√·æ∑¬å °“√·æ∑¬å·ºπ‰∑¬ª√–¬ÿ°µå ·æ∑¬»“ µ√»÷°…“ ·≈–‡√◊ËÕß∑’ˇªì𧫓¡√Ÿâ∑—Ë«‰ª∑’˧«√√Ÿâ‡ªìπ®”π«π¡“° ´÷Ëß¡’‡π◊ÈÕÀ“‡¢â“„®ßà“¬ ‡À¡“–°—∫ºŸâÕà“π∑ÿ°∑à“π „πß“π ª√–™ÿ¡«‘™“°“√§√∫√Õ∫ Ú ªï §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å ¡’ºŸâ π„® ¡—§√‡ªìπ ¡“™‘°‡ªìπ®”π«π¡“° ·≈– ¡’ºŸâ π„® àß∫∑§«“¡≈ßµ’æ‘¡æ凪ìπ®”π«π¡“°‡™àπ°—π · ¥ß«à“«“√ “√¢Õ߇√“°”≈—߇µ‘∫‚µ¢÷Èπ∑ÿ°«—π ‚¥¬¡’°Õß∫√√≥“∏‘°“√∑’Ë ‡¢â¡·¢Áߧլ¥Ÿ·≈Õ¬à“ß„°≈♑¥ ‰¡à„Àâ§≈“¥ “¬µ“ ”À√—∫ ¡“™‘°„À¡à∑’˵âÕß°“√«“√ “√∏√√¡»“ µ√凫™ “√©∫—∫¬âÕπÀ≈—ß ¢Õ„Àâ·®â߉ª¬—ß°Õß®—¥°“√∏√√¡»“ µ√凫™ “√‡æ◊ËÕ®–‰¥â¥”‡π‘π°“√®—¥ àß„Àâ·°à∑à“π ¡“™‘°µàÕ‰ª ∏√√¡»“ µ√凫™ “√‰¥â√—∫¢à“«¥’®“°ºŸâ∫√‘À“√«à“ „Àâµ’æ‘¡æå«“√ “√ªï≈– ı ©∫—∫ ´÷Ëß«“ß·ºπ«à“‡ªìπ©∫—∫ª√°µ‘ Ù ©∫—∫ ·≈–©∫—∫摇»… Ò ©∫—∫ ´÷Ëß©∫—∫摇»…®–‡ªìπ°“√√«∫√«¡∫∑§«“¡®“°«‘∑¬“°√ ·≈–∫∑§«“¡«‘®—¬∑’Ë√à«¡π”‡ πÕ„πß“πª√–™ÿ¡ «‘™“°“√¢Õߧ≥–·æ∑¬»“ µ√å √—∫√Õß«à“‡π◊ÈÕÀ“®– ¥„À¡à·≈–∑—π ¡—¬·πàπÕπ °Õß∫√√≥“∏‘°“√¬‘π¥’√—∫¢âÕµ‘™¡®“°ºŸâÕà“π∑ÿ°∑à“π‡æ◊ËÕ‡ªìπæ≈—ß„π°“√æ—≤π“ Õ“®“√¬å·æ∑¬å√ÿàπ„À¡à∑’Ë π„®ß“π«“√ “√ ·≈–Õ¬“°‡¢â“¡“√à«¡ß“π‰¡à«à“Àπâ“∑’Ë„¥°Áµ“¡ “¡“√∂·®âß¡“‰¥â‚¥¬µ√ߧ√—∫

√Õß»“ µ√“®“√¬å 𓬷æ∑¬å°âÕ߇°’¬√µ‘ °Ÿ≥±å°—π∑√“°√ ∫√√≥“∏‘°“√

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

251

∫∑∫√√≥“∏‘°“√

µà“ߧ«“¡§‘¥-µà“ßÕÿ¥¡°“√≥å °âÕ߇°’¬√µ‘ °Ÿ≥±å°—π∑√“°√

∫√√≥“∏‘ ° “√¡’ ‚ Õ°“ ‡¢â “ √à « ¡„π°√√¡°“√®— ¥ ∑” æ®π“πÿ ° √¡»— æ ∑å · æ∑¬»“ µ√å Õ— ß °ƒ…-‰∑¬ ¢Õß √“™∫—≥±‘µ¬ ∂“𠉥â√∫— §«“¡√Ÿ·â µ°©“π¥â“π¿“…“·≈–»—æ∑å ·æ∑¬»“ µ√å‡æ‘Ë¡¢÷ÈπÕ¬à“ß¡“° ‡π◊ËÕߥ⫬°√√¡°“√„π§≥– ª√–°Õ∫¥â«¬∫ÿ§≈“°√µà“ß«—¬ µà“ß ∂“∫—π ·≈–∑’Ë ”§—≠µà“ß Õÿ¥¡°“√≥å„π·π«§‘¥ ¥—ßπ—Èπ„π°“√ª√–™ÿ¡∑ÿ°§√—Èß ®÷ß¡’°“√ Õ¿‘ª√“¬§àÕπ¢â“߇π‘πË π“π°àÕπ≈ß¡µ‘ ´÷ßË ‡™◊ÕË «à“‰¡à‡Õ°©—π∑åπ°— „𧫓¡µâÕß°“√¢Õß°√√¡°“√∫“ß∑à“π ·µàµâÕß®”¬Õ¡µ“¡ ‡ ’¬ß¢â“ß¡“° À√◊Õµ“¡§”¬ÿµ‘¢Õߪ√–∏“π°√√¡°“√ °√Õ∫ß“π¢Õߧ≥–°√√¡°“√™ÿ ¥ π’È ª √–°Õ∫¥â « °“√∫—≠≠—µ‘»—æ∑å ·≈–Õ∏‘∫“¬»—æ∑嵓¡·∫∫æ®π“πÿ°√¡´÷Ëß ·µ°µà“ß®“°°“√®—¥∑” “√“πÿ°√¡ À≈—°°“√∫—≠≠—µ‘»—æ∑å „™â«‘∏’¢Õß√“™∫—≥±‘µ¬ ∂“π ‚¥¬°µ‘°“«à“ À“°¡’§”∑’Ë„™â°—πÕ¬Ÿà·≈â« ·≈–∑’˪√–™ÿ¡‡ÀÁπ«à“ ‡À¡“– ¡°Á„™â§”‡¥‘¡ „π°√≥’∑’˵âÕߺŸ°§”¢÷Èπ„À¡à„À⧑¥„™â §”‰∑¬°àÕπ µàÕ‡¡◊ÕË À“§”‰∑¬∑’‡Ë À¡“–‰¡à‰¥â ®÷ßÀ“§”®“°¿“…“ ∫“≈’·≈– —π °ƒµ À√◊Õ∑⓬∑’Ë ÿ¥À“°‰¡à “¡“√∂∫—≠≠—µ‘‡ªìπ ¿“…“‰∑¬‰¥â °Á„Àℙ⫑∏’∑—∫»—æ∑å - §”∑’˺Ÿ°¢÷Èπ®“°§”‰∑¬ „Àâ¡’®”π«π§” —Èπ∑’Ë ÿ¥ ·≈–‰¡à„™â∫ÿæ∫∑‚¥¬‰¡à®”‡ªìπ ‡æ◊ËÕ„À⧔»—æ∑å —Èπ°–∑—¥√—¥ ‰¡à‡ªìπ§”𑬓¡»—æ∑å

§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å

- »—æ∑å∑’˺Ÿ°¢÷Èπ®“°§”∫“≈’·≈– —π °ƒµ „™â§” ¢¬“¬ª√–°Õ∫Àπⓧ”π“¡ ´÷Ëß·µ°µà“ß®“°°“√ ¡“ À√◊Õ π∏‘µ“¡À≈—°‰«¬“°√≥å‰∑- °“√∑—∫»—æ∑å §◊Õ °“√‡¢’¬π»—æ∑å¿“…“µà“ß ª√–‡∑»‡ªìπ¿“…“‰∑¬‚¥¬«‘∏∂’ à“¬‡ ’¬ß À√◊Õ∂Õ¥Õ—°…√ ‡™àπ thyroid ‡ªìπ ‰∑√Õ¬¥å (∂à“¬‡ ’¬ß) À√◊Õ ∏—¬√Õ¬¥å (∂Õ¥ Õ—°…√), chromatoplasm ‡ªì𠂧√¡“‚∑æ≈“´÷¡ (∂à“¬‡ ’¬ß) À√◊Õ ‚¶√¡“‚∑æ≈“ ¡ (∂Õ¥Õ—°…√) ; §”∑—∫»—æ∑å∫“ߧ” Õ“®‰¥â„™â°—π®π‡§¬™‘π‡ªì𧔉∑¬‰ª·≈â« °ÁÕ“®µâÕß„™â‡ªì𠧔∑’ˉ¥â√—∫°“√‚Õπ‡ªìπ‰∑¬·≈â« ‡™àπ øÿµ∫Õ≈, √—°∫’È ∂÷ß·¡â‰¥â¡’À≈—°°“√‡ªìπ¡—Ëπ‡À¡“–¥—ß°≈à“«·≈â«π—Èπ ¬—ß¡’¢âÕ‚µâ·¬â߇ ¡Õ„π∑’˪√–™ÿ¡ ‚¥¬·π«§‘¥·≈–Õÿ¥¡°“√≥å ∑’Ë·µ°µà“ß°—π ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π«‘∏’°“√∑—∫»—æ∑å√–À«à“ß ΩÉ“¬∂à“¬‡ ’¬ß°—∫ΩÉ“¬∂Õ¥Õ—°…√ ·≈–√–À«à“ߧ”∑’Ë„À⧫“¡ À¡“¬°”°«¡ ‡™àπ spinal fluid ‡ªìπ “√πÈ”‰¢ —πÀ≈—ß °—∫ “√πÈ”À≈àÕ‰¢ —πÀ≈—ß, epiglottis ‡ªìπΩ“°≈àÕ߇ ’¬ß °—∫ Ω“ªî¥°≈àÕ߇ ’¬ß

252 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

π‘æπ∏åµπâ ©∫—∫

The risk factors of deep vein thrombosis in Thammasat University Hospital Assanee Tongyoo, Veeraya Paocharoen

Abstract Background:

Method:

Results:

Conclusion:

Key words:

The deep vein thrombosis (DVT) is the condition that the thrombus occurs in the deep portion of venous system and causes obstruction of venous return.

It can lead to many consequences and even fatal complication such as pulmonary embolism. Its risk factors should be identified for prevention and appropriate treatment.

The patients with clinical suspicion of DVT and undergone Doppler ultrasound performed by radiologists at Thammasat University Hospital during 2007-2008 were selected. Then clinical data of included patients were reviewed. The dependent variable was positive result of ultrasound diagnosing DVT. The data was analyzed by univariate and multivariate logistic regression analysis to identify significant independent variables.

The Doppler ultrasound examinations were performed in 236 included patients.

After univariate logistic regression analysis, the 7 variables (ischemic heart disease, dyslipidemia, malignancy, operation, hospitalization, immobilization, affected side) were selected into multivariate analysis. The strongest predictive variable was recent immobilization with OR 5.94. Other 3 significant factors were malignancy of abdominopelvic organs, left side of leg, and recent hospitalization with OR 2.61 2.59, and 2.00, respectively.

The significant risk factors of DVT are immobilization, intra-abdominal cancers, clinically affected left side, and hospitalization. The patients, who present with unilateral leg swelling and have these predictors, should be suspected to have DVT and should be tested by Doppler ultrasound.

Deep vein thrombosis, DVT, Risk factor, Doppler ultrasound

Department of Surgery, Faculty of Medicine, Thammasat University Correspondence to : Assanee Tongyoo, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand.

Phone: 02-926-9523. FAX: 02-926-9530.

E-mail address: ast_7_4@yahoo.com

253

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Background Although deep vein thrombosis (DVT) is an uncommon disease, it leads to many consequences such as varicose vein, venous ulcer, dermatosclerosis and chronic venous insufficiency. Even serious complication such as pulmonary embolism can happen and may finally result in mortality. The pathophysiology of DVT is clarified into 3 main causes as known çVirchowÝs triadÊ; 1) decreased venous blood flow, 2) endothelial injury and 3) hypercoagulable state. There are many conditions precipitating venous stasis; for example, poor ambulation after major operation, impaired physical function following stroke or spinal cord injury, immobilization from orthopedic injury and holding same position in a long travel. Vascular intimal tear, which can activate coagulation processes in vessel, occurs from trauma or venous catheterization. For hypercoagulable state, thrombus can be produced intravascularly easier than normal from increased function of coagulating factors. This condition is the result of cancer, contraceptive pills use, or some hematologic disorder e.g. protein C or S deficiency.

The presentation of DVT may lead to further diagnosis of occult malignancy or unknown hematologic disorder finally. Then searching for the risk factors of developing DVT is important to prevent recurrence and to treat the actual cause correctly.

Lee et al. summarized from many studies and reported at least 1 identifiable risk factor can be defined in 44-86% of DVT patients.1 Furthermore, either known malignancies or occult cancers found out later represented approximately 10% of cases.1 However, DVT without potential cause was still reported at 11-48%.2-6 Another important risk factor is race. Higher prevalence of thrombophilic disorder in Caucasian than in Asian population correlated with higher incidence of DVT. Almost of published studies in DVT were conducted in Caucasian countries. There were some studies defining the risk factors estab-

lished in Thai patients. However, most of them were designed just to evaluate the effect of specific variables such as patient undergone orthopedic operation or after traumatic injury. The purpose of this study is to clarify the impact of several different factors to the incidence of DVT in Thai patients.

Methods A number of patients who was examined

by Doppler ultrasound was collected from procedural records at Radiology department of Thammasat University Hospital, Pathumthani, Thailand, between 2007 and 2008. Some patients either being performed with upper extremities ultrasound or having other indications than clinical suspicion of DVT were excluded from the study. Clinical data and Doppler ultrasound results were retrospectively reviewed. The clinical features were gathered from both out-patient and admission files. The information included demographic data and potential risk factors of DVT; for example, hospitalization, immobilization, previous operations, and cancers.

Doppler ultrasound was used to confirm the evidence of DVT. Only if there is thrombus demonstrated in external iliac, common femoral, superficial femoral or popliteal vein, the result Doppler ultrasound tests is reportedly. Other results were defined as negative. All information was recorded and then analyzed by PASW (SPSS version 17.0).

Firstly, the collected data were summarized and reported in percentages. This included demographic data, underlying diseases, risk factors, and clinical presentations. At second step, univariate logistic regression analysis was used to separately analyze the effect of each factor for DVT developing at of lower extremities. The dependent variable was set at the result of Doppler ultrasound at the affected extremities. The proportion of each factor in both DVT and non-DVT groups were reported together with P-value. The statistical significance was set at P-value < 0.05. Finally, the variables with

254 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

P-value ≤ 0.3 were considered to be highly potential factors and were selected to continuously proceed on multivariate logistic regression analysis. Again, the dependent variable was the presence of thrombus in deep venous system of lower extremities. The purpose of this step is to identify the variables which independently affect the incidence of DVT of lower extremities. The adjusted odd ratios with 95% confidence interval of each variable were also calculated.

Results During 2007-2008, four hundred and seventeen Doppler ultrasound examinations were performed by radiologists at Thammasat University Hospital with several indications. One hundred and sixty-eight patients were excluded because their investigations were done from other indications; for example, identifying venous abnormality of

varicose vein, diagnosing renal artery or carotid artery stenosis, and pre-operative preparation for vascular access in patient with chronic renal failure. Thus, there were the rest 249 patients with swelling of extremities with or without pain suspected to diagnose DVT. They were evaluated by clinicians and examined by Doppler ultrasound to confirm diagnosis. Finally, 13 of 249 ultrasound-examined patients were also excluded because their investigated parts were upper extremities, not lower extremities.

The demographic data and underlying diseases of the included 236 patients in this study were summarized and shown in Table 1. The number of female patients was higher than male patients which represented 65.25% and 34.75%, respectively.

Patientsû ages in the study range from 14 to 99 with mean 61 and median 64 years.

417 Doppler ultrasound examinations

▼

▼

168 excluded ---------------------- (other reasons for Doppler ▼ ultrasound) 249 examinations for diagnosing DVT 13 excluded ---------------------(upper extremities) ▼ 236 examinations of lower extremities Fig. 1 Patient flow of the included and excluded patients in this study

255

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Table 1 Demographic data and clinical manifestations of patients (total = 236) Number Gender male female Age - less than 21 years - 21-40 years - 41-60 years - 61-80 years - more than 80 years Underlying disease - hypertension - dyslipidemia - diabetes mellitus - ischemic heart disease - chronic renal failure - cerebrovascular accident Previously diagnosed cancers Patient status - out-patient department - admitted - medicine - surgery - orthopedic - gynecology

There were 43 patients with known malignancy included in this study. Cervical cancer were in 9 patients. Other gynecologic malignancies were 3 ovarian cancers, 1 endometrial cancer, and 1 squamous cell carcinoma of external genitalia.

Gastrointestinal malignancies presented 14 cases, such as 3 colonic cancers, 3 rectal cancers, 2 cholangiocarcinomas, 1 hepatocellular carcinoma, 1 gastric cancer, 1 anal canal cancer, and 3 metastatic adenocarcinomas of unknown origin. Three

Percentage

82 154

34.75% 65.25%

2 34 73 91 36

0.85% 14.41% 30.93% 38.56% 15.25%

97 78 54 50 24 19 43

41.10% 33.05% 22.88% 21.19% 10.17% 8.05% 18.22%

107 129 67 54 4 4

45.34% 54.66% 28.39% 22.88% 1.69% 1.69%

non-Hodgkin lymphomas, 3 multiple myelomas, and 1 acute myeloid leukemia were underlying hematologic malignancies collected in the study. Urologic cancers consisted of 1 bladder, 1 testicular, and 2 prostatic cancers patients. Other types of cancer were 2 breast cancers and 2 lung cancers. In patient with unknown malignancy, no cancer was newly discovered after the time of Doppler ultrasound performed.

256 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Table 2 Clinical manifestations of included patients (total = 236) Number leg(s) swelling - unilateral - left - right - bilateral pain at affected leg(s)

Percentage

199 97 102 37 30

The clinical manifestations were swelling of lower extremities with or without pain. Most of them were unilateral as shown in Table 2. The single

84.32% 41.10% 43.22% 15.68% 12.71%

leg involvement represented approximately 40% for each side, while both legs involvement was 15.68%.

Table 3 Affected side(s) of lower extremities.

Examined by ultrasound unilateral bilateral left right

97 102

}

37

total 134 139

Finally diagnosed DVT clinically bilateral clinically total unilateral positive positive one side both sides 40 3 47 4 38 3 45

}

After Doppler ultrasound examinations were performed, 88 patients in all 236 clinically-suspected patients (37.3%) were diagnosed DVT of lower extremities. In unilaterally-performed groups, 40 of 97 left-sided and 38 of 102 right-sided examinations were reported positive results as

percentage 35.1% 32.4%

shown in Table 3. Thirty-seven patients were examined by Doppler ultrasound bilaterally, the ultrasound demonstrated the evidences of DVT at lower extremities in 10 patients; 3 left legs, 3 right legs and both legs in 4 patients.

Table 4 Proportion of DVT in patients with each potential risk factor Potential risk factors Immobilization Known malignancy Hospitalization within 3 months Operation Medical illness

Total patients

DVT-diagnosed patients

Percentage

29 43 97 62 125

18 24 46 24 45

62.1% 55.8% 47.4% 38.7% 36.0%

257

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

As illustrated in Table 4, the highest proportion of patients with DVT of lower extremities was found in immobilized patients group. About half of patients with underlying cancer or recent hospitalization within 3 months were reported to demonstrate DVT in this study. The patients with un-

derlying medical disease including DM, hypertension, dyslipidemia, ischemic heart disease, chronic renal failure, and cerebrovascular accident represented 36% of patients with diagnosis of DVT in this present study.

Table 5 Provided investigation for 88 DVT-diagnosed patients.

Investigations Radiologic study - abdominal ultrasound - CT with contrast Serum laboratory tests - Tumor marker - Hematologic workup - Rheumatologic workup Endoscopy - Gastroscopy - Colonoscopy

Some patients with positive ultrasound result were further investigated with other radiologic, laboratory or GI endoscopic workup to identify the occult diseases, as shown in Table 5. These undiscovered diseases may be the causes of hypercoagulable state and result in DVT of extremities. Serum laboratory tests included hematologic (e.g., protein

Number 51 24 27 43 32 14 6 22 19 13

Percentage 57.95% 27.27% 30.68% 48.86% 36.36% 15.91% 6.82% 25.00% 21.59% 14.77%

C, protein S, antithrombin III), rheumatologic (e.g., antinuclear antibody, antiphospholipin, anticardiolipin) and tumor markers (e.g., CEA, CA19-9, PSA, AFP) were examined. At least 1 investigation was performed in 64 in 88 ultrasound-positive patients (72.73%) and 15 patients (17.05%) were received all investigations.

258 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Table 6 Univariate logistic regression analysis of potential variables for DVT. Results of Doppler ultrasound

P-value

Positive (N = 88)

Negative (N = 148)

64 50 33 13 30

(72.7%) (56.8%) (37.5%) (14.8%) (34.1%)

112 77 49 26 52

(75.7%) (52.0%) (33.1%) (17.6%) (35.1%)

0.615 0.475 0.493 0.576 0.871

22 36 15 7 25 8

(25.0%) (40.9%) (17.0%) (8.0%) (28.4%) (9.1%)

32 61 35 17 53 11

(21.6%) (41.2%) (23.6%) (11.5%) (35.8%) (7.4%)

0.550 0.963 0.230 0.385 0.242 0.651

Age - 50 or more than - 60 or more than - 70 or more than - 80 or more than Gender, male Underlying disease - diabetic mellitus - hypertension - ischemic heart disease - chronic renal failure - dyslipidemia - cerebrovascular accident Malignancy - abdominopelvic organ - hematologic - other Operation - abdominopelvic - orthopedic - other Post-operative period - within 1 month - within 3 months - within 6 months - within 12 months Traumatic fracture During admission or post-hospitalization - within 1 month - within 3 months - within 6 months - within 12 months Immobilization - recent immobilization < 3 months - chronic immobilization > 3 months Side(s) of clinically affected leg - both - left - right

17 (19.3%) 3 (3.4%) 4 (4.5%)

14 (9.5%) 4 (2.7%) 1 (0.7%)

0.030 0.757 0.046

13 (14.8%) 5 (5.7%) 6 (6.8%)

12 (8.1%) 14 (9.5%) 12 (8.1%)

0.108 0.302 0.718

6 10 11 14 6

(6.8%) (11.4%) (12.5%) (15.9%) (6.8%)

8 12 15 22 7

(5.4%) (8.1%) (10.1%) (14.9%) (4.7%)

0.657 0.406 0.575 0.829 0.496

41 46 46 47

(46.6%) (52.3%) (52.3%) (53.4%)

43 51 55 60

(29.1%) (34.5%) (37.2%) (40.5%)

0.007 0.007 0.023 0.055

10 (11.4%) 8 (9.1%)

5 (3.4%) 6 (4.1%)

0.015 0.113

10 (11.4%) 40 (45.5%) 38 (43.2%)

27 (18.2%) 57 (38.5%) 64 (43.2%)

reference 0.295 0.993

259

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

The univariate logistic regression analysis (Table 6) demonstrated that there were 7 variables such as ischemic heart disease, dyslipidemia, known malignancy, operation, hospitalization, immobiliza-

tion, and affected side, associated with P-value < 0.30. These variables were considered to be potentially significant risk factors, which were selected for further multivariate logistic regression analysis.

Table 7 Multivariate logistic regression analysis of potential variables for DVT.

P-value Underlying disease - ischemic heart disease - dyslipidemia Malignancy - abdominopelvic organ - hematologic - other Operation - abdominopelvic - orthopedic - other During admission or post-hospitalization - within 3 months Immobilization - recent immobilization < 3 months - chronic immobilization > 3 months Side(s) of clinically affected leg - left - right

By multivariate logistic regression analysis, 4 independent variables were significantly identified from previously mentioned 7 variables. The results of analysis were demonstrated in Table 7. The strongest predictive variable was recent immobilization which occurred within 3 months before the event of DVT. Its odd ratio was 5.94 with 95% confidence interval 1.77-19.99. The other 3 significant factors with odd ratios 2.61, 2.59, and 2.00, were malignancy of abdominopelvic organs, left leg involvement, and recent hospitalization, respectively.

Odd ratio

95% CI

0.208 0.475

0.60 0.78

0.27-1.33 0.39-1.55

0.049 0.583 0.067

2.61 1.57 11.17

1.01-6.79 0.31-7.82 0.84-147.88

0.856 0.177 0.087

0.91 0.44 0.35

0.32-2.60 0.13-1.46 0.10-1.16

0.031

2.00

1.07-3.75

0.004 0.182

5.94 2.33

1.77-19.99 0.67-8.08

0.044 0.192

2.59 1.84

1.03-6.54 0.74-4.60

Discussion This retrospective study aimed to demonstrate the correlation between any risk factors and the incidence of DVT of lower extremities in Thai population. Its population was Thai patients at Thammasat University Hospital with clinicians没 consideration of DVT either during hospitalization or treating as OPD cases. The results and statistical analysis will be compared with the previous studies to confirm the impact of each variable.

For the correlation of surgery and DVT, we found DVT occurred in 38.7% of post-operative

260 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

patients compared with 15-40% reviewed by Geerts et al.7 In the patients with medical illnesses such as DM, hypertension, CVA, Geerts reported DVT incidence at 10-20% while it was 36% in this present study. In subset of CVA, the incidences of DVT in these 2 studies were 20-50% and 42.1% (8/19 patients), respectively. A Thai study by Aniwan S et al. reported immobilization (74%), active cancer

(52%), and rheumatologic disease (12%) were the common risk factors of venous thromboembolism in Thai hospitalized medical patients.8 In comparison with this study, the percentage of DVT in patients with immobilization was 62.1% and in malignancy was 55.8%. Other published literatures which also studied in the risk factors of DVT were reviewed and shown in Table 8.

Table 8 Comparison of proportion of risk factors for DVT from previously published studies.

Proportion of risk factors (%)

Identifiable risk factors - Hospitalization - Immobilization - Cancer - Surgery - Prior venous thrombosis - Venous catheterization - Trauma - Neurologic deficit - Heart failure - Renal failure - Hormonal therapy - Obesity - Fracture - Hemophilic disorder Idiopathic

Hettiarachchi2 1998

Heit3 2002

65 25 17.5 13.8 19.5 9 11.5 7 4.5 1 35

74 22 18 24 5 9 12 7 10 26

A large study, which was collected and analyzed with multivariate regression model by Edelsberg et al., showed significant risk factors for clinical venous thromboembolism (VTE) included history of VTE within six months (HR, 6.14), operative procedure within 30 days (HR, 1.81), heart failure during admission (HR, 1.72), peripheral artery disease during admission (HR, 1.68), and history of cancer (HR, 1.67).9

Cushman4 Goldhaber5 Spencer6 2004 2004 2006 52 27 8 25 22 3 3 4 3 48

84 23 34 32 38 22 15 4 22 13 7 27 5 5 16

89 39 45 34 34 19 18 5 12 10 11

In the recent study, Tan et al. reported the increased incidence of DVT 2.6 and 1.8 times from immobilization and malignancy, respectively.10 Similarly, our study demonstrated that these 2 variables were the strong variables predicting the chance of DVT of lower extremities. We found the higher odd ratios of 5.94 for recent immobilization within 3 months and 2.61 for abdominopelvic malignancy which indicated the higher level of significance than that of previous study.

261

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

All recent hospitalization within 1, 3, and 6 months were significant by univariate analysis.

However, multivariate analysis showed significance result only at 1 and 3 months. This study demonstrated that recent hospitalization within 3 months had the significant risk factor with 2.0 times increased in the incidence of DVT. The side of edematous leg also affected the final diagnosis of DVT. The incidence of patients with clinically suspected left legs DVT were significantly confirmed diagnosis more than right legs. The Odd ratio of left edematous leg was 2.59.

There was no statistical significance for right leg DVT. It should be explained by anatomical reason that left common iliac vein is compressed by right common iliac artery just below the bifurcation of inferior vena cava. It makes more tendency of venous flow stasis and more potential to develop intravenous thrombus with additional hypercoagulable state.7 There were some limitations of this study.

Because it was retrospective cross-sectional study, it was difficult to collect the patients没 information with completeness. Some aspects of risk factors cannot be completely gathered such as minor trauma, contraceptive pills, and immobilization during travel.

Nearly three-forth of DVT-diagnosed patients were investigated by at least 1 modality to find out occult malignancy or hematologic disorder. However, only about one-sixth were completed all these investigations. It seems to be too small percentage for the completion of diagnosing process to find out the possibly occult disease.

For the future prospective study, the investigating modalities should be completely performed in every participant for accurate incidence of these disorders.

Although this study was retrospective, it was the initial analysis to determine the independent factors for the model predicting whether the result of Doppler ultrasound was positive or not. The

accuracy of this model should be further proven by prospective study. If the effective predictive model could be established, it should be able to determine the probability of positive result of Doppler ultrasound and diagnosing DVT of lower extremities. It would be very helpful for many reasons. Firstly, the model would be a reasonable clinical predictor to determine the chance of DVT. Then the clinicians could decide to start the anticoagulant therapy before the diagnosis was proven by Doppler ultrasound.

Another purpose was to use this model in the other healthcare center without availability of Doppler ultrasound or specialized radiologist. In the next step, it may be used to identify the normal patient with potential risk of DVT. The anticoagulant prophylaxis was needed in this high-risk group.

Conclusion The significant risk factors of DVT concluded from this study are recent immobilization, intra-abdominal cancers, clinically affected left side, and recent hospitalization. The patients, who present with unilateral leg swelling and have these predictors, should be highly suspected to diagnose DVT by positive Doppler ultrasound and received the appropriate management promptly.

Acknowledgements The authors are thankful to TU Research Fund of Thammasat University for funding this project.

References 1. Lee AY, Levine MN. Venous thromboembolism and cancer: risks and outcomes. Circulation 2003;107:17-21.

2. Hettiarachchi RJ, Lok J, Prins MH, B眉ller HR, Prandoni P. Undiagnosed malignancy in patients with deep vein thrombosis: incidence, risk indicators, and diagnosis. Cancer 1998;83:1805.

262 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

3. Heit JA, OûFallon WM, Petterson TM, Lohse CM, Silverstein MD, Mohr DN, et al. Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: a population-based study. Arch Intern Med 2002;162:1245-8.

4. Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P, et al. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med 2004;117:1925.

5. Goldhaber SZ, Tapson VF. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol 2004;93:259-62.

6. Spencer FA, Emery C, Lessard D, Anderson F, Emani S, Aragam J, et al. The Worcester venous thromboembolism study: a population-based study of the clinical epidemiology of venous thromboembolism. J Gen Intern Med 2006;21: 722-7.

7. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of Venous Thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:338S-400S. 8. Aniwan S, Rojnuckarin P. High incidence of symptomatic venous thromboembolism in Thai hospitalized medical patients without thromboprophylaxis. Blood Coagul Fibrinolysis 2010; 21:334-8.

9. Edelsberg J, Hagiwara M, Taneja C, Oster G. Risk of venous thromboembolism among hospitalized medically ill patients. Am J Health Syst Pharm 2006;63:S16-22.

10. Tan KK, Koh WP, Chao AK. Risk Factors and Presentation of Deep Venous Thrombosis among Asian Patients: A Hospital-Based Case-Control Study in Singapore. Ann Vasc Surg 2007;21:4905.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

∫∑§—¥¬àÕ ªí®®—¬‡ ’ˬ߄π°“√‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥¥”™—Èπ≈÷°Õÿ¥µ—π„π‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘ Õ— π’ ∑ÕßÕ¬Ÿà, «’√¬– ‡¿“‡®√‘≠ ‚§√ß°“√®—¥µ—Èß¿“§«‘™“»—≈¬»“ µ√å §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å ∫∑π”:

√–‡∫’¬∫«‘∏’»÷°…“:

º≈°“√»÷°…“:

√ÿª:

§” ”§—≠:

‚√§À≈Õ¥‡≈◊Õ¥¥”™—Èπ≈÷°Õÿ¥µ—π (Deep vein thrombosis; DVT) ‡ªìπ¿“«–∑’ˇ≈◊Õ¥¡’°“√·¢Áßµ—«‡ªìπ≈‘Ë¡‡≈◊Õ¥ Õ¬Ÿ„à π√–∫∫À≈Õ¥‡≈◊Õ¥¥”∑’ÕË ¬Ÿ≈à °÷ ‡¢â“‰ª„π à«π¢Õߢ“ ·≈–Õÿ¥µ—π∑“߇¥‘π‡≈◊Õ¥∑’‰Ë À≈°≈—∫‡¢â“ ŸÀà «— „® ¿“«–π’ È “¡“√∂ 𔉪 Ÿ¿à “«–·∑√°´âÕπ∑’µË “¡¡“Õ’°¡“°¡“¬ ´÷ßË Õ“®√⓬·√ß∂÷߇ ’¬™’«µ‘ ‰¥â ¥—ßπ—πÈ ®÷ߧ«√∑√“∫∂÷ßªí®®—¬‡ ’¬Ë ߢÕß°“√ ‡°‘¥‚√§‡æ◊ËÕ°“√ªÑÕß°—π·≈–°“√√—°…“∑’ˇÀ¡“– ¡ ºŸâªÉ«¬∑’Ë¡’≈—°…≥–‡«™°√√¡∑”„Àâ ß —¬«à“¡’ DVT ∑’Ë¢“·≈–‰¥â∑”°“√µ√«®À≈Õ¥‡≈◊Õ¥¥”¥â«¬Õ—≈µ√“´“«π¥å ·∫∫§Õª‡ª≈Õ√å (Doppler ultrasound) „π™à«ßªï æ.». Úıı-ÚııÒ ‚¥¬√—ß ’·æ∑¬å„π‚√ß欓∫“≈ ∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘ ®“°π—πÈ ∑”°“√√«∫√«¡¢âÕ¡Ÿ≈∑“ߧ≈‘π°‘ ·≈–«‘‡§√“–Àå¢Õâ ¡Ÿ≈‚¥¬Õ“»—¬ ∂‘µ«‘ ‡‘ §√“–Àå §«“¡∂¥∂Õ¬‚≈®‘ µ‘°∑—Èß·∫∫µ—«·ª√‡¥’¬«·≈–À≈“¬µ—«·ª√ ‡æ◊ËÕ√–∫ÿ§«“¡ ”§—≠¢Õßªí®®—¬‡ ’ˬߵà“ßÊ ∑’Ë¡’º≈µàÕ Õÿ∫—µ‘°“√≥å¢Õß°“√‡°‘¥‚√§ DVT π’È ºŸªâ «É ¬∑’∂Ë °Ÿ §—¥‡≈◊Õ°‡¢â“ Ÿ°à “√»÷°…“∑—ßÈ À¡¥ ÚÛˆ √“¬ À≈—ß®“°«‘‡§√“–À奫⠬ ∂‘µ«‘ ‡‘ §√“–À姫“¡∂¥∂Õ¬‚≈®‘ µ‘° ·∫∫µ—«·ª√‡¥’¬« æ∫«à“¡’ª®í ®—¬‡ ’¬Ë ß ˜ ªí®®—¬∑’πË “à ®–¡’º≈µàÕ°“√‡°‘¥‚√§π’È ®÷߇¢â“ Ÿ°à “√«‘‡§√“–À奫⠬ ∂‘µ«‘ ‡‘ §√“–Àå §«“¡∂¥∂Õ¬‚≈®‘ µ‘°·∫∫À≈“¬µ—«·ª√µàÕ‰ª æ∫«à“ªí®®—¬∑’¡Ë º’ ≈¡“°∑’ Ë ¥ÿ §◊Õ ¿“«–∑’µË Õâ ßπÕππ“πÊ ‡§≈◊ÕË π‰À« ‰¡à‰¥â ¿“¬„π Û ‡¥◊Õπ∑’˺à“π¡“ ‡æ‘Ë¡‚Õ°“ ‡ ’ˬߢ÷Èπ ı.˘Ù ‡∑à“ ªí®®—¬Õ◊ËπÊ ‰¥â·°à ¡–‡√ÁߢÕßÕ«—¬«–„π™àÕß∑âÕß, Õ“°“√∫«¡∑’¢Ë “¢â“ߴ⓬ ·≈–°“√æ—°√—°…“Õ¬Ÿ„à π‚√ß欓∫“≈¿“¬„π Û ‡¥◊Õπ∑’ºË “à π¡“ ‚¥¬¡’§«“¡‡ ’¬Ë ß Ÿß¢÷πÈ Ú.ˆÒ, Ú.ı˘ ·≈– Ú. ‡∑à“ µ“¡≈”¥—∫ ®“°°“√»÷°…“æ∫«à“¡’ªí®®—¬‡ ’Ë¬ß Ù ªí®®—¬¢â“ßµâπ∑’Ë¡’º≈µàÕ°“√‡°‘¥‚√§ DVT ´÷ËߺŸâªÉ«¬∑’Ë¡’≈—°…≥–‡«™°√√¡∑’Ë ß —¬«à“¡’¿“«–π’È √à«¡°—∫¡’ª®í ®—¬‡ ’¬Ë ߇À≈à“π’ÕÈ ¬Ÿ¥à «â ¬ ¡’§«“¡‡ªìπ‰ª‰¥â ߟ ∑’®Ë –¡’¿“«–π’ÕÈ ¬Ÿ®à √‘ß ®÷ߧ«√µ√«®«‘π®‘ ©—¥â«¬Õ—≈µ√“´“«π¥å·∫∫¥Õª‡ª≈Õ√å·≈–‡√‘Ë¡°“√√—°…“‰¥âÕ¬à“ß√«¥‡√Á«·≈–‡À¡“– ¡µàÕ‰ª ‚√§À≈Õ¥‡≈◊Õ¥¥”™—Èπ≈÷°Õÿ¥µ—π, ªí®®—¬‡ ’ˬß, °“√µ√«®‡ âπ‡≈◊Õ¥¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß

263

264 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

π‘æπ∏åµπâ ©∫—∫

The value of middle cerebral artery-umbilical artery pulsatility index ratio in prediction of severe fetal growth restriction Tongta Nanthakomon, Charintip Somprasit

Abstract Objective:

Materials and methods:

Results:

Conclusion:

Key words:

To evaluate the value of the ratio of middle cerebral artery pulsatility index (MCA PI) to the umbilical artery pulsatility index (UA PI) for predicting of adverse perinatal outcome in the fetal growth restriction (FGR).

A prospective study was performed on 82 pregnant women in Thammasat University Hospital between January 1, 2009 and December 31, 2009. The study population comprised 27 pregnant women who delivered FGR fetuses and 55 pregnant women whose fetuses were normal growth. The MCA PI, UA PI and MCA PI/ UA PI ratio were assessed. Mild and severe FGR were defined as a fetus having the fetal weight below the 10th and 5th percentile, respectively.

Abnormal MCA PI/ UA PI (CU ratio) were defined as the ratio < 1.08.

Of the 82 pregnant women, In FGR cases have high oligohydramnios, high cesarean section rate, lower GA at delivery, low birth weight and high rate of neonatal intensive care unit (NICU) admission compared with normal cases (P<0.05). 8 out of 27 women with FGR showed abnormal CU ratio but only 2 in 55 fetuses in normal group (P <0.001). Among these, mild and severe FGR with abnormal CU ratio were 5 (26.3%) and 3 (37.5%), respectively which was demonstrated not significantly difference (P = 0.658).

The MCA PI/ UA PI ratio could not be used as the predictor of the severe FGR from mild FGR in a particularly severe case of FGR. Doppler Ultrasound, Fetal growth restriction, Cerebro-umbilical ratio, Middle cerebral artery, Umbilical artery

Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University

265

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Introduction Fetal Growth Restriction (FGR) indicates under development rate of fetal growth in maternal uterus in contrast to its genetic growth potential.

Since the genetic growth potential cannot be practically measured, the most common practice is birthweight lower than 10 percentile of the average weight at each gestational age. The method is designed for small gestational age and thus data derived from this method should be used cautiously.

These fetuses are usually known to carry a higher morbidity and mortality rates as been compared to normal fetuses. In progress reference for the management of FGR fetuses is to monitor fetal wellbeing and timely delivery for the compromised fetuses.1 Doppler ultrasound has been acceptable for detected surveillance of FGR fetuses by assessment of the uteroplacental insufficiency. Diagnosis of uteroplacental insufficiency using Doppler ultrasound found umbilical artery (UA) to have high resistance to circulation. When symptom persists, resistance of UA increases. The examination using high frequency Doppler will show wave Absent End Diastolic Flow (AEDF) or Reverse End Diastolic Flow (REDF). This leads to the body adjustment for more circulation to brain known as çbrain sparing phenomenonÊ that was showen by increase in UA resistance and a decrease in middle cerebral artery (MCA) resistance.2 There are many relationships and benefits of Doppler ultrasound in fetal growth restriction.

Previous studies3, 4 proved that Doppler ultrasound can be used to identify restricted growth fetus from small healthy fetus with better precision than using weight showed that Doppler ultrasound can predict the prenatal outcome of FGR and abnormal UA pulsatility index (PI) was the best indicator for abnormal prenatal outcome. The absent or reverse end diastolic flow of UA was related to bad perinatal outcomes compared to normal UA PI.5

In current studies have showed prenatal cerebral vasodilatation on the MCA Doppler is sensitive to a physiologic response to hypoxia and good prediction of perinatal outcome.6 There are many studies7, 8 use of umbilical-cerebral Doppler ratios or used Doppler cerebro-umbilical ratio (C/ U ratio) in predicting fetal growth restriction in the assessment of perinatal outcome in growth-restricted and hypoxic fetuses but in previous studies were not present value to predicted specify to mild or severe FGR. This study intended to investigate the value of middle cerebral artery-umbilical artery pulsatility index ratio in prediction of severe fetal growth restriction compared to mild FGR.

Methods A prospective study was performed on singleton pregnant women in Thammasat University Hospital after having been approved by Institutional Ethics Committee between January 1, 2009 and December 31, 2009. Inclusion criteria were accurate gestational age (GA), which was defined by a reliable last menstrual period and confirmed by first or second trimester sonography, delivery between 32-40 weeksĂť gestation in Thammasat University Hospital. Incomplete data, no antenatal UA and MCA Doppler studies and cases with structural or chromosomal anomalies detected at birth were excluded.

To accept the rationale of the study, the authors classified the patients into 3 groups according to the birthweight based on reference range.

Group 1 was normal fetal growth and birth weight, Group 2 was mild FGR defined as a fetus having the fetal weight below the 10th percentile and Group 3 was severe FGR with fetal weight below the 5th percentile for the gestational age at birth. Doppler studies of UA, MCA, were performed by color Doppler system. The Doppler flow velocimetry in umbilical artery was obtained at free loop of UA, angle of ultrasound beam to blood flow was less

266 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

than 30° and showed at least five waveforms, then recorded of pulsatility index (PI), resistance index (RI) and uniform of wave-forms (positive absent or reverse end diastolic flow). The Doppler of MCA was recorded PI, RI and MCA PI/ UA PI ratio (cerebro-umbilical ratio; CU ratio) were assessed and results of UA and MCA Doppler define based on Harringtonûs chart9 and abnormal MCA PI/ UA PI was defined as the ratio < 1.08.10 The frequency of Doppler study depended on severity of case.

Nonstress test, biophysical profile was performed differently in each case depending on indication of the test and gestational age.

Maternal characteristics including age, parity, GA at last ultrasound, GA at delivery, presence of oligohydramnios, mode of delivery, and results of Doppler study were collected.

Neonatal outcomes were collected for birth weight, 1 minute Apgar score and neonatal morbidity.

Results were evaluation of maternal and neonatal characteristics were presented as mean ±

standard deviation (SD) or percentage. Comparison of maternal and neonatal characteristics between groups of FGR fetuses were performed using one way ANOVA for continuous variable or Chi-square test for categorized variable. A p-value < 0.05 was considered statistically significant.

Results Initially, there were 82 pregnant women recruited. The study population comprised 55 pregnant women whose fetuses were normal growth (group 1) and 27 pregnant women who delivered FGR fetuses. Among 19 patients with FGR classified in mild FGR (group 2) and 8 patients in severe FGR. Fifty-five (67%) pregnant women were classified as normal group, 19 (23.2%) patients as mild FGR and 8 (9.8%) patients as severe FGR Maternal characteristics are offered in Table 1. The mean maternal age of FGR fetuses were not significantly different with normal growth fetuses 25.59 ± 6.24 and 31.22 ± 5.98 years respectively

Table 1 Maternal and neonatal characteristic in normal fetal growth and fetal growth restriction

Maternal Age, years* Primipara Oligohydramnios CU ratio < 1.08 Route of delivery Vaginal delivery Cesarean section GA at delivery, weeks* EFW, grams* NICU admission

Normal (n = 55) (%) 31.22 ± 5.98 (17 - 42) 20(36.4) 1(1.8) 2(3.6)

FGR (n = 27) (%) 25.59 ± 6.24 (16 - 39) 21(77.8) 13(48.1) 8(29.6)

P value

43(78.2) 112(21.8) 37.38 ± 0.65 (36-38) 2733 ± 430.94 (2060 - 4322) 2(3.6)

12(21.8) 18(66.7) 37.18 ± 1.61 (32-39) 1968.5 ± 366.55 (740 - 2400) 13(48.1)

<0.001 <0.001 0.039

0.805 <0.001 <0.001 <0.001

<0.001 <0.001

FGR = fetal growth restriction, CU = crerbro-umbilical ratio; middle cerebral artery pulsatility index / umbilical artery pulsatility index, GA = gestational age, C/S = cesarean section * Mean ± SD (range)

267

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

(p = 0.805). 8 out of 27 women with fetal growth restriction showed abnormal MCA PI/ UA PI ratio (CU ratio <1.08) and only 2 in 55 fetuses in normal group showed abnormal CU ratio (p <0.001). In FGR cases have higher oligohydramnios, high cesarean section rate, low GA at delivery, low birth weight and high rate of neonatal intensive care unit (NICU) admission compared with normal case (p <0.05). The comparisons about characteristic of mild and severe FGR were shown in Table 2.

Among these, No significant difference from mild and severe FGR in maternal age, primigravida, oligohydramnios, GA at delivery, birthweight and all of Doppler indicies. There were higher rates of cesarean section, NICU admission and lower birthweight in severe FGR cases (p <0.001, p =0.13 and p <0.001 respectively). Abnormal CU ratio were 5 (26.3%) and 3 (37.5%), respectively which did not significantly any difference (p = 0.658).

Table 2 Maternal and Neonatal characteristic in mild and severe fetal growth restriction

Maternal Age, years* Primipara Oligohydramnios Route of delivery Vaginal delivery Cesarean section GA at delivery, weeks* EFW, grams* NICU admission CU ratio < 1.08 Doppler† UA PI UA RI MCA PI MCA RI UA PI/MCA PI MCA PI/UA PI

Mild FGR (n = 19) (%) 25.10 ± 6.76 (19-39) 16(84.2) 9(47.4)

Severe FGR (n = 8) (%) 26.75 ± 4.97 (21-34) 5(62.5) 4(50)

P value

9(47.4) 10(52.6) 37.47 ± 1.30 (33-39) 2117.6 ± 184.91 (1665-2400) 6(33.3) 5(26.3) 1.15 ± 0.27 (0.80-1.73) 0.67 ± 0.81 (0.55-0.84) 1.72 ± 0.68 (0.90-3.98) 0.79 ± 1.38 (0.60-1.20) 0.77 ± 0.37 (0.24-1.80) 1.59 ± 0.81 (0.56-4.10)

0(0) 8(100.0) 36.50 ± 2.13 (32-38) 1614.4 ± 161.0 (740-2025) 7(87.5) 3(37.5) 1.09 ± 0.25 (0.78-1.47) 0.65 ± 0.91 (0.55-0.80) 1.37 ± 0.28 (1.04-1.77) 0.73 ± 0.27 (0.66-0.82) 0.82 ± 0.30 (0.55-1.41) 1.30 ± 1.73 (0.71-0.81)

<0.001 <0.001 0.157

0.542 0.045 0.887

<0.001 0.332 0.013 0.635 0.620 0.243 0.330 0.739 0.412

FGR = fetal growth restriction, CU = cere-umbilical ratio; middle cerebral artery pulsatility index/umbilical artery pulsatility index, GA = gestational age, C/S = cesarean section, * Mean ± SD (range) † Severe FGR group n=6 (exclude 2 cases; 1 case for absent end diastolic flow, 1 case for reverse end diastolic flow)

268 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Discussion Fetal Growth Restriction caused from several factors. Besides finding the cause of the symptom, one important aspect that must be investigated into is to predict the likelihood of the disease in order to avoid morbidities. Fetal birth weight analysis alone is insufficient as a tool to identify a healthy, small for gestational age fetus from fetal growth restriction, thus, further investigation into this subject is essential for treatments, counseling and management of patient. FGR caused by uteroplacental insufficiency has been confirmed to transmit an increased risk of perinatal morbidity and mortality.5,11 Contemporary study by Bate JA. et al.3 proved that Doppler Ultrasound can be used to identify FGR from small for gestational age. The study compared Doppler Ultrasound with weight analysis and concluded that FGR is better identified using Doppler Ultrasound and appears to be the most promising diagnostic tool for supervision of these at-risk fetuses.11 Doppler ultrasound can be use to predict the prenatal outcome of fetal growth restriction and abnormal UA PI was the best indicator for abnormal perinatal outcome.4 Seyam YS et al.5 studied for the relationship between umbilical artery Doppler flow velocimetry and perinatal outcome. The study found restricted growth fetus with abnormal UA Doppler flow velocimetry to have a higher rate of admission at neonatal intensive care unit, birth weight and GA at delivery statistically lower than normal group. Gerber S et al.12 reported that absent or reverse end diastolic flow in umbilical artery was correlated with poor perinatal outcome and some fetuses have major handicaps. The use of Doppler umbilical indices for fetal surveillance had a standard in high risk pregnancy especially in FGR follow up.13 First sign of uteroplacental insufficiency is the diagnosis of increase pressure in umbilical artery. When a symptom persists, there is increased resistance in the umbilical artery. The examination

using high frequency Doppler will show wave Absent End Diastolic Flow (AEDF) or Reverse End Diastolic Flow (REDF). Also, the fetus will adjust its circulation by increasing blood flow to central brain (centralization) causing çbrain sparing phenomenoné. When symptoms are more, blood vessels in fetal brain will lose its tuning ability causing compensatory vasodilatation.1,4 Fetal MCA PI value below 95th percentile of the normal range was found to be highly predictive of subsequent neurological outcomes.6,14,15 The addition of placento-cerebral ratios has been shown to increase the sensitivity of these indices in detecting this pathological brain sparing effect and in predicting adverse neurological outcome.16 Abnormal umbilical Doppler indices and cerebro-umbilical ratios are strong predictors of fetal growth restriction and of adverse perinatal outcome in pre-eclampsia, while the MCA PI alone is not a reliable indicator.17 Such results indicate that the combination of fetal umbilical and cerebral Doppler indices to produce an umbilico-cerebral ratio can increase the utility of Doppler ultrasound in high-risk pregnancies. Obido AO et al.10 presented cerebro-placental Doppler ratio (CPR) with categorical threshold in the prediction of adverse perinatal outcomes in growth-restricted pregnancies with a CPR threshold of less than 1.08, the sensitivity, specificity, positive and negative predictive values were 72%, 62%, 68%, and 67% respectively. The present study shows significant higher incidence of abnormal CU ratio in severe FGR compared to mild FGR. However, because of limitation of sample size, the data could not demonstrate the significant higher rate of NICU admission in severe FGR compare to mild FGR. Furthermore, the authors do not compare perinatal outcomes between FGR fetuses with normal CU ratio and abnormal CU ratio. Further investigation with a large number of cases may be needed to prove this hypothesis.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

The MCA PI/ UA PI ratio could be used as the predictor for fetuses with growth restriction compared to normal cases but cannot differentiate mild from severe cases of FGR but in the study that had a small number of patients, further study that has a higher population may be need to proved this hypothesis.

Reference 1. Intrauterine growth restriction. Clinical management guidelines for obstetrician-gynecologists.

American College of Obstetricians and Gyne cologists. Int J Gynaecol Obstet 2001;72:85-96.

2. Vyas S, Nicoladies KH, Bower S, Campell S. Middle cerebral artery flow velocity waveforms in fetal hypoxaemia. Br J Obstet Gynecol 1990; 97:797-803.

3. Bates JA, Evans JA, Mason G. Differentiation of growth retarded from normally grown fetuses and prediction of intrauterine growth retardation using Doppler ultrasound. Br J Obstet Gynaecol 1996;103:670-5.

4. Fong KW, Ohlsson A, Hannah ME, Grisaru S, Kingdom J, Cohen H, et al. Prediction of perinatal outcome in fetuses suspected to have intrauterine growth restriction: Doppler US study of fetal cerebral, renal, and umbilical arteries.

Radiology 1999;213:681-9.

5. Seyam YS, Al-Mahmeid MS, Al-Tamimi HK. Umbilical artery Doppler flow velocimetry in intrauterine growth restriction and its relation to perinatal outcome. Int J Gynaecol Obstet 2002; 77:131-7.

6. Chan FY, Pun TC, Lam P, Lam C, Lee CP, Lam YH. Fetal cerebral Doppler studies as a predictor of perinatal outcome and subsequent neurologic handicap. Obstet Gynecol 1996;87:981-8.

7. To WW, Chan AM, Mok KM. Use of umbilicalcerebral Doppler ratios in predicting fetal growth restriction in near-term fetuses. Aust N Z J Obstet Gynaecol 2005;45:130-6.

269

8. Habek D, Hodek B, Herman R, Jugovi D, Habek JC, Salinagi A. Fetal Biophysical Profile and Cerebro-Umbilical Ratio in Assessment of Perinatal Outcome in Growth-Restricted Fetuses.

Fetal Diagn Ther 2003;18:12-6.

9. Harrington K. Doppler values of maternal and fetal circulation. In: Chervenak FA, Isaacson GC, Campbell S, editors. Ultrasound in obstetrics and gynecology. Boston, MA: Little, Brown & Co; 1993. 1799-801.

10. Obido AO, Riddick C, Pare E, Stamilio DM, Macones GA. Cerebroplacental Doppler ratio and adverse perinatal outcomes in intrauterine growth restriction: evaluating the impact of using gestational age-specific reference values. J Ultrasound Med 2005;24:1223-8.

11. Omtzigt AM, Reuwer PJ, Bruinse HW. A randomized controlled trial on the clinical value of umbilical Doppler velocimetry in antenatal care.

Am J Obstet Gynecol 1994;170:625-34.

12. Gerber S, Hohlfeld P, Viquerat F, Tolsa JF, Vial Y. Intrauterine growth restriction and absent or reverse end-diastolic blood flow in umbilical artery (Doppler class II or III): A retrospective study of short- and long-term fetal morbidity and mortality. Eur J Obstet Gynecol Reprod Biol 2006;126:20-6.

13. Neilson JP, Alfirevic Z. Doppler ultrasound for fetal assessment in high risk pregnancies.

Cochrane Database Syst Rev 2000;2. CD000073.

14. Rizzo G, Arduini D, Luciano R. Prenatal cerebral Doppler ultrasonography and neonatal neurologic outcome. J Ultrasound Med 1989;8: 237-40.

15. Eixarch E, Meker E, Iraola A, Illa M, Cripi F, Hernandez-Andrade E, et al. Neurodevelopmental outcome in 2-year-old infants who were smallfor-gestational age term fetuses with cerebral blood flow redistribution Ultrasound Obstet Gynecol 2008;32:894-9.

270 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

16. Scherjon SA, Smolders-DeHaas H, Kok JH, Zondervan HA. The ùbrain-sparingû effect: antenatal cerebral Doppler findings in relation to neurologic outcome in very preterm infants.

Am J Obstet Gynecol 1993;169:169-75.

17. Ozeren M, Dinc H, Ekmen U, Senekayli C, Aydemir V. Umbilical and middle cerebral artery Doppler indices in patients with preeclampsia.

Eur J Obstet Gynecol Reprod Biol 1999;82:116.

∫∑§—¥¬àÕ §«“¡ “¡“√∂¢ÕßÕ—µ√“ à«π pulsatility index ¢Õß°“√µ√«®¥â«¬§≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß middle cerebral °—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ „π°“√∑”π“¬∑“√°‚µ™â“„π §√√¿å√–¥—∫√ÿπ·√ß µâÕßµ“ π—π∑‚°¡≈, ®√‘π∑√å∑‘æ¬å ¡ª√– ‘∑∏‘Ï Àπ૬‡«™»“ µ√å¡“√¥“·≈–∑“√°„π§√√¿å ‚§√ß°“√®—¥µ—Èß¿“§«‘™“ Ÿµ‘»“ µ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å «—µ∂ÿª√– ߧå:

«‘∏’°“√»÷°…“:

º≈°“√»÷°…“:

√ÿª:

§” ”§—≠:

‡æ◊ËÕª√–‡¡‘𧫓¡ “¡“√∂¢ÕßÕ—µ√“ à«π pulsatility index ¢Õߧ≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß ¡‘¥‡¥‘≈‡´‡√∫√—≈°—∫§≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ „π°“√∑”π“¬∑“√°‚µ™â“„π§√√¿å√–¥—∫ √ÿπ·√ß °“√»÷°…“·∫∫‰ª¢â“ßÀπâ“∑’Ë‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘µ—Èß·µà Ò ¡°√“§¡- ÛÒ ∏—𫓧¡ ÚııÚ „π µ√’µß—È §√√¿å‡¥’¬Ë «∑’¡Ë “√—∫°“√Ω“°§√√¿åµ√«®§≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√å∑À’Ë π૬‡«™»“ µ√å¡“√¥“·≈–∑“√°„π §√√¿å‚¥¬¡’°“√µ√«®«—¥¥—™π’µ“à ßÊ¢Õߧ≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß¡‘¥‡¥‘≈‡´‡√∫√—≈°—∫§≈◊πË ‡ ’¬ß §«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ ‰¥â·°à MCA pulsatility index (MCA PI), umbilical (UA) PI, UA PI/ MCA PI and MCA PI/ UA PI ∑“√°‚µ™â“„π§√√¿å‰¥â√—∫°“√·∫àßÕÕ°‡ªìπ Ú °≈ÿࡧ◊Õ °≈ÿà¡∑’Ë πÈ”Àπ—°·√°‡°‘¥µË”°«à“ Ò ‡ªÕ√凴Áπ‰∑≈å ·≈–°≈ÿà¡∑’ˇªìπ∑“√°‚µ™â“„π§√√¿å·∫∫√ÿπ·√ß‚¥¬¥Ÿ®“°πÈ”Àπ—°·√°‡°‘¥ µË”°«à“ ı ‡ªÕ√凴Áπ‰∑≈å ·≈–„Àâ§”π‘¬“¡§«“¡º‘¥ª√°µ‘¢ÕßÕ—µ√“ à«π pulsatility index ¢Õߧ≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß¡‘¥‡¥‘≈‡´‡√∫√—≈°—∫§≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ < Ò.¯ µ√’µ—Èߧ√√¿å‡¥’ˬ«®”π«π ¯Ú §π ·∫à߇ªìπ∑“√°∑’Ë¡’°“√‡®√‘≠‡µ‘∫‚µ·≈–¡’πÈ”Àπ—°·√°‡°‘¥ª√°µ‘®”π«π ıı §π ·≈–æ∫«à“‡ªìπ∑“√°‚µ™â“„π§√√¿å Ú˜ §π ‚¥¬æ∫«à“¡’§«“¡·µ°µà“ß°—π¢Õß∑—ßÈ Õß°≈ÿ¡à „π‡√◊ÕË ß °“√µ—ßÈ §√√¿å§√—ßÈ ·√° ¿“«–πÈ”§√Ë”πâÕ¬ °“√§≈Õ¥ª√°µ‘ Õ“¬ÿ§√√¿å∑’˧≈Õ¥ πÈ”Àπ—°·√°§≈Õ¥ ·≈–°“√‡¢â“√—∫°“√√—°…“∑’ËÀπ૬∑“√° ·√°‡°‘¥«‘°ƒµ ·≈–æ∫«à“Õ—µ√“ à«π pulsatility index ¢Õߧ≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß ¡‘¥‡¥‘≈‡´‡√∫√—≈°—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ∑’˺‘¥ª√°µ‘ < Ò.¯ æ∫„π∑“√°°≈ÿà¡ ∑’¡Ë π’ È”Àπ—°·√°‡°‘¥πâÕ¬°«à“ Ò ‡ªÕ√凴Áπ‰∑≈å Úˆ.Û% ·≈–æ∫„π∑“√°∑’¡Ë π’ È”Àπ—°·√°‡°‘¥πâÕ¬°«à“ ı ‡ªÕ√凴Áπ‰∑≈å Û˜.ı% ´÷Ë߉¡à¡’§«“¡·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (§à“æ’ = .ˆı¯) §«“¡º‘¥ª√°µ‘¢ÕßÕ—µ√“ à«π pulsatility index ¢Õߧ≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß¡‘¥‡¥‘≈‡´‡√∫√—≈°—∫§≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß “¬ –¥◊Õ ‰¡à “¡“√∂„™â„π°“√∑”π“¬∑“√°‚µ™â“„π§√√¿å √–¥—∫√ÿπ·√߉¥âÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ∑“√°‚µ™â“„π§√√¿å, §≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥ “¬ –¥◊Õ, §≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥ ‡≈◊Õ¥·¥ß¡‘¥‡¥‘≈‡´‡√∫√—≈

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

271

π‘æπ∏åµπâ ©∫—∫

Uterine artery Doppler flow in advanced maternal age at 17-24 weeks of gestation Tongta Nanthakomon, Athita Chanthasenanont, Charintip Somprasit

Abstract

Objective:

Methods:

Results:

Conclusions:

Key words:

To present the Doppler flow of uterine artery for gestational age in early second trimester in advanced maternal age compared with low risk young pregnant women.

132 singleton pregnant women with age at least 35 years old were enrolled as advanced maternal age group. 87 normal singleton pregnant women younger than 35 year old defined as control group. The uterine artery pulsatility indices (PI), resistance indices (RI), systolic/diastolic ratio (SD ratio), maximum velocity (Vmax) and presence of diastolic notch of both sides were recorded. The SPSS software version 13.0 was used to create graphs of both side uterine arteries Doppler flow throughout gestational age in second trimester of both groups.

The distribution of uterine artery PI, RI and SD ratio at gestational age 17-24 weeks of elderly pregnant women were higher than young pregnant women statistically significant. However, presence of uterine artery notch of both groups did not have significant differences.

Uterine artery PI, RI and SD ratio for gestational age in early second trimester in advanced maternal age are higher than low risk young pregnant women.

These findings show increase uterine artery impedance in women above the aged of 35.

Advanced maternal age, Doppler, Uterine artery

Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Thammasat University

272 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Introduction Advanced maternal age is known as a predispose factor of many obstetrics complications as intrauterine growth restriction, preterm, gestational diabetes, chronic hypertension and pre-eclampsia.1,2 Recently, there are many studies to show Doppler evaluation to predict obstetrics complication for either arterial or venous blood flow.3-8 The uterine artery Doppler flow is one of blood vessels that had been investigated the correlation with adverse perinatal outcomes7, 9-14 and assessment of uteroplacental circulation.

Abnormal uterine arteries Doppler flow reflects increased impedance in the uterine circulation.

Nevertheless, the abnormal uterine artery blood flow was defined in a different definition and reference values.9,12,13,15 Because advanced maternal age is one of the risk factors of obstetrics complications that relates with decrease in uteroplacental blood flow or increase in uterine impedance as intra uterine growth restriction and preeclampsia. The authors have a suspicion that advanced maternal age might have uterine artery blood flow different from young low risk pregnant women.

Therefore, the aim of the present study was to demonstrate whether the uterine artery Doppler flow in early second trimester in elderly gravidarum is different from low risk pregnancy.

Material and Method In this prospective cross sectional study, uterine arteries Doppler ultrasound was performed on 219 singleton pregnant women who attended the Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Thammasat University between January 2010 - June 2010. There were 132 cases of pregnancy of 35 years and older and 87 cases of pregnant women younger than 35 year old.

Pregnant women of 35 years and older defined as study group and pregnancy of younger than 35 year

old defined as control group. The present study was approved by the Ethics Committee of the Faculty of Medicine, Thammasat University. Exclusion criteria were multiple pregnancies, pregnancy with fetal anomalies, pregnant women with serious medical disease, diabetes mellitus, smoking, alcohol consumption or drug addiction. Gestational age was identified by last menstrual period and then confirmed by ultrasound biometry measurement.

After gestational age was confirmed and fetal anomaly was scanned, uterine arteries Doppler waveforms were obtained using Voluson E8 Expert ultrasound machine 3.5 or 5 MHz. transducer was placed on left and right lower quadrant of the maternal abdominal wall to identify the external iliac arteries and the uterine artery medial to it flow velocity waveforms were obtained from each uterine artery near to the external iliac artery, before division if the uterine artery into branches.16 Recordings were performed in the absence of fetal breathing or movements. Uterine artery pulsatility index (PI), resistance index (RI), systolic/diastolic ratio (SD ratio) and maximum velocity (Vmax) were calculated from three even subsequent blood flow velocity waveforms. Presence or absence of an early diastolic notch was recorded.

The uterine artery PI, RI, SD ratio and Vmax for each gestational age in each group were calculated using SPSS software package version 13.0 for Windows (SPSS Inc, Chicago, III, USA) and expressed in 5th, 50th and 95th percentile. Linear regression of gestational age and PI, RI, SD ratio and Vmax with r2 were present.

Results The study included 87 control cases and 132 elderly pregnant women. The mean gestational age of control and elderly group were 20.64 and 19.65 weeks, respectively. The demographic data was present in Table 1. Number of cases in each group for each gestational age was present in Table 2.

273

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Table 1 Demographic data of both groups Characteristics Maternal age Mean ± SD (years) Range (years) Gestational age Mean ± SD (weeks) Range (weeks) Estimated fetal weight Range (grams)

Age < 35 year (n = 87)

Age ≥ 35 year (n = 132)

27.86 ± 4.62 17-34

38.29 ± 2.85 35-49

20.64 ± 1.81 17-24

19.65 ± 1.85 17-24

212-777

172-863

Table 2 Number of cases in each gestational age Gestational age (complete weeks)

Age < 35 year (n = 87)

Age ≥ 35 year (n = 132)

17 18 19 20 21 22 23 24

3 9 13 15 17 16 9 5

7 34 36 21 11 10 4 9

The distribution of PI of the right and left uterine arteries at 17-24 weeks gestation of both control group and elderly pregnant women are shown in Fig. 1, 2. The authors also presented the 5th, 50th and 95th percentile for gestational age.

The uterine artery PI was linear decreased across gestation (right uterine artery PI = 1.569 - (0.033 × GA), r2 = 0.030, p = 0.011 and left uterine artery PI = 1.690-(0.035 × GA), r2 = 0.032, p = 0.008). The curve-fitted percentile charts of right and left uterine arteries RI of both groups were created (Fig. 3, 4).

The uterine artery RI was linear decreased across gestation (right uterine artery RI = 0.810 - (0.013 × GA), r2 = 0.033, p = 0.007 and left uterine artery RI = 0.830 - (0.012 × GA), r2 = 0.024, p = 0.022).

The systolic/ diastolic ratio of right and left uterine arteries were presented. It showed in a linear relationship along gestational age (Fig. 5, 6) (right uterine artery SD ratio = 4.240 - (0.092 × GA), r2 = 0.041, p = 0.003 and left uterine artery SD ratio = 5.192 - (0.126 × GA), r2 = 0.047, p = 0.001).

Maximum velocities of the right and left uterine arteries were presented (Fig. 7, 8). It presented a nonlinear relation with gestational age; differed from other Doppler flows (right uterine artery Vmax = 43.510 + (1.096 × GA), r2 = 0.005, p = 0.304 and left uterine artery Vmax = 33.573 + (1.848 × GA), r2 = 0.015, p = 0.068).

274 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

PI; pulsatility index, GA; gestational age, o; age < 35 years, o; age

≥

35 years

Fig. 1 Pulsatility indices of the right uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

PI; pulsatility index, GA; gestational age, o; age

<

35 years, o; age

≥

35 years

Fig. 2 Pulsatility indices of the left uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

275

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

RI; resistance index, GA; gestational age, o; age

<

35 years, o; age

â&#x2030;Ľ

35 years

Fig. 3 Resistance indices of the right uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

RI; resistance index, GA; gestational age, o; age

<

35 years, o; age

â&#x2030;Ľ

35 years

Fig. 4 Resistance indices of the left uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

276 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

SD ratio; systolic/diastolic ratio, GA; gestational age, o; age

<

35 years, o; age

≥

35 years

Fig. 5 Systolic/diastolic ratios of the right utery artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

SD ratio; systolic/diastolic ratio, GA; gestational age, o; age

<

35 years, o; age

≥

35 years

Fig. 6 Systolic/diastolic ratios of the left uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

277

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Vmax; maximum velocity, GA; gestational age, o; age

<

35 years, o; age

â&#x2030;Ľ

35 years

Fig. 7 Maximum velocities of the right uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

Vmax; maximum velocity, GA; gestational age, o; age

<

35 years, o; age

â&#x2030;Ľ

35 years

Fig. 8 Maximum velocities of the left uterine artery in control and study group at 17-24 weeks gestation; the 5th, 50th and 95th percentile

278 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Mean of uterine artery Doppler flow of both elderly maternal age group and control group were present in Table 3. Mean of uterine arteries PI, RI and SD ratio in advanced maternal age were higher than low risk young pregnant women signifi-

cantly. Presence of early diastolic notch of uterine arteries was present in Table 4. There was no statistically significant difference between both groups.

Table 3 Comparisons of mean of uterine arteries pulsatility indices (PI), resistance indices (RI), systolic/ diastolic ratio (SD ratio) and maximum velocity (Vmax) between control group and study group Mean of Doppler flow Doppler flow

Right uterine PI Right uterine RI Right S/D ratio Right Vmax Left uterine PI Left uterine RI Left S/D ratio Left Vmax

Age < 35 year (n = 87) Mean ± SD (range)

Age ≥ 35 year (n = 87) Mean ± SD (range)

p value*

0.80 ± 0.26 (0.35-1.57) 0.51 ± 0.10 (0.29-0.84) 2.18 ± 0.64 (1.4-6.11) 72.39 ± 42.70 (21.30-325) 0.89 ± 0.31 (0.36-1.75) 0.55 ± 0.15 (0.29-1.42) 2.46 ± 1.11 (1.42-10.33) 78.78 ± 93.94 (26.14-239.3)

0.96 ± 0.40 (0.16-2.35) 0.56 ± 0.15 (0.64-0.98) 2.95 ± 5.26 (1.04-62.05) 62.43 ± 26.95 (21.80-161.50) 1.06 ± 0.51 (0.17-4.97) 0.61 ± 0.13 (0.27-1.00) 2.88 ± 1.23 (1.36-8.19) 66.38 ± 29.13 (20.61-156.8)

0.002*

PI; pulsatility index, RI; resistant index, SD ratio; systolic/diastolic ratio, Vmax; maximum velocity; * Chi-square test : p < 0.05 ; significant

0.009* 0.001* 0.062 0.004* 0.003* 0.001* 0.087

279

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Table 4 Presence of early diastolic notch of uterine arteries in both groups Number of cases (percent) Uterine artery Right uterine artery notch Left uterine artery notch * Chi- square test : p

<

Age < 35 year (n = 87)

Age â&#x2030;Ľ 35 year (n = 132)

p value*

18 (20.7) 16 (18.4)

19 (14.4) 18 (13.6)

0.302 0.447

0.05; significant

Discussion Several Doppler flow studies have investigated the correlation of maternal age on uterine arteries.17 Some studies found no evidence of increased uterine vascular impedance with patient age.18-19 But the present study shows significant higher PI, RI and SD ratio in elderly pregnant women compared to young pregnant women as PirhonenĂťs study.17 Maximum velocities of uterine artery in elderly group appeared higher than young pregnant women but did not have statistically significant difference. It might have been to limitation of sample size. The higher Doppler flow of uterine artery in elderly group presents the increase impedance in the uterine circulation which could be seen normally in elderly pregnancy.17 Early diastolic notches can be a physiologic finding in second trimester.15 The prevalence of diastolic notches in the present study is the same as previous reports.20 The frequency of diastolic notches in both elderly and young groups is not different significantly. It may be from the insufficiently number of cases.

This finding may be related to the physiologic process of aging and may partly explain why pregnancies in older women are associated with diverse complications more often than those in younger women. Thus, the abnormal uterine artery blood flow in elderly might be used for reference values for advanced maternal age. Nonetheless, further investigation of the clinical value for

prediction of poor perinatal outcomes by using uterine Doppler flow with reference values for elderly may be need.

References 1. Jacobsson B, Ladfors L, Milsom I. Advanced maternal age and adverse perinatal outcome.

Obstet Gynecol 2004;104:727-33.

2. Seoud MA, Nassar AH, Usta IM, Melhem Z, Kazma A, Khalil AM. Impact of advanced maternal age on pregnancy outcome. Am J Perinatol 2002;19:1-8.

3. Ozden S, Ficicioglu C, Guner R, Arioglu P, Oral O. Comparison of the intrapartum analysis of Doppler blood flow velocity waveform of the umbilical artery and fetal heart rate tracing for the prediction of perinatal outcome. J Obstet Gynaecol 1998;18:445-50.

4. Muller T, Nanan R, Rehn M, Kristen P, Dietl J. Arterial and ductus venosus Doppler in fetuses with absent or reverse end-diastolic flow in the umbilical artery: correlation with shortterm perinatal outcome. Acta Obstet Gynecol Scand 2002;81:860-6.

5. Seyam YS, Al-Mahmeid MS, Al-Tamimi HK. Umbilical artery Doppler flow velocimetry in intrauterine growth restriction and its relation to perinatal outcome. Int J Gynaecol Obstet 2002;77:131-7.

280 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

6. Baschat AA, Gembruch U, Reiss I, Gortner L, Diedrich K. Demonstration of fetal coronary blood flow by Doppler ultrasound in relation to arterial and venous flow velocity waveforms and perinatal outcome--the ùheart-sparing effectû.

Ultrasound Obstet Gynecol 1997;9:162-72.

7. Iwata M, Mitsuda N, Masuhara K, Fuke S, Shikado K, Bekku S, et al. [Prenatal detection of the growth-retarded fetuses with a serious risk of adverse perinatal outcome by uterine artery Doppler flow velocimetry: a prospective study]. Nippon Sanka Fujinka Gakkai Zasshi 1995;47:1365-70.

8. den Ouden L, van Bel F, van de Bor M, Stijnen T, Ruys J. Doppler flow velocity in anterior cerebral artery for prediction of outcome after perinatal asphyxia. Lancet 1987;1:562.

9. Ghosh GS, Gudmundsson S. Uterine and umbilical artery Doppler are comparable in predicting perinatal outcome of growth-restricted fetuses. BJOG 2009;116:424-30.

10. Toal M, Keating S, Machin G, Dodd J, Adamson SL, Windrim RC, et al. Determinants of adverse perinatal outcome in high-risk women with abnormal uterine artery Doppler images. Am J Obstet Gynecol 2008;198:330 e1-7.

11. Lopez-Quesada E, Vilaseca MA, Vela A, Lailla JM. Perinatal outcome prediction by maternal homocysteine and uterine artery Doppler velocimetry. Eur J Obstet Gynecol Reprod Biol 2004; 113:61-6.

12. Ruangvutilert P, Sutantawibul A, Sunsaneevithayakul P, Boriboonhirunsarn D. Uterine artery resistance index above 95 percentile: prevalence and adverse perinatal outcome prediction in pregnancies complicated by hypertensive disorders.

J Med Assoc Thai 2003;86:964-9.

13. Hernandez-Andrade E, Brodszki J, Lingman G, Gudmundsson S, Molin J, Marsal K. Uterine artery score and perinatal outcome. Ultrasound Obstet Gynecol 2002;19:438-42.

14. Hofstaetter C, Dubiel M, Gudmundsson S, Marsal K. Uterine artery color Doppler assisted velocimetry and perinatal outcome. Acta Obstet Gynecol Scand 1996;75:612-9.

15. Sritippayawan S, Phupong V. Risk assessment of preeclampsia in advanced maternal age by uterine arteries Doppler at 17-21 weeks of gestation. J Med Assoc Thai 2007;90:1281-6.

16. Campbell S, Diaz-Recasens J, Griffin DR, Cohen-Overbeek TE, Pearce JM, Willson K, et al. New doppler technique for assessing uteroplacental blood flow. Lancet 1983;1:6757.

17. Pirhonen J, Bergersen TK, Abdlenoor M, Dubiel M, Gudmundsson S. Effect of maternal age on uterine flow impedance. J Clin Ultrasound 2005;33:14-7.

18. Guanes PP, Valbuena D, Remohi J, et al. Age does not affect uterine resistance to vascular flow in patients undergoing oocyte donation.

Fertil Steril 1997;68:607.

19. Check JH, Dietterich C, Lurie D, et al. No evidence of increased uterine vascular impedance with patient ageing following IVF. Hum Reprod 2000;15:1697.

20. Bower S, Bewley S, Campbell S. Improved prediction of preeclampsia by two-stage screening of uterine arteries using the early diastolic notch and color Doppler imaging. Obstet Gynecol 1993;82:78-83.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

281

∫∑§—¥¬àÕ °“√µ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ°„πÀ≠‘ßµ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿµ—Èß·µà Ûı ªï ¢÷Èπ‰ª ¢≥–¡’Õ“¬ÿ§√√¿å Ò˜-ÚÙ —ª¥“Àå µâÕßµ“ π—π∑‚°¡≈, Õ∏‘µ“ ®—π∑‡ π“ππ∑å, ®√‘π∑√å∑‘æ¬å ¡ª√– ‘∑∏‘Ï Àπ૬‡«™»“ µ√å¡“√¥“·≈–∑“√°„π§√√¿å ¿“§«‘™“ Ÿµ‘»“ µ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å «—µ∂ÿª√– ߧå:

«— ¥ÿ·≈–«‘∏’°“√:

º≈°“√»÷°…“:

√ÿª:

§” ”§—≠:

‡æ◊ËÕ»÷°…“°“√‰À≈‡«’¬π‡≈◊Õ¥¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ° ‚¥¬°“√µ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√å „πÀ≠‘ß µ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿµ—Èß·µà Ûı ªï¢÷Èπ‰ª ‡ª√’¬∫‡∑’¬∫°—∫À≠‘ßµ—Èߧ√√¿åÕ“¬ÿπâÕ¬∑’Ë¡’§«“¡‡ ’ˬߵ˔ „π™à«ß‰µ√¡“ ∑’Ë Õß ¢Õß°“√µ—Èߧ√√¿å ‰¥â∑”°“√µ√«®§≈◊πË ‡ ’¬ß§«“¡∂’ Ë ßŸ ¥Õæ‡≈Õ√åÀ≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ° „πÀ≠‘ßµ—ßÈ §√√¿å‡¥’¬Ë «∑’¡Ë Õ’ “¬ÿµß—È ·µà Ûı ªï¢π÷È ‰ª ®”π«π ÒÛÚ √“¬ ‡ª√’¬∫‡∑’¬∫°—∫À≠‘ßµ—Èߧ√√¿å‡¥’ˬ« ∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ Ûı ªï ®”π«π ¯˜ √“¬ §à“ pulsatility indices (PI), resistance indices (RI), systolic/diastolic ratio (SD ratio), maximum velocity (Vmax) ·≈–°“√¡’ diastolic notch ¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ°∑—Èß Õߢâ“߉¥â∂Ÿ°∫—π∑÷°·≈–‡ª√’¬∫‡∑’¬∫√–À«à“ß Õß°≈ÿà¡ §à“ PI, RI ·≈– SD ratio ¢ÕßÀ≠‘ßµ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿ¡“°°«à“ Ûı ªï Ÿß°«à“ À≠‘ßµ—Èߧ√√¿åÕ“¬ÿπâÕ¬ Õ¬à“ß¡’ π—¬ ”§—≠∑“ß ∂‘µ‘ Õ¬à“߉√°Áµ“¡ æ∫«à“ °“√¡’ diastolic notch ¢Õß∑—Èß Õß°≈ÿà¡ ‰¡à·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠ ∑“ß ∂‘µ‘ „π‰µ√¡“ ∑’Ë ÕߢÕß°“√µ—Èߧ√√¿å æ∫«à“ §à“ PI, RI ·≈– SD ratio ¢ÕßÀ≠‘ßµ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿ¡“°°«à“ Ûı ªï Ÿß°«à“ À≠‘ßµ—Èߧ√√¿åÕ“¬ÿπâÕ¬ ´÷Ëß· ¥ß„Àâ‡ÀÁπ«à“ „πÀ≠‘ßµ—Èߧ√√¿å∑’Ë¡’Õ“¬ÿµ—Èß·µà Ûı ªï¢÷Èπ‰ª ¡’§«“¡µâ“π∑“π¢Õß À≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ° Ÿß¢÷Èπ À≠‘ßµ—Èߧ√√¿åÕ“¬ÿ¡“°°«à“ Ûı ªï, §≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¥Õæ‡≈Õ√å, À≈Õ¥‡≈◊Õ¥·¥ß¡¥≈Ÿ°

282 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

π‘æπ∏åµπâ ©∫—∫

º≈°“√§≈Õ¥¢Õß µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«–∂ÿßπÈ”§√Ë”·µ° °àÕπ°“√‡®Á∫§√√¿å‡°‘π ÒÚ ™—Ë«‚¡ß §”π«√ ®‘µ√¡≥’«√√≥

∫∑§—¥¬àÕ ªí≠À“„π°“√¥Ÿ·≈ µ√’µ—Èߧ√√¿å§√∫°”Àπ¥∑’Ë¡’¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å„πªí®®ÿ∫—π¬—߉¡à¡’§«“¡ ™—¥‡®π√–À«à“ß°“√™—°π”°“√§≈Õ¥‚¥¬∑—π∑’∑’Ë«‘π‘®©—¬‰¥âÀ√◊Õ°“√√Õ„À⇮Á∫§√√¿å‡Õß®–¡’º≈¥’µàÕ¡“√¥“·≈–∑“√° ·≈– ¡’º≈µàÕ°“√§≈Õ¥‡™àπ„¥ ‚¥¬«—µ∂ÿª√– ߧå„π°“√»÷°…“π’‡È æ◊ÕË ‡ª√’¬∫‡∑’¬∫º≈°“√µ—ßÈ §√√¿å√–À«à“ß µ√’µßÈ— §√√¿å∑¡Ë’ π’ ”È §√Ë” ·µ°‡°‘π ÒÚ ™—Ë«‚¡ß°—∫ µ√’µ—Èߧ√√¿å∑’Ë¡“¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’¡Ÿ°‡≈◊Õ¥¡“‚√ß欓∫“≈ ‚¥¬‡ªìπ°“√»÷°…“ ‡™‘ßæ√√≥π“¬âÕπÀ≈—ß·∫∫µ—¥¢«“ß ®“°°“√§âπ§«â“®“°‡«™√–‡∫’¬π∑’ËÀâÕߧ≈Õ¥µ—Èß·µà‡¥◊Õπ°—𬓬π æ.». ÚıÙ¯ µÿ≈“§¡ æ.». ÚııÚ ‚¥¬√«∫√«¡ µ√’µ—Èߧ√√¿å∑’Ë¡’∂ÿßπÈ”§√Ë”·µ°‰¥â ÛÚÒ √“¬ °—∫ µ√’µ—Èߧ√√¿å∑’Ë∂ÿßπÈ”§√Ë”¬—߉¡à ·µ° Ò,ÙÛ √“¬ ‚¥¬¡’‡°≥±å§—¥‡¢â“ (Ò) ¡’πÈ”§√Ë”·µ°·≈–¬—߉¡à¡’°“√À¥√—¥µ—«¢Õß¡¥≈Ÿ°‡°‘π ÒÚ ™—Ë«‚¡ß‚¥¬¬—ß ‰¡à‡®Á∫§√√¿å (Ú) §√√¿å§√∫°”Àπ¥¡’Õ“¬ÿ§√√¿å Û˜ - ÙÒ —ª¥“Àå ·≈–¡’§«“¡‡ ’ˬߵ˔ (Û) °≈ÿà¡πÈ”§√Ë”¬—߉¡à·µ° ª“°¡¥≈Ÿ°‡ªî¥‰¡à‡°‘π Ú ‡´πµ‘‡¡µ√ ‚¥¬„™â ∂‘µ‘ Chi square test, Fisherûs exact test ·≈– student t test „π°“√«‘‡§√“–Àå ®“°º≈°“√»÷°…“æ∫«à“ µ√’µ—Èߧ√√¿å∑’Ë¡’∂ÿßπÈ”§√Ë”·µ°∑’ˉ¥â¬“™—°π”°“√§≈Õ¥¡’§«“¡‡ ’ˬ߇æ‘Ë¡¢÷Èπ„π °“√ºà“µ—¥§≈Õ¥ odd ratio Ò.¯˜˜ (˘ı% CI Ò.ÙıÙ-Ú.ÙÚı) „π¢≥–∑’ËπÈ”Àπ—°µ—«¢Õß¡“√¥“ ·≈–¢Õß∑“√°∑—Èß Ú °≈ÿࡉ¡à·µ°µà“ß°—π √ÿª«à“ °“√™—°π”°“√§≈Õ¥„π µ√’µ—Èߧ√√¿å∑’Ë¡’∂ÿßπÈ”§√Ë”·µ°°àÕπ‡®Á∫§√√¿å‡°‘π ÒÚ ™—Ë«‚¡ß ¡’§«“¡‡ ’ˬ߄π°“√ºà“µ—¥§≈Õ¥¡“°¢÷Èπ‡¡◊ËÕ‡∑’¬∫°—∫°≈ÿà¡∑’Ë∂ÿßπÈ”§√Ë”¬—ßÕ¬Ÿà §” ”§—≠: °“√µ—Èߧ√√¿å, ¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å

∫∑π” ¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ¡’°“√‡®Á∫§√√¿å „π µ√’ µ—ßÈ §√√¿å§√∫°”Àπ¥ (Premature rupture of membranes: PROM) ‡ªìπªí≠À“∑’Ëæ∫∫àÕ¬ ‚¥¬æ∫√âÕ¬≈– ¯ ¢Õß°“√ µ—Èߧ√√¿åÒ,Ú ·≈–‚¥¬∑—Ë«‰ª¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ¡’°“√ ‡®Á∫§√√¿åπ’È ¡—°®–µ“¡¥â«¬Õ“°“√‡®Á∫§√√¿åµ“¡¡“¿“¬„π ı ™—Ë«‚¡ß ‚¥¬√âÕ¬≈– ˜ ®–§≈Õ¥¿“¬„π ÚÙ ™—Ë«‚¡ßÛ ·≈– √âÕ¬≈– ˘ı ®– “¡“√∂§≈Õ¥‰¥â¿“¬„π Ú¯ - ˜Ú ™—Ë«‚¡ßÛ ¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å §◊Õ ¿“«– ∂ÿßπÈ”§√Ë”√—Ë«À√◊Õ·µ°°àÕπ∑’Ë®–‡√‘Ë¡¡’Õ“°“√‡®Á∫§√√¿å ‡¡◊ËÕ∂ÿß πÈ”§√Ë”·µ°¡“°°«à“ Û˜ —ª¥“Àå‡√’¬°«à“ ∂ÿßπÈ”§√Ë”·µ° °àÕπ‡®Á∫§√√¿å§√∫°”Àπ¥ °≈ÿà¡ß“π Ÿµ‘»“ µ√å-π√’‡«™«‘∑¬“ ‚√ß欓∫“≈æ√–π—Ë߇°≈â“ ®—ßÀ«—¥ππ∑∫ÿ√’

¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ¡’°“√‡®Á∫§√√¿å‡æ‘Ë¡§«“¡ ‡ ’ˬߵàÕ°“√µ‘¥‡™◊ÈÕµàÕ¡“√¥“·≈–∑“√° ‚¥¬§«“¡‡ ’Ë¬ß ‡æ‘Ë¡¡“°¢÷Èπµ“¡√–¬–‡«≈“∑’Ë∂ÿßπÈ”§√Ë”·µ°∂÷߇«≈“∑’˧≈Õ¥Ú ¥—ßπ—Èπ‡¡◊ËÕ‡°‘¥¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ¡’°“√‡®Á∫§√√¿å„π µ√’µ—Èߧ√√¿å§√∫°”Àπ¥∑’ËÕ“¬ÿ§√√¿å¡“°°«à“ Û˜ —ª¥“Àå ®÷ß·π–π”„Àâ™—°π”°“√§≈Õ¥„Àâ°“√µ—Èߧ√√¿å ‘Èπ ÿ¥‚¥¬‡√Á« ‡æ◊ËÕ≈¥§«“¡‡ ’ˬ߰“√µ‘¥‡™◊ÈÕ„π¡“√¥“·≈–∑“√°Ú ‚¥¬∂â“ πÈ”§√Ë”·µ°‡°‘π ÒÚ ™—Ë«‚¡ß·µà¬—߉¡à¡’Õ“°“√‡®Á∫§√√¿å‡Õß §«√„À⬓™—°π”°“√§≈Õ¥∑—π∑’∑’Ë«‘π‘®©—¬‰¥â ‡π◊ËÕß®“°πÈ”§√Ë” ·µ°‡°‘π ÚÙ ™—Ë«‚¡ß®–‡æ‘Ë¡§«“¡‡ ’ˬ߄π°“√µ‘¥‡™◊ÈÕ∑’Ë√° ·≈–∂ÿßπÈ”§√˔٠(chorioamnionitis) „π∫“ß√“¬ß“πæ∫∂÷ß √âÕ¬≈– ÙÒ ·≈–æ∫¿“«–µ‘¥‡™◊ÈÕ„π∑“√°¡’¡“°¢÷Èπ ∑—È߬—ß

283

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

æ∫¿“«–πÈ”§√Ë”·µ°π“π∑“√°®–‡ ’ˬߵàÕ¿“«– ”≈—°¢’ȇ∑“ı (meconium aspiration syndrome) ¡“°¢÷Èπ¥â«¬ ·µà °“√µ—¥ ‘π„® „À⬓™—°π”°“√§≈Õ¥‡æ◊ËÕ≈¥√–¬–‡«≈“πÈ”§√Ë” ·µ°„Àâ —Èπ≈ßæ∫«à“®–‡ªìπ°“√‡æ‘Ë¡§«“¡‡ ’ˬߵàÕ°“√ºà“µ—¥ §≈Õ¥¡“°¢÷Èπ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’Ë√Õ„À⇰‘¥°“√‡®Á∫ §√√¿å‡Õ߈ „π°≈ÿà¡ µ√’µ—Èߧ√√¿å∑’ˇ°‘¥¿“«–∂ÿßπÈ”§√Ë”·µ° °àÕπ¡’°“√‡®Á∫§√√¿å¡“°°«à“ ÒÚ ™—Ë«‚¡ß·≈–µâÕß„Àâ ¬ “ ™—°π”°“√§≈Õ¥ ®–¡’§«“¡‡ ’¬Ë ßµàÕ°“√§≈Õ¥·≈–®–¡’º≈µàÕ ∑“√°·√°§≈Õ¥Õ¬à“߉√ ‡¡◊ÕË ‡∑’¬∫°—∫ µ√’µß—È §√√¿å§√∫°”Àπ¥ ∑’ˉ¡à¡’πÈ”‡¥‘π·≈–¡“‚√ß欓∫“≈¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’ ¡Ÿ°‡≈◊Õ¥ÕÕ°®“°™àÕߧ≈Õ¥‡æ’¬ßÕ¬à“߇¥’¬« ´÷Ëß®–‡ªìπ°“√ »÷°…“„π§√—ßÈ π’È

«—µ∂ÿª√– ß§å «— µ ∂ÿ ª √– ß§å ¢ Õß°“√»÷ ° …“π’È ‡ ªì π °“√»÷ ° …“º≈ §≈Õ¥„π¡“√¥“·≈–∑“√°„π§√√¿å§√∫°”Àπ¥∑’Ë¡’¿“«–∂ÿß πÈ”§√Ë”·µ°°àÕπ¡’°“√‡®Á∫§√√¿å¡“°°«à“ ÒÚ ™—«Ë ‚¡ß ‡™àπ Õ—µ√“ °“√ºà“µ—¥§≈Õ¥ Õ—µ√“°“√§≈Õ¥∑“ß™àÕߧ≈Õ¥¥â«¬°“√„™â ‡§√◊ËÕß¡◊ՙ૬ πÈ”Àπ—°∑“√° ·≈–¿“«–∑“√°·√°§≈Õ¥¡’ Apgar scores πâÕ¬°«à“ ˜ ∑’Ë ı π“∑’ ‡ªìπµâπ ‡¡◊ËÕ‡ª√’¬∫ ‡∑’¬∫°—∫ µ√’µß—È §√√¿å§√∫°”Àπ¥∑’‰Ë ¡à¡π’ È”‡¥‘π´÷ßË ¡“§≈Õ¥∑’Ë ‚√ß欓∫“≈¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’¡Ÿ°‡≈◊Õ¥ÕÕ°®“° ™àÕߧ≈Õ¥

«— ¥ÿ·≈–«‘∏’°“√ °“√»÷ ° …“‡™‘ ß æ√√≥π“¬â Õ πÀ≈— ß ·∫∫µ— ¥ ¢«“ß (retrospective descriptive cross-sectional analysis) ‚¥¬√«∫√«¡®“°‡«™√–‡∫’ ¬ π∑’Ë Àâ Õ ß§≈Õ¥‚√ß欓∫“≈ æ√–π—Ë߇°≈â“ √–À«à“ß«—π∑’Ë Ò °—𬓬π ÚıÙ¯ ∂÷ß«—π∑’Ë ÛÒ µÿ≈“§¡ ÚııÚ ‚¥¬‡≈◊Õ°°≈ÿࡵ—«Õ¬à“ß∑’ˇªìπ µ√’µ—Èߧ√√¿å §√∫°”Àπ¥¡’Õ“¬ÿ§√√¿å√–À«à“ß Û˜-ÙÒ —ª¥“Àå ∑“√°¡’ à«π𔇪ìπ»’√…– ‡ªìπ§√√¿å∑’ˉ¡à¡’‚√§·∑√°´âÕ𠇙àπ §√√¿å ‡ªìπæ‘… §«“¡¥—π‚≈À‘µ Ÿß ‚√§‡∫“À«“π §√√¿å·Ω¥ ·≈–‰¡à ‡§¬ºà“µ—¥§≈Õ¥¡“°àÕπ ‚¥¬°≈ÿࡵ—«Õ¬à“ß∑’Ë»÷°…“®–‡≈◊Õ° µ√’µ—Èߧ√√¿å§√∫ °”Àπ¥∑’Ë¡“‚√ß欓∫“≈¥â«¬¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ¡’°“√ ‡®Á∫§√√¿å¡“°°«à“ ÒÚ ™—Ë«‚¡ß ª“°¡¥≈Ÿ°‡ªî¥‰¡à‡°‘π Ú ‡´πµ‘‡¡µ√ ‡ª√’¬∫‡∑’¬∫°—∫ µ√’µ—Èߧ√√¿å§√∫°”Àπ¥∑’Ë¡“ ¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’¡Ÿ°‡≈◊Õ¥ÕÕ°®“°™àÕߧ≈Õ¥‚¥°≈ÿࡇª√’¬∫‡∑’¬∫®–¡’ª“°¡¥≈Ÿ°‡ªî¥‰¡à‡°‘π Ú ‡´πµ‘‡¡µ√

‡™àπ°—π „π°“√«‘π‘®©—¬¿“«–πÈ”‡¥‘π à«π„À≠à®–«‘π‘®©—¬‰¥â ®“°°“√´—°ª√–«—µ‘ ·≈–°“√µ√«®¿“¬„π®“°°“√„™â speculum æ∫πÈ”§√Ë”‰À≈®“°ª“°¡¥≈Ÿ° À√◊Õ¢—ß„π™àÕߧ≈Õ¥ „π∫“ß√“®–¡’°“√µ√«®¥â«¬ fern test (arborization) ‡æ◊ËÕ¬◊π¬—π °“√«‘π‘®©—¬ ÿ¥∑⓬¡’®”π«ππâÕ¬√“¬∑’ˬ—߉¡à™—¥‡®π®–∑”°“√ √—∫ µ√’µ—Èߧ√√¿åπ’ȉ«â‡æ◊ËÕ —߇°µÕ“°“√‚¥¬„Àâ„ àºâ“Õπ“¡—¬‰«â À“°¡’πÈ”§√Ë”·µ°®√‘ß®–¡’°“√µ√«®¿“¬„πÕ’°§√—Èß „π°≈ÿà¡∑’Ë¡’¿“«–∂ÿßπÈ”§√Ë”·µ°°àÕπ¡’°“√‡®Á∫§√√¿å ∑ÿ°√“¬‰¥â√—∫¬“ oxytocin „π°“√°√–µÿâπ„À⇮Á∫§√√¿å‡æ◊ËÕ„Àâ §≈Õ¥¿“¬„π ÚÙ ™—Ë«‚¡ß®“°‡«≈“∂ÿßπÈ”§√Ë”‡√‘Ë¡·µ° µ“¡ ·ºπ°“√√—°…“¢Õß°≈ÿà¡ß“π Ÿµ‘°√√¡‚√ß欓∫“≈æ√–π—Ë߇°≈â“ ·µà°≈ÿ¡à µ√’µß—È §√√¿å§√∫°”Àπ¥∑’¡Ë “¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ ¡’¡Ÿ°‡≈◊Õ¥ÕÕ°®“°™àÕߧ≈Õ¥ ®–¡’°“√„Àâ oxytocin ‡¡◊ËÕ¡’ ¢âÕ∫àß™’ȇ™àπ °“√§≈Õ¥¡’§«“¡°â“«Àπⓙ⓷≈–‰¡à‡ªìπ‰ªµ“¡ ‡°≥±å„π partogram ‚¥¬¡’‡°≥±å§—¥ÕÕ°§◊Õ°√≥’∑’Ë¡’¢âÕ ∫àß™’‡È ¡◊ÕË ·√°√—∫¢Õß¡“√¥“À√◊Õ∑“√°„π°“√ºà“µ—¥§≈Õ¥©ÿ°‡©‘π À√◊Õ¡’¿“«–µ‘¥‡™◊ÈÕ„ππÈ”§√Ë”·≈â« √«¡∂÷ß¡’¿“«–πÈ”‡¥‘π‡°‘π ÚÙ ™—Ë«‚¡ß ®–‰¡àπ”¡“‡¢â“»÷°…“„π§√—Èßπ’È ‚¥¬®–√«∫√«¡¢âÕ¡Ÿ≈æ◊πÈ ∞“π¢Õß µ√’µß—È §√√¿å§√∫ °”Àπ¥ Õ“¬ÿ¡“√¥“ ®”π«π°“√µ—Èߧ√√¿å‡ªìπ§√√¿å·√°·≈– §√√¿åÀ≈—ß (§√√¿å∑’Ë Ú ¢÷Èπ‰ª) Õ“¬ÿ§√√¿å «‘∏’§≈Õ¥ πÈ”Àπ—° ∑“√° Apgar scores ∑’Ë ı π“∑’ ·≈– ¿“«– fetal distress ¢âÕ¡Ÿ≈®–π”¡“«‘‡§√“–Àå∑“ß ∂‘µ‘¥â«¬‚ª√·°√¡ SPSS for Window version 15 «‘‡§√“–Àå¢âÕ¡Ÿ≈æ◊Èπ∞“π «‘∏’§≈Õ¥ ¡’ °“√‡ª√’¬∫‡∑’¬∫º≈‚¥¬„™â Chi- square tests À√◊Õ Fisherûs exact test „π¢âÕ¡Ÿ≈‡™‘ߧÿ≥¿“æ À√◊Õ ‡™‘ß°≈ÿà¡ ·≈– student t test „π¢âÕ¡Ÿ≈‡™‘ߪ√‘¡“≥ ‡™àπ Õ“¬ÿ¢Õß¡“√¥“ πÈ”Àπ—°¡“√¥“ ·≈–πÈ”Àπ—°∑“√°·√°§≈Õ¥ „™â risk estimation ”À√—∫§«“¡‡ ’ˬ߄π°“√ºà“µ—¥§≈Õ¥ ·≈–°“√ §≈Õ¥∑“ß™àÕߧ≈Õ¥¥â«¬°“√„™â‡§√◊ËÕß¡◊ՙ૬ ¿“«– prolonged first stage of labor ·≈– ¿“«– prolonged second stage of labor ‡ªìπ odds ratio ∑’Ë 95% confidence interval

º≈°“√»÷°…“ °≈ÿà¡»÷°…“¡’ µ√’µ—Èߧ√√¿å®”π«π ÛÚÒ √“¬∑’Ë¡“ ‚√ß欓∫“≈¥â«¬¿“«–πÈ”‡¥‘π¡“°°«à“ ÒÚ ™—Ë«‚¡ß‚¥¬‰¡à¡’ Õ“°“√‡®Á∫§√√¿å (PROM) æ∫‡ªìπ√âÕ¬≈– Û.˜ ¢Õß°“√ §≈Õ¥∑—ÈßÀ¡¥„π™à«ß‡«≈“∑’Ë»÷°…“ ‡ª√’¬∫‡∑’¬∫°—∫ µ√’µ—Èß §√√¿å∑’Ë¡“¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’¡Ÿ°‡≈◊Õ¥¡“‚¥¬ª“° ¡¥≈Ÿ°‡ªî¥πâÕ¬°«à“ Ú ‡´πµ‘‡¡µ√®”π«π Ò,ÙÛ √“¬ (non

284 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

PROM) (µ“√“ß∑’Ë Ò) °“√Ω“°§√√¿å„π°≈ÿà¡ PROM ¡’ ª√–«—µ‘Ω“°§√√¿å®“°‚√ß欓∫“≈Õ”‡¿Õ ¡“°°«à“°≈ÿà¡ non PROM ∑’ËΩ“°§√√¿å®“°‚√ß欓∫“≈æ√–π—Ë߇°≈â“ (µ“√“ß∑’Ë

Ò) ‡π◊ËÕß®“°¿“«– PROM ¡—°‡ªìπ‡Àµÿº≈Àπ÷Ëß∑’Ë µ√’µ—Èß §√√¿å®“°‚√ß欓∫“≈Õ”‡¿Õ„π°“√ àßµàÕ¡“¬—ß‚√ß欓∫“≈ æ√–π—Ë߇°≈Ⓡæ◊ËÕ°“√√—°…“µàÕ

µ“√“ß∑’Ë Ò ¢âÕ¡Ÿ≈æ◊Èπ∞“π∑’ˇ°’ˬ«¢âÕß°—∫°“√µ—Èߧ√√¿å∑’Ë»÷°…“ ¢âÕ¡Ÿ≈æ◊πÈ ∞“π Õ“¬ÿ µ√’µ—Èߧ√√¿å (ªï ± SD) πÈ”Àπ—° (°°. ± SD) Õ“¬ÿ§√√¿å (‡©≈’ˬ ± SD) §√√¿å·√° (√âÕ¬≈–) §√√¿åÀ≈—ß (√âÕ¬≈–) Ω“°§√√¿å∑’Ë √æ.æ√–π—Ë߇°≈â“ (√âÕ¬≈–) √æ.Õ”‡¿Õ„π‡¢µππ∑∫ÿ√’ √æ.Õ◊ËπÊ ‰¡à‡§¬Ω“°§√√¿å * Student t test

PROM (n = ÛÚÒ)

non PROM (n = Ò,ÙÛ)

§à“æ’

Úı.ı ± ˆ.Ú ı˘. ± ˆ.Ú Û¯.˜ ± Ò.Û Ò˘ı (ˆ.˜) ÒÚˆ (Û˘.Û) Òˆı (ıÒ.Ù) ˘˘ (Û.¯) Ùˆ (ÒÙ.Û) ÒÒ (Û.Ù)

Úˆ.Ú ± ˆ.Ù ı¯.Ò ± ˆ.Ù Û¯.¯ ± Ò.Ú ÙÒ¯ (Ù.Ò) ˆÚı (ı˘.˘) ˜Û (˜.) ÒÒÙ (Ò.˘) ÒÛ˘ (ÒÛ.Û) ˆ (ı.¯)

.ıˆ* .Û* .˘˜* .a .a .a

aChi-square

º≈°“√§≈Õ¥„π§√√¿å·√°¢Õß°≈ÿà¡ PROM ¡’ Õ—µ√“ºà“µ—¥§≈Õ¥¡“°°«à“ ´÷Ëß·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (µ“√“ß∑’Ë Ú) à«π§√√¿åÀ≈—ß¡’Õ—µ√“ºà“µ—¥§≈Õ¥πâÕ°«à“ ·µà‰¡à·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ‡¡◊ËÕ‡∑’¬∫°—∫ °≈ÿà¡ non PROM à«π°“√§≈Õ¥∑“ß™àÕߧ≈Õ¥‚¥¬„™â ‡§√◊ËÕß¡◊ՙ૬·≈–º≈µàÕ∑“√° ‡™àπ fetal distress, Apgar

scores ∑’Ë ı π“∑’ πâÕ¬°«à“ ˜ ·≈– πÈ”Àπ—°∑“√°·√°§≈Õ¥ ‰¡à·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘„π∑—Èß Ú °≈ÿà¡ (µ“√“ß ∑’Ë Ú) æ∫Õ“°“√¡’‰¢âÀ≈—ß ÚÙ ™—Ë«‚¡ßÀ≈—ߧ≈Õ¥ (puerperal fever) „π°≈ÿà¡ PROM ¡“°°«à“ °≈ÿà¡ non PROM ·µà‰¡à·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (µ“√“ß∑’Ë Ú)

µ“√“ß∑’Ë Ú º≈°“√§≈Õ¥·≈–º≈µàÕ∑“√°·√°§≈Õ¥ PROM (n = ÛÚÒ)

º≈

non PROM (n = Ò,ÙÛ)

«‘∏’§≈Õ¥ §≈Õ¥ª√°µ‘ (√âÕ¬≈–) ÒˆÒ (ı.Û) ˆ¯ı (ˆı.˜) ºà“µ—¥§≈Õ¥ §√√¿å·√° Ò˜ (ÛÛ.Û) ÒÛı (ÒÚ.˘) §√√¿åÀ≈—ß Ù˜ (ÒÙ.ˆ) ÚÒÙ (Ú.ı) §≈Õ¥∑“ß™àÕߧ≈Õ¥¥â«¬‡§√◊ËÕß¡◊ՙૈ (Ò.¯) ˘ (.˘) Fetal distress (√âÕ¬≈–) Ú (.ˆ) Òˆ (Ò.ı) Apgar score ∑’Ë ı π“∑’ πâÕ¬°«à“ ˜ (√âÕ¬≈–) Û (.˘) ı (.ı) πÈ”Àπ—°∑“√°·√°§≈Õ¥ (°√—¡ ± SD) Û,˘Ù.ˆ ± Ùı.Û Û,ÒÚÒ.Ú ± ÙÒˆ.Ò st Prolonged 1 stage of labor (√âÕ¬≈–) Û (.˘) ı (.ı) nd Prolonged 2 stage of labor (√âÕ¬≈–) ı (Ò.ˆ) ÒÒ (Ò.Ò) Puerperal fever (√âÕ¬≈–) Ù (Ò.Ú) Û (.Û) * Student t test

aChi-square

bFisherûs

exact test

§à“æ’ .ıa .a .ÙÒÚa .ÛÚ˘a .ÚÒ˜b .ÒÒÒb .ÛÚ¯* .ÙÒb .ııÚb .ı˜b

285

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

æ∫Õÿ∫—µ‘°“√≥凰‘¥‰¢âÀ≈—ߧ≈Õ¥¢Õß°≈ÿà¡ PROM æ∫√âÕ¬≈– Ò.Ú ·≈–„π°≈ÿà¡ non PROM √âÕ¬≈– .Û à«π Õÿ∫—µ‘°“√≥凰‘¥ chorioamnionitis „π µ√’µ—Èߧ√√¿åæ∫ √âÕ¬≈– .Ù ·≈–‰¡à‰¥â®—¥Õ¬Ÿà„π°“√»÷°…“π’È Õÿ∫—µ‘°“√≥嵑¥‡™◊ÈÕ„π∑“√°·√°§≈Õ¥ (incidence of neonatal sepsis) ®“°¢âÕ¡Ÿ≈„π‡«™√–‡∫’¬π¢Õß°≈ÿà¡ ß“π°ÿ¡“√‡«™°√√¡ æ∫Õ—µ√“°“√‡°‘¥‚√§ Û µàÕ Ò, ∑“√° §≈Õ¥¡’™’æ ·µà‰¡à “¡“√∂®”·π°∑“√°°≈ÿà¡π’ȉ¥â«à“‡°‘¥®“° ¡“√¥“°≈ÿà¡„¥‡π◊ËÕß®“°¢âÕ¡Ÿ≈®“°‡«™√–‡∫’¬π‰¡à‰¥â®”·π°‰«â §«“¡‡ ’¬Ë ß®“°°“√ºà“µ—¥§≈Õ¥„π°≈ÿ¡à PROM ‡¡◊ÕË ‡∑’¬∫°—∫°≈ÿà¡ non PROM æ∫«à“°“√ºà“µ—¥§≈Õ¥¡’¡“°¢÷Èπ

„π°≈ÿà¡ PROM Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ·≈–§«“¡‡ ’Ë¬ß „π°“√§≈Õ¥∑“ß™àÕߧ≈Õ¥¥â«¬°“√„™â‡§√◊ËÕß¡◊ՙ૬æ∫πâÕ„π°≈ÿà¡ PROM ¿“«– prolonged first stage of labor ·≈– ¿“«– prolonged second stage of labor æ∫¡’ §«“¡‡ ’ˬ߄π°≈ÿà¡ PROM ¡“°°«à“ °≈ÿà¡ non PROM ‡™à𠇥’¬«°—∫¿“«–¡’‰¢âÀ≈—ߧ≈Õ¥ ·µà‰¡à¡’§«“¡·µ°µà“ßÕ¬à“ß¡’ π—¬ ”§—≠∑“ß ∂‘µ‘ (µ“√“ß∑’Ë Û) ¢âÕ∫àß™’È„π°“√ºà“µ—¥§≈Õ¥¡’§«“¡·µ°µà“ß°—π¡“° „π°√≥’ protracted of cervical dilatation ·≈–πÈ”‡¥‘π‡°‘π ÚÙ ™—Ë«‚¡ß (µ“√“ß∑’Ë Ù)

µ“√“ß∑’Ë Û º≈¢Õߧ«“¡‡ ’Ë¬ß (risk estimation) ∑’ˇ°‘¥·°à°“√µ—Èߧ√√¿å∑’Ë¡’πÈ”‡¥‘π°àÕπ°“√‡®Á∫§√√¿å §«“¡‡ ’ˬ߮“°¿“«–πÈ”‡¥‘𠧫“¡‡ ’ˬ߮“°°“√ºà“µ—¥§≈Õ¥ §«“¡‡ ’ˬ߮“°°“√§≈Õ¥∑“ß™àÕߧ≈Õ¥¥â«¬‡§√◊ËÕß¡◊ՙ૧«“¡‡ ’Ë¬ß prolonged 1st stage of labor §«“¡‡ ’Ë¬ß prolonged 2nd stage of labor §«“¡‡ ’ˬ߮“°¡’‰¢âÀ≈—ߧ≈Õ¥ (puerperal fever)

Odds ratio Ò.¯˜˜ .ÛıÛ Ò.˘ı¯ Ò.Ù¯Ù Ù.Û˜Ù

95% confidence interval Ò.ÙıÙ .ÒÚÙ .Ùˆı .ıÒÚ .˘˜Ù

- Ú.ÙÚı - Ò.ı - ¯.ÚÙ - Ù.Ûı - Ò˘.ˆÙ¯

µ“√“ß∑’Ë Ù ¢âÕ∫àß™’È„π°“√ºà“µ—¥§≈Õ¥ (indication for caesarean section) ¢âÕ∫àß™’È„π°“√ºà“µ—¥§≈Õ¥ Cephalic pelvis disproportion (√âÕ¬≈–) Non progressive on active phase of labor (√âÕ¬≈–) Protracted of dilatation with PROM > 24 Hr Prolonged 1st & 2nd of labor (√âÕ¬≈–) Fetal distress (√âÕ¬≈–)

«‘®“√≥å ¿“«–∂ÿ ß πÈ” §√Ë” ·µ°°à Õ π¡’ ° “√‡®Á ∫ §√√¿å „ π µ√’ µ—Èߧ√√¿å§√∫°”À𥇪ìπªí≠À“Àπ÷Ëß∑“ß Ÿµ‘»“ µ√å∑’Ëæ∫‰¥â ∫àÕ¬ ·≈–‡ªìπªí≠À“„π°“√¥Ÿ·≈¿“«–‡π◊ËÕß®“°¡’¢âÕ®”°—¥ ¢Õ߇«≈“„π°“√§≈Õ¥ ‚¥¬¡’√“¬ß“π°“√»÷°…“æ∫§«“¡ ‡ ’ˬ߄π°“√µ‘¥‡™◊ÈÕ„π¡“√¥“·≈–∑“√°®–‡æ‘Ë¡¢÷Èπ —¡æ—π∏å°—∫ √–¬–‡«≈“∑’ËπÈ”§√Ë”·µ° À“°¡’πÈ”§√Ë”·µ°π“π®–¬‘Ë߇æ‘Ë¡

PROM (n = ÒıÙ)

non PROM (n = ÛÙ˘)

¯˘ Ú˘ Úˆ ¯ Ú

Úˆ ÒÚ  ˜ Òˆ

(ı˜.¯) (Ò¯.¯) (Òˆ.˘) (ı.Ú) (Ò.Û)

(ı˘.) (ÛÙ.Ù) (Ú.) (Ù.ˆ)

§«“¡‡ ’ˬßÛ ‚¥¬æ∫«à“‡¡◊ËÕπÈ”§√Ë”·µ°‡°‘π ÚÙ ™—Ë«‚¡ß ¬—߉¡à§≈Õ¥®–‡ ’ˬߵàÕ¿“«– chorioamnionitis ·≈–∑“√° ¡’‚Õ°“ µ‘¥‡™◊ÈÕ‡æ‘Ë¡¢÷ÈπÒ,Ú,Û,Ù ‚¥¬‡©æ“–∑“√°·√°§≈Õ¥ °≈ÿà¡π’È®–∂Ÿ°√—∫‰«â‡æ◊ËÕ —߇°µÕ“°“√µ‘¥‡™◊ÈÕ ·≈–µ√«®∑“ß ÀâÕߪؑ∫—µ‘°“√ À√◊Õ„À⬓ªØ‘™’«π–∑ÿ°√“¬ ¡’∫“ß√“¬ß“π∑’Ë ¡“√¥“¡’ª√–«—µ‘πÈ”§√Ë”·µ°‡°‘π Ò¯ ™—Ë«‚¡ß ‡¡◊ËÕ§≈Õ¥°Á®– ‡√‘Ë¡µ√«®°“√µ‘¥‡™◊ÈÕ„π∑“√°À√◊Õ„À⬓ªØ‘™’«π–˜ ·≈–‡ªìπ

286 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

‰ªµ“¡·π«∑“ß°“√√—°…“ (Clinical Practice Guideline: CPG) ¢Õß°≈ÿà¡ß“π°ÿ¡“√‡«™°√√¡‚√ß欓∫“≈æ√–π—Ë߇°≈â“ ∑’Ë„™âªØ‘∫—µ‘ ·¡â®–¡’°“√„À⬓ªØ‘™’«π–·°à¡“√¥“√–À«à“ß°“√ §≈Õ¥°Áµ“¡ ¥—ßπ—Èπ°“√„À⬓™—°π”°“√§≈Õ¥®÷ß∂Ÿ°π”¡“„™â „π°“√‡√àß°“√§≈Õ¥„Àâ —Èπ≈߇æ◊ËÕ®ÿ¥¡ÿàßÀ¡“¬„π°“√≈¥¿“«– µ‘¥‡™◊ÈÕ„π¡“√¥“·≈–‚¥¬‡©æ“–„π∑“√° ·≈–‡ªìπ‡Àµÿ„Àâ¡’ Õ—µ√“°“√ºà“µ—¥§≈Õ¥¡“°¢÷Èπ‚¥¬‡©æ“–‡¡◊ËÕπÈ”§√Ë”·µ°‡°‘π ÚÙ ™—Ë«‚¡ß „π°“√»÷°…“π’ȉ¥â√«∫√«¡ µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«–πÈ” §√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å„π§√√¿å§√∫°”Àπ¥®”π«π ÛÚÒ √“¬ ∑’Ë¡’πÈ”§√Ë”‡¥‘π¡“°°«à“ ÒÚ ™—Ë«‚¡ß·≈–¬—߉¡à‡®Á∫§√√¿å ®÷߉¥â„À⬓™—°π”°“√‡®Á∫§√√¿å‡ªìπ oxytocin ∑ÿ°√“¬‡æ◊ËÕ ™—°π”°“√§≈Õ¥µ“¡·ºπ°“√§≈Õ¥„π¿“«–πÈ”§√Ë”·µ°¢Õß °≈ÿà¡ß“π Ÿµ‘°√√¡∑’Ë®–„À⇮Á∫§√√¿å§≈Õ¥¿“¬„π ÚÙ ™—Ë«‚¡ß À≈—ßπÈ”§√Ë”·µ° ‡æ◊ËÕ≈¥°“√µ‘¥‡™◊ÈÕ„π∑“√° ‡ª√’¬∫‡∑’¬∫°—∫ °≈ÿ¡à µ√’µß—È §√√¿å∑‰’Ë ¡à¡π’ È”§√Ë”·µ°∑’πË ”¡“»÷°…“§√—ßÈ π’È æ∫«à“ ¢âÕ¡Ÿ≈æ◊Èπ∞“π¢Õß∑—Èß Ú °≈ÿà¡ ‰¡à·µ°µà“ß°—π ¬°‡«âπ°≈ÿà¡∑’Ë πÈ”§√Ë”·µ°æ∫„π§√√¿å·√°¡“°°«à“§√√¿åÀ≈—ß Õ¥§≈âÕß °—∫°“√»÷°…“¢Õß Chan ·≈–§≥–¯ ∑’Ëæ∫¿“«–πÈ”§√Ë”·µ° °àÕπ°“√‡®Á∫§√√¿åæ∫‡°‘¥„π§√√¿å·√°¡“°°«à“‡™àπ°—π ´÷Ëß “‡Àµÿ§«√®–‰¥â»÷°…“µàÕ‰ª ·≈–æ∫«à“ µ√’µ—Èߧ√√¿å°≈ÿà¡π’È ¡’ª√–«—µ‘°“√Ω“°§√√¿å∑’Ë‚√ß欓∫“≈√–¥—∫ª∞¡¿Ÿ¡‘¡“°°«à“ ‡π◊Ë Õ ß®“°¿“«–πÈ” §√Ë” ·µ°°à Õ π¡’ Õ “°“√‡®Á ∫ §√√¿å ¡— ° ‡ªì π ‡Àµÿº≈„π°“√ àßµàÕ µ√’µ—Èߧ√√¿å¥—ß°≈à“«¡“‚√ß欓∫“≈∑’Ë¡’ §«“¡æ√âÕ¡„π°“√¥Ÿ·≈‰¥â¡“°°«à“ · ¥ß∂÷ߪí≠À“¿“«– πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å‡ªìπªí≠À“∑’Ë¡’§«“¡®”‡ªìπ„π °“√¥Ÿ·≈¡“°°«à“°≈ÿà¡∑’Ë¡’Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’¡Ÿ°‡≈◊Õ¥¡“ Õ¬à“߇¥’¬« º≈°“√§≈Õ¥æ∫«à“¿“«– fetal distress, ¿“«– Apgar scores ∑’Ë ı π“∑’ µË”°«à“ ˜ πÈ”Àπ—°∑“√°·√° §≈Õ¥ ·≈–¿“«– prolonged of labor ∑—Èß Ú °≈ÿà¡æ∫‰¡à¡’ §«“¡·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ·µ°µà“ß®“° °“√»÷°…“¢Õß Sheiner ·≈– §≥–˘ ∑’Ëæ∫«à“¿“«–πÈ”§√Ë” ·µ°°àÕπ°“√‡®Á∫§√√¿å‡ªìπªí®®—¬‡ ’ˬ߄À⇰‘¥¿“«– prolonged 1st stage of labor √«¡∂÷ß°“√»÷°…“¢Õß Park ·≈– §≥–Ò ∑’Ëæ∫«à“‡ªìπªí®®—¬‡ ’ˬ߄À⇰‘¥¿“«– prolonged 2nd stage of labor ¡“°¢÷Èπ‡¡◊ËÕ‡∑’¬∫°—∫°“√§≈Õ¥∑’ËπÈ”§√Ë”¬—ß ‰¡à·µ° ·≈–°“√»÷°…“¢Õß Park ·≈–§≥–Ò ¬—ßæ∫¥â««à“¡’°“√ºà“µ—¥§≈Õ¥¡“°¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠‡π◊ËÕß®“°°“√ ™—°π”°“√§≈Õ¥≈⡇À≈«‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’ËπÈ”§√Ë”¬—ß ‰¡à·µ° Õ¥§≈âÕß°—∫°“√»÷°…“§√—ßÈ π’æÈ ∫«à“°≈ÿ¡à µ√’µß—È §√√¿å

∑’Ë¡’¿“«–πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å¡’§«“¡‡ ’ˬ߇æ‘Ë¡¢÷Èπ „π°“√ºà“µ—¥§≈Õ¥®“°¿“«–πÈ”§√Ë”·µ°‡ªìπªí®®—¬‡ ’ˬ߇Õß ‡¡◊ËÕ‡∑’¬∫°—∫°≈ÿà¡∑’ËπÈ”§√Ë”¬—߉¡à·µ° ‡π◊ËÕß®“°µ—«·ª√¢Õß À≠‘ßµ—Èߧ√√¿å ‡™àπ Õ“¬ÿ¡“√¥“ πÈ”Àπ—°µ—« ·≈–Õ“¬ÿ§√√¿å ‡©≈’ˬ „π∑—Èß Ú °≈ÿࡉ¡à·µ°µà“ß°—π µ—«·ª√¢Õß∑“√° ‡™àπ πÈ”Àπ—°∑“√°‡©≈’ˬ æ∫«à“∑—Èß Ú °≈ÿࡉ¡à·µ°µà“ß°—π‡™àπ°—π ´÷Ë߬—ß Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß Ben-Haroush ·≈– §≥–ÒÒ ∑’Ëæ∫Õ—µ√“°“√ºà“µ—¥§≈Õ¥„π µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«– πÈ” §√Ë” ·µ°°à Õ π°“√‡®Á ∫ §√√¿å ¡ “°°«à “ µ√’ µ—È ß §√√¿å ∑’Ë ¡ “ ‚√ß欓∫“≈¥â«¬Õ“°“√‡®Á∫§√√¿å§≈Õ¥‡Õß ¿“«–πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å„π§√√¿å∑’˧√∫ °”Àπ¥ ¡’°“√»÷°…“∂÷ß·π«∑“ß„π°“√√—°…“æ∫«à“¡’§«“¡‡ÀÁπ ·µ°µà“ß°—π√–À«à“ß°“√„Àâ°√–µÿâπ°“√§≈Õ¥‚¥¬‡√Á«‡æ◊ËÕ≈¥ §«“¡‡ ’ˬߵàÕ¿“«–°“√µ‘¥‡™◊ÈÕ„π¡“√¥“·≈–∑“√°Ú ·≈–°“√ ‡ΩÑ“√–«—ß√Õ„À⇮Á∫§√√¿å§≈Õ¥‡Õߥ⫬‡Àµÿº≈‡æ◊ËÕ≈¥Õ—µ√“ °“√ºà“µ—¥§≈Õ¥ˆ ¢≥–∑’Ë·π«∑“ߪؑ∫—µ‘ß“π¢Õß°≈ÿà¡ß“π Ÿµ‘°√√¡‚√ß欓∫“≈æ√–π—Ë߇°≈â“®–„Àâ™—°π”°“√§≈Õ¥¢Õß µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«–πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å„À⇮Á∫ §√√¿å·≈–§≈Õ¥„π ÚÙ ™—Ë«‚¡ß ‡æ◊ËÕ‡ªì𧫓¡√à«¡¡◊Õ°—∫ °≈ÿà¡ß“π°ÿ¡“√‡«™°√√¡‡æ◊ËÕ∑’Ë®–≈¥§«“¡‡ ’ˬߵàÕ°“√µ‘¥ ‡™◊ÈÕ„π∑“√°·√°§≈Õ¥ ‡π◊ËÕß®“°¡’√“¬ß“πæ∫«à“πÈ”§√Ë”‡¥‘π ‡°‘π ÚÙ ™—Ë«‚¡ß∑“√°®–¡’‚Õ°“ µ‘¥‡™◊ÈÕ¡“°¢÷ÈπÒ,Ú,Û,Ù ¥â«¬‡Àµÿº≈¥—ß°≈à“«®÷ß¡’°“√™—°π”°“√§≈Õ¥„π µ√’µ—Èߧ√√¿å ∑’Ë ¡’ ¿ “«–πÈ” §√Ë” ·µ°°≈ÿà ¡ π’È · ≈–‡ªì 𠓇Àµÿ „ Àâ ¡’ Õ— µ √“°“√ ºà“µ—¥§≈Õ¥¡“°¢÷Èπ ‡π◊ËÕß®“°™—°π”°“√§≈Õ¥‰¡àª√– ∫º≈ ”‡√Á® Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß Saropala ·≈–§≥–ˆ ·≈– Park ·≈–§≥–Ò ‡æ◊ËÕ‡ªìπ°“√≈¥Õ—µ√“°“√ºà“µ—¥§≈Õ¥®“° “‡Àµÿ∑’Ë πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å ®÷߇ÀÁπ§«√ª√—∫ª√ÿß·π«∑“ß „π°“√¥Ÿ · ≈ µ√’ µ—È ß §√√¿å ∑’Ë ¡’ ¿ “«–πÈ” §√Ë” ·µ°·≈–¡’ § «“¡ ‡ ’ˬߵ˔°≈ÿà¡π’È‚¥¬§«√√Õ„À⇰‘¥°“√‡®Á∫§√√¿å‡ÕßÀ√◊Õ¡’°“√ ™—°π”°“√§≈Õ¥‡¡◊ËÕ¡’¢âÕ∫àß™’ÈÕ¬à“߇À¡“– ¡ ‡™à𠪓° ¡¥≈Ÿ°¡’§«“¡æ√âÕ¡ (ripen cervix) ¡“°¢÷Èπ ‡π◊ËÕß®“°¡’ °“√»÷°…“æ∫«à“„π ˜Ú ™—Ë«‚¡ß µ√’µ—Èߧ√√¿å∑’Ë¡’πÈ”§√Ë”·µ° ®–‡°‘¥°“√§≈Õ¥‡Õ߉¥â√âÕ¬≈– ˘ıÛ ·≈–‰¡à‡æ‘Ë¡§«“¡‡ ’Ë¬ß „π°“√µ‘¥‡™◊ÈÕ„π∑“√° πÕ°®“°π’È¡’°“√»÷°…“¢Õß Kenyon ·≈–§≥–ÒÚ ∑’Ë»÷°…“°“√„À⬓ªØ‘™’«π–„π µ√’µ—Èߧ√√¿å∑’Ë¡’¿“«–πÈ”§√Ë” ·µ°°àÕπ°“√‡®Á∫§√√¿åæ∫«à“ “¡“√∂≈¥°“√µ‘¥‡™◊ÈÕ∑—Èß„π ¡“√¥“·≈–∑“√°∑’§Ë ≈Õ¥‡°‘π Ù¯ ™—«Ë ‚¡ßÀ≈—ßπÈ”§√Ë”·µ° ·≈– °“√»÷°…“¢Õß Ratanakorn ·≈–§≥–ÒÛ ∑’Ë‚√ß欓∫“≈

287

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

æ√–¡ß°ÿƇ°≈â“ ∑’Ëæ∫«à“§«“¡‡ ’ˬ߄π°“√µ‘¥‡™◊ÈÕ„π∑“√°æ∫ ·µ°µà“ß°—π‚¥¬¢÷πÈ °—∫Õ“¬ÿ§√√¿å·≈–¿“«–°“√µ‘¥‡™◊ÕÈ „ππÈ”§√Ë” À“°Õ“¬ÿ§√√¿å Û˜ —ª¥“Àå¢÷Èπ‰ª ‰¡à¡’Õ“°“√µ‘¥‡™◊ÈÕ„ππÈ” §√Ë”™—¥‡®π (Clinical chorioamnionitis) ·≈–πÈ”§√Ë”·µ° ‰¡à‡°‘π ˜Ú ™—Ë«‚¡ß®–¡’§«“¡‡ ’ˬߵ‘¥‡™◊ÈÕ„π∑“√°µË” „π°“√»÷°…“¢Õß Dare ·≈–§≥–ÒÙ ∑’»Ë °÷ …“√“¬ß“π µà“ßÊ æ∫«à“°“√™—°π”°“√§≈Õ¥À√◊Õ°“√‡ΩÑ“ —߇°µ„À⇰‘¥ °“√‡®Á∫§√√¿å‡Õß„Àâº≈°“√§≈Õ¥·≈–¿“«–µ‘¥‡™◊ÈÕ„π∑“√°‰¡à ·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠ à«π°“√»÷°…“¢Õß MozurkewichÒı æ∫«à“°“√™—°π”°“√§≈Õ¥∑—π∑’‡¡◊ËÕ‡∑’¬∫°—∫°“√√Õ (delayed induction) „π§√√¿å§√∫°”Àπ¥‰¡à∑”„À⇰‘¥ °“√µ‘¥‡™◊ÕÈ „π∑“√°·µ°µà“ß°—π ·≈–°“√»÷°…“¢Õß Seaward ·≈–§≥–Òˆ ‰¥â»°÷ …“æ∫¢âÕ∫àß™’∂È ß÷ §«“¡‡ ’¬Ë ß∑’∑Ë “√°·√°§≈Õ¥ ®–µ‘¥‡™◊ÈÕ¡—°‡°‘¥®“°¡“√¥“ª√“°ØÕ“°“√ chorioamnionitis ·≈â« À√◊Õ¡“√¥“µ‘¥‡™◊ÈÕ Groups B streptococcus ¥—ßπ—Èπ·π«∑“ß°“√¥Ÿ·≈√—°…“ µ√’µ—Èߧ√√¿å∑’ËÕ“¬ÿ §√√¿å§√∫°”Àπ¥∑’Ë¡’¿“«–πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å∑’Ë ‰¡à¡’¿“«– chorioamninitis ·≈–¡’§«“¡‡ ’ˬߵ˔‡ÀÁπ¡’°“√ §«√ª√—∫ª√ÿß ‚¥¬¢¬“¬‡«≈“‡ªìπ‰¡à‡°‘π Ù¯-˜Ú ™—Ë«‚¡ß ·≈–„Àⵑ¥µ“¡¿“«–°“√µ—Èߧ√√¿åÕ¬à“ß„°≈♑¥ ‚¥¬‡ΩÑ“√–«—ß °“√µ‘¥‡™◊ÈÕ„ππÈ”§√Ë” ·≈– fetal heart monitoring Õ¬à“ß ¡Ë”‡ ¡Õ ‚¥¬„Àâ™—°π”°“√§≈Õ¥‡¡◊ËÕ¡’¢âÕ∫àß™’È„Àâ§≈Õ¥ ¿“¬„π Ù¯-˜Ú ™—«Ë ‚¡ß ‡æ◊ÕË ‡ªìπ°“√≈¥Õ—µ√“°“√ºà“µ—¥§≈Õ¥ ¥â«¬ “‡Àµÿ®“°πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å ·µà§«√¡’°“√»÷°…“ ‡æ‘Ë¡‡µ‘¡‚¥¬„™â °“√»÷°…“·∫∫ ÿà¡¡’°≈ÿࡧ«∫§ÿ¡®”·π°µ“¡ Õ“¬ÿ§√√¿å‡æ◊ËÕ»÷°…“§«“¡‡ ’ˬߢÕßÕ—µ√“°“√µ‘¥‡™◊ÈÕ„π·µà≈– Õ“¬ÿ§√√¿å∑—Èß„π¡“√¥“·≈–∑“√° ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈ ∑’ˇÀ¡“– ¡µàÕ‰ª ‡π◊ËÕß®“°¡’°“√»÷°…“∂÷ß°≈‰°∑’Ë ∑”„Àâ πÈ” §√Ë” ·µ° æ∫«à“πÈ”§√Ë”·µ°¡’®“°À≈“¬ “‡Àµÿ ‚¥¬§√√¿å∑§’Ë √∫°”Àπ¥ ¡—°‡°‘¥®“°°“√‡ ◊ËÕ¡À√◊ÕÀ¡¥Õ“¬ÿ¢—¬¢Õ߇´≈≈å∂ÿßπÈ”§√Ë” ´÷Ë߇ªìπ°≈‰°µ“¡∏√√¡™“µ‘„π°“√§≈Õ¥ à«π “‡Àµÿ®“°°“√ µ‘¥‡™◊ÈÕ∑’ˇªìπ‡Àµÿ∑”„ÀâπÈ”§√Ë”·µ°‰¥â¡—°‡°‘¥„π§√√¿å∑’ˬ—߉¡à §√∫°”À𥇪ìπ à«π„À≠àÚ,Û ¥—ßπ—È𠧫“¡‡ ’ˬߵ‘¥‡™◊ÈÕ ®“°¿“«–πÈ”§√Ë”·µ°„π·µà≈–°≈ÿ¡à Õ“¬ÿ§√√¿å ®÷ß·µ°µà“ß°—π‰¥â Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß Ratanakorn ·≈–§≥–ÒÛ ∑’Ë æ∫«à“∑“√°∑’ˇ°‘¥¢≥–Õ“¬ÿ§√√¿å§√∫°”Àπ¥¡’§«“¡‡ ’Ë¬ß„π °“√µ‘¥‡™◊ÕÈ µË”°«à“°≈ÿ¡à ∑“√°∑’§Ë ≈Õ¥°àÕπ°”Àπ¥¥—ß°≈à“«·≈â«

√ÿª °“√»÷ ° …“π’È æ ∫«à “ ¿“«–πÈ” §√Ë” ·µ°°à Õ π°“√‡®Á ∫ §√√¿å„π§√√¿å§√∫°”Àπ¥∑’Ë¡’§«“¡‡ ’ˬߵ˔ ·≈–‰¡à¡’¿“«– ·∑√°´âÕ𠇙àπ ¿“«– chorioamnionitis À√◊Õ¿“«–∑’˵âÕß ºà“µ—¥§≈Õ¥©ÿ°‡©‘π ¡’§«“¡‡ ’ˬߡ“°¢÷Èπ∑’Ë®–ºà“µ—¥§≈Õ¥ ‡¡◊ËÕ‡∑’¬∫°—∫°“√µ—Èߧ√√¿å∑’Ë¡“¥â«¬Õ“°“√‡®Á∫§√√¿åÀ√◊Õ¡’ ¡Ÿ°‡≈◊Õ¥¡“∑’Ë‚√ß欓∫“≈ ‚¥¬¡’ “‡Àµÿ®“°°“√™—°π”°“√ §≈Õ¥∑’ˉ¡àª√– ∫º≈ ”‡√Á® ‡π◊ËÕß®“°¢âÕ®”°—¥¢Õ߇°≥±å ∫àß™’È„π°“√‡√àߧ≈Õ¥„À≥â°àÕπ‡°‘¥§«“¡‡ ’ˬ߰“√µ‘¥‡™◊ÈÕ„π ∑“√°∑’Ë ÚÙ ™—Ë«‚¡ßÀ≈—ßπÈ”§√Ë”·µ° À“°¡’°“√ª√—∫ª√ÿß ‡°≥±å∫àß™’È‚¥¬¢¬“¬‡«≈“‡ªìπ Ù¯ - ˜Ú ™—Ë«‚¡ß‡æ◊ËÕ„Àâ ª“°¡¥≈Ÿ°¡’§«“¡æ√âÕ¡¡“°¢÷Èπ °Á®–‡æ‘Ë¡‚Õ°“ ∑’Ë°“√™—°π” °“√§≈Õ¥„Àâª√– ∫§«“¡ ”‡√Á®¡’¡“°¢÷ÈπÀ√◊Õ‡ΩÑ“√Õ„À⇮Á∫ §√√¿å‡Õß Õ—µ√“°“√ºà“µ—¥§≈Õ¥„π°≈ÿà¡π’ÈÕ“®®–≈¥≈ß„°≈â ‡§’¬ß°≈ÿà¡∑’ËπÈ”§√Ë”¬—߉¡à·µ° ‚¥¬∑’˧«“¡‡ ’ˬߵàÕ°“√µ‘¥‡™◊ÈÕ „π¡“√¥“·≈–∑“√°‰¡à‡æ‘Ë¡¢÷Èπ

°‘µµ‘°√√¡ª√–°“» ¢Õ¢Õ∫§ÿ ≥ §≥–°√√¡°“√§«∫§ÿ ¡ ß“π«‘ ®— ¬ ¢Õß ‚√ß欓∫“≈æ√–π—ßË ‡°≈â“∑’ÕË πÿ≠“µ„Àâ∑”°“√«‘®¬— ·≈–Õπÿ≠“µ „Àâæ‘¡æ出¬·æ√à ‡®â“Àπâ“∑’Ë欓∫“≈ÀâÕߧ≈Õ¥∑’˙૬„π°“√ §âπ§«â“·≈–√«∫√«¡¢âÕ¡Ÿ≈

‡Õ° “√Õâ“ßÕ‘ß Ò. ∏’√–æß»å ‡®√‘≠«‘∑¬å. ¿“«–πÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å. „π: ∏’√–æß»å ‡®√‘≠«‘∑¬å, ∫ÿ≠™—¬ ‡Õ◊ÈÕ‰æ‚√®πå°‘®, »—°π—π ¡–‚π∑—¬, ¡™“¬ ∏π«—≤𓇮√‘≠, °√–‡…’¬√ ªí≠≠“§”‡≈‘», ∫√√≥“∏‘°“√. Ÿµ‘»“ µ√å. æ‘¡æå§√—Èß∑’Ë Û. °√ÿ߇∑æ¡À“π§√: ‚Õ ‡Õ æ√‘Èπµ‘Èß ‡Œâ“ å; ÚıÙ¯: ÛÚ˘-Ù. Ú. ACOG committee on Practice Bulletins- Obstetrics. ACOG Practice Bulletin No. 80: premature rupture of membranes. Clinical management guidelines for obstetrician- gynecologists.

Obstet Gynecol 2007;109:1007-19. Û. Parry S, Strauss JF. Premature rupture of the fetal membranes. N Engl J Med 1998;338:66370.

288 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Ù. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC III, Wenstrom KD. Normal Labor and Delivery. Williams obstetrics 22nd ed. New York: McGraw-Hill;2005:p 409-41. ı. ‰æ‚√®πå ∫ÿ≠≈—°…≥廑√‘, §™“¿√≥å π‘Ë¡‡¥™. Õÿ∫—µ‘°“√≥å ·≈–ªí®®—¬‡ ’¬Ë ß°“√‡°‘¥°≈ÿ¡à Õ“°“√ ”≈—°¢’‡È ∑“„π∑“√°·√° ‡°‘¥∑’‚Ë √ß欓∫“≈À“¥„À≠à. ߢ≈“π§√‘π∑√凫™ “√ ÚÛ;ÚÒ:Ò˜˘-¯ˆ. ˆ. Saropala N, Chaturachinda K. Outcome of premature rupture of membranes (PROM) at term: Ramathibodi Hospital, 1988. J Med Assoc Thai 1993;76 (Suppl 1):56-9. ˜. π“‡√» «ß»å‰æ±Ÿ√¬å. °“√¥Ÿ·≈∑“√°·√°‡°‘¥∑’Ë¡“√¥“¡’ ∂ÿßπÈ”§√Ë”·µ°°àÕπ°“√‡®Á∫§√√¿å. „π: ™“≠™—¬ «—π∑π“»‘√‘, «‘∑¬“ ∂‘∞“æ—π∏å, ª√“‚¡∑¬å ‰æ√ ÿ«√√≥“, ÿπ∑√ ŒâÕ‡ºà“æ—π∏å, ∫√√≥“∏‘°“√. ‡«™»“ µ√åª√‘°”‡π‘¥. æ‘¡æå§√—Èß∑’Ë Ò. °√ÿ߇∑æ¡À“π§√: ∫. ¬Ÿ‡π’ˬπ §√’‡Õ™—Ëπ ®”°—¥;Úıı:˘˜-˘. ¯. Chan BC, Leung WC, Lao TT. Prelabor rupture of membranes at term requiring labor induction- a feature of occult fetal cephalopelvic disproportion? J Perinat Med 2009;37:118-23. ˘. Sheiner E, Levi A, Feinstein U, Hallak M, Mazer M. Risk factors and outcome of failure to progress during the first stage of labor: a population-based study. Acta Obstet Gynecol Scand 2002;81:222-6. Ò. Park KH, Hong JS, Ko JK, Cho YK, Lee CM, Choi H, et al. Comparative study of induction of labor in nulliparous women with premature rupture of membranes at term compared to those with intact membranes: duration of labor and mode of delivery. J Obstet Gynaecol Res 2006;32:482-8.

ÒÒ. Ben-Haroush A, Yogev Y, Glickman H, Bar J, Kaplan B, Hod M. Mode of delivery in pregnancies with premature rupture of membranes at or before term following induction of labor with prostaglandin E2. Am J Perinatol 2004;21:263-8. ÒÚ. Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol 2004;104:10517. ÒÛ. Ratanakorn W, Srijariya W, Chamnanvanakij S, Saengaroon P. Incidence of neonatal infection in newborn infants with a maternal history of premature rupture of membranes (PROM) for 18 hours or longer by using Phramongkutklao Hospital clinical practice guideline (CPG). J Med Assoc Thai 2005;88:973-8. ÒÙ. Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2006;25: CD005302. Òı. Mozurkewich E. Prelabor ruptures of membranes at term: induction techniques. Clin Obstet Gynecol 2006;49:672-83. Òˆ. Seaward PG, Hannah ME, Myhr TL, Farine D, Ohlsson A, Wang EE, et al. International multicenter term PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Premature rupture of the membranes. Am J Obstet Gynecol 1998;179:635-9.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Abstract Outcomes of pregnancy with premature rupture of membranes more than 12 hours Khamnuan Jitmaneewan Department of Obstetrics and Gynecology, Pranungklao Hospital Background:

Aim:

Methods:

Results:

Conclusions:

Key words:

The management of premature rupture of membranes at term pregnancy is not certain whether the immediate watchful induction or waiting is better for both mother and infant. It also affects on mode of delivery.

To evaluate the effect of premature rupture of the membranes (PROM) more than 12 hours at term, comparing upon intact membranes at term who present with mucous bloody show at admission, upon outcomes and mode of delivery.

This retrospective descriptive study was performed by searching medical records from September 2004 to October 2009. There were 321 cases of PROM pregnant and 1,043 cases of non PROM pregnant. Criteria for enrolment include (1) PROM more than 12 hours (2) Low risk and term pregnancy, gestational age 37-41 weeks (3) Cervical dilatation of non PROM group less than 2 cm. Statistics were analyzed with Chi square test, Fisher没s exact test and student t test.

321 PROM pregnant whose labor was inducted with oxytocin had a significant higher risk of cesarean section than 1,043 non PROM group (odds ratio 1.877, 95% CI 1.454-2.425). With no differences were detected for maternal body weight and infant没s body weight.

Planed labor induction for PROM is associated with higher risk of cesarean in comparison to those with intact membranes.

Pregnancy, Premature rupture of membranes

289

290 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

π‘æπ∏åµπâ ©∫—∫

Scarless hysterectomy and minimally invasive gynecologic operations in Nopparat Rajathani Hospital : initial experience Chalermpol Assawatheerangkoon

Abstract To show that scarless hysterectomy is the best way of hysterectomy in the selected benign gynecologic patients who have not too big uterus, no severe adhesion or endometriosis. It has advantages of lower morbidity, faster recovery, lower cost and good cosmetic results.

Materials and A case series study was carried out in Nopparat Rajathani Hospital between Methods: April 2009 and April 2010 in 20 women without uterine prolapse who requested hysterectomy for various benign diseases of the uterus. Scarless hysterectomies were done by the technique adapted from Purohit Ram Krishna and Masaaki Andou. Successful operation, intra and post operative morbidity, post operative pain, re-admission and cosmetic result were observed.

Scarless hysterectomy was succeeded in all 20 cases and bilateral salpingoResults: oophorectomy in 5 indicated cases. No intra-or post-operative morbidity, no re-admission, less postoperative pain, low cost and good cosmetic result were observed.

Conclusion: Scarless hysterectomy is a good alternative way for hysterectomy in the selected cases of benign diseases of the uterus. It needs some surgical skills but gives less morbidity, less pain, less cost and good cosmetic result.

Objective:

Key words:

Scarless hysterectomy, Natural orifice hysterectomy, Vaginal hysterectomy, nonprolapsed uterus, Minimally invasive gynecologic operations (MIGO)

Department of Obstetrics and Gynecology, Nopparat Rajathani Hospital

291

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Introduction

Materials and Methods

Minimally Invasive Gynecologic Operations (MIGO) started in Nopparat Rajathani Hospital (NRH) from 1995. MIGO comprised of 2 parts.

The first part was hysterectomy that had 3 categories, as follow: 1. Vaginal Hysterectomy (VH) that had many synonym: - Natural orifice hysterectomy (NOH) - Scarless hysterectomy (SH) 2. Hysterectomy and Laparoscopy that had 3 subsets: - Total laparoscopic hysterectomy (TLH) - Laparoscopic hysterectomy (LH) - Laparoscopic assisted vaginal hysterectomy (LAVH) 3. Mini total abdominal hysterectomy (Mini TAH) The second part of MIGO was adnexal surgery that was done by laparoscopy or minilaparotomy (4-6 cm. skin incision length).

Laparoscopic surgery and mini TAH will be reported in other papers.

VH or NOH or SH was done in the old days for prolapsed uterus only. Now, I started SH in non prolapsed uterus with benign pathology cases. SH had more advantages for lower morbidity, faster recovery1, and not required for special instruments as in laparoscopy. But SH was more complex in non-prolapsed uterus and had some absolute and relative contraindications.2

A case series study was carried out between April, 2009 and April, 2010 on 20 women without uterine prolapse who required hysterectomy for different benign diseases of the uterus. There were 10 cases of leiomyoma, 3 cases of a denomyosis, 1 case of DUB, 3 cases of chronic pelvic pain, 1 case of CIN III, 2 cases of mental retardation. The demographic data were shown in Table 1.

The surgery techniques were adapted from Purohit Ram Krishna 3 and Masaaki Andou. 4 The principles of techniques were 1. Hydrodissection of the plane of vaginal mucosa at the fornices of cervix by injection of NSS 20 ml. + 2 drops of 1 : 1000 adrenaline (in non hypertensive patients) 2. Use of electrocautery for - incision by monopolar (MP) 30 watt, pure cut.

- coagulation by bipolar (BP) 45 watt, fine tip long legs.

- tissue desiccation/coagulation by Liga-Sure (mostly), PK. 3. Bulge of uterine arteries were approached and secured extraperitoneally.

4. No sutures for any pedicles, except for lateral vaginal angles fixation (vault prolapse prevention) and stump closures by vicryl 2-0.

5. Conventional volume reduction maneuvers are used for large uterus.5,6,7

Table 1 The demographic data Patients 1.

2.

3.

4.

age (year) parity previous cesarean section (no.) previous other abdominal surgery (no.)

Mean

Range

43.2 1.7 0.5 0.3

15-74 0-5 (P = 0, 4 cases) 0-3 0-1

292 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

6. For an obstacle or poor visibility, I use a 10 mm telescope with light source to illuminate transvaginally and proceed further step of the operation.8,9

Results The operative data was shown in Table 2 as below.

Table 2 The operative data Operative data 1.

2.

3.

4.

5.

operative time (min) for SH operative time (min) for BSO blood loss (ml.) specimen weight (g.) hospital stay (days)

Scarless hysterectomy was completed in all 20 cases. Vaginal salpingo-oophorectomy was completed in 5 indicated cases. All operation were succeeded without complications, including 4 nulliparous cases. The 2 teenagers (Downûs syndrome) needed additional small episiotomy to improve vaginal diameter. There was mild post-operative pain, same as D & C patients that needed only oral acetaminophen tablets. No post-operative hemorrhage, no vault hematoma, no febrile morbidity and no readmission were observed. All patients were very satisfied for this operation.

Discussion Hysterectomy and/or salpingo-oophorectomy are essential operations for many patients and gynecologists. There are four choices of hysterectomy: 1. TAH is the basic approach.

2. LAVH, LH, TLH need more laparoscopic surgery skills & more expensive instruments.

3. Mini TAH needs more surgical skills but less cost.

4. SH, VH, NOH, is the same principle as Mini TAH, but no scar seen on the abdomen.

I believe that SH is safe, effective and cheap operation for almost all cases of benign disease of

Mean 88.5 25 379.4 170.9 2.3

Range 60-120 20-30 50-1,000 40-500 2-3

the uterus without prolapse, including nulliparous cases. In the near future, I will operate the bigger size uterus.10,11 So, I think that many more TAH or TLH/LH/LAVH could be avoided by SH.

References 1. Dicker RC, Greenspan JR, Strauss LT. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982;144: 841-8.

2. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol 2001;184: 1386-91.

3. Purohit RK. Purohit technique of vaginal hysterectomy: a new approach. BJOG 2003;110: 1115-9.

4. M. Minimally invasive hysterectomy for difficult fibroid and endometriosis. Program & Abstract Book of XVIII Annual Congress of International Society for Gynecologic Endoscopy;2009:101.

5. Magos A, Bournas N, Sinha R. Vaginal hysterectomy for the large uterus. BJOG 1996;103: 246-51.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

6. Unger JB. Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams. Am J Obstet Gynecol 1999;180: 1337-44.

7. Pelosi MA 3rd, Pelosi MA. The Pryor technique of uterine morcellation. Int J Gynaecol Obstet 1997;58:299-303.

8. Paparella P, Sizzi O, Rossetti A, De Benedittis F, Paparella R. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet 2004;270:104-9.

293

9. Sizzi O, Paparella P, Bonito C, Paparella R, Rossetti A. Laparoscopic assistance after vaginal hysterectomy and unsuccessful access to the ovaries or failed uterine mobilization: changing trends. JSLS 2004;8:339-46.

10. Sahin Y. Vaginal hysterectomy and oophorectomy in women with 12-20 weeks size uterus.

Acta Obstet Gynecol Scand. 2007;86:1359-69.

11. Purohit RK. Purohit technique of vaginal hysterectomy learn by step by step. Asian J Obstet Gynecol Pract. 2007;11:12-8.

∫∑§—¥¬àÕ ª√– ∫°“√≥å‡∫◊ÈÕßµâπ„π°“√ºà“µ—¥¡¥≈Ÿ°™π‘¥ª√“»®“°·º≈‡ªìπ∫πÀπâ“∑âÕߺŸâªÉ«¬·≈–°“√ºà“µ—¥∑“ßπ√’‡«™∑’Ë ≈ÿ°≈È”πâÕ¬„π‚√ß欓∫“≈πæ√—µπ√“™∏“π’ ‡©≈‘¡æ≈ Õ—»«∏’√“ß°Ÿ√ °≈ÿà¡ß“π Ÿµ‘-π√’‡«™»“ µ√å ‚√ß欓∫“≈πæ√—µπ√“™∏“π’ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ «—µ∂ÿª√– ߧå:

«— ¥ÿ·≈–«‘∏’°“√:

º≈°“√»÷°…“:

√ÿª:

§” ”§—≠:

‡æ◊ÕË · ¥ß„Àâ‡ÀÁπ«à“ °“√ºà“µ—¥¡¥≈Ÿ°™π‘¥ª√“»®“°·º≈‡ªìπ∫πÀπâ“∑âÕߺŸªâ «É ¬ ‡ªìπ°“√ºà“µ—¥¡¥≈Ÿ°∑’¥Ë ∑’ ’Ë ¥ÿ „πºŸªâ «É ∑’˧—¥ √√·≈â««à“¢π“¥¡¥≈Ÿ°‰¡à‚µ¡“°‡°‘π‰ª ‰¡à¡’æ—ߺ◊¥™π‘¥√ÿπ·√ß„πÕÿâ߇™‘ß°√“π ·≈–‰¡à ß —¬«à“‡ªìπ¡–‡√Áß¡¥≈Ÿ° °“√ºà“µ—¥™π‘¥π’È¡’¿“«–·∑√°´âÕπµË” ºŸâªÉ«¬øóôπµ—«‡√Á« §à“„™â®à“¬∂Ÿ°·≈– «¬ß“¡°«à“ ‡ªìπ°“√»÷°…“√“¬ß“πºŸâªÉ«¬∑’Ë√—°…“„π‚√ß欓∫“≈πæ√—µπ√“™∏“π’ √–À«à“߇¥◊Õπ‡¡…“¬π 2552 ·≈–‡¥◊Õπ‡¡…“¬π 2553 ®“°®”π«πºŸâªÉ«¬À≠‘ß 20 §π ∑’˵âÕß°“√µ—¥¡¥≈Ÿ° ‡π◊ËÕß®“°æ¬“∏‘ ¿“æ™π‘¥‰¡à„™à¡–‡√Áß ‚¥¬∑’ˉ¡à¡’¿“«– ¡¥≈Ÿ°À¬àÕπ√à«¡¥â«¬ ‡∑§π‘§°“√ºà“µ—¥¥—¥·ª≈ß®“° ªÿ‚√À‘µ √“¡ °ƒ…≥– ·≈–¡“´“°‘ ‡Õπ‚¥– ‚¥¬°“√«—¥º≈ §«“¡ ”‡√Á®¢Õß°“√ºà“µ—¥ ¿“«–·∑√°´âÕπ∑’ˇ°‘¥¢≥–·≈–À≈—ß°“√ºà“µ—¥ §«“¡‡®Á∫ª«¥À≈—ß°“√ºà“µ—¥ °“√°≈—∫ ‡¢â“Õ¬Ÿà„π‚√ß欓∫“≈À≈—ß®“°®”Àπà“¬ºŸâªÉ«¬°≈—∫∫â“π·≈â« §à“„™â®à“¬·≈–§«“¡ «¬ß“¡¢Õß∫“¥·º≈ºà“µ—¥ °“√ºà“µ—¥™π‘¥π’Ȫ√– ∫§«“¡ ”‡√Á®Õ¬à“ߥ’„πºŸâªÉ«¬∑—ÈßÀ¡¥ 20 √“¬ ¡’ 5 √“¬ ∑’ˉ¥â√—∫°“√µ—¥√—߉¢à·≈–∑àÕπ”‰¢àÕÕ° 2 ¢â“ßµ“¡∑’˺ŸâªÉ«¬µâÕß°“√·≈–¡’ 4 √“¬∑’ˉ¡à‡§¬§≈Õ¥∫ÿµ√ ‰¡àæ∫¿“«–·∑√°´âÕπ®“°°“√ºà“µ—¥ ‰¡àæ∫°“√°≈—∫ ‡¢â“Õ¬Ÿà„π‚√ß欓∫“≈´È” ª«¥·º≈ºà“µ—¥πâÕ¬°«à“ §à“„™â®à“¬∂Ÿ°°«à“·≈– «¬ß“¡°«à“ „πºŸªâ «É ¬∑’¡Ë æ’ ¬“∏‘ ¿“æ™π‘¥‰¡à„™à¡–‡√ÁߢÕß¡¥≈Ÿ° ∂Ⓣ¥â§¥— √√ºŸªâ «É ¬∑’‡Ë À¡“– ¡·≈â« °“√ºà“µ—¥¡¥≈Ÿ°™π‘¥ª√“»®“° ·º≈‡ªìπ∫πÀπâ“∑âÕߺŸâªÉ«¬®–‡ªìπ∑“߇≈◊Õ°∑’Ë¥’∑“ßÀπ÷Ëß ·¡â·µà„πºŸâªÉ«¬∑’ˉ¡à‡§¬§≈Õ¥∫ÿµ√°“√ºà“µ—¥ ™π‘¥π’È µâÕß °“√∑—°…–„π°“√ºà“µ—¥¡“°æÕ ¡§«√ ·µà„Àâº≈§ÿ¡â §à“„π·ßà¢Õß¿“«–·∑√°´âÕπ∑’πË Õâ ¬°«à“ §«“¡‡®Á∫ª«¥∑’πË Õâ ¬°«à“ §à“„™â®à“¬πâÕ¬°«à“ «¬ß“¡°«à“ °“√ºà“µ—¥¡¥≈Ÿ°∑“ß™àÕߧ≈Õ¥„π°√≥’¡¥≈Ÿ°‰¡àÀ¬àÕπ, °“√ºà“µ—¥¡¥≈Ÿ°™π‘¥ª√“»®“°·º≈‡ªìπ∫πÀπâ“∑âÕߺŸâªÉ«¬, °“√ºà“µ—¥‰¡‚°–

294 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

π‘æπ∏åµπâ ©∫—∫

º≈°“√‡ª≈’ˬπ·ª≈ß·∫∫‡©’¬∫æ≈—πµàÕ°“√¢¬“¬¢Õß∑√«ßÕ° ¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬„πºŸâÀ≠‘ß∑’Ë„ à‡ ◊ÈÕ√—¥√Ÿª æ√À¡«¥’ Õ—»‡®√’¬å«—≤π“, ÿ«‘¡≈ ¥”√ß»’≈, πæ«√√≥ ®“√ÿ ÿ ‘π∏å, æ—™√’ §ÿ≥§È”™Ÿ

∫∑§—¥¬àÕ °“√„ à‡ ◊ÕÈ √—¥√Ÿª‡ªìπ∑’πË ¬‘ ¡¡“°„π°≈ÿ¡à «—¬√ÿπà ·≈–¬—߉¡à‡ªìπ∑’∑Ë √“∫·πà™¥— ‡°’¬Ë «°—∫º≈°√–∑∫∑’‡Ë °‘¥¢÷πÈ µàÕ √à“ß°“¬ πÕ°®“°π’¬È ß— ‰¡à¡ß’ “π«‘®¬— „¥Ê ∑’∑Ë ”°“√»÷°…“‡°’¬Ë «°—∫°“√À“¬„®·≈–°“√¢¬“¬µ—«¢Õß∑√«ßÕ° ®“°°“√ «¡‡ ◊ÈÕ√—¥√Ÿª «—µ∂ÿª√– ߧå: ‡æ◊ÕË »÷°…“º≈°“√‡ª≈’¬Ë π·ª≈ß·∫∫‡©’¬∫æ≈—π¢Õß°“√„ à‡ ◊ÕÈ √—¥√ŸªµàÕ°“√¢¬“¬µ—«¢Õß∑√«ßÕ° (Chest expansion) ¿“¬À≈—ßÕÕ°°”≈—ß°“¬„πºŸâÀ≠‘ß ÿ¢¿“楒 Õ“ “ ¡—§√∑’Ë «¡„ à‡ ◊ÈÕ√—¥√ŸªÀ√◊Õ‰¡à√—¥√Ÿª®”π«π Û §π ÕÕ°°”≈—ß°“¬¥â«¬°“√ªíòπ®—°√¬“π Òı π“∑’ «‘∏’°“√»÷°…“: §à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë√–¥—∫√—°·√â (axilla), ≈‘Èπªïò (xiphoid) ·≈–°√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë Ò (10th costal cartilage) °àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬®–∂Ÿ°π”¡“«‘‡§√“–Àå¢Õâ ¡Ÿ≈∑“ß ∂‘µ¥‘ «â ¬ PairedSamples Test º≈°“√»÷°…“: °“√¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπÕÕ°°”≈—ß°“¬„π¢≥–„ à‡ ◊ÕÈ ‰¡à√¥— √Ÿª∑’√Ë –¥—∫√—°·√â ≈‘πÈ ªïò ·≈–°√–¥Ÿ° ´’Ë‚§√ß™‘Èπ∑’Ë Ò ¡’§à“ ˜.¯ ± Ò.˜Ò ˆ.ıÚ ± Ò.¯¯ ·≈– ˆ.ˆˆ ± Ú.ı ´¡. ·≈–¿“¬À≈—ß °“√ÕÕ°°”≈—ß°“¬ ¡’§à“ ˆ.˘˘ ± Ò.ıÙ ˆ.Ù˘ ± Ò.ı ·≈– ˆ.Ù˘ ± Ò.¯˘ ´¡. „π¢≥–∑’Ë¡’°“√ „ à‡ ◊ÈÕ√—¥√Ÿª æ∫«à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπ°“√ÕÕ°°”≈—ß°“¬¡’§à“ ˆ.ıˆ ± Ò.ıÛ ˆ.Ú¯ ± Ò.ˆ˜ ·≈– ˆ.ÛÛ ± Ú.˜ ´¡. ·≈–¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬ ¡’§à“ ˆ.ˆÒ ± Ò.ıÙ ˆ.ÚÚ ± Ò.ı˘ ·≈– ˆ.ÚÚ ± Ú.Û ´¡. ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ° √–À«à“ß°“√„ à‡ ◊ÈÕ √—¥√Ÿª·≈–‰¡à√—¥√Ÿª∑’Ë√–¥—∫√—°·√â°àÕπÀ√◊Õ¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬ æ∫«à“ ¡’§à“§«“¡·µ°µà“ß°—π Õ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘µ∑‘ ß—È °àÕπ·≈–À≈—ßÕÕ°°”≈—ß°“¬ (§à“æ’ ≤ .ı) ‚¥¬°àÕπÕÕ°°”≈—ß°“¬¡’§“à °“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°µà“ß°—π .ıÚ ± Ò.Ûˆ ´¡. ·≈–¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬¡’§“à µà“ß°—π .Û˜ ± .˘˜ ´¡. ·µà‰¡àæ∫§«“¡·µ°µà“ߢÕß∑√«ßÕ°„π√–¥—∫Õ◊Ëπ √ÿªº≈°“√»÷°…“: °“√∑’∑Ë √«ßÕ° à«π∫π¡’°“√¢¬“¬µ—«∑’≈Ë ¥≈ßÕ“®‡°‘¥®“°°“√®”°—¥¢Õßµ—«‡ ◊ÕÈ ∑’ Ë «¡„ à ·µà‡π◊ÕË ß®“°„π °“√»÷°…“§√—ßÈ π’‡È ªìπ°“√»÷°…“º≈°“√‡ª≈’¬Ë π·ª≈ß√–¬– —πÈ ®÷߉¡à “¡“√∂Õ∏‘∫“¬°“√‡ª≈’¬Ë π·ª≈ßÀ√◊Õ º≈°√–∑∫√–¬–¬“«∑’ÕË “®‡°‘¥¢÷πÈ °—∫ºŸ∑â ’Ë «¡„ à‡ ◊ÕÈ √—¥√Ÿª‡ªìπ‡«≈“π“π Ê ¥—ßπ—πÈ ®÷ߧ«√∑”°“√»÷°…“‡æ‘¡Ë ‡µ‘¡ µàÕ‰ª„πÕ𓧵‡æ◊ËÕ»÷°…“∂÷ߺ≈°√–∑∫¥—ß°≈à“« §«“¡‡ªìπ¡“:

§” ”§—≠: °“√¢¬“¬µ—«¢Õß∑√«ßÕ°, ‡ ◊ÈÕ√—¥√Ÿª, °“√ÕÕ°°”≈—ß°“¬, °“√‰À≈‡«’¬πÕ“°“»„πªÕ¥, °“√À“¬„®

¿“§«‘™“°“¬¿“æ∫”∫—¥ §≥– À‡«™»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å

295

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

∫∑π” ªí®®ÿ∫—πæ∫«à“ºŸâÀ≠‘߉∑¬¡’·π«‚πâ¡∑’Ë®–„ à‡ ◊Èպⓠ√—¥√Ÿª¡“°¢÷Èπ ¢π“¥¢Õ߇ ◊ÈÕ∑’Ëπ‘¬¡„ à°Á¡’¢π“¥‡≈Á°≈¥≈ß ‡√◊ËÕ¬Ê ®π¡’¢π“¥‡≈Á° ÿ¥‡æ’¬ß SSSSS (ıS) §«“¡π‘¬¡„π °“√„ à‡ ◊ÈÕ√—¥√Ÿªπ—∫‡ªìπªí≠À“Àπ÷Ëß∑“ß —ߧ¡∑’˵âÕß°“√°“√ ·°â‰¢ ‡æ√“–Õ“® àߺ≈°√–∑∫µàÕ ÿ¢¿“æ√à“ß°“¬¢ÕߺŸ â «¡„ à ‚¥¬‰¡à√Ÿâµ—« ·¡â«à“®–¡’π—°«‘™“°“√∫“ß°≈ÿà¡·≈–·æ∑¬å‰¥âÕÕ° ¡“°≈à“«∂÷ߺ≈°√–∑∫µàÕ ÿ¢¿“æ¢ÕߺŸâ «¡„ à‡ ◊ÈÕ√—¥√Ÿª‡ªìπ ®”π«π¡“° ·µà§«“¡‡ÀÁπ∑’‰Ë ¥â√∫— °Á¡∑’ ß—È à«π∑’ Ë Õ¥§≈âÕß·≈– ¢—¥·¬âß°—π π—°«‘™“°“√·≈–·æ∑¬åÀ≈“¬∑à“π‡™◊ËÕ«à“ °“√„ à ‡ ◊ÈÕπ—°»÷°…“∑’Ë√—¥¡“°Ê ‡ªìπ°“√ªî¥™àÕß∑“ß°“√À“¬„®∑’Ë ∂Ÿ°µâÕß ∑”„À⺟⠫¡„ à‰¡à “¡“√∂À“¬„®„Àâ≈÷°·≈–¬“«æÕ∑’Ë ®–∑”„ÀâÕ“°“»‰À≈‡¢â“‰ª Ÿà√à“ß°“¬‰¥â‡æ’¬ßæÕ ‚¥¬ºŸâ∑’Ë «¡„ à ‡ ◊ÕÈ √—¥√Ÿª®–À“¬„®‰¥â π—È ·≈–µ◊πÈ ≈¡À“¬„®‰¡à ¡Ë”‡ ¡Õ ∑”„Àâ π”ÕÕ°´‘‡®π‰ª Ÿ à ¡Õß·≈–‡´≈≈å∑«—Ë √à“ß°“¬‰¥â‰¡à∑«—Ë ∂÷ß √à“ß°“‰¥â√∫— °ä“´ÕÕ°´‘‡®ππâÕ¬®–‡°‘¥¿“«–°ä“´§“√å∫Õπ‰¥ÕÕ°‰´¥å §—Ëß„π°√–· ‡≈◊Õ¥ ®÷ßÕ“®∑’Ë®–∑”„À⇰‘¥¿“«–§«“¡‡ªìπ°√¥ ·≈–¥à“ߢÕ߇≈◊Õ¥º‘¥ª√°µ‘ àߺ≈„À⇰‘¥¿“«–∑”„Àâ‡Àπ◊ÕË ¬ßà“«‘߇«’¬π»’√…–·≈–Àπâ“¡◊¥ πÕ°®“°π’¬È ß— ¡’°“√ ”√«®¥â«¬°“√ Õ∫∂“¡π—°»÷°…“„π¡À“«‘∑¬“≈—¬µà“ßÊ ‡°’ˬ«°—∫°“√„ à‡ ◊ÈÕ π—°»÷°…“√—¥√Ÿªæ∫«à“ à«π„À≠à√Ÿâ ÷°À“¬„®‰¡àÕÕ°·≈–µâÕß À“¬„®‡√Á«Ê ·≈– —ÈπÊ À√◊Õ‰¡à “¡“√∂À“¬„®‰¥â‡µÁ¡∑’Ë ·µà„π ∑“ßµ√ß¢â“¡π—°«‘™“°“√∫“ß°≈ÿà¡°≈—∫¡Õß«à“°“√„ à‡ ◊ÈÕ∑’Ë√—¥ Àπâ“Õ°„π«—¬√ÿàπÀ≠‘߉¡à‰¥â°àÕ„À⇰‘¥‚√§√⓬·√ß πÕ°®“°®– ∑”„À⇰‘¥Õ“°“√·æâºâ“∑’Ë «¡„ à‡∑à“π—ÈπÀ√◊ÕÕ“®®–∑”„Àâ ºŸâ ∑’Ë «¡„ àÀ“¬„®≈”∫“° À√◊Õ‡°‘¥°“√√–§“¬‡§◊Õߺ‘«Àπ—ß∫√‘‡«≥ ∑√«ßÕ° ®“°°“√»÷°…“„πÕ¥’µ∑’˺à“π¡“ æ∫«à“ À“°¡’°“√ «¡‡ ◊Èպ⓷≈–Õÿª°√≥å∑’Ë√—¥∑√«ßÕ°·πàπ‡°‘π‰ª ®– àߺ≈ µàÕ°“√∑”ß“π¢Õߪե·≈–°“√¢¬“¬µ—«¢Õß∑√«ßÕ°‰¥â ‡™àπ °“√æ—πºâ“√—¥Õ°À√◊Õ°“√„ àÕÿª°√≥åæ¬ÿß≈”µ—«Ò °“√ –æ“°√–‡ªÜ“‡ªÑ‡ âπ‡¥’¬«„π≈—°…≥–æ“¥Õ° (single strap: cross chest) ®–∑”„À⇰‘¥°“√°¥µàÕ∑√«ßÕ°¡“°°«à“°“√ –æ“·∫∫ Õ߇ âπ (double straps)Ú ‡π◊ËÕß®“°∑”„À⇰‘¥°“√ ®”°—¥¢Õß°“√¢¬“¬µ—«¢Õß∑√«ßÕ°„π¢≥–À“¬„®‡¢â“ ∑”„Àâ °“√√–∫“¬Õ“°“»¢Õߪե≈¥πâÕ¬≈ß∑—Èߢ≥–æ—°·≈–ÕÕ° °”≈—ß°“¬ ®÷ß∑”„À⇰‘¥Õ“°“√‡Àπ◊ËÕ¬ßà“¬·≈–¡’ª√‘¡“≥¢Õß ÕÕ°´‘‡®π„π°√–· ‡≈◊Õ¥µË”°«à“ª√°µ‘°“√ –擬‡ªÑ∑’Ë “√—¥·πàπ¡“°®π‡°‘π‰ªÛ ®–¡’º≈°√–∑∫Õ¬à“ß¡“°µàÕ°“√ ∑”ß“π¢Õߪե‡π◊ËÕß®“°®–‰ª®”°— ¥ °“√·≈°‡ª≈’Ë ¬ π°ä “ ´ ·≈–≈¥°“√¢—∫Õ“°“»ÕÕ°®“°ªÕ¥ (expiratory flow)

πÕ°®“°π’Ȭ—ßæ∫«à“ °“√„ à‡ ◊ÈÕ™—Èπ„π∑’Ë√—¥·πàπ‡°‘π‰ªÙ ®–¡’ º≈µàÕ°“√°¥∑—∫∑√«ßÕ° ¥—ßπ—Èπ‡¡◊ËÕ„ à‡ ◊ÈÕ™—Èπ„π‡ªìπ‡«≈“ π“πÊ ®–∑”„À⇰‘¥°“√°¥∑—∫µàÕº‘«Àπ—ß·≈–‡ âπ‡≈◊Õ¥„µâ º‘«Àπ—ß·≈–Õ“®®–∑”„À⇰‘¥°“√¢—¥¢«“ß°“√‰À≈‡«’¬π¢Õß ‡≈◊ Õ ¥„π∫√‘ ‡ «≥¥— ß °≈à “ «‰¥â ¬‘Ë߉ª°«à “ π—È π ¬— ß æ∫«à “ °“√„ à Õÿª°√≥å‡æ◊Ëՙ૬æ¬ÿß≈”µ—«µ≈Õ¥‡«≈“°ÁÕ“® àߺ≈°√–∑∫µàÕ °“√∑”ß“π¢Õߪե‰¥â‡™àπ°—π ‚¥¬æ∫«à“°“√„ à Boston brace „π«—¬√ÿàπ∑’ˇªìπ scoliosisı,ˆ àߺ≈∑”„Àâ§à“ vital capacity (VT), residual volume, FRC, TLC, FEV1 ·≈– specific lung compliance ≈¥≈ß Õ’°∑—È߬—ß∑”„Àâ pulmonary function ·≈–°“√·≈°‡ª≈’ˬπ°ä“´≈¥≈ß ·µà¬—߉¡à¡’ß“π«‘®—„¥∑’Ë· ¥ß„Àâ‡ÀÁπÕ¬à“ß™—¥‡®π«à“ °“√„ à‡ ◊ÈÕºâ“√—¥√Ÿª àߺ≈ °√–∑∫Õ¬à“߉√µàÕ°“√¢¬“¬µ—«¢Õß∑√«ßÕ° (chest expansion) À√◊Õ°“√∑”ß“π¢Õߪե ¥—ßπ—Èπ °“√»÷°…“„π§√—Èßπ’È®÷ß ¡’«µ— ∂ÿª√– ߧå‡æ◊ÕË »÷°…“‡ª√’¬∫‡∑’¬∫°“√¢¬“¬µ—«¢Õß∑√«ßÕ° „π·µà≈–√–¥—∫¢ÕߺŸâ∑’Ë„ à‡ ◊ÈÕ√—¥√Ÿª∑—Èß°àÕπ·≈–¿“¬À≈—ß®“° °“√ÕÕ°°”≈—ß°“¬

ª√–™“°√∑’Ë»÷°…“·≈–«‘∏’°“√ ª√–™“°√ºŸâ‡¢â“√à«¡‚§√ß°“√«‘®—ª√–™“°√°≈ÿࡵ—«Õ¬à“߇ªìπÕ“ “ ¡—§√À≠‘߉∑¬∑’Ë ¡’ ÿ¢¿“楒Փ¬ÿ√–À«à“ß Ò¯-Úı ªï ®”π«π Û §π ‚¥¬¡’ §à“¥—™π’¡«≈°“¬ (BMI) √–À«à“ß Ò¯-ÚÙ.ı °‘‚≈°√—¡/ ‡¡µ√Ú ·≈–ÕÕ°°”≈—ß°“¬πâÕ¬°«à“ Û §√—ÈßµàÕ —ª¥“ÀåÀ√◊Õ ‰¡àÕÕ°°”≈—ß°“¬ ‰¡à¡ª’ √–«—µ¢‘ Õß‚√§∑“ß√–∫∫∑“߇¥‘πÀ“¬„® ‚√§∑“ß√–∫∫À—«„®·≈–°“√‰À≈‡«’¬π‡≈◊Õ¥ ‰¡à¡§’ «“¡º‘¥ª√°µ‘ ¢Õß√–∫∫ª√– “∑ √–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕÀ√◊Õ‰¥â√—∫ ∫“¥‡®Á∫∑’¢Ë Õâ ‡¢à“À√◊Õ¢âÕ‡∑â“ ‡§¬‡¢â“√—∫°“√ºà“µ—¥„π√–¬–‡«≈“ ˆ ‡¥◊Õπ°àÕπ‡¢â“√à«¡‚§√ß°“√«‘®—¬ ºŸâ‡¢â“√à«¡°“√«‘®—¬∑ÿ°§π ®–‰¥â√—∫°“√™’È·®ß¢âÕ¡Ÿ≈‡°’ˬ«°—∫«‘∏’°“√„π°“√»÷°…“·≈–§” ·π–𔂧√ß°“√«‘®—¬ À≈—ß®“°π—Èπ∑ÿ°§π®–µâÕß≈ß™◊ËÕ„π„∫ ¬‘π¬Õ¡°àÕπ‡¢â“√à«¡„π°“√»÷°…“·≈–°√Õ°·∫∫ Õ∫∂“¡ ‡æ◊ÕË µ√«® Õ∫¢âÕ¡Ÿ≈æ◊πÈ ∞“π„π°“√§—¥‡¢â“µ“¡‡°≥±å°“√»÷°…“

«‘∏°’ “√ Õ“ “ ¡—§√∑ÿ°§π «¡„ à‡ ◊ÕÈ ¢π“¥ª√°µ‘¢Õßµπ‡Õß ·≈–«—¥°“√¢¬“¬µ—«¢Õß∑√«ßÕ°‚¥¬„™â “¬«—¥ ∫√‘‡«≥„µâ√°— ·√â (axilla), à«π∞“π¢ÕßÕ° (xiphoid) ·≈– 10th CC «—¥ ´È” Û §√—Èß„π·µà≈–√–¥—∫ ‚¥¬„ÀâÕ“ “ ¡—§√À“¬„®ÕÕ°„Àâ ÿ¥ À≈—ß®“°π—Èπ„ÀâÀ“¬„®‡¢â“Õ¬à“߇µÁ¡∑’Ë ·≈–ºŸâ«‘®—¬∑”°“√«—¥°“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°„π·µà≈–√–¥—∫ æ—° Û «‘π“∑’À≈—ß°“√

296 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

«—¥„π·µà≈–√–¥—∫ ®“°π—Èπ„ÀâÕ“ “ ¡—§√®–µâÕß∑”°“√ªíòπ ®—°√¬“π¥â«¬®—°√¬“π«—¥ß“π (Monark ergometer) ¥—ß · ¥ß„π√Ÿª∑’Ë Ò ‡ªìπ‡«≈“ Òı π“∑’ ‚¥¬·∫àßÕÕ°‡ªìπ Û ™à«ß §◊Õ™à«ßÕ∫Õÿàπ√à“ß°“¬ (warm up) ı π“∑’ ‚¥¬„Àâ Õ“ “ ¡—§√ªíòπ®—°√¬“π·∫∫‰¡à¡’°“√ª√—∫§«“¡Ωó¥ (load) ™à«ß∑’Ë Ú ‡ªìπ™à«ßÕÕ°°”≈—ß°“¬ „™â‡«≈“ ı π“∑’„π°“√ªíòπ ®—°√¬“π ‚¥¬ª√—∫§«“¡Ωó¥Õ¬Ÿà∑’Ë Ò.ı °‘‚≈°√—¡·≈–™à«ß∑’Ë Û ‡ªìπ™à«ßºàÕπ§≈“¬ (cool down) „™â‡«≈“ ı π“∑’ ‚¥¬„Àâ ªíòπ®—°√¬“π·∫∫§«“¡‡√Á«§ß∑’Ë ı-ˆ °‘‚≈‡¡µ√/™—Ë«‚¡ß

À≈—ß®“°π—Èπ®÷ß∑”°“√«—¥°“√¢¬“¬µ—«¢Õß∑√«ßÕ° ´È”Õ’°§√—È߇À¡◊Õπ°àÕπ°“√ÕÕ°°”≈—ß°“¬ Õ“ “ ¡—§√∑ÿ°§π ®–æ—°‡ªìπ‡«≈“ Ò ™—Ë«‚¡ß®πÀ“¬‡Àπ◊ËÕ¬ À≈—ß®“°π—Èπ®– ‡ª≈’Ë¬π¡“ «¡„ à‡ ◊ÈÕ∑’Ë¡’¢π“¥‡≈Á°°«à“√Õ∫Õ°¢Õßµπ‡Õß ª√–¡“≥ Ò π‘È« ·≈–∑”°“√«—¥°“√¢¬“¬µ—«¢Õß∑√«ßÕ° °àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬¥—ß∑’Ë°≈à“«¡“·≈â«„π‡∫◊ÈÕßµâπ ¢âÕ¡Ÿ≈∑’‰Ë ¥â√∫— ®–∂Ÿ°π”¡“«‘‡§√“–À奫⠬ Paired-Sample Test ‡æ◊ËÕ·ª≈º≈°“√»÷°…“∑’ˇ°‘¥¢÷Èπ

º≈°“√»÷°…“ Õ“ “ ¡—§√„π°“√«‘®—¬§√—Èßπ’ȇªìπÀ≠‘߉∑¬ ÿ¢¿“楒 ∑’Ë¡’Õ“¬ÿ√–À«à“ß Ò¯-Úı ªï ®”π«π Û §π (µ“√“ß∑’Ë Ò) Õ“ “ ¡—§√¡’Õ“¬ÿ‡©≈’ˬ Ú.ˆ˜ ± Ò.Ú˜ ªï ¡’πÈ”Àπ—°‡©≈’ËÕ¬Ÿà∑’Ë ıÛ.˜ ± Ù.ˆÛ °‘‚≈°√—¡ ¡’§«“¡ Ÿß‡©≈’ˬ Òı˘.Ù˘ ± Ù.ˆı ‡´πµ‘‡¡µ√ §à“‡©≈’ˬ¢Õß BMI Õ¬Ÿà∑’Ë ÚÒ.Òˆ ± Ò.ˆ˘ °°/¡Ú ·≈–¡’§“à ‡©≈’¬Ë §«“¡°«â“ߢÕß√Õ∫Õ° ÛÚ.˜ı ± Ò.ÛÚ π‘È« µ“√“ß∑’Ë Ò ≈—°…≥–¢ÕߺŸâ‡¢â“√à«¡‚§√ß°“√«‘®—Characteristics (n = 30) Age (years) Weight (kg) Height (cm) BMI (kg/m2) Chest circumference (inches)

Mean

±

SD

20.67 53.7 159.49 21.16 32.75

±

1.27 4.63 4.65 1.65 1.32

± ± ± ±

√Ÿª∑’Ë Ò ºŸâ‡¢â“√à«¡°“√«‘®—¬ªíòπ®—°√¬“π«—¥ß“π °“√¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“µ“√“ß∑’Ë Ú · ¥ß°“√‡ª√’¬∫§à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπ·≈–À≈—ßÕÕ°°”≈—ß°“Pre-exercise (chest expansion) Measure level Axilla (cm.)

Loose-shirt Tight-shirt (Mean ± SD) (Mean ± SD) 7.08 ± 1.71 6.56 ± 1.53

Mean difference 0.52 ± 1.36*

Post-exercise (chest expansion) Loose-shirt Tight-shirt (Mean ± SD) (Mean ± SD) 6.99 ± 1.54 6.61 ± 1.54

Mean difference 0.37 ± 0.97*

Xiphoid (cm.)

6.52 ± 1.88

6.28 ± 1.67

0.24 ± 1.41

6.49 ± 1.50

6.22 ± 1.59

0.27 ± 1.14

10th CC (cm.)

6.66 ± 2.05

6.33 ± 2.07

0.32 ± 1.13

6.49 ± 1.89

6.22 ± 2.03

0.27 ± 0.86

*§à“æ’ ≤ .ı

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

®“°µ“√“ß∑’Ë Ú æ∫«à“§à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ° °àÕπÕÕ°°”≈—ß°“¬„π¢≥–„ à‡ ◊ÈÕ‰¡à√—¥√Ÿª∑’Ë√–¥—∫√—°·√â ≈‘Èπªïò ·≈–°√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë Ò ¡’§à“ ˜.¯ ± Ò.˜Ò ˆ.ıÚ ± Ò.¯¯ ·≈– ˆ.ˆˆ ± Ú.ı ´¡. ·≈–¿“¬À≈—ß°“√ÕÕ° °”≈—ß°“¬ ¡’§à“ ˆ.˘˘ ± Ò.ıÙ ˆ.Ù˘ ± Ò.ı ·≈– ˆ.Ù˘ ± Ò.¯˘ ´¡. à«π°“√¢¬“¬µ—«¢Õß∑√«ßÕ°„π¢≥–∑’Ë ¡’ ° “√„ à ‡ ◊ÈÕ√—¥√Ÿª æ∫«à“¡’°“√¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπ°“√ÕÕ° °”≈—ß°“¬∑’Ë√–¥—∫√—°·√â ≈‘Èπªïò ·≈–°√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë Ò ¡’ §à“ ˆ.ıˆ ± Ò.ıÛ ˆ.Ú¯ ± Ò.ˆ˜ ·≈– ˆ.ÛÛ ± Ú.˜ ´¡. ·≈–¿“¬À≈—ß°“√ÕÕ°°”≈—ß°“¬ ¡’§à“ ˆ.ˆÒ ± Ò.ıÙ ˆ.ÚÚ ± Ò.ı˘ ·≈– ˆ.ÚÚ ± Ú.Û ´¡. ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§à“§«“¡·µ°µà“ߢÕß°“√¢¬“¬µ—« ¢Õß∑√«ßÕ°√–À«à“ß°“√„ à‡ ◊ÈÕ√—¥√Ÿª ·≈–‰¡à √— ¥ √Ÿ ª ∑’Ë √ –¥— ∫ µà“ßÊ ¢Õß∑√«ßÕ° æ∫«à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë√–¥—∫ √—°·√â¡’§«“¡·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑—Èß°àÕπ ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬ ‚¥¬æ∫«à“°“√¢¬“¬µ—«¢Õß ∑√«ßÕ°°àÕπÕÕ°°”≈—ß°“¬¡’§“à §«“¡·µ°µà“ßÕ¬Ÿ∑à ’Ë .ıÚ ± Ò.Ûˆ ´¡. (§à“æ’ ≤ .ı) ·≈–°“√¢¬“¬µ—«¢Õß∑√«ßÕ° ¿“¬À≈—ßÕÕ°°”≈—ß°“¬¡’§à“ .Û˜ ± .˘˜ ´¡. (§à“æ’ ≤ .ı) „π¢≥–∑’Ë°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë∫√‘‡«≥≈‘Èπªïò ·≈–°√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë Ò ‰¡à¡’§«“¡·µ°µà“ß°—πÕ¬à“ß¡’ π—¬ ”§—≠∑“ß ∂‘µ‘ „π°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑—Èß Õß√–¥—∫ ‚¥¬æ∫«à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë∫√‘‡«≥≈‘Èπªïò¡’§à“§«“¡ ·µ°µà“ߢÕß°“√¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπÕÕ°°”≈—ß°“¬Õ¬Ÿ∑à ’Ë .ÚÙ ± Ò.ÙÒ ´¡. ·≈–¿“¬À≈—ßÕÕ°°”≈—ß°“¬¡’§à“ .Ú˜ ± Ò.ÒÙ ´¡. ·≈–°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë∫√‘‡«≥°√–¥Ÿ° ´’Ë‚§√ß™‘Èπ∑’Ë Ò ¡’§à“§«“¡·µ°µà“ߢÕß°“√¢¬“¬µ—«¢Õß ∑√«ßÕ°°àÕπÕÕ°°”≈—ß°“¬Õ¬Ÿà∑’Ë .ÛÚ ± Ò.ÒÛ ´¡. ·≈– ¿“¬À≈—ßÕÕ°°”≈—ß°“¬¡’§à“ .Ú˜ ± .¯ˆ ´¡.

Õ¿‘ª√“¬º≈ ‚¥¬ª√°µ‘·≈â«π—Èπ¡πÿ…¬å®–„™â°“√À“¬„® Ú √Ÿª·∫∫ √à«¡°—π§◊Õ °“√À“¬„®‚¥¬„™âÀπâ“Õ° (thoracic breathing) ·≈–°“√À“¬„®‚¥¬„™âÀπâ“∑âÕß (abdominal breathing/ diaphragmatic breathing) ‡æ◊ËÕπ”Õ“°“»‡¢â“ªÕ¥¢Õß µπ‡Õß ´÷Ëß°“√À“¬„®‚¥¬„™âÀπâ“Õ°‡ªìπ°“√À“¬„®∑’Ë¡’°“√ ‡§≈◊ËÕπ‰À«¢Õß™àÕßÕ°∑’Ë¡’°“√„™â°√–¥Ÿ° Ú à«π §◊Õ∑—Èß °√–¥Ÿ°´’Ë‚§√ß·≈–°√–¥Ÿ°Àπâ“Õ° „π¢≥–∑’˺π—ßÀπâ“∑âÕß®– ‰¡à‡°‘¥°“√‡§≈◊ËÕπ‰À« °“√À“¬„®„π≈—°…≥–¥—ß°≈à“«π’È®–„Àâ

297

ª√‘¡“≥¢ÕßÕ“°“»πâÕ¬°«à“°“√À“¬„®‚¥¬„™âÀπâ“∑âÕß¡“° à«π°“√À“¬„®‚¥¬„™âÀπâ“∑âÕß ®–‡ªìπ°“√À“¬„®∑’Ë ¡’ ° “√ ‡§≈◊ÕË π‰À«¢Õߺπ—ßÀπâ“∑âÕß ∑’‡Ë °‘¥®“°°“√À¥µ—«¢Õß°–∫—ß≈¡ √à«¡°—∫°“√‡§≈◊ËÕπ‰À«¢Õß°√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë ¯ ‡ªìπµâπ‰ª ∑”„À⇰‘¥°“√¢¬“¬µ—«ÕÕ°¢Õß∑√«ßÕ°ÕÕ°∑“ߥâ“π¢â“ß ·≈– ‡°‘¥°“√‡§≈◊ËÕπ‰À«¢Õߺπ—ß∑√«ßÕ°·∫∫ bucket handle ∑”„Àâ¡’ª√‘¡“≥¢ÕßÕ“°“»‰À≈‡¢â“ ŸàªÕ¥‰¥â„πª√‘¡“≥∑’ˇæ‘Ë¡ ¡“°¢÷Èπ ´÷Ëß‚¥¬ª√°µ‘·≈â«π—Èπ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑—Èß ¥â“π∫π ¥â“π¢â“ß·≈–¥â“πÀ≈—ß®–¡’°“√¢¬“¬µ—«πâÕ¬°«à“°“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°∑“ߥâ“π≈à“ߘ,¯ ‡¡◊Ë Õ ‡ª√’ ¬ ∫‡∑’ ¬ ∫º≈°“√»÷ ° …“°“√¢¬“¬µ— « ¢Õß ∑√«ßÕ°°àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬„π°≈ÿà¡Õ“ “ ¡—§√ ∑’Ë„ à‡ ◊ÈÕ√—¥√Ÿª·≈–‰¡à√—¥√Ÿª æ∫«à“‰¡à¡’§«“¡·µ°µà“ß„π°“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°∑—Èß°àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬∑’Ë ∑√«ßÕ°∑—Èß “¡√–¥—∫∑—Èß„π¢≥–∑’ËÕ“ “ ¡—§√„ à‡ ◊ÈÕ√—¥√Ÿª ·≈–‰¡à√—¥√Ÿª (µ“√“ß∑’Ë Ú) ·µà®“°°“√ Õ∫∂“¡Õ“ “ ¡—§√ æ∫«à“ „π¢≥–∑’Ë„ à‡ ◊ÈÕ√—¥√Ÿª°àÕπÕÕ°°”≈—ß°“¬Õ“ “ ¡—§√ ®–√Ÿâ ÷°Õ÷¥Õ—¥ ·µà°Á¬—ß “¡“√∂∑’Ë®–À“¬„®‰¥âµ“¡ª√°µ‘ ·µà ¿“¬À≈—ß®“°°“√ÕÕ°°”≈—ß°“¬Õ“ “ ¡—§√√Ÿ â °÷ Õ÷¥Õ—¥¡“°¢÷πÈ ·≈–À“¬„®‰¡à‡µÁ¡∑’Ë (‰¡à‰¥â· ¥ß¢âÕ¡Ÿ≈‰«â„π°“√»÷°…“) ∑—Èßπ’È Õ“®‡ªìπ‰ª‰¥â«à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°·≈–ºπ—ßÀπâ“∑âÕß ®–¢¬“¬‰¥â¡“° ÿ¥‡∑à“°—∫¢π“¥∑’Ë«à“ß∑’ˇÀ≈◊ÕÕ¬Ÿà¢Õßµ—«‡ ◊ÈÕ ·≈–√à“ß°“¬¢ÕßÕ“ “ ¡—§√ ¥—ßπ—πÈ ·¡â«“à ®–¡’°“√ÕÕ°°”≈—ß°“Àπ—°‡æ‘Ë¡¢÷Èπ°Á‰¡à¡’º≈µàÕ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°¡“°π—° ‡π◊ËÕß®“°æ◊Èπ∑’Ë„π°“√¢¬“¬µ—«∑’Ë¡’Õ¬ŸàÕ¬à“ß®”°—¥¢Õ߇ ◊ÈÕ·≈– √à“ß°“¬¢ÕߺŸâ∑’Ë «¡„ à ®÷ß∑”„À≡àæ∫§«“¡·µ°µà“ß„π°“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°°àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬·¡â«à“ ®–„ à‡ ◊ÈÕ∑’Ë√—¥√Ÿª°Áµ“¡ §ß¡’‡æ’¬ß·µà§«“¡√Ÿâ ÷°∑’ËÕ÷¥Õ—¥·≈– °“√À“¬„®∑’‰Ë ¡à‡µÁ¡∑’∑Ë ‰’Ë ¥â®“°°“√ Õ∫∂“¡Õ“ “ ¡—§√‡∑à“π—πÈ ·µà‡¡◊ËÕπ”§à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°„π¢≥–„ à ‡ ◊È Õ √— ¥ √Ÿ ª ·≈–‰¡à√—¥√Ÿª°àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬¡“ ‡ª√’¬∫‡∑’¬∫°—πæ∫«à“ §à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë√–¥—∫ √—°·√⡧’ «“¡·µ°µà“ß°—πÕ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘µ∑‘ ß—È °àÕπ·≈– À≈—ß°“√ÕÕ°°”≈—ß°“¬ (§à“æ’ ≤ .ı) ·µà‰¡àæ∫§«“¡·µ°µà“ß „π°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’Ë√–¥—∫≈‘Èπªïò·≈–°√–¥Ÿ°´’Ë‚§√ß ™‘Èπ∑’Ë Ò ∑—Èß°àÕπ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬ ´÷Ëß°“√§âπæ∫ ¥—ß°≈à“«π’ȇªìπª√–‡¥Áπ∑’Ëπà“ π„® ‡π◊ËÕß®“°°“√¢¬“¬µ—«¢Õß ∑√«ßÕ°∑—Èß “¡√–¥—∫®–‡ªìπµ—«·∑π„π°“√»÷°…“√Ÿª·∫∫°“√ À“¬„®¢Õß¡πÿ…¬å∑’Ë¡’Õ¬Ÿà Õß√–¥—∫ §◊Õ °“√À“¬„®‚¥¬„™â Àπâ“Õ°·≈–°“√À“¬„®‚¥¬„™âÀπâ“∑âÕß ‚¥¬°“√¢¬“¬µ—«¢Õß ∑√«ßÕ°∑’Ë√–¥—∫√—°·√â®–‡ªìπµ—«·∑π„π°“√»÷°…“°“√À“¬„®

298 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

‚¥¬„™âÀπâ“Õ° à«π°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’√Ë –¥—∫≈‘πÈ ªï·ò ≈– °√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë Ò ®–‡ªìπµ—«·∑π„π°“√»÷°…“°“√ À“¬„®‚¥¬„™âÀπâ“∑âÕß ®“°°“√»÷°…“§√—Èßπ’Èæ∫§«“¡·µ°µà“ß „π°“√¢¬“¬µ—«¢Õß∑√«ßÕ°‡©æ“–∑’Ë√–¥—∫√—°·√â‡∑à“π—Èπ ´÷Ëß · ¥ß„Àâ‡ÀÁπ«à“ §«“¡·µ°µà“ß∑’ˇ°‘¥¢÷Èπ‡ªìπº≈¡“®“°°“√ À“¬„®‚¥¬„™â À πâ “ Õ°‡∑à “ π—È π ‚¥¬‰¡à ¡’ º ≈°√–∑∫µà Õ °“√ À“¬„®‚¥¬„™âÀπâ“∑âÕ߇≈¬ ‡π◊ËÕß®“°‰¡à¡’§«“¡·µ°µà“ß„π °“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑’√Ë –¥—∫≈‘πÈ ªï·ò ≈–°√–¥Ÿ°´’‚Ë §√ß™‘πÈ ∑’Ë Ò ∑—ßÈ π’ÕÈ “®‡ªìπ‰ª‰¥â«“à ¢π“¥¢Õ߇ ◊ÕÈ ∑’‡Ë ≈Á°≈ß„πÕ“ “ ¡—§√ „ à ‡ ◊È Õ √— ¥ √Ÿ ª ®–‡°‘ ¥ °“√≈¥¢π“¥¢Õ߇ ◊È Õ ≈ß‚¥¬‡©æ“–∑’Ë ∫√‘‡«≥¥â“π∫π¢Õ߇ ◊ÈÕ ∑”„À⇰‘¥°“√®”°—¥¢Õß∑√«ßÕ°‚¥‡©æ“–∫√‘‡«≥∑’ËÕ¬Ÿà∑“ߥâ“π∫πÀ√◊Õ∫√‘‡«≥√—°·√â ∑”„À⇰‘¥ °“√®”°—¥°“√‡§≈◊ÕË π‰À«¢Õß∑√«ßÕ°¡“°¢÷πÈ ‡¡◊ÕË ‡ª√’¬∫‡∑’¬∫ °—∫„π¢≥–∑’Ë «¡„ à‡ ◊ÈÕæÕ¥’µ—« ¥—ßπ—Èπ®÷ß àߺ≈„À⇰‘¥§«“¡ ·µ°µà“ߢÕß§à“°“√¢¬“¬µ—«¢Õß∑√«ßÕ°√–¥—∫√—°·√âÕ¬à“ß ™—¥‡®π πÕ°®“°π’Ȭ—ßæ∫«à“¿“¬À≈—ß®“°°“√ÕÕ°°”≈—ß°“√à“ß°“¬®–‡°‘¥°“√∑”ß“π‡æ‘Ë¡¡“°¢÷Èπ°«à“ª√°µ‘ ®÷ß¡’§«“¡ ®”‡ªìπ∑’Ë®–µâÕßπ”‡Õ“Õ“°“»‡¢â“‰ªªÕ¥„πª√‘¡“≥∑’Ë¡“°¢÷Èπ ‡æ◊Ë Õ„À⇰‘¥§«“¡æՇ撬ߵàÕ°“√∑”ß“π¢Õß√à“ß°“¬ Õ’° ∑—È߬—ßæ∫«à“¡’ª√‘¡“≥¢Õߧ“√å∫Õπ‰¥ÕÕ°‰´¥å (CO2) ∑’Ë ‡°‘¥®“°¢∫«π°“√‡¡µ“‚∫≈‘´÷¡¡’ª√‘¡“≥‡æ‘Ë¡¡“°¢÷Èπ ¥—ßπ—Èπ √à“ß°“¬®”‡ªìπµâÕß√—∫‡Õ“ÕÕ°´‘‡®π (O2) ‡¢â“¡“‡æ◊ËÕ —𥓪 °—∫§“√å∫Õπ‰¥ÕÕ°‰´¥å¿“¬„π√à“ß°“¬¯,˘ ®÷ß∑”„ÀâÕ“ “ ¡—§√ µâÕßÀ“¬„®‡¢â“‡æ‘Ë¡¡“°¢÷Èπ ‡æ◊ËÕ¥÷ßÕ“°“»‡¢â“ ŸàªÕ¥ ·µà ‡π◊ËÕß®“°¢π“¥¢Õ߇ ◊ÈÕ∑’ˇ≈Á°≈ßÕ“®®–∑”„Àâª√‘¡“µ√¢Õß Õ“°“»∑’ˇ¢â“ ŸàªÕ¥≈¥≈ß®÷߉¡à‡æ’¬ßæÕµàÕ§«“¡µâÕß°“√¢Õß √à“ß°“¬ ®÷ß∑”„ÀâÕ“ “ ¡—§√∑’Ë„ à‡ ◊ÈÕ√—¥√ŸªÀ“¬„®‰¥â‰¡à‡µÁ¡Õ‘Ë¡ ®÷ß¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ À“¬„® —Èπ ∂’Ë·≈–µ◊Èπ ®÷ßæ∫§«“¡ ·µ°µà“ߢÕß°“√¢¬“¬µ—«¢Õß∑√«ßÕ°√–À«à“ß∑—Èß Õß°≈ÿà¡ ‰¥âÕ¬à“ß™—¥‡®π πÕ°®“°π’¬È ß— æ∫«à“„π¢≥–∑’ÕË “ “ ¡—§√µâÕßÀ“¬„® ‡¢â “ ‡æ‘Ë ¡ ¡“°¢÷È π ‡æ◊Ë Õ„Àâ ¡’ Õ “°“»‡¢â “ Ÿà √à “ ß°“¬„πª√‘ ¡ “≥∑’Ë ‡æ’¬ßæÕµàÕ§«“¡µâÕß°“√ Õ“ “ ¡—§√ à«π„À≠à®–Õ“»—¬°“√ À“¬„®‚¥¬„™âÀπâ“Õ°¡“°°«à“ª√°µ‘ ®÷ß∑”„Àâºπ—ß∑√«ßÕ° ‡°‘¥°“√∑”ß“π·∫∫ pump handle ¡“°¢÷Èπ ‚¥¬°√–¥Ÿ° ´’Ë‚§√ßµ—Èß·µà™‘Èπ∑’Ë Ò-˜ ®–‡°‘¥°“√¢¬“¬µ—«‰ª¥â“πÀπâ“·≈– °√–¥Ÿ°Àπâ“Õ°°Á®–¬°µ—«¢÷πÈ µ“¡¥â«¬ √à«¡°—∫¡’°“√„™â°≈â“¡‡π◊ÕÈ ∑’ËÕ¬Ÿà∫√‘‡«≥§ÕÀ√◊Õ∑√«ßÕ° à«π∫π (accessory muscle) ‡™àπ °≈â“¡‡π◊ÈÕ sternocleidomastoid ·≈–°≈â“¡‡π◊ÈÕ upper trapezius ™à«¬„π°“√À“¬„®‡æ◊ËÕ„Àâ¡’ª√‘¡“≥¢ÕßÕ“°“»„π ªÕ¥¡“°‡æ’¬ßæÕµàÕ°“√‡ª≈’ˬπ·ª≈ߢÕß√à“ß°“¬∑’ˇ°‘¥¢÷Èπ

´÷Ëß°“√»÷°…“„π§√—Èßπ’È Õ¥§≈âÕß°—∫º≈°“√«‘®—¬∑’˺à“π¡“∑’Ë æ∫«à“°“√ «¡„ àÕÿª°√≥åÀ√◊Õ ‘Ëßµà“ßÊ ∑’Ë¡’°“√°¥À√◊Õ√—¥ ∑√«ßÕ°®–∑”„Àâ°“√∑”ß“π¢Õߪե·≈–°“√¢¬“¬µ—«¢Õß ∑√«ßÕ°≈¥≈ß „π¢≥–∑’ˇ¥’¬«°—π°≈—∫‰¡àæ∫§«“¡·µ°µà“ß„π°“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°∑’√Ë –¥—∫≈‘πÈ ªï·ò ≈–°√–¥Ÿ°´’‚Ë §√ß™‘πÈ ∑’Ë Ò ´÷Ë ß · ¥ß„Àâ ‡ ÀÁ π «à “ °“√À“¬„®‚¥¬„™â À πâ “ ∑â Õ ß¡’ º ≈°√–∑∫ §àÕπ¢â“ßπâÕ¬‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√À“¬„®‚¥¬„™âÀπâ“Õ° ∑—Èßπ’ÈÕ“®‡ªìπ‰ª‰¥â«à“®“°≈—°…≥–¢Õßµ—«‡ ◊ÈÕ∑’Ë «¡„ à ∑—È ß ∑’Ë √—¥√Ÿª·≈–‰¡à√—¥√ŸªÕ“®®–‰¡à “¡“√∂ª√—∫‡ª≈’ˬπ¢π“¥∫√‘‡«≥ Àπâ“Õ°‰¥â¡“°π—° ‡π◊ËÕß®“°‚§√ß √â“ߢÕß√à“ß°“¬∫√‘‡«≥ ¥— ß °≈à “ « ∂Ÿ ° ®”°— ¥ ¥â « ¬¢π“¥¢ÕßÀπâ “ Õ°¢ÕߺŸâ «¡„ à πÕ°®“°π’Ȭ—ßæ∫«à“∑’Ë∫√‘‡«≥™à«ß≈à“ߢÕ߇ ◊ÈÕ∑’ËÕ¬Ÿà∫√‘‡«≥ °√–¥Ÿ°´’Ë‚§√ß®–¡’¢π“¥æÕ¥’„π‡ ◊ÈÕ√—¥√Ÿª·≈–¡’≈—°…≥–§àÕπ ¢â“ß°«â“ß„π‡ ◊ÈÕ‰¡à√—¥√Ÿª ∑”„Àâ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑—Èß Õß∫√‘‡«≥‰¡à∂°Ÿ ®”°—¥À√◊Õ¡’§«“¡·µ°µà“ß°—π¡“° ‡π◊ÕË ß®“° ¢π“¥‡ ◊ÈÕ¢Õß∑—Èß Õß√Ÿª·∫∫¬—ß¡’æ◊Èπ∑’Ë„Àâ∑√«ßÕ° “¡“√∂∑’Ë ®–¢¬“¬µ—«‰¥â‡æ‘Ë¡¢÷Èπ‡À¡◊Õπ°—π ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫∑—Èß°àÕπ ·≈–À≈—ß°“√ÕÕ°°”≈—ß°“¬À√◊Õ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫√–À«à“߇ ◊ÈÕ √—¥√Ÿª·≈–‰¡à√¥— √Ÿª ´÷ßË „π°“√»÷°…“§√—ßÈ π’§È Õà π¢â“ß Õ¥§≈âÕß°—∫°“√»÷°…“ ∑’˺à“π¡“„πÕ¥’µ∑’Ëæ∫«à“°“√„ à‡ ◊ÈÕ™—Èπ„π∑’Ë„™â ”À√—∫°“√‡≈àπ °’Ã“ (Sports brassieres) ‰¡à¡’º≈µàÕ°“√À“¬„®„πºŸâ∑’Ë «¡„ à‡ ◊ÈÕ™—Èπ„π∑’Ë„™â ”À√—∫°“√‡≈àπ°’Ó ·¡â«à“®–µâÕß∑” °‘®°√√¡∑’Ë¡’°“√ÕÕ°°”≈—ß°“¬Õ¬à“ß¡“° ·µà°“√„ à‡ ◊ÈÕ™—Èπ„π ∑’Ë„™â ”À√—∫°“√‡≈àπ°’Ó¡’·√ß°¥∑’Ë°√–∑”µàÕ≈”µ—«¢ÕߺŸâ∑’Ë¡’ Àπâ“Õ°‡≈Á°¡“°°«à“Ò ·µà‡π◊ÕË ß®“°ºŸ∑â ’Ë «¡‡ ◊ÕÈ √—¥√Ÿª®–¡’°“√ ®”°—¥°“√¢¬“¬µ—«¢Õß∑√«ßÕ°¥â“π∫π·≈–¥â“π≈à“ß∑’ËÕ¬ŸàµË” ≈ß¡“ „π¢≥–∑’Ë°“√ «¡„ à™ÿ¥™—Èπ„πÕ“®®–¡’º≈°¥√—¥‡©æ“– ∑’ËÀπâ“Õ°¢ÕߺŸâ∑’Ë «¡„ à ·µà°≈—∫‰¡à¡’º≈µàÕ°“√¢¬“¬µ—« ¢Õß∑√«ßÕ°¥â“π∫π·≈–¥â“π≈à“ß∑’ËÕ¬ŸàµË”≈ß¡“ ¥—ßπ—Èπ®÷߉¡à æ∫°“√‡ª≈’ˬπ·ª≈ß¿“¬À≈—ß®“°°“√ÕÕ°°”≈—ß°“·¡â«à“®“°°“√»÷°…“§√—Èßπ’È®–‰¡àæ∫°“√‡ª≈’ˬπ·ª≈ß Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ·µà®–æ∫«à“§à“§«“¡·µ°µà“ß„π °“√¢¬“¬∑√«ßÕ°¢ÕߺŸâ ∑’Ë „ à ‡ ◊È Õ √— ¥ √Ÿ ª ∑—È ß √–¥— ∫ ≈‘È π ªïò · ≈– °√–¥Ÿ°´’Ë‚§√ß™‘Èπ∑’Ë Ò ¡’·π«‚πâ¡¢Õß§à“°“√¢¬“¬µ—«∑’Ë µË”°«à“ºŸâ∑’Ë„ à‡ ◊ÈÕ‰¡à√—¥√Ÿª ¥—ßπ—Èπ®÷ßÕ“® àߺ≈°√–∑∫‚¥¬µ√ß µàÕ°“√π”Õ“°“»‡¢â“ ŸàªÕ¥‚¥¬µ√ß ´÷ËßÀ“°ºŸâ∑’Ë„ à‡ ◊ÈÕ√—¥√Ÿª ‡ªì π ºŸâ ∑’Ë ¡’ ÿ ¢ ¿“楒 °Á Õ “®®–‰¡à‰¥â√—∫º≈°√–∑∫„π√–¬– —Èπ ¡“°π—° ·µàÀ“°‡ªìπºŸ∑â ¡’Ë ‚’ √§ª√–®”µ—« ‡™àπ ‚√§ Ankylosing spondylitisÒÒ À√◊Õ fibrodysplasia ossificans pro-

299

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

gressivaÒÚ ‡ªìπµâπ ´÷ßË ºŸªâ «É ¬‡À≈à“π’¡È °— ®–¡’ª≠ í À“°“√¢¬“µ—«¢Õß∑√«ßÕ°Õ¬Ÿà·≈â« ¥—ßπ—ÈπÀ“°¬‘Ëß¡’°“√°¥∑—∫À√◊Õ√—¥ ∑√«ßÕ°ÒÛ °ÁÕ“®®–¬‘ßË àߺ≈∑”„Àâª√‘¡“≥Õ“°“»∑’‡Ë ¢â“ Ÿªà Õ¥ ‰¡à‡æ’¬ßæÕµàÕ§«“¡µâÕß°“√¢Õß√à“ß°“¬ πÕ°®“°π’ÈÀ“° ‚§√ß √â“ߢÕß√à“ß°“¬º‘¥ª√°µ‘ ‡™àπ ¡’À≈—ß‚°àß (Kyphosis)ÒÙ À√◊ÕÀ≈—ߧ¥ (Scoliosis)Òı ®– àߺ≈„Àâ°“√¢¬“¬µ—«ÕÕ°∑“ß ¥â“π¢â“ߢÕß∑√«ßÕ°∑—ßÈ Õߥâ“π‰¡à‡∑à“°—π ∑”„Àâª√‘¡“≥¢Õß Õ“°“»∑’‡Ë ¢â“ªÕ¥Õ“®®–‰¡à‡æ’¬ßæÕµàÕ§«“¡µâÕß°“√ À√◊ÕÀ“° µâÕß·∫°¢Õß∑’Ë¡’πÈ”Àπ—°∫π∫à“°ÁÕ“®®– àߺ≈°√–∑∫µàÕ°“√ ¢¬“¬µ—«¢Õß∑√«ßÕ°‰¥â ‡π◊ËÕß®“°‡°‘¥°“√°¥∑—∫∑√«ßÕ° ¥â“π∫π ∑”„Àâ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°∑“ߥâ“π∫π‡°‘¥¢÷Èπ ‰¥â‰¡à¥’‡∑à“∑’˧«√ Õ’°ª√–‡¥ÁπÀπ÷Ëß∑’Ëπà“ π„® §◊Õ °“√§—¥‡≈◊Õ°Õ“ “ ¡—§√ ‡π◊ËÕß®“°√Ÿª√à“ß·≈–‚§√ß √â“ß∑“ß√à“ß°“¬¢ÕߺŸâ‡¢â“ √à«¡‚§√ß°“√«‘®—¬¡’§«“¡·µ°µà“ß°—π ¥—ßπ—Èπ®÷ß∑”„À⇰‘¥§à“ §«“¡‡∫’ˬ߇∫π§àÕπ¢â“ß°«â“ß ‡æ√“–„π°“√«‘ ®— ¬ §√—È ß π’È ‰ ¥â °”À𥇰≥±å„π°“√§—¥‡≈◊Õ°ºŸâ‡¢â“√à«¡‚§√ß°“√«‘®—¬‡°’ˬ« °—∫√Ÿª√à“߉«â‡æ’¬ßÀπ÷Ëß§à“ §◊Õ °“√°”Àπ¥§à“ Body mass index (BMI) ´÷ßË ‡ªìπ°“√ª√–‡¡‘π≈—°…≥–√Ÿª√à“߇撬ߧ√à“«Ê ‡∑à“π—Èπ ·µà®“°°“√·∫àß‚§√ß √â“ߢÕß¡πÿ…¬å¢Õß Sheldon¯ æ∫«à“√à“ß°“¬¡πÿ…¬å·∫àßÕÕ°‡ªìπ Û ·∫∫µ“¡ somatotype (°“√ª√–‡¡‘π®“° body composition ·≈– body size) ‰¥â·°à Endomorph (pear-shape) ∑’¡Ë ≈’ °— …≥–¢Õ߉À≈à·§∫ –‚æ°§àÕπ¢â“ß„À≠à ¡’‰¢¡—π – ¡¡“°·≈–¡’‚§√ß°√–¥Ÿ°„À≠à ·∫∫∑’Ë Õߧ◊Õ Mesomorph ®–‡ªìπºŸâ∑’Ë¡’√Ÿª√à“ß —π∑—¥ ¡’ °≈â“¡‡π◊ÕÈ ¡“°·≈–¡’‰¢¡—π – ¡πâÕ¬ à«π·∫∫∑’ Ë “¡ §◊Õ ·∫∫ Ectomorph °≈ÿà¡π’È®–¡’√Ÿª√à“ߧàÕπ¢â“ߺա ‚§√ß°√–¥Ÿ° ‡≈Á°·≈–¡’‰¢¡—π – ¡πâÕ¬ ‡æ√“–©–π—Èπ°“√«—¥ somatotype Õ¬à“ß≈–‡Õ’¬¥®–µâÕß«—¥∑—Èß à«π Ÿß πÈ”Àπ—° §«“¡Àπ“¢Õß ‰¢¡—π – ¡∫√‘‡«≥µà“ßÊ ¢Õß√à“ß°“¬ ‡™àπ °≈â“¡‡π◊ÈÕ Triceps brachii °≈â“¡‡π◊ÈÕ Biceps brachii °≈â“¡‡π◊ÈÕ Subscapularis °≈â“¡‡π◊ÈÕ Supraspinatus °≈â“¡‡π◊ÈÕ∑âÕß °≈â“¡‡π◊ÕÈ µâπ¢“·≈–°≈â“¡‡π◊ÕÈ Gastrosoleus muscle ‡ªìπµâπ √«¡∂÷ß°“√«—¥‡ âπ√Õ∫«ßµ“¡µ”·Àπàß°“¬«‘¿“§ (girth) ¥—ßπ—Èπ∂÷ß·¡â«à“ºŸâ‡¢â“√à«¡‚§√ß°“√«‘®—¬·µà≈–§π®–¡’§à“ BMI ª√°µ‘ ·µà°ÕÁ “®®–¡’√ªŸ √à“ßÀ√◊Õ∑√«ßÕ°∑’¡Ë ¢’ π“¥·µ°µà“ß°—π ¥—ßπ—πÈ ®÷ßÕ“® àߺ≈°√–∑∫µàÕ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°·µ°µà“ß °—𠇙àπ ∫“ߧπ‡ ◊ÈÕ®–√—¥∫√‘‡«≥Àπâ“Õ°¡“° „π¢≥–∑’∫Ë “ß §π‡ ◊ÈÕ®–√—¥∫√‘‡«≥Àπâ“Õ°πâÕ¬°«à“≈”µ—«™à«ß≈à“ß ¥—ßπ—Èπ ‡¡◊ÕË ºŸ∑â ”°“√«‘®¬— „™â‡°≥±å°“√«—¥¢π“¥√Õ∫Õ°‡æ’¬ßÕ¬à“߇¥’¬«

∑”„Àâº≈°“√»÷°…“∑’ˇ°‘¥¢÷Èπ¡’§«“¡À≈“°À≈“¬·≈–‰¡à‡ªì𠉪„π∑‘»∑“߇¥’¬«°—π

¢âÕ®”°—¥„π°“√∑”«‘®—Ò. ‡π◊ÕË ß®“°ºŸ∑â ”°“√«‘®¬— ‰¥â»°÷ …“ºŸ‡â ¢â“√à«¡‚§√ß°“√ «‘®—¬‡æ»À≠‘ß ´÷ËßµâÕß «¡‡ ◊ÈÕ™—Èπ„π∑’Ë¡’√Ÿª∑√ß·µ°µà“ß°—𠇙àπ ‡ ◊ÈÕ™—Èπ„π∑’Ë¡’°“√¥—π∑√ß¡“°Ê Õ“®®– àߺ≈°√–∑∫µàÕ °“√®”°—¥°“√¢¬“¬µ—«¢Õß∑√«ßÕ°‰¥â Ú. ¿“槫“¡æ√âÕ¡¢Õß√à“ß°“¬ (fitness) ¢Õß ºŸâ‡¢â“√à«¡°“√»÷°…“·µà≈–§π°Á¡’§«“¡·µ°µà“ß°—π ∑”„Àâ √–¥—∫§«“¡‡ÀπÁ¥‡Àπ◊ËÕ¬À≈—ß°“√ÕÕ°°”≈—ß°“¬µà“ß°—π ·≈– Õ“® àߺ≈µàÕ°“√À“¬„®·≈–°“√¢¬“¬µ—«¢Õß∑√«ßÕ°¡“° πâÕ¬µà“ß°—π

°“√«‘®¬— „πÕ𓧵 Ò. §«√¡’°“√ª√—∫ª√ÿß«‘∏’°“√∑¥≈Õß (protocol) „Àâ√—¥°ÿ¡¡“°¢÷Èπ ‚¥¬‡©æ“–°“√§—¥‡≈◊Õ°Õ“ “ ¡—§√‡¢â“∑” °“√»÷°…“ §«√„™â‡°≥±å‚§√ß √â“ß∑’Ë¡’√“¬≈–‡Õ’¬¥¡“°°«à“π’È ·≈–Õ“®‡æ‘Ë¡‡«≈“¢≥–ÕÕ°°”≈—ß°“¬„Àâ¡“°¢÷Èπ ‡æ◊ËÕ„Àâ‡ÀÁπ º≈¢Õߧ«“¡Àπ—°„π°“√∑”ß“πÕ¬à“ß™—¥‡®π¡“°¬‘ßË ¢÷πÈ ‚¥Õ“®»÷°…“‡ª√’¬∫‡∑’¬∫µ—«·ª√Õ◊ËπÊ ‡™àπ °“√»÷°…“§«“¡ ‡Àπ◊ËÕ¬®“° VO2 max À√◊Õ °“√«—¥Õ—µ√“°“√‡µâπ¢ÕßÀ—«„® ‡ªìπµâπ Ú. §«√∑”°“√»÷°…“º≈°“√¢¬“¬µ—«¢Õß∑√«ßÕ° „πºŸâ∑’Ë «¡„ à‡ ◊ÈÕ√—¥√Ÿª‡ªìπ‡«≈“π“π √«¡∂÷ß°“√∑”ß“π¢Õß ªÕ¥«à“‡°‘¥°“√‡ª≈’ˬπ·ª≈ßÀ√◊Õ¡’º≈°√–∑∫µàÕ°“√∑”ß“π ¢Õß√–∫∫À“¬„®Õ¬à“߉√ ‡æ◊ËÕ„À⇢Ⓞ®∂÷ߺ≈°√–∑∫∑’ËÕ“® ‡°‘¥¢÷Èπ‡¡◊ËÕµâÕß «¡„ à‡ ◊ÈÕ√—¥√Ÿª‡ªìπ‡«≈“π“πÊ

√ÿªº≈°“√»÷°…“ ®“°°“√»÷°…“§√—Èßπ’È æ∫«à“ °“√„ à‡ ◊ÈÕ√—¥√Ÿª¡’º≈ µàÕ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°√–¥—∫∫π (√–¥—∫√—°·√â) ∑—ßÈ ¢≥– æ—° (°àÕπÕÕ°°”≈—ß°“¬) ·≈–¢≥–∑’¡Ë °’ “√∑”ß“πÀπ—° (¿“À≈—ß®“°°“√ÕÕ°°”≈—ß°“¬) ·≈–æ∫«à“°“√„ à‡ ◊ÕÈ √—¥√Ÿª‰¡à¡º’ ≈ µàÕ°“√¢¬“¬µ—«¢Õß∑√«ßÕ°™à«ß≈à“ß (√–¥—∫≈‘πÈ ªï·ò ≈–°√–¥Ÿ° ´’Ë‚§√ß™‘Èπ∑’Ë Ò) ∑—Èߢ≥–æ—°·≈–¢≥–∑’Ë¡’°“√∑”ß“πÀπ—°

°‘µµ‘°√√¡ª√–°“» ¢Õ¢Õ∫§ÿ≥¿“§«‘™“°“¬¿“æ∫”∫—¥ §≥– À‡«™»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å ∑’„Ë Àâ°“√ π—∫ πÿπ∑ÿπ«‘®¬— ∫“ß à«π„π°“√∑”«‘®—¬§√—Èßπ’È®π ”‡√Á®‰¥â¥â«¬¥’

300 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

‡Õ° “√Õâ“ßÕ‘ß Ò. Caro CG, Butler J, DuBois AB. Some effects of restriction of chest cage expansion on pul monary function in man: an experimental study.

J Clin Invest 1960:573-83. Ú. Legg SJ, Cruz CO. Effect of single and double strap backpacks on lung function. Ergonomics 2004;47:318-23. Û. Bygrave S, Legg SJ, Myers S, Llewellyn M. Effect of backpack fit on lung function. Ergonomics 2004;47:324-9. Ù. W.Byard R. The brassiere ùsignû- A distinctive marker in crush asphyxia. J Clin Forensic Med 2005;12:316-9. ı. Valavanis J, Vassiliou M, Behrakis P.K. The immediate effect of a Boston brace on lung volumes and pulmonary compliance in mild adolescent idiopathic scoliosis. Euro Spine J 1999;8:2-7. ˆ. Refsum HE, Lange JE. Pulmonary function and gas exchange at rest and exercise in adolescent girls with mild idiopathic scoliosis during treatment with Boston thoracic brace. Spine 1990; 15:420-3. ˜. °“𥓠„®¿—°¥’. «‘∑¬“»“ µ√å°“√‡§≈◊ÕË π‰À«. °√ÿ߇∑æœ: ∫√‘…—∑ ”π—°æ‘¡æ奫߰¡≈ (ÚıÚ) ®”°—¥; ÚıÙÚ. ¯. ‡æÁ≠æ‘¡≈ ∏—¡¡√—§§‘µ. °“¬«‘¿“§·≈– √’√«‘∑¬“ ”À√—∫ °“¬¿“æ∫”∫—¥∑√«ßÕ° §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¢Õπ·°àπ ÚıÛÒ.

˘. ™Ÿ»—°¥‘Ï ‡«™·æ∑¬å, °—𬓠ª“≈–«‘«—∏πå. √’√«‘∑¬“°“√ ÕÕ°°”≈—ß°“¬. °√ÿ߇∑æœ: ∏√√°¡≈°“√æ‘¡æå; ÚıÛˆ. Ò. Bowles KA, Steele JR, Chaunchaiyakul R. Do Current Sports Brassiere Designs Impede Respiratory Function? Medicine & Science in Sports & Exercise 2005;37:1633-40. ÒÒ. Fisher LR, Cawley MI, Holgate ST. Relation between chest expansion, pulmonary function, and exercise tolerance in patients with ankylosing spondylitis. Ann Rheum Dis 1990;49:921-5. ÒÚ. Connor JM, Evans CC, Evans DA. Cardiopulmonary function in fibrodysplasia ossificans progressiva. Thorax 1981;36:419-23. ÒÛ. Sybrecht GW, Garrett L, Anthonisen NR. Effect of chest strapping on regional lung function.

Appl Physiol 1975;39:707-13. ÒÙ. Lai JP, Jones AY. The effect of shoulder-girdle loading by a school bag on lung volumes in Chinese primary school children. Early Human Develop 2001;62:79-86. Òı. Chow DHK, Ng XHY, Holmes AD, Cheng JCY, Yao FYD, et al. Effects of Back-pack Loading on the pulmonary capacities of normal schoolgirls and those with adolescent idiopathic scoliosis. Spine 2005;30:E649-E654.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Abstract Immediate effect of chest expansion after exercise in women wearing tight-shirt Bromwadee Asachereewattana, Suwimol Damrongseen, Noppawan Charususin, Patcharee Kooncumchoo Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University Introduction:

Objective: Methods:

Result:

Discussion:

Key words:

Tight-shirt is a popular fashion among teenagers. It is not uncertain that wearing tight-shirt may affect their health. There is still no evidence about respiration and chest expansion problems from tight-shirt wearing.

To study immediate effects of tight-shirt wearing on chest expansion in healthy women.

30 women who wore loose-shirt or tight-shirt were recruited. They exercised by cycling for 15 minutes. Chest expansion; axilla, xiphoid process and 10th costal cartilage were measured before and after exercises, and data will be analyzed by using Paired-Samples Test.

Chest expansion before exercise during wearing loose-shirt at axilla, xiphoid process and 10th costal cartilage were 7.08 ± 1.71, 6.52 ± 1.88, and 6.66 ± 2.05 cm., and after exercise were 6.99 ± 1.54, 6.49 ± 1.50, and 6.49 ± 1.89 cm. Whereas, during wearing tight-shirt before exercise were 6.56 ± 1.53, 6.28 ± 1.67, and 6.33 ± 2.07 cm. and after exercise were 6.61 ± 1.54, 6.22 ± 1.59, and 6.22 ± 2.03 cm. When comparing chest expansion in loose-shirt and tight-shirt before or after exercise, there was statistically significant differences at axilla level (p ≤ 0.05). The difference of axilla chest expansion before exercise was 0.52 ± 1.36 cm. and after exercise was 0.37 ± 0.97 cm. But there were no differences of chest expansion in other levels.

These results suggest that the decrease of upper chest expansion may be due to the restriction of tight-shirt. Anyway, this study showed only short-term effect of tight-shirt on respiratory system, and can not explain the long-term effect of tight-shirt which need further investigation. chest expansion, tight-shirt, exercise, pulmonary ventilation, respiration

301

302 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

π‘æπ∏åµπâ ©∫—∫

ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ π¿— √—≠™πå ƒ°…å‡√◊Õ߃∑∏‘Ï* ‡°…√ ”‡¿“∑Õß** Õ√ÿ≥æ√ Õ‘∞√—µπå***

∫∑§—¥¬àÕ °“√«‘®—¬π’ȇªìπ°“√«‘®—¬‡™‘ß∑”𓬇æ◊ËÕ»÷°…“ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å·ºπ ªí®®ÿ∫—π„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ‚¥¬ —¡¿“…≥å·æ∑¬å∑—ÈßÀ¡¥„π‚√ß欓∫“≈Õà“ß∑Õß®”π«π ÒÚ §π ·≈– ÿࡵ—«Õ¬à“ߺŸâªÉ«¬·∫∫·∫àß™—Èπµ“¡·ºπ° §”π«≥¢π“¥°≈ÿࡵ—«Õ¬à“ß„™â«‘∏’¢Õß Yamane ‰¥â¢π“¥µ—«Õ¬à“ß®”π«π Ù §π ‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈¥â«¬·∫∫ —¡¿“…≥å ∑’ˉ¥âÀ“§«“¡‡∑’ˬߵ“¡«‘∏’¢Õߧ√Õπ∫“§ ·Õ≈ø“ «‘‡§√“–Àå¢âÕ¡Ÿ≈¥â«∂‘µ‘‡™‘ßæ√√≥π“ º≈°“√»÷°…“ æ∫«à“ºŸâªÉ«¬ à«π„À≠à ¡’§«“¡√Ÿâ∑’Ë∂Ÿ°µâÕ߇°’ˬ«°—∫ ¡ÿπ‰æ√„π√–¥—∫ª“π°≈“ß √âÕ¬≈– ˆı.ı ¡’∑—»π§µ‘‚¥¬√«¡„π√–¥—∫ Ÿß ·≈–¡’§«“¡æ÷ßæÕ„®√–¥—∫¡“°‚¥¬¡’§«“¡æÕ„®°—∫√Ÿª·∫∫ ªí®®—¬§«“¡µâÕß°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√¡“°∑’Ë ÿ¥ (Odd ratio = ˜.˘Ù, §à“æ’ <.ı) ·≈–ªí®®—¬√Õß≈ß ¡“§◊Õ °“√ à߇ √‘¡°“√„™â®“°§√Õ∫§√—« º≈°“√»÷°…“„π¡‘µ‘¢Õß·æ∑¬å æ∫«à“·æ∑¬å¡’§«“¡√Ÿâ∑’Ë∂Ÿ°µâÕß√âÕ¬≈– ¯¯.ı ¡’∑—»π§µ‘∑’Ë¥’ µàÕ°“√ —Ëß®à“¬“ ¡ÿπ‰æ√ ·≈–‡™◊ËÕ«à“¬“ ¡ÿπ‰æ√ “¡“√∂∑¥·∑𬓷ºπªí®®ÿ∫—π‰¥â∫“ßÕ“°“√‚√§ (√âÕ¬≈– ˘Ò.˜) §«“¡ª≈Õ¥¿—¢Õ߬“‡ªìπªí®®—¬∑’Ë∑”„Àâ·æ∑¬å —Ëß®à“¬¬“„π‚√ß欓∫“≈ÕŸà∑Õß¡“°∑’Ë ÿ¥ ·µàªí®®—¬¥â“π∑—»π§µ‘µàÕ°“√„™â ¡ÿπ‰æ√ æ∫«à“ ¡’§–·πππâÕ¬„π‡√◊ËÕß·æ∑¬å‰¡à‡™◊ËÕ¡—Ëπ„πª√– ‘∑∏‘¿“æ¢Õ߬“ ¡ÿπ‰æ√ √ÿª: ªí®®—¬À≈—°¢ÕߺŸâªÉ«¬µàÕ°“√„™â¬“§◊Õ§«“¡µâÕß°“√¢ÕߺŸâªÉ«¬‡Õß∑’Ë¡“®“°ª√– ∫°“√≥å°“√„™â°—∫ µπ‡Õß·≈–‰¥â·√ß π—∫ πÿπ®“°§√Õ∫§√—« ·µàªí®®—¬∑’Ë„Àâ·æ∑¬å®à“¬¬“ ¡ÿπ‰æ√§◊Õ¢âÕ¡Ÿ≈ª√– ‘∑∏‘¿“æ·≈–ª√– ‘∑∏‘º≈ ¢Õ߬“∑’ˉ¥â®“°ß“π«‘®—§” ”§—≠: °“√„™â¬“ ¡ÿπ‰æ√, ªí®®—¬, ‚√ß欓∫“≈, ºŸâªÉ«¬, ·æ∑¬å·ºπªí®®ÿ∫—π

* π—°»÷°…“ª√‘≠≠“‚∑ À≈—° Ÿµ√ “∏“√≥ ÿ¢»“ µ√¡À“∫—≥±‘µ «‘™“‡Õ°°“√®—¥°“√ √â“߇ √‘¡ ÿ¢¿“æ §≥– “∏“√≥ ÿ¢»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å ** §≥– “∏“√≥ ÿ¢»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å *** “¢“«‘™“°“√·æ∑¬å·ºπ‰∑¬ª√–¬ÿ°µå §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å ∂“π∑’˵‘¥µàÕºŸâ‡¢’¬π : √».¥√.Õ√ÿ≥æ√ Õ‘∞√—µπå “¢“°“√·æ∑¬å·ºπ‰∑¬ª√–¬ÿ°µå §≥–·æ∑¬»“ µ√å ¡∏. »Ÿπ¬å√—ß ‘µ ‚∑√»—æ∑å -Ú˘Úˆ-˘˜Ù˘ ¡◊Õ∂◊Õ ¯ˆ-˘ˆÙ-ı˘ˆÙ E-mail : iarunporn@yahoo.com

303

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

∫∑π” °“√ª√–™ÿ¡Õߧ尓√Õπ“¡—¬‚≈°¡’§«“¡‡ÀÁπ™Õ∫µàÕ ªØ‘≠≠“ªí°°‘Ëß (Beijing Declaration) ‡æ◊ËÕ à߇ √‘¡Õß§å §«“¡√Ÿâ°“√·æ∑¬å¥—È߇¥‘¡∑’Ë¡’Õ¬Ÿà„π∑ÿ°Ê ª√–‡∑» ª√–‡∑» ‰∑¬µ—ßÈ ·µà¡·’ ºπæ—≤π“ “∏“√≥ ÿ¢ ©∫—∫∑’Ë Ù (æ.». ÚıÚÚıÚÙ) ∂÷ß·ºπæ—≤π“ “∏“√≥ ÿ¢ ©∫—∫∑’Ë ˘ (æ.». ÚıÙıÚıÙ˘) √—∞∫“≈¡’π‚¬∫“¬ π—∫ πÿπ°“√„™âª√–‚¬™π宓° ¡ÿ π‰æ√·≈–°“√·æ∑¬å ·ºπ‰∑¬Õ¬à“ßµàÕ‡π◊ËÕß æ√–√“™ ∫—≠≠—µ ‘ ¢ÿ ¿“æ·Ààß™“µ‘ æ.». Úıı ¡“µ√“ Ù˜ (¢âÕ ˜)Ò ‰¥â°”Àπ¥„Àâ¡’°“√ à߇ √‘¡ π—∫ πÿπ °“√„™â·≈–°“√æ—≤π“ ¿Ÿ¡‘ªí≠≠“∑âÕß∂‘Ëπ¥â“π ÿ¢¿“æ°“√·æ∑¬å·ºπ‰∑¬ °“√·æ∑¬å æ◊πÈ ∫â“π ·≈–°“√·æ∑¬å∑“߇≈◊Õ°Õ◊πË „À⇪ìπ‰ªÕ¬à“ß Õ¥§≈âÕß °—∫«‘∂™’ «’ µ‘ ™ÿ¡™π ¢π∫∏√√¡‡π’¬¡ª√–‡æ≥’«≤ — π∏√√¡∑âÕß∂‘πË ‡æ◊ËÕ√Õß√—∫À≈—°°“√æ÷Ëßµπ‡Õߥâ“π ÿ¢¿“æ ·≈–‡æ◊ËÕ„Àâ°“√ ∫√‘°“√ “∏“√≥ ÿ¢¡’∑“߇≈◊Õ°∑’ËÀ≈“°À≈“¬ ·≈–°√–∑√«ß “∏“√≥ ÿ¢¬—ß¡’π‚¬∫“¬ π—∫ πÿπ°“√ “∏“√≥ ÿ¢·∫∫æ÷Ëß µπ‡Õß¿“¬„µâª√—™≠“‡»√…∞°‘®æÕ‡æ’¬ß ®÷߉¥âπ”°“√·æ∑¬å ·ºπ‰∑¬ ¡ÿπ‰æ√·≈–°“√·æ∑¬å∑“߇≈◊Õ°¡“‡ªìπ à«π√à«¡„π °“√¥Ÿ·≈ ÿ¢¿“æ¢Õߪ√–™“™π æ√âÕ¡∑—Èß π—∫ πÿπ„Àâ¡’°“√ „™â¬“®“° ¡ÿπ‰æ√„π ∂“π∫√‘°“√ “∏“√≥ ÿ¢∑ÿ°√–¥—∫¡“°¢÷πÈ ·µà®“°¢âÕ¡Ÿ≈¢Õß ”π—°π‚¬∫“¬·≈–¬ÿ∑∏»“ µ√å °√–∑√«ß “∏“√≥ ÿ¢„πªï æ.». ÚıÙı æ∫«à“ª√–™“™π§π‰∑¬¡’ √“¬®à“¬∑“ߥâ“π ÿ¢¿“æ¥â«¬°“√´◊ÈÕ¬“√—∫ª√–∑“π‡Õ߇©≈’ˇ¥◊Õπ≈– Ûı ∫“∑µàÕ§√—«‡√◊Õπ ·≈–¡’°“√∫√‘‚¿§¬“∑—ÈßÀ¡¥ ‡ªìπ¡Ÿ≈§à“ √âÕ¬≈– Ú.ÚÒ ¢Õߺ≈‘µ¿—≥±å¡«≈√«¡¿“¬„π ª√–‡∑» (GDP) ´÷Ëߧ‘¥‡ªìπ§à“„™â®à“¬∂÷ß√âÕ¬≈– Ûˆ.Ù ¢Õß §à“„™â®à“¬∑“ߥâ“π ÿ¢¿“æ∑—ÈßÀ¡¥ ®–‡ÀÁπ‰¥â«à“°“√„™â»“ µ√å °“√·æ∑¬å·ºπªí®®ÿ∫—π∑”„À⇰‘¥ªí≠À“§à“„™â®à“¬ Ÿß ´÷Ë߉¡à Õ¥§≈âÕß°—∫ ∂“π–∑“߇»√…∞°‘®¢Õߪ√–™“™π‚¥¬∑—«Ë ‰ªÚ Õ’°∑—Èß·ºπ¬ÿ∑∏»“ µ√噓µ‘ °“√æ—≤π“¿Ÿ¡‘ªí≠≠“‰∑ ÿ¢¿“æ «‘∂’‰∑ æ.». Úıı›ÚııÙÛ √–∫ÿ„Àâ¡’°“√®—¥°“√§«“¡√Ÿâ ‡°‘ ¥ ¬“‰∑¬·≈–¬“ ¡ÿπ‰æ√∑’Ë ¡’ §ÿ ≥ ¿“æ„π°“√√—°…“ ‡æ‘Ë¡ ¡Ÿ≈§à“°“√„™â¬“ ¡ÿπ‰æ√ ·≈–¡’√–∫∫°≈‰°°“√§ÿ⡧√Õß¿Ÿ¡‘ ªí≠≠“‰∑¬ ¡’°“√‡√àß√—¥°“√„™â¬“‰∑¬ ·≈–¬“®“° ¡ÿπ‰æ√ ‚¥¬¡’°“√‡æ‘Ë¡¡Ÿ≈§à“/ª√‘¡“≥ °“√„™â¬“‰∑¬·≈–¬“ ¡ÿπ‰æ√ Õ¬à“ßπâÕ¬ √âÕ¬≈– Úı ¿“¬„π ı ªïÙ ¥—ßπ—πÈ °“√»÷°…“«‘®¬— ‡√◊ÕË ßªí®®—¬∑’¡Ë Õ’ ∑‘ ∏‘æ≈µàÕ°“√ „™â¬“ ¡ÿπ‰æ√¢Õß‚√ß欓∫“≈ÕŸ∑à ÕߢÕß·æ∑¬å·≈–ª√–™“™π ∑’Ë¡“√—∫∫√‘°“√ ®÷߇ªìπ°“√§âπÀ“§«“¡√Ÿâ‡™‘ߪ√–®—°…å∑’ˇªìπ ª√–‚¬™πå„π°“√ à߇ √‘¡°“√„™â¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈∑’Ë¡’ °“√º≈‘µ¬“ µ≈Õ¥®π„™â‡ªìπ¢âÕ¡Ÿ≈‡æ◊ËÕ𔉪 Ÿà°“√®—¥∑”¢âÕ

‡ πÕ·π–„π°“√«“ß·ºπ√–∫∫π‚¬∫“¬¢Õß‚√ß欓∫“≈ ‡æ◊ËÕ „Àâ ‡ °‘ ¥ °“√æ— ≤ π“ª√— ∫ ª√ÿ ß √–∫∫°“√„™â¬“¢Õß·æ∑¬å·ºπ ªí®®ÿ∫—π µ≈Õ¥®π∫ÿ§≈“°√¥â“π “∏“√≥ ÿ¢ ·≈–ºŸâªÉ«¬∑’Ë¡“ √—∫∫√‘°“√µàÕ‰ª

«—µ∂ÿª√– ߧå¢Õß°“√«‘®—‡æ◊ËÕ»÷°…“ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å·ºπªí®®ÿ∫—π„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’

«‘∏’¥”‡π‘π°“√«‘®—°“√«‘®¬— §√—ßÈ π’‡È ªìπ°“√«‘®¬— ‡™‘ß∑”𓬠(predictive study) ‡æ◊ËÕ»÷°…“ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å·ºπªí®®ÿ∫—π„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ª√–™“°√ ª√–™“°√∑’Ë„™â„π°“√»÷°…“·∫à߇ªìπ Ú °≈ÿà¡ §◊Õ Ò.Ò ·æ∑¬å∑—ÈßÀ¡¥„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ®”π«π ÒÚ §π Ò.ÚºŸªâ «É ¬ §◊Õ ºŸªâ «É ¬∑’¡Ë “√—∫∫√‘°“√„π·ºπ°ºŸªâ «É πÕ°‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ·≈–‰¥â√—∫°“√ —Ëß ®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å·ºπªí®®ÿ∫—π ´÷Ëß¡’®”π«πºŸâªÉ«¬¡“ √—∫∫√‘°“√„πªï æ.». ÚııÚ ®”π«π Û˜,Ú¯ §π ( ∂‘µ‘ ®”π«πºŸâªÉ«¬πÕ°‚√ß欓∫“≈ÕŸà∑Õߪï æ.». ÚııÚ) °≈ÿࡵ—«Õ¬à“ß °≈ÿࡵ—«Õ¬à“ß §◊Õ ºŸâªÉ«¬∑’Ë¡“√—∫∫√‘°“√„π·ºπ° ºŸªâ «É ¬πÕ°‚√ß欓∫“≈ÕŸ∑à Õß ·≈–‰¥â√∫— °“√ —ßË ®à“¬¬“ ¡ÿπ‰æ√ ®“°·æ∑¬å·ºπªí®®ÿ∫—π®”π«π Ù §π ÿࡵ—«Õ¬à“ߺŸâªÉ«·∫∫·∫àß™—πÈ µ“¡·ºπ° §”π«≥¢π“¥°≈ÿ¡à µ—«Õ¬à“ß„™â«∏‘ ¢’ Õß Yamane µ—«·ª√∑’„Ë ™â„π°“√«‘®¬— µ—«·ª√Õ‘ √– §◊Õ ªí®®—¬∑’ˇ°’ˬ«¢âÕß°—∫°“√„™â¬“ ¡ÿπ‰æ√ §◊Õ ªí®®—¬¥â“π√–∫∫¢Õß‚√ß欓∫“≈ ªí®®—¬¥â“π °“√ —Ëß®à“¬¢Õß·æ∑¬å·ºπªí®®ÿ∫—π ªí®®—¬¥â“πºŸâªÉ«¬ ªí®®—¥â“πº≈‘µ¿—≥±å à«πµ—«·ª√µ“¡ §◊Õ °“√„™â¬“ ¡ÿπ‰æ√∑’ Ë ß—Ë ®à“¬‚¥·æ∑¬å·ºπªí®®ÿ∫—π„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ·≈–°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√¢Õß·æ∑¬å

304 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√«‘®—‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈„π°“√«‘®—§√—Èßπ’È„™â‡§√◊ËÕß¡◊Õ∑—ÈßÀ¡¥ Ú ™ÿ¥ ¥—ßπ’È ™ÿ¥∑’Ë Ò ·∫∫ Õ∫∂“¡ ”À√—∫ºŸâªÉ«¬ ª√–°Õ∫ ¥â«¬¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕߺŸâªÉ«¬ §«“¡√Ÿâ°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å·ºπªí®®ÿ∫—π ∑—»π§µ‘°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å·ºπªí®®ÿ∫—π ·≈–ªí®®—¬¥â“πº≈‘µ¿—≥±å∑’Ë¡’ Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬„π‚√ß欓∫“≈ÕŸà∑Õß ™ÿ¥∑’Ë Ú ·∫∫ —¡¿“…≥å·∫∫¡’‚§√ß √â“ß ”À√—∫ ·æ∑¬å·ºπªí®®ÿ∫—πª√–°Õ∫¥â«¬ ¢âÕ¡Ÿ≈∑—Ë«‰ª ªí®®—¬¥â“π √–∫∫¢Õß‚√ß欓∫“≈ ªí®®—¬¥â“πº≈‘µ¿—≥±å ·≈–ªí≠À“ Õÿª √√§·≈–¢âÕ‡ πÕ·π–Õ◊ËπÊ °“√µ√«® Õ∫§ÿ≥¿“æ¢Õ߇§√◊ËÕß¡◊Õ °“√«‘®¬— π’„È ™â°“√À“§«“¡µ√߇™‘߇π◊ÕÈ À“ (Content Validity) ‚¥¬ºŸâ∑√ߧÿ≥«ÿ≤‘ ®”π«π Û §π ª√—∫ª√ÿß·°â‰¢ ¢âÕ§«“¡ ‡æ◊ËÕ„Àâ¡’‡π◊ÈÕÀ“µ√ß°—∫‡√◊ËÕß∑’˵âÕß°“√ ‚¥¬„™â‡°≥±å „π°“√µ—¥ ‘π §◊Õ §«“¡§‘¥‡ÀÁπ¢ÕߺŸ∑â √ߧÿ≥«ÿ≤µ‘ √ß°—π Ú „π Û ∑à“π ®÷ß®–∂◊Õ«à“‡ªìπ¡µ‘¢Õߧ≥–°√√¡°“√ºŸâµ√«® ·∫∫ Õ∫∂“¡ ∑¥ Õ∫§«“¡‡∑’ˬߢÕ߇§√◊ËÕß¡◊Õ (Reliability) ‚¥¬π”·∫∫ Õ∫∂“¡∑’˪√—∫ª√ÿß·≈⫉ª ∑¥ Õ∫ (Tryout) °—∫°≈ÿࡵ—«Õ¬à“ß∑’Ë¡’≈—°…≥–„°≈⇧’¬ß°—∫°≈ÿࡵ—«Õ¬à“ß ∑’Ë®–»÷°…“ §◊ÕºŸâªÉ«¬∑’Ë¡“√—∫∫√‘°“√·ºπ°ºŸâªÉ«¬πÕ°„π ‚√ß欓∫“≈∫“ߪ≈“¡â“ ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ®”π«π Û √“·≈â«π”¡“µ√«® Õ∫À“§«“¡‡∑’ˬߢÕ߇§√◊ËÕß¡◊Õ«‘‡§√“–ÀåÀ“ §à“§«“¡‡∑’ˬߢÕß·∫∫ Õ∫∂“¡¥â«¬«‘∏’¢Õߧ√Õπ∫“§ ‚¥À“§à“ Cronbachûs Coefficient Alpha ‰¥â§à“§«“¡‡∑’Ë¬ß ∑—»π§µ‘ ‡∑à“°—∫ .¯¯ ·≈–√–¥—∫§«“¡æ÷ßæÕ„®®“°ªí®®—µà“ßÊ ¥â“πº≈‘µ¿—≥±å ‡∑à“°—∫ .˘Ù à«π·∫∫ª√–‡¡‘𠧫“¡√Ÿâ„™â°“√À“§«“¡‡∑’Ë¬ß ¥â«¬«‘∏’¢ÕߧŸ‡¥Õ√å √‘™“¥ —πµå (KR21) ‰¥â§à“§«“¡‡∑’ˬ߇∑à“°—∫ .¯Û ¢—ÈπµÕπ°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈ Ò. ‡ πÕ‚§√ß√à“ß«‘®—¬§≥–°√√¡°“√®√‘¬∏√√¡„π ¡πÿ…¬å®“° §≥– “∏“√≥ ÿ¢»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å Õπÿ¡—µ‘®√‘¬∏√√¡ ‰¥âµ“¡‡Õ° “√‡≈¢∑’Ë ˆ/ıÛ ≈ß«—π∑’Ë Ú˘ ¡’π“§¡ æ.». ÚııÛ ÕÕ°„Àâ‚¥¬§≥–°√√¡°“√®√‘¬∏√√¡ „π¡πÿ…¬å Ú. ∑”Àπ— ß ◊ Õ ¢ÕÕπÿ ≠ “µ‡°Á ∫ ¢â Õ ¡Ÿ ≈ ºŸâ ªÉ « ¬∑’Ë ‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ‚¥¬ºŸâ«‘®—¬‡ªìπºŸâ‡°Á∫ ¢âÕ¡Ÿ≈¥â«¬µπ‡Õß

Û. ¥”‡π‘π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈ ‚¥¬„™â · ∫∫ —¡¿“…≥å°—∫·æ∑¬åºŸâ —Ëß®à“¬¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ ·≈– —¡¿“…≥å°≈ÿࡵ—«Õ¬à“ߥ⫬µπ‡Õß ‚¥¬µâÕß™’È·®ß°≈ÿࡵ—«Õ¬à“ß·≈–„Àâ°≈ÿࡵ—«Õ¬à“ß≈ß≈“¬¡◊Õ™◊ËÕ „π„∫¬‘π¬Õ¡°àÕπ°“√ —¡¿“…≥å °“√«‘‡§√“–Àå¢âÕ¡Ÿ≈ °“√«‘‡§√“–Àå¢âÕ¡Ÿ≈„™â Ò. ∂‘µ‘æ√√≥π“ ‚¥¬„™â ∂‘µ‘æ◊Èπ∞“π ‰¥â·°à √âÕ¬≈– §à“‡©≈’¬Ë à«π‡∫’¬Ë ߇∫π¡“µ√∞“π„π‡√◊ÕË ß¢âÕ¡Ÿ≈∑—«Ë ‰ª∑’‡Ë °’¬Ë «¢âÕß °—∫ ∂“π¿“æ »“ π“ ∂“π»÷°…“ ª√– ∫°“√≥å°“√∑”ß“π ‡»√…∞°‘®·≈– —ߧ¡ ∑—Èß·æ∑¬å·≈–ºŸâªÉ«¬ ”À√—∫ºŸâªÉ«¬®–¡’ °“√‡°Á∫ªí®®—¬∑’ˇ°’ˬ«°—∫°“√®à“¬¬“‡¡◊ËÕ‡°‘¥°“√‡®Á∫ªÉ«¬‡™à𠧫“¡√ÿπ·√ߢÕß‚√§ √–¬–‡«≈“°“√‡®Á∫ªÉ«¬ ª√– ∫°“√≥å °“√„™â¬“ ¡ÿπ‰æ√ §«“¡µâÕß°“√„™â ¡ÿπ‰æ√ °“√‰¥â√—∫°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√ °“√‰¥â√—∫°“√ π—∫ πÿπ®“°§√Õ∫§√—« „π°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ëß®à“¬ ‚¥¬·æ∑¬å·ºπªí®®ÿ∫—π„π ‚√ß欓∫“≈ÕŸ∑à Õß Ú. ∂‘µ‘«‘‡§√“–ÀåÀ“§«“¡ —¡æ—π∏å√–À«à“ßªí®®—µà“ßÊ ∑’Ë°”Àπ¥°—∫°“√„™â¬“ ¡ÿπ‰æ√∑’Ë —Ë ß ®à “ ¬‚¥¬·æ∑¬å ·ºπªí®®ÿ∫—π„π‚√ß欓∫“≈ÕŸà∑Õß ‚¥¬„™â Ú.Ò °“√∑¥ Õ∫‰§ ·§«√å (Chi›square test) ”À√—∫¢âÕ¡Ÿ≈∑’Ë«—¥·∫∫°≈ÿà¡ ‰¥â·°à ‡æ» ∂“π¿“æ ¡√ Õ“™’æ ‡¢µ∑’ËÕ¬ŸàÕ“»—Ú.Ú °“√«‘ ‡ §√“–Àå ° “√∂¥∂Õ¬‚ ≈ ®‘ µ‘ § (Logistic Regression Analysis) ‡æ◊Ë Õ À“§«“¡ —¡æ—π∏å√–À«à“ßµ—«·ª√Õ‘ √– ·≈–°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâ ªÉ«¬πÕ°∑’Ë¡“√—∫∫√‘°“√„π‚√ß欓∫“≈ÕŸà∑Õß Û. °“√«‘®¬— §√—ßÈ π’°È ”Àπ¥√–¥—∫§«“¡¡’π¬— ”§—≠∑“ß ∂‘µ‘ (Level of Significant) ‡∑à“°—∫ .ı Ù. «‘ ‡ §√“–Àå · ∫∫‡™‘ ß §ÿ ≥ ¿“æ„π à « π¢Õß°“√ —¡¿“…≥å°≈ÿà¡·æ∑¬å ∑’Ë„™â·∫∫ —¡¿“…≥å∑’Ë¡’‚§√ß √â“ß

º≈°“√«‘®¬— Ò. º≈°“√«‘®—¬¢ÕߺŸâªÉ«Ò.Ò ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕߺŸâªÉ«°≈ÿࡵ—«Õ¬à“ß®”π«π Ù §π à«π„À≠à‡ªìπ‡æ» À≠‘ß (√âÕ¬≈– ˜Ò.Û) Õ“¬ÿ ˆ ªï¢÷Èπ‰ª (√âÕ¬≈– ıÛ.) ∂“π¿“槟à (√âÕ¬≈– Û¯.Û) ¡’√“¬‰¥âµàÕ‡¥◊ÕππâÕ¬°«à“ ı, ∫“∑ (√âÕ¬≈– ˆ) √–¥—∫°“√»÷°…“ª√–∂¡»÷°…“ (√âÕ¬≈– ˜Ú.) Õ¬ŸàπÕ°‡¢µ‡∑»∫“≈ (√âÕ¬≈– ˜˜.Ú)

305

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ª√– ∫°“√≥å°“√„™â¬“æ∫«à“ºŸªâ «É ¬ à«π„À≠à ‡§¬„™â¬“ ¡ÿπ‰æ√ (√âÕ¬≈– ¯¯.) ‡§¬· ¥ß§«“¡µâÕß°“√¢Õ√—∫¬“ ¡ÿπ‰æ√ ®“°·æ∑¬å (√âÕ¬≈– ˜Û.Ú) ‡§¬‰¥â√—∫°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√ ®“°·æ∑¬å (√âÕ¬≈– ˘Ú.Ú) §√Õ∫§√—« π—∫ πÿπ„Àâ¡’°“√„™â ¬“ ¡ÿπ‰æ√ (√âÕ¬≈– ˘Ò.ı) Ò.Ú §«“¡√Ÿ‡â °’¬Ë «°—∫°“√„™â¬“ ¡ÿπ‰æ√∑’ Ë ß—Ë ®à“¬‚¥¬·æ∑¬å ·ºπªí®®ÿ∫π— °≈ÿࡵ—«Õ¬à“ß¡’§à“‡©≈’ˬ§–·π𧫓¡√Ÿâ Ò¯.˜ §–·ππ®“°§–·ππ‡µÁ¡ Û §–·ππ à«π„À≠à¡’§«“¡√Ÿâ ‡°’ˬ«°—∫°“√„™â¬“ ¡ÿπ‰æ√Õ¬Ÿà„π√–¥—∫ª“π°≈“ß (Ò.˘ÙÚı.Ú) √âÕ¬≈– ˆı.ı ‡¡◊ËÕæ‘®“√≥“§«“¡√Ÿâ‡°’ˬ«°—∫°“√ „™â¬“ ¡ÿπ‰æ√‡ªìπ√“¬¢âÕ æ∫«à“°≈ÿࡵ—«Õ¬à“ß à«π„À≠à ¡’ §«“¡√Ÿâ‡°’ˬ«°—∫°“√„™â¬“ ¡ÿπ‰æ√µ“¡·æ∑¬å —Ë߉¥â∂Ÿ°µâÕß„π ª√–‡¥Áπ°“√√—∫ª√–∑“𬓠¡ÿπ‰æ√°àÕπÕ“À“√§«√√—∫ª√–∑“𠬓°àÕπÕ“À“√Õ¬à“ßπâÕ¬ Û π“∑’ (√âÕ¬≈– ˜Ú.ı) °“√√—∫ ª√–∑“𬓠¡ÿπ‰æ√À≈—ßÕ“À“√§«√√—∫ª√–∑“π¬“À≈—ßÕ“À“√ Õ¬à“ßπâÕ¬ Òı π“∑’ (√âÕ¬≈– ˜Ú.ı) ‡¡◊ËÕ„™â ¡ÿπ‰æ√√—°…“ Õ“°“√¢Õß‚√§ ∂Ⓡ°‘¥Õ“°“√·æâ®–À¬ÿ¥¬“∑—π∑’ (√âÕ¬≈– ˘.Û) ·≈–¡’§«“¡√Ÿâ‡°’ˬ«°—∫§ÿ≥ ¡∫—µ‘¢Õ߬“ ¡ÿπ‰æ√‰¥â ∂Ÿ°µâÕß‡æ’¬ß ı ™π‘¥ ‰¥â·°à „π‡√◊ËÕßπÈ”¡—π‰æ≈∑“∂Ÿπ«¥ ∫√√‡∑“Õ“°“√ª«¥°≈â“¡‡π◊ÕÈ (√âÕ¬≈– ¯˜.Û) ¡“°∑’ Ë ¥ÿ √Õß ≈ß¡“ §◊Õ §“≈“‰¡¥å ‡ ≈¥æ—ßæÕπ ∫√√‡∑“Õ“°“√º¥º◊Ëπ§—π ∑’˺‘«Àπ—ß (√âÕ¬≈– ˜Û.ı) øÑ“∑–≈“¬‚®√ ∫√√‡∑“Õ“°“√‰Õ ‡®Á∫§Õ (√âÕ¬≈– ˆ˜.ı) ¡–¢“¡·¢°∫√√‡∑“Õ“°“√∑âÕߺŸ° ∂à“¬Õÿ®®“√–≈”∫“° (√âÕ¬≈– ˆˆ.ı) °“√„™â¬“¢¡‘Èπ™—π ∫√√‡∑“Õ“°“√®ÿ°·πàπ∑âÕß (√âÕ¬≈– ˆı.¯) °≈ÿࡵ—«Õ¬à“ß¡’ §«“¡√Ÿâº‘¥„π‡√◊ËÕß Õ“°“√«‘߇«’¬π»’√…– Àπâ“¡◊¥ ‡ªìπ≈¡ „™â ¬“·°â‰¢âÀâ“√“°¡“°∑’Ë ÿ¥ (√âÕ¬≈– ˆÒ.¯)

Ò.Û ∑—»π§µ‘‡°’¬Ë «°—∫°“√„™â¬“ ¡ÿπ‰æ√∑’ Ë ß—Ë ®à“¬‚¥¬·æ∑¬å ·ºπªí®®ÿ∫π— °≈ÿ¡à µ—«Õ¬à“ß à«π„À≠à¡∑’ »— 𧵑µÕà °“√„™â¬“ ¡ÿπ‰æ√ „π√–¥—∫ ¥’ §◊Õ‡ÀÁπ¥â«¬·≈–‡ÀÁπ¥â«¬Õ¬à“߬‘Ëß„π°“√„™â¬“ ¡ÿπ‰æ√¡“°°«à“ √âÕ¬≈– ¯ „π∑ÿ°¢âÕ ‡√’¬ß≈”¥—∫¢Õß °≈ÿࡵ—«Õ¬à“߇√’¬ß®“°¡“°∑’Ë ÿ¥‰ªπâÕ¬ ÿ¥ ı Õ—π¥—∫·√° §◊Õ ‡ÀÁ π ¥â « ¬°— ∫ °“√ π— ∫ πÿ π„Àâ ¡’ ° “√„™â ¬ “ ¡ÿ π‰æ√„π°“√ √—°…“‚√§ ¬“ ¡ÿπ‰æ√„πªí®®ÿ∫π— ¡’ª√– ‘∑∏‘¿“楒°«à“ ¡—¬°àÕ𠬓 ¡ÿπ‰æ√§«√æ—≤π“‡À¡◊Õπ√Ÿª·∫∫¬“·ºπªí®®ÿ∫—𠬓 ¡ÿπ‰æ√ “¡“√∂∑”„Àℙ⠖¥«° √—∫ª√–∑“πßà“¬ ®–¡’ §π„™â¡“°¢÷È𠬓 ¡ÿπ‰æ√∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å “¡“√∂√—°…“ ‚√§‰¥â¥‡’ À¡◊Õ𬓷ºπªí®®ÿ∫π— (√âÕ¬≈– ˘ˆ.¯, ˘Ù.Û, ˘Ú.Û, ˘Ò.ˆ ·≈– ˘Ò. µ“¡≈”¥—∫) Ò.Ù ªí®®—¬¥â“πº≈‘µ¿—≥±å∑¡’Ë º’ ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√¢Õß ºŸâªÉ«¬„π‚√ß欓∫“≈ÕŸà∑Õß °≈ÿ¡à µ—«Õ¬à“ß∑’‡Ë ªìπºŸªâ «É ¬¡’§«“¡æ÷ßæÕ„®µàÕº≈‘µ¿—≥±å ¬“ ¡ÿπ‰æ√¢Õß‚√ß欓∫“≈ÕŸà∑Õß · ¥ß‡ªìπ§–·ππ‡©≈’ˬ„π ·µà≈–À¡«¥ æ∫«à“ §–·π𧫓¡æ÷ßæÕ„®¡“°°«à“√âÕ¬≈– ¯ ∑ÿ°ªí®®—¬ ªí®®—¬∑’Ë¡’√–¥—∫§«“¡æ÷ßæÕ„®¡“°∑’Ë ÿ¥ (§–·π𠇩≈’¬Ë ¡“°°«à“ √âÕ¬≈– ¯ı) §◊Õ °“√®—¥®”Àπà“¬ ¡’§–·ππ Ÿß ∑’Ë ÿ¥ °“√ à߇ √‘¡°“√¢“¬ √Ÿª·∫∫º≈‘µ¿—≥±å ¥â“πª√– ‘∑∏‘¿“æ¢Õ߬“ ¡ÿπ‰æ√ (√âÕ¬≈– ¯˜.Ò, ¯ı.¯, ¯ı.ˆ ·≈– ¯ı.Ò µ“¡≈”¥—∫) à«πªí®®—¬∑’Ë¡’√–¥—∫æÕ„®¡“° (§–·π𠇩≈’ˬ¡“°°«à“ √âÕ¬≈– ˜ı-¯Ù.˘) §◊Õ√“§“¬“ ¡ÿπ‰æ√ (√âÕ¬≈– ¯.Ú) ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§–·π𧫓¡æÕ„®„πªí®®—¬µà“ßÊ æ∫«à“∑—ÈߺŸâªÉ«¬·≈–·æ∑¬å¡’√–¥—∫§«“¡æÕ„®¡“° ·µà·æ∑¬å ¡’√–¥—∫§«“¡æÕ„®πâÕ¬°«à“ºŸâªÉ«¬¥—ßµ“√“ß∑’Ë Ò

µ“√“ß∑’Ë Ò ‡ª√’¬∫‡∑’¬∫√–¥—∫§«“¡æ÷ßæÕ„®„πªí®®—¬¥â“πµà“ßÊ ¢Õߺ≈‘µ¿—≥±å¢ÕߺŸâªÉ«¬·≈–·æ∑¬å (§–·ππ‡µÁ¡ ı §–·ππ) ¢âÕ§«“¡ Ò. √Ÿª·∫∫¢Õߺ≈‘µ¿—≥±å Ú. √“§“¬“ ¡ÿπ‰æ√ Û. °“√®—¥®”Àπà“¬¬“ ¡ÿπ‰æ√ Ù. °“√ à߇ √‘¡°“√¢“¬¬“ ¡ÿπ‰æ√ ı. ª√– ‘∑∏‘¿“æ¢Õ߬“ ˆ. §«“¡ª≈Õ¥¿—¬„π°“√„™â¬“ √«¡

ºŸâªÉ«Ù.Ú˜ Ù.ÚÛ Ù.Ûı Ù.ÚÚ Ù.¯ Ù.Ú˜ Ù.ÛÚ

§à“‡©≈’ˬ√–¥—∫§«“¡æ÷ßæÕ„® ·ª≈º≈ ·æ∑¬å ¡“° Ù.Òı ¡“° Û.˜Ú ¡“° Ù.ÒÛ ¡“° Û.˘˜ ¡“° Û.¯¯ ¡“° Ù.ÚÚ ¡“° Ù.Ò

·ª≈º≈ ¡“° ¡“° ¡“° ¡“° ¡“° ¡“° ¡“°

À¡“¬‡Àµÿ °“√·ª≈º≈§–·ππ‡µÁ¡ ı ¥—ßπ’È .ı-Ò.Ù˘ πâÕ¬∑’Ë ÿ¥, Ò.ı-Ú.Ù˘ πâÕ¬, Ú.ı-Û.Ù˘ ª“π°≈“ß, Û.ı-Ù.Ù˘ ¡“°, Ù.ı ¢÷Èπ‰ª æÕ„®¡“°∑’Ë ÿ¥

306 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Ò.ı §«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬¥â“𮑵«‘∑¬“ °—∫ª√– ∫°“√≥å∑‰’Ë ¥â ·≈–‰¡à‰¥â√∫— °“√ —ßË ®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å °“√À“§«“¡ — ¡ æ— π ∏å ‚ ¥¬„™â ∂‘ µ‘ ‰ § ·§«√å ¢ Õß ªí®®—¬¥â“𮑵«‘∑¬“∑’˪√–°Õ∫¥â«¬ §«“¡√Ÿâ ∑—»π§µ‘ §«“¡ µâ Õ ß°“√¢Õ√— ∫ ¬“ ª√– ∫°“√≥å ° “√„™â ·≈–§√Õ∫§√— « π—∫ πÿπ„Àℙ⬓ ¡ÿπ‰æ√ ¡’§«“¡ —¡æ—π∏å°—∫ª√– ∫°“√≥å ∑’ˉ¥â·≈–‰¡à‰¥â√—∫°“√ —Ëß®à“¬®“°·æ∑¬å ∑’Ë√–¥—∫π—¬ ”§—≠∑“ß ∂‘µ‘‡∑à“°—∫ .ı æ∫«à“¡’‡æ’¬ß·µà∑—»π§µ‘ §«“¡µâÕß°“√ ¢Õ√—∫¬“ ¡ÿπ‰æ√ ª√– ∫°“√≥å°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬

„π‚√ß欓∫“≈ÕŸà∑Õß ·≈–§√Õ∫§√—«‡§¬ π—∫ πÿπ„Àℙ⬓ ¡ÿπ‰æ√¡’§«“¡ —¡æ—π∏å°—∫ª√– ∫°“√≥å°“√‰¥â√—∫°“√ —Ëß ®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (§à“æ’ < .ı) ·µà§«“¡√Ÿâ‰¡à¡’§«“¡ —¡æ—π∏å°—∫ª√– ∫°“√≥å°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å (µ“√“ß∑’Ë Ú ) · ¥ß«à“§π∑’Ë¡’ §«“¡√ŸâÕ“®¡’À√◊Õ‰¡à¡’ª√– ∫°“√≥宓°·æ∑¬å„π°“√ —Ëß®à“·µà§π∑’Ë¡’∑—»π§µ‘ ·≈–‡§¬¡’ª√– ∫°“√≥å À√◊Õ§√Õ∫§√—« ‡§¬„™â ·æ∑¬å¡—°®–®à“¬¬“„Àâ¡“°°«à“

µ“√“ß∑’Ë Ú §«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬¥â“𮑵«‘∑¬“¢ÕߺŸªâ «É ¬°—∫ª√– ∫°“√≥å∑‰’Ë ¡à‰¥â√∫— °“√ —ßË ®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å ·≈– ∑’ˉ¥â√—∫°“√ —Ëß®à“¬®“°·æ∑¬å

ªí®®—¬¥â“𮑵«‘∑¬“

ª√– ∫°“√≥å∑’ˉ¡à‰¥â√—∫°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å

χ2

p-value

§«“¡√Ÿâ

.¯Ú

∑—»π§µ‘

ª√– ∫°“√≥å∑’ˉ¥â√—∫°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å

χ2

p-value

.ˆˆÙ

.Ù¯Ú

.˜¯ˆ

˘.˘Ù¯*

.ÒÛ

ˆ.ÒıÒ*

.Ùˆ

§«“¡µâÕß°“√¢Õ√—∫¬“ ¡ÿπ‰æ√

ıÙ.˘˜**

<.Ò

ÙÙ.ÛÒ**

<.Ò

ª√– ∫°“√≥儙⬓ ¡ÿπ‰æ√

˜˜.ÛÒÛ**

<.Ò

˜˜.ÛÒÛ**

<.Ò

§√Õ∫§√—«‡§¬ π—∫ πÿπ„Àℙ⬓ ¡ÿπ‰æ√

Ûˆ.Ú˘¯**

<.Ò

ÛÒ.Ùˆ**

<.Ò

*· ¥ßπ—¬ ”§—≠∑’Ë√–¥—∫ <.ı, **· ¥ßπ—¬ ”§—≠∑’Ë√–¥—∫ <.Ò

Ò.ˆ §«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬°—∫ª√– ∫°“√≥å°“√„™â ¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬„π‚√ß欓∫“≈ÕŸà∑Õß ‡¡◊ËÕπ”ªí®®—¬∑’ˇ°‘¥®“°¢âÕ¡Ÿ≈∑—Ë«‰ª ·≈–∑—»π§µ‘ ¡“À“§«“¡ —¡æ—π∏å°—∫ª√– ∫°“√≥å°“√„™â¬“ ¡ÿπ‰æ√∑’ˉ¡à ‰¥âºà“π°“√ —Ëß®à“¬¬“®“°·æ∑¬å¢ÕߺŸâªÉ«¬‚√ß欓∫“≈ÕŸà∑Õß ∑’√Ë –¥—∫π—¬ ”§—≠∑“ß ∂‘µ‡‘ ∑à“°—∫ .ı ¡“«‘‡§√“–À奫⠬°“√ ∂¥∂Õ¬ ‚≈®‘ µ‘° å º≈°“√»÷°…“æ∫«à“ ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈ µàÕ°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬‚¥¬‰¡à‰¥âºà“π°“√ —Ëß®à“¬¬“ ®“°·æ∑¬å„π‚√ß欓∫“≈ÕŸà∑Õß¡’ Ú ªí®®—¬‡∑à“π—Èπ §◊Õ §«“¡ µâÕß°“√„™â¬“ ¡ÿπ‰æ√ ·≈–°“√ à߇ √‘¡°“√„™â¬“ ¡ÿπ‰æ√®“° §√Õ∫§√—« ‚¥¬æ∫«à“§«“¡µâÕß°“√„™â¬“ ¡ÿπ‰æ√¡’Õ‘∑∏‘æ≈ µàÕ°“√„™â¬“ ¡ÿπ‰æ√¡“°∑’Ë ÿ¥ (Odd ratio = ˆ.ıÛ, §à“æ’ <.ı) √Õß≈ß¡“ §◊Õ °“√ à߇ √‘¡°“√„™â¬“ ¡ÿπ‰æ√ ®“°§√Õ∫§√—« (Odd ratio = Û.Ò¯˘, §à“æ’ <.ı) ·µà∑—»π§µ‘·≈–Õߧåª√–°Õ∫Õ◊Ëπ¢ÕߺŸâªÉ«¬ ‡™àπ √–¥—∫

°“√»÷°…“‰¡à¡’§«“¡ —¡æ—π∏å· ¥ß«à“°“√∑’˺ŸâªÉ«¬Õ¬“°„™â¬“ ¡ÿπ‰æ√¢÷πÈ °—∫§«“¡µâÕß°“√ºŸªâ «É ¬‡Õß°Õª√°—∫°“√ π—∫ πÿπ ®“°§√Õ∫§√—« ®–¡’º≈„π°“√„™â∂÷ß·¡â«à“®–‰¡à‡§¬‰¥â√—∫¬“ ¡ÿπ‰æ√®“°‚√ß欓∫“≈‡≈‡¡◊ËÕæ‘®“√≥“§«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬∑’ˇ°‘¥®“° ¢âÕ¡Ÿ≈∑—Ë«‰ª ·≈–∑—»π§µ‘ °—∫ª√– ∫°“√≥å°“√‰¥â√—∫°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å¢ÕߺŸâªÉ«¬„π‚√ß欓∫“≈ÕŸà∑Õß æ∫«à“¡’ Û ªí®®—¬ §◊Õ ∑—»π§µ‘¢ÕߺŸâªÉ«¬ §«“¡µâÕß°“√„™â ¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬ ·≈–°“√ à߇ √‘¡°“√„™â¬“ ¡ÿπ‰æ√ ®“°§√Õ∫§√—« ‚¥¬§«“¡µâÕß°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬¡’ Õ‘∑∏‘æ≈¡“°∑’Ë ÿ¥ (Odd ratio = ˜.˘Ù, §à“æ’ <.ı) ‡™àπ°—π √Õß≈ß¡“ §◊Õ °“√ à߇ √‘¡°“√„™â¬“ ¡ÿπ‰æ√®“° §√Õ∫§√—« (Odd ratio = Û.ÒÚ, §à“æ’ <.ı) ·≈–∑’Ë¡’ Õ‘∑∏‘æ≈πâÕ¬∑’Ë ÿ¥ §◊Õ ∑—»π§µ‘ (Odd ratio = .Ùˆ˘, §à“æ’ <.ı) · ¥ß«à“∑—»π§µ‘¡’ à«π‡ √‘¡„Àâ·æ∑¬å —Ëß®à“¬

307

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

¬“ ¡ÿπ‰æ√√à«¡¥â«¬ ·µàÕ¬à“߉√°Áµ“¡§«“¡µâÕß°“√ºŸªâ «É ¬‡Õß °Õª√°—∫°“√ π—∫ πÿπ®“°§√Õ∫§√—« ®–¡’º≈„π°“√„™â∂÷ß ·¡â«à“®–‰¡à‡§¬ À√◊Õ‡§¬‰¥â√—∫¬“ ¡ÿπ‰æ√®“°‚√ß欓∫“≈ Ú. º≈°“√»÷°…“®“°·æ∑¬å·ºπªí®®ÿ∫—π ®“°°≈ÿࡵ—«Õ¬à“ß·æ∑¬å®”π«π ÒÚ §π ‡æ»™“ˆ §π ‡æ»À≠‘ß ˆ §π ª√–°Õ∫¥â«¬·æ∑¬å‡©æ“–∑“ß “¢“ »—≈¬·æ∑¬å Õ“¬ÿ√·æ∑¬å Õ“¬ÿ√°√√¡©ÿ°‡©‘π Ÿµ‘π√’·æ∑¬å °ÿ¡“√·æ∑¬å ·æ∑¬å∑—Ë«‰ª ·≈–·æ∑¬å∑—Ë«‰ª ª√– ∫°“√≥å °“√∑”ß“π‡°’¬Ë «°—∫ ¡ÿπ‰æ√¢Õß·æ∑¬å ·æ∑¬å¡ª’ √– ∫°“√≥å °“√∑”ß“π‡°’Ë¬«°—∫ ¡ÿπ‰æ√ -Ò ªï Ú §π ¡’ª√– ∫°“√≥å ∑”ß“π Ú-ı ªï Ù §π ·≈– ¡’ª√– ∫°“√≥å∑”ß“π ¡“°°«à“ ı ªï ˆ §π Ú.Ò §«“¡√Ÿâ ¢ Õß·æ∑¬å µà Õ √√æ§ÿ ≥ ¢Õ߬“ ¡ÿπ‰æ√ ·æ∑¬å¡’§«“¡√Ÿâ‡°’ˬ«°—∫¬“ ¡ÿπ‰æ√‡©≈’ˬ ÒÙ.Òˆ ®“°§–·ππ‡µÁ¡ Òˆ (§‘¥‡ªìπ√âÕ¬≈– ¯¯.ı) ‚¥¬·µà≈– √“¬¢âÕ æ∫«à“·æ∑¬å√«Ÿâ “à ¬“∏“µÿÕ∫‡™¬√—°…“‚√§∑âÕßÕ◊¥ Õ“À“√ ‰¡à¬àÕ¬ ∫“≈å¡ ¡ÿπ‰æ√·°âª«¥‡¡◊ËÕ¬ ∑ÿ°§π¬°‡«âπ ¢¡‘Èπ™—π √—°…“Õ“°“√∑âÕßÕ◊¥ ®ÿ°·πàπ∑âÕß À— ∏“√“ √—°…“ Õ“°“√ ª«¥°≈â“¡‡π◊ÈÕ °√–‡∑’¬¡√—°…“Õ“°“√‰¢¡—π„π‡≈◊Õ¥ Ÿß·≈– §«“¡¥—π‚≈À‘µ Ÿß µÕ∫∂Ÿ° ÒÒ §π ™“§”ΩÕ¬√—°…“Õ“°“√ ‰¢¡—π„π‡≈◊Õ¥ Ÿß·≈–§«“¡¥—π‚≈À‘µ ‡ÀÁ¥À≈‘π®◊Õ√—°…“Õ“°“√ ¿Ÿ¡‘·æâ ∫”√ÿß ÿ¢¿“æ µÕ∫∂Ÿ° Ò §π ·µàµÕ∫«à“ â¡·¢° “¡“√∂√—°…“Õ“°“√‰¢¡—π„π‡≈◊Õ¥ Ÿß µÕ∫∂Ÿ°‡æ’¬ß§√÷ËßÀπ÷Ëß · ¥ß„Àâ‡ÀÁπ«à“ √√æ§ÿ≥ ¡ÿπ‰æ√∑’Ë®”Àπà“¬„π‚√ß欓∫“≈ ·æ∑¬å°Á¬—߉¡à√Ÿâ∑ÿ°√“¬°“√·¡â°√–∑—Ëß ¢¡‘Èπ™—π´÷Ë߇ªìπ¬“∑’ˇªìπ ¡ÿπ‰æ√„π∫—≠™’¬“À≈—°·Ààß™“µ‘°Á¬—ßµÕ∫‰¡à∂Ÿ° Ò §π ∑—Èßπ’È ‡æ√“–‡ªìπ·æ∑¬å‡©æ“–∑“ß∑’ˉ¡à‰¥â —Ëß®à“¬¬“ ¡ÿπ‰æ√‡À≈à“π’È Ú.Ú ∑—»π§µ‘¢Õß·æ∑¬åµÕà °“√ —ßË ®à“¬¬“ ¡ÿπ‰æ√ ·æ∑¬å ¡’ ∑— » 𧵑 ∫ «°µà Õ °“√ —Ë ß ®à “ ¬¬“ ¡ÿ π‰æ√ ¿“æ√«¡‡©≈’ˬ §‘¥‡ªìπ √âÕ¬≈– ˜˘.ˆ ∑’ˇÀÁπ¥â«¬·≈–‡ÀÁπ ¥â «¬Õ¬à “ ߬‘Ëß„π∑ÿ°¿“æ√«¡ (§–·ππ‡©≈’ˬ Û.˘¯ ®“° §–·ππ‡µÁ¡ ı §–·ππ) ‡¡◊ÕË æ‘®“√≥“‡ªìπ√“¬¢âÕ æ∫«à“ ·æ∑¬å ‡™◊ËÕ«à“ °“√„™â¬“ ¡ÿπ‰æ√‡ªìπ°“√ à߇ √‘¡¿Ÿ¡‘ªí≠≠“∑âÕß∂‘Ëπ À“ßà“¬„π™ÿ¡™π ·≈–¬Õ¡√—∫«à“ “¡“√∂∑¥·∑𬓷ºπªí®®ÿ∫π— ‰¥â„π∫“ßÕ“°“√ §–·ππ‡©≈’ˬ¡“°°«à“ Ù §–·ππ ·µà√–¥—∫ §–·ππ¢Õß°“√∑’Ë · æ∑¬å ‰ ¡à —Ë ß ®à “ ¬‡æ√“–‰¡à ∑ √“∫¢π“¥∑’Ë ·πàπÕπ ¬—ß‰¡à‡™◊ËÕ¡—Ëπ„π √√æ§ÿ≥¢Õ߬“ ¡ÿπ‰æ√ à«π√–¥—∫

§«“¡æ÷ßæÕ„®µàÕªí®®—¬¥â“πº≈‘µ¿—≥±å ¡ÿπ‰æ√¢Õß·æ∑¬å æ∫«à“ ·æ∑¬å¡’§«“¡æ÷ßæÕ„®„π‡√◊ËÕß√Ÿª·∫∫¢Õߺ≈‘µ¿—≥±å °“√®—¥®”Àπà“¬ §«“¡ª≈Õ¥¿—¬¢Õ߬“¡’√–¥—∫§–·ππ¡“° °«à“ Ù §–·ππ §◊Õ‡√◊ËÕß∫√√®ÿ¢«¥∑—π ¡—¬ æ° –¥«° ∑¥·∑𬓷ºπªí®®ÿ∫—π‰¥â ·µà„π‡√◊ËÕß√“§“¬“ ¡ÿπ‰æ√ °“√ à߇ √‘¡°“√¢“¬ ª√– ‘∑∏‘¿“æ¢Õ߬“ ¡’§–·π𧫓¡æ÷ß æÕ„®„π√–¥—∫§–·ππ Û.ı-Û.˘ ∂◊Õ«à“‡ªìπ∑—»π§µ‘∫«° À√◊Õ∑—»π§µ‘∑¥’Ë ’ ·æ∑¬å¬ß— ¡’§«“¡‡ÀÁπ«à“¬“ ¡ÿπ‰æ√ √“§“∂Ÿ° ¡’πâÕ¬∑’Ë ÿ¥ §◊Õ√–¥—∫§–·ππ Û.ı ∂◊Õ‰¥â«à“¡’∑—»π§µ‘∫«° ª“π°≈“ß Ú.Û √–∫∫¢Õß‚√ß欓∫“≈ º≈®“°°“√ —¡¿“…≥凮“–≈÷°¢Õß·æ∑¬å µàÕ√–∫∫ °“√„™â¬“ ¡ÿπ‰æ√¢Õß‚√ß欓∫“≈ æ∫«à“·æ∑¬å à«π„À≠à„™â ¬“µ“¡π‚¬∫“¬°√–∑√«ß “∏“√≥ ÿ¢·≈– ®“°§≥–°√√¡°“√ ‡¿ —™°√√¡·≈–°“√∫”∫—¥·æ∑¬å¢Õß‚√ß欓∫“≈ «‘∏’°“√√—∫ ¢âÕ¡Ÿ≈®–‰¥â®“°§Ÿ¡à Õ◊ °“√„™â¬“ ¡ÿπ‰æ√„π√“¬°“√∫—≠™’¬“ ¡ÿπ‰æ√ „π‚√ß欓∫“≈·µà·æ∑¬å∫“ߧπ‰¡à‡ÀÁπ¥â«¬„π √√æ§ÿ≥ ∫“ß √“¬°“√‡æ√“–·æ∑¬å‰¡à‡§¬‰¥â√—∫¢âÕ¡Ÿ≈‡°’ˬ«°—∫ß“π«‘®—¬‡√◊ËÕß ¬“ ¡ÿπ‰æ√®“°µ—«·∑π∫√‘…—∑ºŸâº≈‘µ (√«¡Õߧ尓√‡¿ —™°√√¡) ¥—ßπ—Èπ®÷߉¡à‡™◊ËÕ¡—Ëπ„π°“√„™â¬“ ·π«∑“ß·°â‰¢ §«√¡’ °“√ª√–™“ —¡æ—π∏å‡√◊ËÕߢâÕ¡Ÿ≈ °“√„™âª√– ‘∑∏‘º≈¢Õ߬“ ¢π“¥¬“ ‡À¡◊Õπ°—∫¬“·ºπªí®®ÿ∫—π∑’Ë¡’ß“π«‘®—¬ π—∫ πÿπ ®“°§”°≈à“«∑’Ë«à“ ç √√æ§ÿ≥¬“·µà≈–™π‘¥§«√¡’ß“π«‘®—π—∫ πÿπ °“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬åπâÕ¬‡π◊ËÕß®“°‰¡à ∑√“∫ √√æ§ÿ≥·≈–¢âÕ§«√√–«—ß∑’Ë™—¥‡®πé

«‘®“√≥å °“√«‘®¬— ‡√◊ÕË ßªí®®—¬∑’¡Ë Õ’ ∑‘ ∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√ ∑’Ë —Ëß®à“¬‚¥¬·æ∑¬å·ºπªí®®ÿ∫—π„π‚√ß欓∫“≈ÕŸà∑Õß ®—ßÀ«—¥ ÿæ√√≥∫ÿ√’ „π à«π¢Õߪ√–™“™πæ∫«à“ §«“¡√Ÿâ‰¡à¡’§«“¡ —¡æ—π∏å°∫— °“√„™â¬“ ¡ÿπ‰æ√∑’ Ë ß—Ë ®à“¬‚¥¬·æ∑¬å „π‚√ß欓∫“≈ ´÷Ëß®–·µ°µà“ß°—∫ß“π«‘®—¬¢ÕßÕ√ÿ≥æ√ Õ‘∞√—µπå·≈–‡æ™√πâÕ‘ß™à“ß™—¬ı ∑’Ëæ∫«à“§«“¡√Ÿâ¡’Õ‘∑∏‘æ≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√ µ“¡‚§√ß°“√ “∏“√≥ ÿ¢¡Ÿ≈∞“π¢Õߪ√–™“™π π—Ëπ· ¥ß °“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈∫√‘∫∑ºŸâªÉ«¬ æ∫«à“ §«“¡√ŸâÕ“®¡’§«“¡ ”§—≠πâÕ¬°«à“ªí®®—¬Õ◊Ëπ ·µà ‘Ëß∑’Ë ”§—≠ §◊Õ ª√– ∫°“√≥å°“√ —Ëß®à“¬¬“¢Õߪ√–™“™π∑’ˉ¥â®“°·æ∑¬å ∂⓺ŸâªÉ«¬¡’ª√– ∫°“√≥宓°°“√„™â¬“·≈⫧√—Èß·√° §√—ÈßµàÕÊ ‰ª °Á®– àߺ≈„Àâ ºŸâ ªÉ « ¬„™â¬“µàÕÀ√◊Õ¡’§«“¡µâÕß°“√∑’Ë®– „Àâ·æ∑¬å ß—Ë ®à“¬¬“ ¡ÿπ‰æ√ º≈ Õ¥§≈âÕß°—∫π‘»“™≈ ª√– “π

308 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ÿ¢ˆ ∑’ˉ¥â Õ∫∂“¡ºŸâªÉ«¬µàÕ°“√ —Ëß®à“¬¬“¢Õß·æ∑¬å æ∫«à“ §«“¡µâÕß°“√¢ÕߺŸâªÉ«¬‡ªìπªí®®—¬∑’Ë∑”„Àâ·æ∑¬å¡’°“√®à“¬“ ¡ÿ π‰æ√„π‚√ß欓∫“≈°ÿ ¥ ™ÿ ¡ ¡“°¢÷È π ·≈–∂â “ ¡’ ° “√ π—∫ πÿπ®“°§√Õ∫§√—«∑’‡Ë §¬¡’ª√– ∫°“√≥å®–æ∫«à“ ®–∑”„Àâ ·æ∑¬åÕ¬“°∑’Ë —Ëß®à“¬¬“®“° ¡ÿπ‰æ√‰¥â¡“°¢÷Èπ ·≈–®“°°“√ À“§à“§«“¡ —¡æ—π∏å√–À«à“ß∑—»π§µ‘‡ª√’¬∫‡∑’¬∫√–À«à“ߺŸâ∑’Ë ‡§¬‰¥â√—∫°“√ —Ëß®à“¬¬“ ·≈–ºŸâ‰¡à‡§¬‰¥â√—∫°“√ —Ëß®à“¬ ¡ÿπ ‰æ√æ∫«à“ ∑—»π§µ‘ ‰¡à¡º’ ≈°—∫ºŸ∑â ‰’Ë ¡à‰¥â√∫— °“√ —ßË ®à“¬ ¡ÿπ‰æ√ ·µà∂Ⓡ§¬‰¥â√—∫·≈â« æ∫«à“∑”„Àâ∑—»π§µ‘∑’Ë¥’µàÕ ¡ÿπ‰æ√∑”„Àâ ¡’Õ‘∑∏‘æ≈µàÕ°“√ —Ëß®à“¬¬“¢Õß·æ∑¬å ´÷Ëß Õ¥§≈âÕß°—∫ß“π «‘®—¬ ®“√ÿ√—µπå ‡æ™√ ß¶å˜ ∑’Ë°≈à“««à“ªí®®—¬∑’Ë¡’º≈µàÕ°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√®“°·æ∑¬å§◊Õ§«“¡µâÕß°“√À√◊Õ∑—»π§µ‘ ∑’Ë¥’¢ÕߺŸâªÉ«¬ ·≈–®“°¿“æ√«¡§–·ππ∑—»π§µ‘¢ÕߺŸâªÉ«Õ¬Ÿà„π√–¥—∫ Ÿß„π∑ÿ°√“¬¢âÕ§à“‡©≈’ˬ¢Õß∑—»π§µ‘µàÕ°“√„™â¬“ ¡ÿπ‰æ√¢ÕߺŸâªÉ«¬®“°§–·ππ‡µÁ¡ ˆ §–·ππ ¡’§à“‡©≈’Ëı.ˆ˘ §–·ππ ´÷ßË Õ¥§≈âÕß°—∫ß“π«‘®¬— ¢ÕßÕ√ÿ≥æ√ Õ‘∞√—µπå ·≈–§≥–¯ æ∫«à“ ∑—»π§µ‘∑’Ë¥’¡’º≈µàÕ°“√„™â¬“ ¡ÿπ‰æ√ „π à«π¢Õßªí®®—¬∑’Ë∑”„Àâª√–™“™π·≈–·æ∑¬åºŸâ —Ëß®à“¬æÕ„® ¡’ §«“¡ Õ¥§≈âÕß°—πµ“¡µ“√“ß∑’Ë Ò æ∫«à“∑—Èߪ√–™“™π·≈– ·æ∑¬å¡§’ «“¡æÕ„®∑’‡Ë À¡◊Õπ°—π·≈– Õ¥§≈âÕß°—π‚¥¬‡©æ“– ‡ªìπº≈‘µ¿—≥±å∑’˺≈‘µ„π‚√ß欓∫“≈ÕŸà∑Õß §◊Õ„π à«π¢Õß °“√®—¥®”Àπà“¬¡“°∑’Ë ÿ¥ ‡™àπ º≈‘µ¿—≥±åµâÕß¡’°“√®—¥ ®”Àπà“¬¬“∑’Ë‚√ß欓∫“≈∑’Ë¡’∫ÿ§≈“°√∑’Ë¡’§«“¡√Ÿâ ∂“π∑’Ë µâÕß –Õ“¥πà“‡™◊ËÕ∂◊Õ √Õß≈ß¡“§◊Õº≈‘µ¿—≥±åµâÕߪ≈Õ¥¿—´÷ßË Õ¥§≈âÕß°—∫ß“π«‘®¬— ¢Õß Õ¿‘√µ— πå «ß§å√µ— π噬— ·≈–§≥–˘ ∑’Ëæ∫«à“ ªí®®—¬∑’Ë∑”„À⺟âªÉ«¬„™â¬“ ¡ÿπ‰æ√§◊Õ √√æ§ÿ≥·≈– §«“¡ª≈Õ¥¿—¬ πÕ°®“°π’È √Ÿª·∫∫º≈‘µ¿—≥±å®–µâÕßπà“„™â –¥«° ºŸâªÉ«¬®÷ß®–π‘¬¡„™â ·æ∑¬å·≈–ª√–™“™π¬—߇™◊ËÕ¡—Ëπ «à“°“√º≈‘µ‚¥¬‚√ß欓∫“≈¡’§«“¡ª≈Õ¥¿—¬¡“°°«à“ ·≈– √Ÿª·∫∫¡’ à«π™à«¬„Àâ·æ∑¬å·≈–ª√–™“™πÕ¬“°„™â‡æ√“–¡’ §«“¡ –¥«°„π°“√æ°æ“·≈–„™âßà“¬¢÷Èπ ´÷Ëß Õ¥§≈âÕß°—∫ ß“π«‘®—¬¢Õß π—π∑«—π ∫ÿ≥¬–ª√–¿—»√Ò æ∫«à“ ºŸâªÉ«¬®– ‰¡à„™â¬“∂⓬“¡’√Ÿª·∫∫∑’ˉ¡àπà“„™â ·≈–ß“π«‘®—¬¢Õß ·¥π √«ß «√√≥«ß»å ÕπÒÒ ·≈–«√“¿√≥å ‚¿§“π—π∑åÒÚ æ∫«à“ª√–™“™π ¡’§«“¡‡™◊ËÕ¡—Ëπ„π √√æ§ÿ≥¬“ ¡ÿπ‰æ√·≈–‡™◊ËÕ∂◊Õ„π ∂“π∑’Ë º≈‘µ®÷ß®–¡’°“√„™â¬“ ¡ÿπ‰æ√¡“°¢÷Èπ „π à«π§«“¡æÕ„®∑’Ë µà“ß°—π√–À«à“ß·æ∑¬å·≈–ª√–™“™π§◊Õ‡√◊ËÕß√“§“¬“ ·æ∑¬å ¬—߇™◊ËÕ«à“¬“ ¡ÿπ‰æ√√“§“‰¡à∂Ÿ°∂Ⓡ∑’¬∫°—∫¬“·ºπªí®®ÿ∫—π ‡æ√“–·æ∑¬å¡’ª√– ∫°“√≥å‡√◊ËÕßµâπ∑ÿπ·≈–√“§“∑ÿπ¢Õ߬“ ·ºπªí®®ÿ∫—π∑’Ëæ∫«à“√“§“∂Ÿ°¡“°°«à“·µàª√–™“™π¬—ߧ‘¥«à“ ¬“ ¡ÿπ‰æ√π—Èπ√“§“∂Ÿ°·≈– “¡“√∂®à“¬„π√“§“∑’Ë°”À𥉥â

”À√—∫º≈°“√«‘®—¬∑’ˇ°’ˬ«°—∫·æ∑¬åæ∫«à“·æ∑¬å„π ‚√ß欓∫“≈ÕŸà∑Õß¡’§«“¡√Ÿâ¥’„π‡√◊ËÕß ¡ÿπ‰æ√ ¡’§–·ππ‡©≈’Ë√âÕ¬≈– ¯¯.ı ∂◊Õ«à“‡ªìπ§–·ππ∑’ Ë ßŸ ∑—ßÈ π’‡È π◊ÕË ß„π‚√ß欓∫“≈ ¡’ § ≥–°√√¡°“√æ‘ ® “√≥“°“√„™â ¬ “„π‚√ß欓∫“≈∑’Ë § Õ„Àâ°“√ π—∫ πÿπ·≈–¡’ª√–™“ —¡æ—π∏å¡’§«“¡ –¥«°„π°“√ —ßË ®à“¬¬“‡æ√“–‚√ß欓∫“≈º≈‘µ‡Õß ‰¡à Õ¥§≈âÕß°—∫Õ√ÿ≥æ√ Õ‘∞√—µπå ·≈–§≥–¯ æ∫«à“ ·æ∑¬å¡’§«“¡√Ÿâ∑’Ë∂Ÿ°µâÕßπâÕ¬¡“° ‡°’ˬ«°—∫ ¡ÿπ‰æ√ (¡’‡æ’¬ß√âÕ¬≈– ˆ.˜) ´÷Ë߇ªìπ‡æ√“–‡ªìπ °“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈®“°·æ∑¬å∑—ÈßÀ¡¥·≈–‡ªìπ·æ∑¬å∑’ˉ¡à Õ¬Ÿà„π‚√ß欓∫“≈∑’˺≈‘µ¬“ ¡ÿπ‰æ√ ‡™àπ‡¥’¬«°—∫‚√ß欓∫“≈ ÕŸà∑Õß ¥—ßπ—È𧫓¡√Ÿâ¬àÕ¡·µ°µà“ß°—π√–À«à“ß·æ∑¬å∑’ËÕ¬Ÿà„π ‚√ß欓∫“≈º≈‘µ¬“ ¡ÿπ‰æ√‡Õß·≈–·æ∑¬å∑‰’Ë ¡à¡ª’ √– ∫°“√≥å ®“°‚√ß欓∫“≈‡≈¬ Õ’°∑—Èß√–¬–‡«≈“„πªí®®ÿ∫—π¡’°“√ à߇ √‘¡ §«“¡√Ÿßâ “π«‘®¬— ¡“°¢÷πÈ ∑”„À⧫“¡√Ÿ‡â °’¬Ë «°—∫¬“ ¡ÿπ‰æ√¡’¡“° ¢÷Èπ ·µàÕ¬à“߉√°Áµ“¡ ·æ∑¬å§«√¡’§–·π𧫓¡√Ÿâ„π°“√„™â ¡ÿ π‰æ√‡ªìπ§–·ππ‡µÁ¡ ‡æ√“–º≈‘µ¿—≥±å ¡ÿπ‰æ√‡ªì π ¡ÿπ‰æ√∑’˺≈‘µ‰¥â„π‚√ß欓∫“≈‡Õß ·µàæ∫«à“·æ∑¬å∑’˵Õ∫ º‘¥ ‡ªìπ·æ∑¬å∑’ˇ¢â“¡“„Àâ„π√–¬–∑”ß“π‡æ’¬ß Ò ªï ¥—ßπ—Èπ ‚√ß欓∫“≈µâÕß„À⧫“¡√Ÿµâ Õà ‡π◊ÕË ß°—∫·æ∑¬å∑‡’Ë ¢â“¡“∑”ß“π„À¡à ·µà‡¡◊ÕË Õ∫∂“¡¥â“π∑—»π§µ‘¢Õß·æ∑¬å®“°‚√ß欓∫“≈ÕŸ∑à Õß æ∫«à“ ¡’∑—»π§µ‘µàÕ°“√„™â¬“ ¡ÿπ‰æ√„π√–¥—∫§–·ππ‡©≈’Ë√“¬¢âÕ Û.˘¯ §–·ππ ®”π«π Ò √“¬¢âÕ∂◊Õ«à“¡’∑—»π§µ‘ §àÕπ¢â“ß Ÿß ´÷Ëß Õ¥§≈âÕß°—∫Õ√ÿ≥æ√ Õ‘∞√—µπå ·≈–§≥–¯ æ∫«à“∑—»π§µ‘¢Õß∫ÿ§≈“°√∑“ß°“√·æ∑¬å‡°’ˬ«°—∫°“√„™â ¡ÿπ‰æ√¡’§–·ππ Ÿß®–¡’°“√ —ßË ®à“¬¬“‰¥â ߟ ·≈–®– π—∫ πÿπ „Àâ¡°’ “√„™â¬“ ¡ÿπ‰æ√„π°“√√—°…“‚√§ ¥â“π√–¥—∫§«“¡æ÷ßæÕ„® ¢Õß·æ∑¬åµàÕªí®®—¬µà“ßÊ ¥â“πº≈‘µ¿—≥±å¬“ ¡ÿπ‰æ√¢Õß ‚√ß欓∫“≈ ∑’Ë ¡’ º ≈µà Õ °“√„™â ¬ “ ¡ÿ π‰æ√¢ÕߺŸâ ªÉ « ¬„π ‚√ß欓∫“≈ÕŸà∑Õß ·æ∑¬å à«π„À≠à¢Õß‚√ß欓∫“≈ÕŸà∑Õß æÕ„®°—∫√Ÿª·∫∫¢Õߺ≈‘µ¿—≥±å¬“ ¡ÿπ‰æ√ ∑’ˉ¡à¡’ “√‡§¡’ ªπ –Õ“¥ ∑—π ¡—¬ °“√®—¥®”Àπà“¬∑’Ë¡’∫√‘°“√Õ◊Ëπ‡ √‘¡‡™àπ π«¥ Õ∫ ª√–§∫ §«“¡ª≈Õ¥¿—¬¢Õ߬“ „π‡√◊ËÕߺ≈¢â“߇§’¬ß πâÕ¬ °√–∫«π°“√º≈‘µπà“‡™◊ËÕ∂◊Õ ¡’°“√§«∫§ÿ¡§ÿ≥¿“æ ·µà √“§“¬“ ¡ÿπ‰æ√ ª√– ‘∑∏‘¿“æ ®–æÕ„®„π√–¥—∫ª“π°≈“ß ∑—Èßπ’È‚√ß欓∫“≈Õ“®®–µâÕß¡’π‚¬∫“¬ µ‘¥µ“¡º≈°“√„™â¬“ ¡ÿ π‰æ√∑’Ë ®à “ ¬‚¥¬‚√ß欓∫“≈µàÕ‰ª‡æ◊Ë Õ„Àâ · æ∑¬å ¡’ § «“¡ ‡™◊ËÕ∂◊ÕµàÕº≈‘µ¿—≥±å¡“°¢÷Èπ æ√âÕ¡°—∫µâÕß¡’§Ÿà¡◊Õß“π«‘®—‡°’ˬ«°—∫ª√– ‘∑∏‘º≈„Àâ·æ∑¬å‰¥â√—∫√Ÿâ„πÕ𓧵 À√◊Õ§≥– °√√¡°“√‡¿ —™°√√¡·≈–°“√∫”∫—¥§«√¡’∫∑∫“∑Àπâ“∑’™Ë ·’È ®ß ·≈–®—¥∑”§Ÿà¡◊Õ°“√„™â¬“ ¡ÿπ‰æ√„π√“¬°“√∫—≠™’¬“ ¡ÿπ‰æ√ „π‚√ß欓∫“≈‡æ◊ËÕ„Àâ·æ∑¬å¡’§«“¡‡™◊ËÕ¡—Ëπ„π°“√ —Ëß®à“¬¬“ ¡ÿπ‰æ√¡“°¢÷Èπ

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

√ÿª „π¿“æ√«¡¢Õßß“π«‘®—¬π’È √ÿª‰¥â«à“ ªí®®—¬∑’Ë¡’ Õ‘ ∑∏‘ æ ≈µàÕ °“√„™â¬“ ¡ÿπ‰æ√„π‚√ß欓∫“≈ÕŸà∑Õß ”À√—∫ ºŸâªÉ«¬ §◊ÕµâÕß„Àâ¡’°“√ —Ëß®à“¬®“°·æ∑¬å°àÕπ ºŸâªÉ«¬®÷ß®–¡’ ∑—»π§µ‘∑’Ë¥’µàÕ°“√„™â¬“ ¡ÿπ‰æ√ ·≈–°“√®à“¬¬“ ·æ∑¬å®– µâÕß´—°ª√–«—µ‘«à“¡’§π„π§√Õ∫§√—«‡§¬„™â ¡ÿπ‰æ√À√◊Õ‰¡à ∂Ⓡ§¬ °“√ —Ëß®à“¬°Á®–¡’°“√„™âµàÕ‡π◊ËÕ߉¥â ·µà§«“¡√Ÿâ √–¥—∫ °“√»÷°…“ ªí®®—¬∑“߇»√…∞°‘®Õ◊Ëπ¢ÕߺŸâªÉ«¬‰¡à„™àªí®®—¬∑’Ë ∑”„Àâ ºŸâ ªÉ « ¬®–Õ¬“°„™â ¬ “ ¡ÿ π‰æ√ ·≈–§«“¡æ÷ßæÕ„®„π ¿“æ√«¡¢Õߺ≈‘µ¿—≥±å∑’˺≈‘µ®“°‚√ß欓∫“≈ÕŸà∑Õß „π∑ÿ° ¥â“π‡™àπ√Ÿª·∫∫ √“§“ °“√®—¥®”Àπà“¬ °“√ à߇ √‘¡°“√¢“ª√– ‘∑∏‘¿“欓 §«“¡ª≈Õ¥¿—¬ ºŸâªÉ«¬„À⧖·ππ∑ÿ°¥â“π ¡“°°«à“ Ù §–·ππ®“°§–·ππ‡µÁ¡ ı §–·ππ „π∑ÿ°¥â“π „π à«π¢Õß·æ∑¬åæ∫«à“ §«“¡√Ÿâ‡√◊ËÕߺ≈‘µ¿—≥±åÕ¬Ÿà„π√–¥—∫ Ÿß ·µà°Á‰¡à„™à§–·ππ‡µÁ¡ ´÷Ëß∂◊Õ‰¥â«à“ ‚√ß欓∫“≈®–µâÕß ª√—∫ª√ÿß°“√ª√–™“ —¡æ—π∏å°“√„À⧫“¡√Ÿâ¢Õß·æ∑¬å‡æ‘Ë¡¢÷Èπ à«π§«“¡æ÷ßæÕ„®„πº≈‘µ¿—≥±åæ∫«à“ ·æ∑¬åæÕ„®„π‡√◊ËÕß √Ÿª·∫∫ §«“¡ª≈Õ¥¿—¬ °“√®—¥®”Àπà“¬„π‚√ß欓∫“≈¡“° ·µà¬ß— æÕ„®πâÕ¬„π‡√◊ÕË ß√“§“ ·≈–ª√– ‘∑∏‘¿“æ¢Õ߬“ ¡ÿπ‰æ√ ·µàÕ¬à“߉√°Áµ“¡°Á¬—ß¡’¢âÕ®”°—¥¢Õ߇§√◊ËÕß¡◊Õ„π°“√«—¥·∫∫ §«“¡√Ÿâ ∑—»π§µ‘·≈–§«“¡æ÷ßæÕ„® ‡π◊ËÕß®“°¡’®”π«π√“¢âÕ¡’®”π«ππâÕ¬ ∂â“¡’°“√∂“¡Õ’°§«√¡’√“¬¢âÕ¢Õߧ«“¡√Ÿâ „Àâ¡“°°«à“ Ò ¢âÕ

‡Õ° “√Õâ“ßÕ‘ß Ò. Õߧ尓√Õπ“¡—¬‚≈°. π‚¬∫“¬°“√ à߇ √‘¡°“√·æ∑¬å ¥—ßÈ ‡¥‘¡¢ÕßÕߧ尓√Õπ“¡—¬‚≈°. √“¬ß“π°“√ª√–™ÿ¡ WHO Congress on Traditional Medicine. ÚııÒ. Ú. §≥–∑”ß“π¬àÕ¬ ‡æ◊ËÕ°“√»÷°…“«‘‡§√“–Àå √–∫∫¬“·ºπ ‚∫√“≥·≈–¬“®“° ¡ÿπ‰æ√ √–∫∫¬“¢Õߪ√–‡∑»‰∑ÚıÙı æ‘¡æå§√—Èß∑’Ë Ò °√ÿ߇∑æœ: Õ√ÿ≥°“√æ‘¡æå. Û. »Ÿπ¬å¢âÕ¡Ÿ≈‡™‘߬ÿ∑∏»“ µ√å. °“√∫Ÿ√≥“°“√°“√·æ∑¬å ·ºπ‰∑¬: √–∫∫¬“‰∑¬·≈–¬“®“° ¡ÿπ‰æ√„π ∂“π∫√‘°“√ “∏“√≥ ÿ¢. ÚııÒ æ‘¡æå§√—ßÈ ∑’Ë Ò °√ÿ߇∑æœ: ”π—°ß“π °‘®°√√¡‚√ßæ‘¡æåÕߧ尓√ ߇§√“–Àå∑À“√ºà“π»÷°. Ù.. §≥–°√√¡°“√¬ÿ∑∏»“ µ√å °“√æ—≤π“¿Ÿ¡‘ªí≠≠“‰∑ÿ¢¿“æ«‘∂’‰∑¬ ·ºπ¬ÿ∑∏»“ µ√噓µ‘ ·ºπ¬ÿ∑∏»“ µ√å ¿Ÿ¡‘ªí≠≠“‰∑¬ ÿ¢¿“æ«‘∂’‰∑¬ æ.». ÚıÙ-ÚıÙÙ æ‘¡æå§√—ßÈ ∑’Ë Û ππ∑∫ÿ√’ Õߧ尓√ ߇§√“–Àå∑À“√ºà“π»÷°

309

ı.. Õ√ÿ≥æ√ Õ‘∞√—µπå ·≈– ‡æ™√πâÕ¬ ‘ßÀå™à“ß™—¬ °“√ ”√«®°“√„™â ¡ÿπ‰æ√µ“¡‚§√ß°“√ “∏“√≥ ÿ¢¡Ÿ≈∞“π „π‡¢µ¿“§„µâ¢Õ߉∑¬ «“√ “√ ߢ≈“π§√‘π∑√å ©∫—∫ ‡∑§‚π‚≈¬’ ÚıÛÒ;ÒÚ:˘Ò-ÒÚ. ˆ. π‘»“™≈ ª√– “√ ÿ¢. §«“¡§‘¥‡ÀÁπ¢ÕߺŸâªÉ«¬µàÕ°“√ „™â¬“ ¡ÿπ‰æ√∑’ˉ¥â√—∫°“√ —Ëß®à“¬®“°‚√ß欓∫“≈°ÿ¥™ÿ¡ ®—ßÀ«—¥¬‚ ∏√. «‘∑¬“π‘æπ∏åª√‘≠≠“¡À“∫—≥±‘µ, ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à, §≥– “∏“√≥ ÿ¢»“ µ√å ÚıÛ˘. ˜. ®“√ÿ√—µπå ‡æ™√ ß¶å ªí®®—¬∑’Ë¡’º≈µàÕ°“√®à“¬¬“®“° ¡ÿπ‰æ√¢Õß·æ∑¬å„π‚√ß欓∫“≈™ÿ¡™π. «‘∑¬“π‘æπ∏å ª√‘≠≠“¡À“∫—≥±‘µ, ¡À“«‘∑¬“≈—¬¡À‘¥≈, §≥–‡¿ —™»“ µ√å ÚııÙ.. ¯. Õ√ÿ≥æ√ Õ‘∞√—µπå, ‡æ™√πâÕ¬ ‘ßÀå™à“ß™—¬, ¿—§«‘¿“ §ÿ‚√ª°√≥åæß»å, ≥√ߧ廗°¥‘Ï ‘ßÀå‰æ∫Ÿ≈¬åæ√, ª√“≥’ √—µπ ÿ«√√≥, ‚ ¿“ §”¡’. 惵‘°√√¡·≈–§«“¡æ√âÕ¡ „π°“√„™â ¡ÿπ‰æ√µ“¡‚§√ß°“√ “∏“√≥ ÿ¢¡Ÿ≈∞“π¢Õß ∫ÿ§≈“°√∑“ß°“√·æ∑¬å„π®—ßÀ«—¥¿“§„µâ¢Õߪ√–‡∑»‰∑¬. «“√ “√ ߢ≈“π§√‘π∑√å ÚıÙÛ;Ò¯:˘Û-ÒÛ. ˘. Õ¿‘√—°…å «ß»å√—µπ™—¬, Õ√«√√≥ ‡°‘¥‡ «’¬¥, ‘∏√“ ‡∑æ∑—µµå, æ™√¡π °“«‘π”. °“√„™â¬“®“° ¡ÿπ‰æ√„π ∫—≠™’¬“À≈—°·Ààß™“µ‘ æ.». ÚıÙ˘ ‡æ◊ËÕ√—°…“µπ‡Õß ¢ÕߺŸâ¡“√—∫∫√‘°“√„π√â“𬓠°√ÿ߇∑æ¡À“π§√. «“√ “√ ¡À“«‘∑¬“≈—¬π‡√»«√ ÚııÒ;Òˆ:ˆ˜-˜ˆ. Ò. π—π∑«—π ∫ÿ≥¬–ª√–¿—»√ °â“«‰ª°—∫ ¡ÿπ‰æ√ ÚıÛ æ‘¡æå§√—Èß∑’Ë Ò °√ÿ߇∑æœ: ∏√√¡°¡≈°“√æ‘¡æå. ÒÒ. ·¥π √«ß «√√≥«ß»å Õπ. °“√¬Õ¡√—∫º≈‘µ¿—≥±å‡§√◊ÕË ß Ì“Õ“ß®“° ¡ÿπ‰æ√¢Õߪ√–™“™π »÷°…“°√≥’: º≈‘µ¿—≥±å ‡§√◊ÕË ß Ì“Õ“ß®“° ¡ÿπ‰æ√¢Õß‚√ß欓∫“≈»Ÿπ¬å‡®â“æ√–¬“ Õ¿—¬¿Ÿ‡∫»√. «‘∑¬“π‘æπ∏åª√‘≠≠“¡À“∫—≥±‘µ, ¡À“«‘∑¬“≈—¬¡À‘¥≈, §≥– ‘Ëß·«¥≈âÕ¡ ÚıÙÙ. ÒÚ. «√“¿√≥å ‚¿§“π—π∑å. °“√ ◊ËÕ “√°“√µ≈“¥º≈‘µ¿—≥±å ¡ÿπ‰æ√Õ¿—¬¿Ÿ‡∫»√°—∫惵‘°√√¡°“√µ—¥ ‘π„®´◊ÈÕ¢Õß ºŸ∫â √‘‚¿§. «‘∑¬“π‘æπ∏åª√‘≠≠“¡À“∫—≥±‘µ, ¡À“«‘∑¬“≈—∏ÿ√°‘®∫—≥±‘µ, §≥–π‘‡∑»»“ µ√å ÚıÙÙ.

310 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Abstract Factors influencing on use of herbal medicinal products in U-Thong hospital, Suphanburi province.

Naphatsaran Roekruangrit* Kaysorn Sumpaothong** Arunporn Itharat *** * Master student, Public Health Programe, Health Promotion Management Faculty of Public Health, Thammasat University ** Faculty of Public Health, Thammasat University *** Applied Thai Traditional Medicine Centre, Faculty of Medicine, Thammasat University This research is a predictive study. The objectives are to investigate the factors which influence uses of herbal medicine by physicians in U-Thong Hospital, Suphanburi Province. Specific sampling was used to select the 12 physicians while the 400 patients were selected on a stratified sampling. The responses to questions about knowledge, attitudes, and satisfaction levels of the factors related to the products with Cronbach alpha coefficient The samples possessed correct knowledge about herbal medicines at a medium level (65.5%). The attitude of patients for herbal medicine usage was a high level. The majority of the respondents were reportedly satisfied at a high level with pattern of products. The most influential factor for the uses of herbal medicines prescribed by physicians was that the patientsû need to use herbal drugs (Odd ratio = 7.904, p<.05).

The results showed that the knowledge of physicians was 80% correct, with good attitude. The physicians believed that the herbal drugs can be used instead of using modern drugs (91.7%). The greatest influence on physicians for prescribing herbal drugs was their safety. The factor that revealed the lowest level of attitude for physicians was the efficacy the herbal drugs.

In summary, patientsû needs were the key factor for using herbal medicine, followed by encouragement from their family. Empirical data exemplifying the efficacy of herbal drug should be provided to physicians.

Key words: Use of herbal medicine, Factors of using herbal medicine, Hospital, Patients, Physician.

311

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

∫∑§«“¡ª√‘∑—»πå

Cellular aging Pintusorn Hansakul

Abstract Aging is associated with the gradual accumulation of irreversible physiological changes that ultimately result in susceptibility to death. To date, the most widely accepted theories of aging that explain cellular aging are categorized into structural damage and programmed theories. A wide range of aging causes can be classified into four major groups: free radicals, glycation, telomere shortening, and accumulation of toxic and non-toxic garbage. These extrinsic and intrinsic factors collectively stimulate physiologic stresses to all types of cells. Postmitotic and mitotic cells conferring different proliferative capacity, undergo aging in response to these stresses via distinct mechanisms of cell death and cellular senescence, respectively. The progressive accumulation of these aged cells eventually contributes to dysfunction of aged tissues.

Key words: Cellular aging, Cellular senescence, Apoptosis

Introduction

Cellular theories of aging

Aging is characterized by a gradual decline in the capacity of physiologic systems, eventually leading to failure of a critical system, then death.

Considering the aging process, it is surprising that there remain many unanswered questions about how aging happens at the cellular level. This review article has therefore summarized the current state of knowledge regarding some particular aspects of cellular aging, including the most widely accepted theories, the major causes, the cellular responses, and anti-aging interventions.

Scientists have tried to develop theories of aging for centuries, which in turn help them formulate the questions that drive research. Some theories have fallen out of favor over time. At present, two groups of cellular theories of aging become more widely accepted: structural damage theories and programmed theories. The first group states that aging is caused by accumulated damage to cellular components over time whereas the second group describes aging as a direct consequence of genetic programming. The two most widely accepted theories of each group are listed below.

Division of Biochemistry, Department of Preclinical Science, Faculty of Medicine, Thammasat University

312 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Structural damage theories: The free radical theory of aging The free radical theory of aging (FRTA) was first proposed in 19571, stating that aging is the result of cumulative oxidative damage to biomolecules, e.g. lipid, protein, and nucleic acid (Fig. 1A). Such damage is indeed caused by increased production of free radical-containing reactive oxygen species (ROS) (e.g., O2.-, OH.) and reactive nitrogen-oxygen species (RNOS) (e.g. nitric oxide, and NO), decreased antioxidant levels, and the inability to repair oxidative damage.

Evidence to support the FRTA comes from the inverse correlation between basal metabolic rate and maximum lifespan of mammals and from the accumulation of oxidative damaged DNA, proteins, and lipids in aged organisms.2 Additionally, increased expression of antioxidant enzymes can slow aging and increase the lifespan of flies and worms, but such a beneficial effect did not occur in mammals.3

Structural damage theories: The mitochondrial theory of aging The mitochondrial theory of aging (MTA) was first proposed in 1972.4 It is a variant of free radical theory of aging2, treating aging as the result of damage to mitochondrial DNA (mtDNA).

Mitochondria are the energy generators of the cell, which produce 90% or most of the ATP in the body and generate ROS through increased electron leakage in the respiratory chain.5 Also, these organelles have limited capacity for DNA repair and mtDNA is not protected by a sheath of histones.

Thus, mtDNA is especially sensitive to mutations (e.g., deletions, point mutations, gross DNA rearrangements, etc.) and its damage leads to defective functions of mitochondria, eventually resulting in aging. This theory has been supported by the observations that mtDNA mutations increase with age in mammals, especially in post-mitotic highly aerobic tissues such as brain, heart, skeletal muscle.6

Fig. 1 (A) Free-radical-mediated cellular injury (B) Antioxidant pathways against oxygen toxicity

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Programmed theories: The genetic theory of aging In contrast to structural damage theories, the genetic theory of aging, one of the most widely accepted programmed theories formulated in 1981, proposes that lifespan is largely determined by the effect of genetics.7 There are at least 30 genes that have a significant effect on human life span. However, such effect accounts for only 20-50% of lifespan, the other 50-80% being attributed to environment and developmental variations. The genetic theory of aging is apparent in animal studies. For example, mutations in genes of the insulin/insulin-like growth factor I (IGF-I) signaling network can significantly extend lifespan in diverse species ranging from worms8 to rodents.9 In humans, this network has been shown to be involved in the control of aging and longevity.10 Recently, Jewish centenarians have been revealed to have more mutations in the IGF1R gene.11 Interestingly, the effects of mutations in genes of the insulin-like signaling network on longevity are likely associated with reduced oxidative damage and increased stress resistance. Besides, there are other genes associated with increased longevity in humans, e.g. variants in Apolipoprotein E (ApoE)12 and cholesteryl ester transfer protein (CETP).13

313

However, these genes seem to increase mean lifespan, probably by helping a person metabolize cholesterol, rather than increase longevity.

Programmed theories: The cellular senescence theory of aging The cellular senescence theory of aging was formulated in 1965, describing cellular senescence as a biological program that limits the ability of normal human cells to proliferate in culture.14 As mitotically competent cells normally increase in number of divisions (maximum ~ 50 to 70 times), they gradually lose proliferative capacity and their telomeres shorten slightly each time they divide.

This phenomenon is termed replicative senescence.

At the end of the replicative lifespan, all cells stop their proliferation, but remain viable. A prime cause of replicative senescence is progressive telomere shortening. Telomeres are the repeats of a specific 6-nucleotide DNA sequence with a loop-like structure at the end of a chromosome (Fig. 2A). Some experimental data indicate a link between telomere length and aging and lifespan15, suggesting that telomere length could serve as a biomarker for aging in human somatic cells that continue to divide, e.g. hematopoietic stem cells, skin cells, epithelial cells.

Fig. 2 (A) Telomere structure (B) Telomere shortening determines the proliferative lifespan of mitotically competent cells

314 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

The causes of cellular aging Although aforementioned aging theories cover some causes of aging, many of which are still not included. Moreover, new aspects of some particular causes are later discovered besides the old one referred by the theories. Accordingly, this review categorizes various causes of aging into four major groups as follows.

Free radicals Free radicals (oxidants) can originate from many external sources such as air pollution, radiation, domestic chemicals (e.g., pesticides, air-fresheners etc.), cigarette smoke, alcohol, and deep fried foods. Also, free radicals can arise from endogenous sources as a result of normal aerobic respiration, metabolism, and inflammation. At low/ moderate level, ROS/RNOS (e.g., superoxide radical and nitric oxide) perform important biological functions, for example, in defense against infectious agents16, and in the function of many cellular signaling pathways.17 At high level, however, these free radicals from both sources attack various vital cellular components (Fig. 1A).

Cells are protected against these damages by two antioxidant systems. First, antioxidant scavenging enzymes against ROS include superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPX), and glutathione reductase (GRed) whose functions are to convert free radicals to nontoxic and nonradical forms (Fig. 1B). Second, dietary free-radical scavengers (e.g., vitamin E, ascorbic acid, glutathione, carotenoid, and flavonoids) neutralize these free radicals by donating one electron to the radical in non-enzymatic reactions (Fig. 1B). Minerals are also the other dietary antioxidants that are critical to the activity of vital antioxidant enzymes in the body. For example, selenium is required for GPX activity. Zinc is essential for the activity of CAT and SOD. When the antioxidant defense system is overwhelmed by an increased oxidant level or

reduced antioxidant supply, oxidative stress occurs and then causes oxidative damage to biomolecules and cellular components. Oxidized proteins (e.g., oxidized thiols, protein carbonyls) and oxidized lipids (e.g., lipid peroxides) are formed during these damages. Such oxidized lipids are broken down into aldehydes (e.g. malondialdehyde -MDA), which can crosslink proteins, particularly oxidized forms. Both oxidized and cross-linked proteins are resistant to degradation and thus accumulate over time. Additionally, these oxidative damages to lipids and proteins located on organelle membranes of cells result in the loss of membrane integrity and ion leakage. DNA damage (e.g., 8-hydroxydeoxyguanosine -8-OH-dG) is another form of oxidative damage, which tends to interfere with gene expression. MtDNA is even more vulnerable to oxidative damage than nuclear DNA and its damage causes mitochondria to shut down. Collectively, these impaired cellular components fail to accomplish their native roles and result in accelerated cell aging.

Glycation Glycation (Maillard reaction) is another cause of aging. It is a reaction in which glucose and other sugars react spontaneously with free amino groups of proteins, resulting in irreversible crosslinked proteins called Advanced Glycation Endproducts (AGEs). AGEs are slowly formed and accumulate in long-lived structural proteins such as collagen and elastin, thereby leading to increased stiffness of blood vessels and joints, and impaired functions of the lung, kidney, heart, and retina.18 These are commonly seen as features of aging.

Telomere shortening The telomeres lie at the tips of the chromosome (Fig. 2A) and protect chromosome them from being recognized as break points by the DNA repair machinery, which could recombine with their homologous sequences at the ends of other chromosomes. As for the cellular senescence theory of

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

aging, telomere shortening acts as mitotic counter that determines the proliferative lifespan of the cells. Prior to complete erosion of the telomere, such a critical telomere length activates a DNA damage response pathway involving p53 and Rb, mediating the cell to become senescent (Fig. 2B).

However, such cells can enter into a state of senescence rapidly and independently of their intrinsic mechanisms when exposed to various extrinsic physiologic factors including oxidative stress, DNA-damaging agents, oncogene overexpression, and other metabolic perturbations.19 Therefore, apart from being considered as a biological program involved in the replicative senescence, telomere shortening is also induced by physiologic stress.

Both aspects of telomere shortening gives rise to senescent cells that are terminally arrested but remain intact and viable with altered phenotypes20, contributing collectively to the aging of tissues.

However, telomere shortening appears not to deleteriously affect post-mitotic tissues such as brain, heart, and skeletal muscle because these cells cannot divide although they may function throughout adult life.

Accumulation of toxic and non-toxic garbage Examples of this garbage include toxic and inert by-products of cellular metabolism (e.g., cross-linked proteins and lipids, lipid peroxidation debris, and AGEs), as well as other modified proteins formed by other reactions independent of ROS such as racemization, deamination, and alkylation reactions. In addition, lipofuscin (age pigment) is regarded as a product of lysosomes containing hydrolytic enzymes to degrade proteins, lipids and damaged organelles. As lysosomes engulf large amounts of the garbage that are resistant to these hydrolytic enzymes, they are inevitably bloated with indigestible content, thus accumulating in cells as lipofusin granules.21 High levels of metals, especially lead, aluminum, and iron, also tend to

315

accumulate in cells and cause toxic effects to them.

This garbage appears to be a primary cause of aging for non-dividing cells because these cells cannot dilute the garbage away whereas mitotic cells efficiently do during division.

Cellular senescence & cell death: The mechanisms responsible for cellular aging Cellular senescence and cell death are the cellular responses to damage or stress through distinct molecular mechanisms and are mainly responsible for cellular aging. Their roles in the aging process are described below.

Cellular senescence (Arrested cell growth) In addition to replicative senescence, the second form of cellular senescence called stressinduced senescence is subsequently given and viewed as a general cellular response program.

Several studies have indicated that normal cells can undergo senescence rapidly in response to various physiologic stresses.22 Levels of the p53 and Rb activity triggered by these stresses through signaling pathways determine whether cells enter senescence. In fact, cells decide whether to undergo a transient growth arrest, cellular senescence, or apoptosis depending on the type of cellular stress and its severity and the cell type. Accordingly, cellular senescence is one of several programs activated in normal cells in response to physiologic stresses.

As for the mechanisms of cellular senescence, it is triggered through activation of the p53 and Rb following the presence of a critically short telomere. Cellular senescence is a major mechanism responsible for aging in mitotically competent cells since as these cells become senescent, they display a drastically altered phenotype.

For example, they express genes that encode degradative enzymes and inflammatory cytokines. Thus, the accumulation of these senescent cells can disrupt the tissue structure and gradually decrease

316 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

tissue function, resulting in aging and age-related disease (Fig. 3A). Moreover, not only do senescent cells disrupt the tissue architecture but also secrete growth factors, so they might stimulate the proliferation of cells that harbor preneoplastic mutations (Fig. 3B). On the contrary, post-mitotic cells are non-dividing and thus do not enter senescence as a result of telomere shortening.

Cell death (apoptosis) Apoptosis is an active mode of cell death that allows organisms to eliminate damaged or dysfunctional cells in a controlled fashion without damage to surrounding tissues. The first change in a cell undergoing apoptosis is cell shrinkage.

Next, small bubble-like protrusions of cytoplasm (çblebé) start forming at the cell surface as the nucleus and other cellular structures begin to disintegrate. The chromosomal DNA is then degraded into small pieces and the entire cell breaks apart,

forming small fragments known as apoptotic bodies.

Finally, the apoptotic bodies are swallowed up by phagocytes (Fig. 4A). As for its mechanisms, apoptosis can be triggered in a cell through the extrinsic pathway or the intrinsic pathway (Fig. 4B).

In the extrinsic pathway, physiological signals (e.g., tumor necrosis factor, Fas ligand) bind to death receptors on the outer surface and then trigger the caspase cascade. In the intrinsic pathway, damaged DNA stimulates p53 accumulation, leading to alteration in mitochondrial membranes, cytochrome c release, and activation of the caspase cascade Post-mitotic cells contain toxic and inert garbage that is not extensive enough for the removal, so they progressively have impaired functions and exhibit aging features. As this damage increases, these cells are subsequently removed, thereby resulting in a decrease in overall cell number and tissue functions. Hence, cell death causes

Fig. 3 Senescent cells may contribute to aging (A) and age-related pathology e.g., cancer (B)

317

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Fig. 4 (A) Membrane and morphological changes in apoptotic cells (B) Intrinsic & extrinsic pathways and series of biochemical steps in apoptotic cell death

detrimental effect leading to aging phenotype in post-mitotic cells that cannot be readily replaced such as neurons, cardiac myocytes, and skeletal muscle cells. In contrast, this apoptotic mechanism is less efficient in causing aging to some mitotically competent cells because they can dilute out the garbage.

Importantly, there is evidence that cellular senescence and apoptosis are powerful tumor-suppressive mechanisms in relatively young organisms.

Indeed, dysfunctional or damaged cells that undergo senescent or apoptosis cannot further transform into cancer cells, at least early in life. Nevertheless, as more senescent cells accumulate in tissues and apoptosis depletes more cells from post-mitotic tissues, these two mechanisms eventually contribute to aging phenotype late in life.

Interventions to delay aging Calorie restriction (CR) is the only intervention to improve health and extend lifespan in a variety of species23, including primates.24 The mechanism that could explain the effect of longterm CR on aging is related to the reduction of body fat and insulin signaling as well as ROS produced during breathing. Although the effects of CR on human longevity are not yet available, there is now significant evidence that eating appropriate foods or foods with antioxidants has beneficial effects on increasing the functional lifespan, if not the maximal lifespan.25

Conclusion Aging is a complex process that involves different mechanisms. Theories that explain cellular aging can generally be divided into the structural damage and programmed theories of aging. A

318 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

variety of factors induce physiologic stresses to all kinds of cells. Notably, postmitotic and mitotic cells differ in their proliferative capacity and undergo aging in response to these stresses via distinct mechanisms of cell death and cellular senescence, respectively. These aged cells accumulate over time and eventually cause dysfunction of aged tissues.

11.

References 1. Harman D. Aging: a theory based on free radical and radiation chemistry. J Gerontol 1956:298300.

2. Beckman KB, Ames BN. The free radical theory of aging matures. Physiol Rev 1998:547-81.

3. Huang TT, Carlson EJ, Gillespie AM, Shi Y, Epstein CJ. Ubiquitous overexpression of CuZn superoxide dismutase does not extend life span in mice. J Gerontol A Biol Sci Med Sci 2000: B5-9.

4. Harman D. The biologic clock: the mitochondria? J Am Geriatr Soc 1972:145-7.

5. Shigenaga MK, Hagen TM, Ames BN. Oxidative damage and mitochondrial decay in aging.

Proc Natl Acad Sci USA 1994:10771-8.

6. Linnane AW, Zhang C, Baumer A, Nagley P. Mitochondrial DNA mutation and the ageing process: bioenergy and pharmacological intervention. Mutat Res 1992:195-208.

7. Medvedev ZA. On the immortality of the germ line: genetic and biochemical mechanism. A review. Mech Ageing Dev 1981:331-59.

8. Vanfleteren JR, Braeckman BP. Mechanisms of life span determination in Caenorhabditis elegans.

Neurobiol Aging 1999:487-502.

9. Holzenberger M, Dupont J, Ducos B, Leneuve P, Geloen A, Even PC, et al. IGF-1 receptor regulates lifespan and resistance to oxidative stress in mice. Nature 2003:182-7.

10. Bonafe M, Barbieri M, Marchegiani F, Olivieri F, Ragno E, Giampieri C, et al. Polymorphic

12.

13.

14.

15.

16.

17.

18.

19.

variants of insulin-like growth factor I (IGFI) receptor and phosphoinositide 3-kinase genes affect IGF-I plasma levels and human longevity: cues for an evolutionarily conserved mechanism of life span control. J Clin Endocrinol Metab 2003:3299-304.

Suh Y, Atzmon G, Cho MO, Hwang D, Liu B, Leahy DJ, et al. Functionally significant insulinlike growth factor I receptor mutations in centenarians. Proc Natl Acad Sci USA 2008: 3438-42.

Schachter F, Faure-Delanef L, Guenot F, Rouger H, Froguel P, Lesueur-Ginot L, et al. Genetic associations with human longevity at the APOE and ACE loci. Nat Genet 1994:29-32.

Atzmon G, Rincon M, Rabizadeh P, Barzilai N. Biological evidence for inheritance of exceptional longevity. Mech Ageing Dev 2005:3415.

Hayflick L. The Limited in Vitro Lifetime of Human Diploid Cell Strains. Exp Cell Res 1965:614-36.

Njajou OT, Cawthon RM, Damcott CM, Wu SH, Ott S, Garant MJ, et al. Telomere length is paternally inherited and is associated with parental lifespan. Proc Natl Acad Sci USA 2007:12135-9.

Carr AC, McCall MR, Frei B. Oxidation of LDL by myeloperoxidase and reactive nitrogen species: reaction pathways and antioxidant protection. Arterioscler Thromb Vasc Biol 2000:1716-23.

Thannickal VJ, Fanburg BL. Reactive oxygen pecies in cell signaling. Am J Physiol Lung Cell Mol Physiol 2000:L1005-28.

DeGroot J. The AGE of the matrix: chemistry, consequence and cure. Curr Opin Pharmacol 2004:301-5.

Kiyono T. Molecular mechanisms of cellular senescence and immortalization of human cells.

Expert Opin Ther Targets 2007:1623-37.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

20. Campisi J. Cellular senescence and apoptosis: how cellular responses might influence aging phenotypes. Exp Gerontol 2003:5-11.

21. Horie K, Miyata T, Yasuda T, Takeda A, Yasuda Y, Maeda K, et al. Immunohistochemical localization of advanced glycation end products, pentosidine, and carboxymethyllysine in lipofuscin pigments of Alzheimerûs disease and aged neurons. Biochem Biophys Res Commun 1997: 327-32.

22. Gire V. [Senescence: a telomeric limit to immortality or a cellular response to physiologic stresses?]. Med Sci (Paris) 2005:491-7.

23. Masoro EJ. Caloric restriction and aging: an update. Exp Gerontol 2000:299-305.

24. Bodkin NL, Alexander TM, Ortmeyer HK, Johnson E, Hansen BC. Mortality and morbidity in laboratory-maintained Rhesus monkeys and effects of long-term dietary restriction. J Gerontol A Biol Sci Med Sci 2003:212-9.

25. Casadesus G, Shukitt-Hale B, Joseph JA. Qualitative versus quantitative caloric intake: are they equivalent paths to successful aging? Neurobiol Aging 2002:747-69.

∫∑§—¥¬àÕ §«“¡™√“√–¥—∫‡´≈≈å≈–°“√ªØ‘∫—µ‘µπ‡°’ˬ«°—∫ “√ MTBE ¢Õßµ”√«®®√“®√ æ‘π∑ÿ √ À“≠ °ÿ≈ “¢“™’«‡§¡’ ∂“π«‘∑¬“»“ µ√åæ√’§≈‘π‘° §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å §«“¡™√“¿“æ (Aging) ‡°’ˬ«¢âÕß°—∫°“√‡ª≈’ˬπ·ª≈ß∑“ß √’√–·∫∫‰¡à¬âÕπ°≈—∫ ·≈–¡’°“√ – ¡‡æ‘Ë¡¡“°¢÷Èπµ“¡‡«≈“ ´÷ßË ®–𔉪 Ÿ°à “√‡ ’¬™’«µ‘ „π∑’ Ë ¥ÿ ∑ƒ…Æ’§«“¡™√“¿“æ∑’‰Ë ¥â√∫— °“√¬Õ¡√—∫¡“°∑’ Ë ¥ÿ „πªí®®ÿ∫π— ·∫à߉¥â‡ªìπ∑ƒ…Æ’™√“¿“æ∑’‡Ë °‘¥®“°°“√ – ¡ §«“¡‡ ’¬À“¬„π‡´≈≈å (structural damage theories) ·≈–∑ƒ…Æ’™√“¿“æ∑’ˇ°‘¥®“°°“√°”Àπ¥∑“ß™’«¿“æ (Programmed theories) “¡“√∂·∫àß “‡Àµÿµà“ßÊ ∑’Ë∑”„À⇰‘¥§«“¡™√“‰¥â‡ªìπ ’Ë°≈ÿà¡À≈—° §◊Õ Õπÿ¡Ÿ≈Õ‘ √– (free radicals) °“√‡°‘¥°√–∫«π°“√‰°≈‡§™—Ëπ (glycation) °“√À¥ —Èπ¢Õ߇∑‚≈‡¡’¬√å (telomere shortening) ·≈–°“√∑’ˇ´≈≈å¡’°“√ – ¡ by-product ∑’ˉ¥â®“°°√–∫«π°“√µà“ßÊ „π‡´≈≈å √«¡∑—Èß “√‡§¡’·≈–‚≈À–∑’Ë¡’°“√¬àÕ¬ ≈“¬¬“° (accumulation of toxic and non-toxic garbage) ªí®®—¬‡À≈à“π’È°√–µÿâπ„Àâ ‡°‘¥¿“«–‡§√’¬¥ (stress) µàÕ‡´≈≈å∑ÿ°™π‘¥ ”À√—∫‡´≈≈å™π‘¥ postmitotic ·≈– mitotic π—Èπ¡’°“√µÕ∫ πÕßµàÕ§«“¡‡§√’¬¥‚¥‡¢â“ Ÿà°√–∫«π°“√µ“¬ (cell death) ·≈–°√–∫«π°“√·°à™√“ (Cellular senescence) µ“¡≈”¥—∫ ®”π«π∑’˧àÕ¬Ê ‡æ‘Ë¡¢÷Èπ¢Õ߇´≈≈å∑’Ë ·°à™√“‡À≈à“π’È àߺ≈„À⇰‘¥°“√‡ ◊ËÕ¡¢Õ߇π◊ÈÕ‡¬◊ËÕ∑’Ë¡’°“√∑”ß“π≈¥≈ßÀ√◊Õº‘¥ª√°µ‘„π∑’Ë ÿ¥ §” ”§—≠: §«“¡™√“√–¥—∫‡´≈≈å, °√–∫«π°“√™√“, Õ–æÕæ‚∑´‘

319

320 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

∫∑§«“¡ª√‘∑—»πå

°“√ÕÕ°°”≈—ß°“¬„ππÈ”‡æ◊ËÕΩñ°°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ ªî¬“¿“ ·°â«Õÿ∑“π

∫∑§—¥¬àÕ °“√∑√ßµ—«¢÷ÈπÕ¬Ÿà°—∫À≈“¬ªí®®—¬ §◊Õ °“√¡Õ߇ÀÁπ (vision), °“√√—∫√Ÿâ§«“¡‡√Á«‡™‘ß¡ÿ¡·≈–‡™‘߇ âπ„π °“√‡§≈◊ËÕπ‰À«¢Õß»’√…–·≈–≈”µ—«µàÕæ◊Èπ∑’Ë«à“ß„πÕ“°“» (vestibular sense), °“√√—∫√Ÿâµ”·ÀπàߢÕߢâÕµàÕ (proprioception), §«“¡·¢Áß·√ߢÕß°≈â“¡‡π◊ÈÕ (muscle strength) ·≈–‡«≈“ªØ‘°‘√‘¬“µÕ∫ πÕß (reaction time) „π ºŸâ ŸßÕ“¬ÿ´÷Ëß¡’°“√‡ ◊ËÕ¡∂Õ¬¢Õß√à“ß°“¬ °“√∑”ß“πµà“ß Ê ‡À≈à“π’È≈¥≈ß ∑”„Àâ àߺ≈µàÕ°“√∑√ßµ—« ®÷߇ ’ˬߵàÕ°“√≈⡉¥â ßà“¬ ‚√§∑“ß°“√∑√ßµ—«∑’ˇæ‘Ë¡¡“°¢÷Èπ∑”„À⇪ìπ∑’Ëπà“°—ß«≈„π∑“ߥâ“π “∏“√≥ ÿ¢ ‡π◊ËÕß®“°¡’§«“¡ —¡æ—π∏å°—∫°“√≈â¡∑’Ëπ” ‰ª Ÿà°“√∫“¥‡®Á∫ ‚¥¬‡©æ“–ª√–‡∑»∑’Ë¡’ —¥ à«πª√–™“°√ºŸâ ŸßÕ“¬ÿ Ÿß ªí®®—¬À≈—°∑’Ë∑”„À⇰‘¥°“√≈â¡„πºŸâ ŸßÕ“¬ÿ §◊Õ °“√ ÕàÕπ·√ߢÕß°≈â“¡‡π◊ÈÕ ‚¥¬‡©æ“–°≈â“¡‡π◊ÈÕ¢“ °“√ÕÕ°°”≈—ß°“¬„ππÈ”‡æ◊ËÕ‡æ‘Ë¡°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ‡ªìπ∑“߇≈◊Õ°Àπ÷Ëß ¢Õß°“√ÕÕ°°”≈—ß°“¬ ‚¥¬π”§ÿ≥ ¡∫—µ‘¢ÕßπÈ”¡“„™âª√–‚¬™πå„π°“√ÕÕ°°”≈—ß°“¬ ·√ß≈Õ¬µ—« (buoyancy force) ´÷Ëߙ૬æ¬ÿßπÈ”Àπ—°¢Õß√à“ß°“¬ ≈¥·√ß°¥µàÕ¢âÕ‡¢à“ ·≈–∑”„À⇧≈◊ËÕπ‰À«‰¥âßà“¬ πÕ°®“°π’ȇ¡◊ËÕÕ¬Ÿà„π ‘Ëß·«¥≈âÕ¡∑’Ë ‡ªìππÈ” §«“¡‡ ’ˬ߄π°“√≈â¡®–πâÕ¬°«à“∫π∫° ‡π◊ËÕß®“°πÈ”¡’§«“¡Àπ◊¥ (viscosity) ™à«¬æ¬ÿß√à“ß°“¬‰«â‡¡◊ËÕ¡’°“√ ‡´ ∑”„À⺟⠟ßÕ“¬ÿ¡’‡«≈“∑’Ë®–ª√—∫ ¡¥ÿ≈‰¥â∑—π°àÕπ‡°‘¥°“√≈â¡ °“√‰À≈¢ÕßπÈ”·∫∫«°«π (turbulence flow) ∑”„Àâ √à“ß°“¬µâÕß„™â°“√§«∫§ÿ¡ °“√∑√ßµ—«¡“°¢÷Èπ ‡æ◊ËÕµâ“π°“√‡§≈◊ËÕπ‰À«¢ÕßπÈ” Õ¬à“߉√°Áµ“¡ º≈¢Õß°“√ÕÕ°°”≈—ß°“„ππÈ”µàÕ°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ ¬—ߧߵâÕß°“√°“√»÷°…“«‘®—¬‡æ‘Ë¡‡µ‘¡Õ’°¡“° ‡æ◊ËÕ„À≥â¢âÕ¡Ÿ≈∑’Ë™—¥‡®π¡“°¢÷È𠧔 ”§—≠: °“√∑√ßµ—«, ºŸâ ŸßÕ“¬ÿ, °“√ÕÕ°°”≈—ß°“¬„ππÈ”

¿“§«‘™“°“¬¿“æ∫”∫—¥ §≥– À‡«™»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

°“√∑√ßµ—«¢Õß√à“ß°“¬ À¡“¬∂÷ß §«“¡ “¡“√∂ ¢Õß√à“ß°“¬„π°“√§«∫§ÿ¡®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬ (Center of gravity; COG) ¿“¬„π∞“π (Base of support; BOS) °“√∑√ßµ—«¢Õß√à“ß°“¬ “¡“√∂·∫àßÕÕ°‡ªìπ Ú ·∫∫¥â«°—π §◊Õ Ò. °“√∑√ßµ—«¢Õß√à“ß°“¬„π¢≥–∑’Ë√à“ß°“¬Õ¬Ÿàπ‘Ëß (Static balance) ‡ªìπ°“√√—°…“®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬ „Àâ Õ¬Ÿà°—∫∑’Ë„π¢≥–Õ¬Ÿà„π∞“π ‚¥¬‰¡à¡’°“√‡ª≈’Ë¬πµ”·ÀπàߢÕß ®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬ ‡™àπ „π¢≥–π—Ëß, ¬◊𠇪ìπµâπ ‰¡à«à“ ®–¡’∞“π°«â“ßÀ√◊Õ·§∫°Áµ“¡ ‡™àπ °“√¬◊π Õߢ“À√◊Õ¬◊π¢“ ‡¥’¬« Ú. °“√∑√ßµ—«¢Õß√à“ß°“¬„π¢≥–∑’Ë√à“ß°“¬¡’°“√ ‡§≈◊ËÕπ‰À« (Dynamic balance) ‡ªìπ°“√ª√—∫‡ª≈’Ë¬π µ”·ÀπàߢÕß®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬ ÕÕ°‰ª„π∑‘»µà“ßÊ ‰¡à «à“®–‡ªìπÀπâ“-À≈—ß, ´â“¬-¢«“ À√◊Õ ∫π-≈à“ß „π¢≥–∑’Ë¡’ °“√‡§≈◊ËÕπ‰À«¢Õß√à“ß°“¬ ®—¥«à“‡ªìπ°“√‡ª≈’ˬπ·ª≈ߢÕß ®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬ ∑—Èß„π·π«πÕπ·≈–·π«µ—Èß ‡™àπ °“√ °â“«‡∑Ⓡ¥‘π‰ª∑“ߢâ“ßÀπâ“ °“√‡¥‘π‰ª∑“ߥâ“π¢â“ß ∂◊Õ«à“‡ªìπ °“√‡ª≈’ˬπ·ª≈ßµ”·Àπàß„π·π«πÕπ À√◊Õ°“√≈ÿ°¢÷Èπ¬◊π ®“°∑à“π—Ëß∂◊Õ«à“‡ªìπ°“√‡ª≈’Ë¬πµ”·Àπàß„π·π«µ—Èß ‡ªìπµâπÒ §«“¡ “¡“√∂„π°“√∑√ßµ—«π—πÈ ¢÷πÈ Õ¬Ÿ°à ∫— À≈“¬ªí®®—§◊Õ °“√¡Õ߇ÀÁπ (vision), °“√√—∫√Ÿâ§«“¡‡√Á«‡™‘ß¡ÿ¡·≈–‡™‘ß ‡ â π„π°“√‡§≈◊ËÕ π‰À«¢Õß»’ √ …–·≈–≈”µ— « µà Õ æ◊È π ∑’Ë «à “ ß„π Õ“°“» (vestibular sense), °“√√—∫√Ÿâµ”·ÀπàߢÕߢâÕµàÕ (proprioception), §«“¡·¢Áß·√ߢÕß°≈â“¡‡π◊ÈÕ (muscle strength) ·≈–‡«≈“ªØ‘°‘√‘¬“µÕ∫ πÕß (reaction time) „πºŸ â ߟ Õ“¬ÿ°“√∑”ß“πµà“ßÊ ‡À≈à“π’≈È ¥≈ß ∑”„Àâ ßà º≈µàÕ°“√ ∑√ßµ—« ®÷ß∑”„À⇠’ˬߵàÕ°“√≈⡉¥âßà“¬ ‚√§∑“ß°“√∑√ßµ—«∑’Ë ‡æ‘Ë ¡ ¡“°¢÷È π ∑”„Àâ ‡ ªì π ∑’Ë πà “ °— ß «≈„π∑“ߥ⠓ π “∏“√≥ ÿ ¢ ‡π◊ÕË ß®“°¡’§«“¡ —¡æ—π∏å°∫— °“√≈â¡∑’πË ”‰ª Ÿ°à “√∫“¥‡®Á∫ ‚¥‡©æ“–ª√–‡∑»∑’Ë¡’ —¥ à«πª√–™“°√ºŸâ ŸßÕ“¬ÿ Ÿß Àπ÷Ëß„π “¡ §π¢ÕߺŸâ∑’Ë¡’Õ“¬ÿ¡“°°«à“ ˆı ªï ®–¡’°“√≈â¡Õ¬à“ßπâÕ¬ Ò §√—ßÈ µàÕªï ·≈– Ò-ı ‡ªÕ√凴Áπµå ¡—°¡’°“√∫“¥‡®Á∫∑’√Ë πÿ ·√ßÚ °“√∫“¥‡®Á ∫ ∑’Ë ‡ ªì π º≈®“°°“√À°≈â ¡ ∑’Ë ”§— ≠„π ºŸâ ŸßÕ“¬ÿ §◊Õ °√–¥Ÿ°À—°Ú,Û ‚¥¬‡©æ“–°√–¥Ÿ°¢âÕ¡◊Õ ¢âÕ –‚æ°·≈–°√–¥Ÿ° —πÀ≈—ß Õ“°“√∫“¥‡®Á∫‡≈Á°πâÕ¬ ®“°°“√ À°≈â¡∑’Ë¥Ÿ‡À¡◊Õπ®–‰¡à ”§—≠ ·µà°Á‡ªì𠓇Àµÿ¢Õß°“√ Ÿ≠ ‡ ’¬§«“¡¡—Ëπ„®„π°“√‡§≈◊ËÕπ‰À«®π∑”„À⺟⠟ßÕ“¬ÿ¡’√–¥—∫ ¢Õß°‘®°√√¡∑“ß°“¬≈¥≈ß ´÷ßË ®–‡ªìπ°“√𔉪 Ÿ°à “√‡æ‘¡Ë §«“¡ ‡ ’Ë ¬ ßµà Õ °“√À°≈â ¡ ∑’Ë Ÿ ß ¡“°¢÷È π Õ’ °„πÕ𓧵·≈–Õ“°“√

321

∫“¥‡®Á∫®–¬‘Ëß∑«’§«“¡√ÿπ·√ߢ÷ÈπÀ“°¡’°“√À°≈â¡´È” §«“¡ ‡ ’ˬ߄π°“√À°≈â¡¢÷ÈπÕ¬Ÿà°—∫ªí®®—¬µà“ßÊ ¥—ßπ’È ªí®®—¬¿“¬„π ‰¥â·°à - ¬“ - §«“¡ ŸßÕ“¬ÿ - ª√–«—µ°‘ “√À°≈â¡ - ª√–«—µ‘°“√∫“¥‡®Á∫®“°°“√≈â¡ - °“√¢“¥°“√ÕÕ°°”≈—ß°“- °“√ Ÿ≠‡ ’¬§«“¡ ¡¥ÿ≈„π°“√∑√ß∑à“ - §«“¡ÕàÕπ·√ߢÕß°≈â“¡‡π◊ÈÕ¢“ - §«“¡‰¡à ¡∫Ÿ√≥å¢ÕßÕÿª°√≥å™à«¬æ¬ÿß - ªí≠À“‡√◊ËÕß°“√¡Õ߇ÀÁπ - §«“¡¥—πµË”®“°°“√‡ª≈’ˬπ∑à“ - §«“¡º‘¥ª√°µ‘¥â“𧫓¡§‘¥ - ¿“«– ÿ¢¿“æ¢Õß‚√§‡√◊ÈÕ√—ß ªí®®—¬∑“ß√à“ß°“¬ ‰¥â·°à - °“√ Ÿ≠‡ ’¬§«“¡ ¡¥ÿ≈„π°“√∑√ß∑à“ - °“√ÕàÕπ·√ߢÕß°≈â“¡‡π◊ÈÕ¢“ - §«“¡‰«„π°“√µÕ∫ πÕߢÕß√–∫∫ª√– “∑ ≈¥≈ß - °“√≈¥≈ߢÕß°“√∑”ß“πÕ¬à“ߪ√– “π —¡æ—π∏å °—π¢Õß√–∫∫µà“ßÊ „π√à“ß°“- °“√ Ÿ≠‡ ’¬§«“¡¬◊¥À¬ÿàπ¢Õß°≈â“¡‡π◊ÈÕ - °“√‡¥‘π∑’˺‘¥ª√°µ‘ ªí®®—¬¿“¬πÕ° ‰¥â·°à - æ◊Èπ∑’Ë¡’§«“¡¢√ÿ¢√–À√◊Õ≈◊Ëπ - ∫√‘‡«≥∑’Ë¡’· ß «à“ßπâÕ¬À√◊ծⓇ°‘π‰ª - √Õ߇∑â“∑’ˉ¡à‡À¡“– ¡ - ‘Ëß°’¥¢«“ß - ∫—π‰¥À√◊Õ —µ«å‡≈’È¬ß - °‘®°√√¡∑’‡Ë æ‘¡Ë §«“¡‡ ’¬Ë ßµàÕ°“√À°≈â¡ ‡™àπ ªïπ ªÉ“¬∫πÕÿª°√≥å∑’ˉ¡à¡’§«“¡¡—Ëπ§ßÀ√◊Õ‡°â“Õ’È¡’ ≈âÕ‡≈◊ÕË π ºŸâ Ÿ ß Õ“¬ÿ ∑’Ë ‡ §¬≈â ¡ ¡“°à Õ π¡— ° °≈— « °“√≈â ¡ ·≈– ªÑÕß°—π‰¡à„Àâ≈â¡‚¥¬‡§≈◊ËÕπ‰À«„ÀâπâÕ¬≈ß ‡¡◊ËÕ‡§≈◊ËÕπ‰À« πâÕ¬≈ß√à“ß°“¬‰¡à‰¥âª√—∫°“√∑√ßµ—«®“°§«“¡º‘¥æ≈“¥„π °“√‡§≈◊ËÕπ‰À« ∑—°…–„π°“√∑√ßµ—«®÷ß≈¥≈ß àߺ≈„Àâ°“√ ∑√ßµ—«·¬à≈ß ·≈–‡¢â“ Ÿà«ß®√Ù ¥—ß√Ÿª∑’Ë Ò

322 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

√Ÿª∑’Ë Ò «ß®√¢Õß°“√‰¡à‡§≈◊ÕË π‰À«µàÕ°“√§«∫§ÿ¡°“√∑√ß µ—«„πºŸâ ŸßÕ“¬ÿ °≈‰°„π°“√√—°…“°“√∑√ßµ—«¢Õß√à“ß°“¬ ª√°µ‘ √à“ß°“¬®–‡°‘¥°“√·°«àß (Postural sway) πâÕ¬Ê ‚¥¬‰¡à ≈â¡ À“°°“√·°«àßπ—Èπ®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬Õ¬Ÿà¿“¬„π ‡¢µ ®”°—¥§«“¡¡—Ëπ§ß (Limit of stability : LOS) ¥—ß√Ÿª∑’Ë Ú A ·≈– B ·µà‡¡◊ËÕ„¥∑’Ë¡’·√ß®“°¿“¬πÕ°¡“°√–∑” À√◊Õ µâÕß°“√∑’Ë®–‡§≈◊ËÕπ‰À«¡“°¢÷Èπ ®π∑”„À⇰‘¥°“√‡§≈◊ËÕπ¢Õß ®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬ÕÕ°®“°‡¢µ®”°—¥§«“¡¡—Ëπ§ß ®– àߺ≈„À⇰‘¥°“√‡ ’¬ ¡¥ÿ≈¢÷Èπ∑—π∑’ ¥—ß√Ÿª∑’Ë Ú C ∑”„Àâ √à“ß°“¬µâÕßÀ“«‘∏’°“√„π°“√√—°…“°“√∑√ßµ—«¢÷Èπ¡“ ‡æ◊ËÕ„Àâ √à“ß°“¬¬—ߧß∑√ßµ—«Õ¬Ÿà‰¥â

∑”ß“π¢Õß°≈â“¡‡π◊ÈÕ∂’∫ª≈“¬‡∑â“ (Gastrocnemius) ·≈– °≈â“¡‡π◊ÈÕ°√–¥°¢âÕ‡∑â“ (Tibialis anterior) ∑’ËÕ¬Ÿà√Õ∫¢âÕ ‡∑â“ °“√‡§≈◊ËÕπ∑’Ë„π≈—°…≥–π’È∑”ß“π¡“°∑’Ë ÿ¥ ‡¡◊ËÕ¡’°“√ ‡§≈◊Ë Õ π∑’Ë ¢ Õß®ÿ ¥ »Ÿ π ¬å ∂à « ߢÕß√à “ ß°“¬∫π‡¢µ®”°— ¥ §«“¡ ¡—Ëπ§ß‡≈Á°πâÕ¬ ·≈–®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬¬—ßÕ¬Ÿà„π‡¢µ ®”°—¥§«“¡¡—Ëπ§ß ¥—ßπ—Èπ®÷߇ªìπµ—«§«∫§ÿ¡°“√∑√ß∑à“¢≥– √à“ß°“¬Õ¬Ÿàπ‘Ëß (√Ÿª∑’Ë Û) Ú. Hip strategy ‡ªìπ°“√ª√—∫‡ª≈’Ë¬π ¡¥ÿ≈¢Õß √à“ß°“¬‡¡◊ÕË ¡’·√ß¿“¬πÕ°¡“°√–∑”„À⇠’¬ ¡¥ÿ≈„π√–¥—∫∑’ Ë ßŸ ¡“°°«à“∑’¢Ë Õâ ‡∑â“®– “¡“√∂∑√ßµ—«Õ¬Ÿ‰à ¥â ∑”„ÀâµÕâ ßÕ“»—¬°“√ ‡§≈◊ËÕπ∑’Ë¢Õß –‚æ°‰ª¡“‡æ◊ËÕ√—°…“ ¡¥ÿ≈„À¡à ‚¥¬®–∑”ß“π ‡æ◊ÕË §«∫§ÿ¡°“√‡§≈◊ÕË π‰À«¢Õß®ÿ¥»Ÿπ¬å∂«à ߢÕß√à“ß°“¬∑’¡Ë “° ·≈–‡√Á« ‚¥¬∑”°“√À¡ÿπ «π∑‘»∑“ß°—∫¢âÕ‡∑â“ °“√‡§≈◊ËÕπ∑’Ë „π≈—°…≥–π’È∑”ß“π‰¥â¥’‡¡◊ËÕ®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬Õ¬Ÿà„°≈â °— ∫ ¢Õ∫‡¢µ®”°—¥ §«“¡¡—Ëπ§ß ·≈–‡¡◊Ë Õ ‡¢µ®”°— ¥§«“¡ ¡—Ëπ§ßÕ¬Ÿà∫π∞“π∑’ˇ≈Á°¡“°Ê (√Ÿª∑’Ë Û)

√Ÿª∑’Ë Û · ¥ß«‘∏°’ “√„π°“√√—°…“ ¡¥ÿ≈¢Õß√à“ß°“¬‡¡◊ÕË ¡’·√ß ¿“¬πÕ°¡“°√–∑” ¿“æ´â“¬‡ªìπ°“√√—°…“ ¡¥ÿ≈ ·∫∫ Ankle strategy ¿“梫“‡ªìπ°“√√—°…“ ¡¥ÿ≈ ·∫∫ Hip strategy

√Ÿª∑’Ë Ú · ¥ß§«“¡ —¡æ—π∏å√–À«à“ßµ”·ÀπàߢÕß®ÿ¥»Ÿπ¬å∂«à ß ¢Õß√à“ß°“¬·≈–‡¢µ®”°—¥§«“¡¡—Ëπ§ß «‘∏’°“√„π°“√√—°…“°“√∑√ßµ—« ¡’ Û ·∫∫ §◊Õ Ò. Ankle strategy ‡ªìπ°“√ª√—∫‡ª≈’Ë¬π ¡¥ÿ≈ ¢Õß√à “ ß°“¬‡¡◊Ë Õ ¡’ · √ß¿“¬πÕ°¡“°√–∑”„Àâ ‡ ’ ¬ ¡¥ÿ ≈„π √–¥—∫µË”Ê ·≈–‡∑⓬—ßÕ¬Ÿà∑’Ëæ◊Èπ ‚¥¬®–‡°‘¥°“√‡§≈◊ËÕπ∑’Ë¢Õß ≈”µ—«‰ª¡“‡À¡◊Õπ‡ªìπ¡«≈ “√·¢Áß°âÕπÀπ÷Ëß ´÷Ë߇°‘¥®“°°“√

Û. Step strategy ‡ªìπ°“√ª√—∫‡ª≈’Ë¬π ¡¥ÿ≈¢Õß √à“ß°“¬‡¡◊ÕË ‡°‘¥·√ß¿“¬πÕ°¡“°√–∑”¡“° ®π°√–∑—ßË √à“ß°“‡°‘¥°“√‡ ’¬ ¡¥ÿ≈·≈–‰¡à “¡“√∂Õ“»— ¬ °“√‡§≈◊Ë Õ π∑’Ë ¢ Õß –‚æ°‡æ◊ËÕ√—°…“ ¡¥ÿ≈‰¥â ∑”„ÀâµâÕß¡’°“√°â“«¢“ÕÕ°‰ª ∑“ߥ⠓ πÀπâ “ À√◊ Õ ¥â “ π¢â “ ߇æ◊Ë Õ √— ° …“ ¡¥ÿ ≈„À¡à ∑’Ë ‡ °‘ ¥ ¢÷È π ‡π◊ËÕß®“° ®ÿ¥»Ÿπ¬å∂à«ß¢Õß√à“ß°“¬‡°‘¥°“√‡§≈◊ËÕπÀ≈ÿ¥ÕÕ° πÕ°‡¢µ®”°—¥§«“¡¡—Ëπ§ß·≈â«Ò, ı ‚¥¬ “‡ÀµÿÀ≈—°∑’∑Ë ”„À⺠Ÿâ ߟ Õ“¬ÿ≈¡â §◊Õ‰¡à “¡“√∂„™â ankle strategy ‰¥âÕ¬à“߇撬ßæÕı ¥—ßπ—Èπ‡¡◊ËÕ¡’·√ß¡“

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

√∫°«π ¡¥ÿ≈‡≈Á°πâÕ¬ ºŸâ ŸßÕ“¬ÿ‰¡à “¡“√∂ª√—∫ ¡¥ÿ≈‰¥â∑—π ®÷߇ ’¬ ¡¥ÿ≈¡“°¢÷Èπ·≈–„™â Hip strategy ·≈– Step strategy „π°“√ª√—∫ ¡¥ÿ≈·∑π ´÷ËßÀ“°∑—Èß Õß«‘∏’°“√π’ȉ¡à “¡“√∂√—°…“°“√∑√ßµ—«‰«â‰¥â®–‡°‘¥°“√≈â¡ ‡ÀÁπ‰¥â«à“«‘∏’ °“√„π°“√√—°…“°“√∑√ßµ—«µâÕßÕ“»—¬°”≈—ß°≈â“¡‡π◊ÈÕ¢“‡ªìπ Õ¬à“ß¡“° ´÷ËߺŸâ ŸßÕ“¬ÿ à«π„À≠à¡’°“√ÕàÕπ·√ߢÕß°≈â“¡‡π◊ÈÕ ‚¥¬‡©æ“– °≈â“¡‡π◊ÈÕ¢“´÷Ëß àߺ≈∑”„Àâ°“√∑√ßµ—«‰¡à¥’, ¡’√Ÿª ·∫∫°“√‡¥‘πº‘¥ª√°µ‘ ·≈–°“√¡’‡§≈◊ËÕπ‰À«≈¥≈ßÛ ®“° °“√»÷ ° …“∑’Ë ºà “ π¡“æ∫«à “ §«“¡·¢Á ß ·√ߢÕß°≈â “ ¡‡π◊È Õ ‡À¬’¬¥‡¢à“, °√–¥°¢âÕ‡∑â“ ·≈– –‚æ° ∑’Ë≈¥≈ß¡’§«“¡ —¡æ—π∏å°—∫°“√‡æ‘Ë¡Õ—µ√“§«“¡‡ ’ˬ߄π°“√≈â¡ ¥—ßπ—Èπ°“√ ÕàÕπ·√ߢÕß°≈â“¡‡π◊ÈÕ‡ªìπªí®®—¬À≈—°∑’Ë∑”„À⇰‘¥°“√≈â¡„πºŸâ ŸßÕ“¬ÿÚ πÕ°®“°π’È°“√ÕÕ°°”≈—ß°“¬‡æ◊ËÕ‡æ‘Ë¡§«“¡·¢Áß ·√ߢÕß°≈â“¡‡π◊ÕÈ ¢“∑”„À⧫“¡ “¡“√∂„π°“√∑√ßµ—«¥’¢π÷È ˆ,˜ °“√ÕÕ°°”≈—ß°“¬„ππÈ”„πºŸâ ŸßÕ“¬ÿ ¡’¢âÕ¥’À≈“ª√–°“√ ‡π◊ËÕß®“°§ÿ≥ ¡∫—µ‘∑“ßøî ‘° å¢ÕßπÈ” „ππÈ”®–¡’ ·√ß≈Õ¬µ—« (Buoyancy force) ´÷Ëßµ“¡À≈—°Õ“√姒¡‘¥’ ·√ß≈Õ¬µ—«®–¡’§à“‡∑à“°—∫«—µ∂ÿ∑’Ë®¡Õ¬Ÿà„ππÈ” ·√ß≈Õ¬µ—«π’È®– ™à«¬æ¬ÿßπÈ”Àπ—°¢Õß√à“ß°“¬ ¥—ßπ—πÈ À“°Õ¬Ÿ„à ππÈ”≈÷°√–¥—∫‡Õ« πÈ”®–™à«¬æ¬ÿßπÈ”Àπ—°¢Õß√à“ß°“¬ª√–¡“≥ ı ‡ªÕ√凴Áπµå ¢ÕßπÈ”Àπ—°µ—« ·≈–‡¡◊ËÕÕ¬Ÿà„ππÈ”≈÷°¡“°¢÷Èπ πÈ”®–™à«¬æ¬ÿß πÈ”Àπ—°¢Õß√à“ß°“¬¡“°¢÷Èπ¥â«¬¯ ª√–‚¬™πå¢Õß·√ß≈Õ¬µ—« π’∑È ”„Àâ√¬“ß§å «à π≈à“ß√—∫πÈ”Àπ—°µ—«πâÕ¬≈ß ·√ß°¥µàÕ¢âÕ‡¢à“ ≈¥≈ß ´÷ËߺŸâ ŸßÕ“¬ÿ à«π„À≠à¡—°¡’Õ“°“√ª«¥¢âÕ‡¢à“ °“√Õ¬Ÿà „ππÈ”°Á®–™à«¬„ÀâÕ“°“√ª«¥≈¥≈ß À“°ÕÕ°°”≈—ß°“¬∫π∫° ·√ß°¥µàÕ‡¢à“®–‡æ‘Ë¡¡“°¢÷Èπ‚¥¬‡©æ“–„π°“√‡¥‘π °“√«‘Ëß À√◊Õ°√–‚¥¥ πÕ°®“°π’°È “√ÕÕ°°”≈—ß°“¬„ππÈ”¬—ß¡’§«“¡‡ ’¬Ë ß„π °“√≈â¡πâÕ¬°«à“∫π∫° ‡π◊ÕË ß®“°πÈ”¡’§«“¡Àπ◊¥ (viscosity) ‡¡◊ËÕ¡’°“√ Ÿ≠‡ ’¬°“√∑√ßµ—« §«“¡Àπ◊¥¢ÕßπÈ”®–™à«¬∑”„Àâ √à“ß°“¬‡´≈â¡≈ß ™â“°«à“∫π∫° ∑”„À⺟⠟ßÕ“¬ÿ¡’‡«≈“∑’Ë®–§‘¥ ·≈–ª√—∫ ¡¥ÿ≈‰¥â∑—π°àÕπ∑’Ë®–≈â¡ °“√‡§≈◊ËÕπ‰À«„ππÈ”‡ªì𠉪‰¥âßà“¬°«à“∫π∫° ‡æ√“–πÈ”®–™à«¬æ¬ÿß„Àâ¡’°“√‡§≈◊ËÕπ‰À« ßà“¬¢÷Èπ ¥—ßπ—Èπ ”À√—∫ºŸâ ŸßÕ“¬ÿ∑’Ë°≈—«°“√≈â¡ °“√ÕÕ°°”≈—ß °“¬„ππÈ”´÷Ë߇ªìπ ‘Ëß·«¥≈âÕ¡∑’˧àÕπ¢â“ߪ≈Õ¥¿—¬µàÕ°“√≈â¡ ·≈–‡§≈◊ÕË π‰À«‰¥âß“à ¬®–∑”„À⺠Ÿâ ߟ Õ“¬ÿ¡°’ “√‡§≈◊ÕË π‰À«¡“°¢÷πÈ ·≈–¡’§«“¡¡—Ëπ„®„π°“√‡§≈◊ËÕπ‰À«˘ ®“°°“√»÷°…“∑’˺à“π¡“æ∫«à“°“√ÕÕ°°”≈—ß°“¬„π πÈ”∑”„Àâ°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ¥’¢÷ÈπÙ,˘-ÒÛ ®“°°“√»÷°…“ ‡ª√’¬∫‡∑’¬∫§«“¡ “¡“√∂„π°“√∑√ßµ—«„πºŸâ ŸßÕ“¬ÿ√–À«à“ß Ù °≈ÿà¡ §◊Õ ÕÕ°°”≈—ß°“¬„ππÈ”, ÕÕ°°”≈—ß°“¬∫π∫°, °“√

323

π—Ëß„ππÈ” ·≈–°“√π—Ëß∫π∫° §√—Èß≈– Ùı π“∑’ —ª¥“Àå≈– Ú §√—Èß ‡ªìπ‡«≈“ ı —ª¥“Àå æ∫«à“„π —ª¥“Àå∑’Ë ı °≈ÿà¡ÕÕ° °”≈—ß°“¬„ππÈ”¡’§«“¡ “¡“√∂„π°“√∑√ßµ—«¡“°°«à“ °≈ÿ¡à Õ◊πË Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µÙ‘ Õ’°°“√»÷°…“Àπ÷Ëß»÷°…“º≈¢Õß °“√ÕÕ°°”≈—ß°“¬„ππÈ”√à«¡°—∫‚ª√·°√¡°“√¥Ÿ·≈µπ‡Õß„π ºŸâ ŸßÕ“¬ÿ ‚¥¬ÕÕ°°”≈—ß°“¬ §√—Èß≈– ı π“∑’ „À⧫“¡√Ÿâ Ò π“∑’ Õߧ√—ßÈ µàÕ —ª¥“À凪ìπ‡«≈“ Ò —ª¥“Àå æ∫«à“¡’§«“¡ “¡“√∂„π°“√∑√ßµ—«·≈–§ÿ≥¿“æ™’«µ‘ ¥’°«à“°≈ÿ¡à §«∫§ÿ¡ÒÛ πÕ°®“°π’Ȭ—ß¡’°“√»÷°…“æ∫«à“À≈—ßÕÕ°°”≈—ß°“¬„ππÈ” §√—Èß ≈– Ù π“∑’ Ú §√—ÈßµàÕ —ª¥“Àå ‡ªìπ‡«≈“ ÒÚ —ª¥“Àå ºŸâ ŸßÕ“¬ÿ¡’°“√∑√ßµ—«¥’¢÷Èπ·≈–Õ“®∑”„À⧫“¡‡ ’ˬ߄π°“√≈â¡ ≈¥≈ߥ⫬˘ „π°“√ÕÕ°°”≈—ß°“¬‚¥¬°“√‡¥‘π °“√‡¥‘π„ππÈ”µà“ß ®“°∫π∫°‡π◊ËÕß®“°¢≥–‡¥‘π„ππÈ” µâ Õ ß„™â ° ≈â “ ¡‡π◊È Õ ≈”µ— « §«∫§ÿ¡°“√∑√ßµ—«‡æ◊ÕË µâ“π°—∫°√–· «°«π¢ÕßπÈ” (turbulent flow) µ≈Õ¥‡«≈“ ·≈–‡¡◊ËÕ‡¥‘π‡√Á«¢÷Èπ°√–· «°«π°Á ¡“°¢÷Èπ ®÷ßµâÕß„™â°≈â“¡‡π◊ÈÕ≈”µ—«§«∫§ÿ¡°“√∑√ßµ—«¡“°¢÷Èπ ´÷ßË °“√‡¥‘π∫π∫°®–„™â°≈â“¡‡π◊ÕÈ ≈”µ—«„π°“√™à«¬§«∫§ÿ¡°“√ ∑√ßµ—«πâÕ¬°«à“„ππÈ” πÕ°®“°π’È°“√∑”∑à“∑“ß„π°“√ÕÕ° °”≈—ß°“¬„ππÈ”·µà≈–§√—Èß®–¡’°“√‡ª≈’ˬπ·ª≈ßµ≈Õ¥‡«≈“ ‡π◊ËÕß®“°¡’πÈ”‡ªìπµ—«°≈“ß ·¡â®–‡ªìπ°“√‡§≈◊ËÕπ‰À«∑à“‡¥‘¡ °“√‡§≈◊ËÕπ∑’Ë¢ÕßπÈ”¢≥–‡ª≈’ˬπ∑à“∑“ß„ππÈ”·µà≈–§√—Èß°Á‰¡à ‡À¡◊Õπ°—π ´÷Ëß·µ°µà“ß®“°°“√ÕÕ°°”≈—ß°“¬∫π∫° °“√ ‡§≈◊ËÕπ‰À«„π∑à“‡¥‘¡ ®–„À⧫“¡√Ÿâ ÷°‡À¡◊Õπ‡¥‘¡ ·≈–„™â °≈â“¡‡π◊ÈÕ‡¥‘¡„π°“√‡§≈◊ËÕπ‰À«·µà≈–§√—Èß ¥—ß®“°°“√»÷°…“ ∑’˺à“π¡“ æ∫«à“°“√ÕÕ°°”≈—ß°“¬„ππÈ” “¡“√∂‡æ‘Ë¡°“√ ∑√ßµ—«‰¥â¡“°°«à“°“√ÕÕ°°”≈—ß°“¬∫π∫° ·≈–°“√∑√ßµ—« ∑’ˇæ‘Ë¡¢÷Èππ—Èπ ‡æ‘Ë¡¢÷Èπ∑ÿ° —ª¥“Àå (ÕÕ°°”≈—ß°“¬ Ú §√—ÈßµàÕ —ª¥“Àå ‡ªìπ‡«≈“ ı —ª¥“Àå) „π¢≥–∑’Ë°“√ÕÕ°°”≈—ß°“∫π∫°¡’°“√∑√ßµ—«∑’ˇæ‘Ë¡¢÷Èπ„π°“√ÕÕ°°”≈—ß°“¬ —ª¥“Àå ·√°‡∑à“π—ÈπÛ °“√ÕÕ°°”≈— ß °“¬‡ªì π °≈ÿà ¡„ππÈ” ‡¡◊Ë Õ ¡’ ° “√ ‡§≈◊Ë Õ π‰À«¢ÕßÀ≈“¬§π®–∑”„Àâ ‡°‘ ¥°“√‰À≈¢ÕßπÈ”·∫∫ «°«π (turbulence flow) ·≈–∑”„ÀâµâÕß„™â°“√§«∫§ÿ¡ °“√∑√ßµ—«¡“°¢÷Èπ ‡æ◊ËÕµâ“π°“√‡§≈◊ËÕπ‰À«¢ÕßπÈ” °“√‰À≈ ¢ÕßπÈ”·∫∫«°«π ¬—ß∑”„Àâ°“√‡§≈◊ËÕπ‰À«¢Õß√à“ß°“¬„ππÈ” ∑”‰¥âßà“¬¢÷ÈπÀ√◊Õ¬“°¢÷Èπ ¢÷ÈπÕ¬Ÿà°—∫∑‘»∑“ß°“√‡§≈◊ËÕπ‰À« ·≈–°“√‰À≈¢ÕßπÈ” ‡™àπ °“√®—∫¡◊Õ°—π‡¥‘π‡ªìπ«ß°≈¡„ππÈ” —°√–¬–Àπ÷ßË ®–æ∫«à“°“√‡¥‘π‡ªìπ«ß°≈¡π—πÈ ßà“¬¢÷πÈ ‡π◊ÕË ß®“° °“√‰À≈¢ÕßπÈ”‰ª„π∑‘»‡¥’¬«°—∫°“√‡§≈◊ËÕπ‰À« πÈ”®÷ߙૄÀ⇰‘¥°“√‡§≈◊ËÕπ‰À«ßà“¬¢÷Èπ À“°µâÕß°“√À¬ÿ¥°“√‡¥‘π∑—π∑’

324 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

®–æ∫«à“°“√À¬ÿ¥‡ªìπ‰ª‰¥â¬“° ‡π◊ÕË ß®“°°“√‡§≈◊ÕË π‰À«¢«“ß °“√‰À≈¢ÕßπÈ” πÈ”®–‡ªìπ·√ßµâ“π∑”„Àâ°“√À¬ÿ¥‡¥‘π∑”‰¥â¬“° ¥—ßπ—Èπ°“√ÕÕ°°”≈—ß°“¬‡ªìπ°≈ÿà¡„ππÈ”πÕ°®“°®–∑”„Àâ ¡’ §«“¡ πÿ° π“π„π°“√ÕÕ°°”≈—ß°“¬¡“°¢÷Èπ·≈â« ¬—ß∑”„Àâ ¡’°“√‰À≈«°«π¢ÕßπÈ”¡“°¢÷Èπ ´÷Ëß√à“ß°“¬µâÕß„™â°“√§«∫§ÿ¡ °“√∑√ßµ—«¡“°¢÷πÈ ·µ°µà“ß®“°°“√ÕÕ°°”≈—ß°“¬∫π∫° °“√ ÕÕ°°”≈—ß°“¬‡ªìπ°≈ÿà¡ À√◊Õµ“¡≈”æ—ß °“√∑”ß“π¢Õß °≈â“¡‡π◊ÕÈ ‡À¡◊Õπ°—π∑ÿ°ª√–°“√ ·§à‡æ’¬ß∑”„Àâ πÿ° π“π πà“ π„® ¡’·√ß®Ÿß„®„π°“√ÕÕ°°”≈—ß°“¬ ·≈–‰¥â查§ÿ¬·≈– ‡ª≈’Ë¬π§«“¡§‘¥‡ÀÁπ°—π‡∑à“π—Èπ ·¡â «à “ °“√ÕÕ°°”≈— ß °“¬„ππÈ” ®–¡’ ¢â Õ ¥’ ¡ “°°«à “ °“√ÕÕ°°”≈—ß°“¬∫π∫°À≈“¬Õ¬à“ß ·µà¬—ß¡’¢âÕ®”°—¥ ‡™àπ ¬ÿà߬“° §à“„™â®à“¬ Ÿß πÕ°®“°π’Ȭ—ß¡’¢âÕ§«√√–«—ß„π°“√ÕÕ° °”≈—ß°“¬„ππȔՒ°¥â«¬ ª√–°“√·√° „ππÈ”¡’·√ߥ—πÕÿ∑° ∂‘µ¬å (hydrostatic pressure) ∑’Ë¥—π∑ÿ°¥â“π¢Õß√à“ß°“∑’Ë®¡Õ¬Ÿà„ππÈ”¯ (√Ÿª∑’Ë Ù) À“°πÈ”≈÷°√–¥—∫∑√«ßÕ°À√◊Õ‰À≈à ·√ߥ—πÕÿ∑° ∂‘µ®–¥—π√Õ∫∫√‘‡«≥∑√«ßÕ°∑”„Àâ°“√À“¬„®

‡ªìπ‰ª‰¥â¬“°¢÷Èπ ¥—ßπ—Èπ„πºŸâ ŸßÕ“¬ÿ∑’Ë¡’°“√À“¬„®≈”∫“°Õ¬Ÿà ·≈â«¢≥–∫π∫° À√◊Õ¡’‚√§∑’Ë∑”„À⧫“¡®ÿªÕ¥≈¥≈ß „π°≈ÿà¡ ‚√§∑’Ë¡’°“√Õÿ¥°—Èπ¢Õߪե ‡™àπ ‚√§∂ÿß≈¡‚ªÉßæÕß À“° µâÕß°“√ÕÕ°°”≈—ß°“¬„ππÈ” §«√‰¥â√—∫°“√¥Ÿ·≈Õ¬à“ß„°≈♑¥ ®“°π—°°“¬¿“æ∫”∫—¥ À√◊ÕºŸâ‡™’ˬ«™“≠ ª√–°“√∑’Ë Õß „π ºŸâ ŸßÕ“¬ÿ∑’Ë¡’‚√§À—«„® §«√‰¥â√—∫°“√¥Ÿ·≈Õ¬à“ß„°≈♑¥ ‡π◊ËÕß ®“°·√ߥ— π Õÿ ∑ ° ∂‘ µ ¬å ®–¥— π ¢Õ߇À≈«∑’Ë Õ ¬Ÿà π Õ°‡´≈≈å (extravascular fluid) °≈—∫‡¢â“ ŸÀà ≈Õ¥‡≈◊Õ¥ ∑”„Àâª√‘¡“µ√ ‡≈◊Õ¥‡æ‘Ë¡¡“°¢÷Èπ ·≈–ª√‘¡“µ√‡≈◊Õ¥∑’ˉÀ≈°≈—∫‡¢â“ ŸàÀ—«„® ¡“°¢÷Èπ¥â«¥—ßπ—Èπ °“√ÕÕ°°”≈—ß°“¬„ππÈ”‡æ◊ËÕ‡æ‘Ë¡°“√∑√ßµ—« „πºŸâ ŸßÕ“¬ÿ ‡ªìπ∑“߇≈◊Õ°Àπ÷Ëß„π°“√ÕÕ°°”≈—ß°“¬‡æ◊ËÕ ªÑÕß°—π°“√≈â¡∑’ËÕ“®‡°‘¥¢÷Èπ‰¥â„πºŸâ ŸßÕ“¬ÿ Õ¬à“߉√°Áµ“¡ °“√ ÕÕ°°”≈—ß°“¬„ππÈ”∑’Ë àߺ≈µàÕ°“√∑√ßµ—« ¬—ߧߵâÕß°“√ °“√»÷°…“«‘®—¬‡æ‘Ë¡‡µ‘¡¡“°¢÷Èπ ‡æ◊ËÕ„Àâ∑√“∫º≈∑’Ë™—¥‡®π √«¡ ∂÷ß∑√“∫∑à“„π°“√ÕÕ°°”≈—ß°“¬ §«“¡Àπ—° §«“¡∂’Ë ·≈– √–¬–‡«≈“„π°“√ÕÕ°°”≈—ß°“¬∑’ˇÀ¡“– ¡Õ’°¥â«¬

√Ÿª∑’Ë Ù ·√ß∑’Ë°√–∑”¢≥–√à“ß°“¬Õ¬Ÿà„ππÈ” (·√ß≈Õ¬µ—« ·≈–·√ߥ—πÕÿ∑° ∂‘µ¬å)

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

‡Õ° “√Õâ“ßÕ‘ß Ò. Brody LT Dewane J. Therapeutic exercise: moving toward function. 2nd Ed. Philadelphia: Lippincott Williams & Wilkins 2005:149-66. Ú. Sturnieks DL, St George R, Lord SR. Balance disorders in the elderly. Neurophysiol Clin.

2008 Dec;38:467-78. Û. Lord SR, Sturnieks DL. The physiology of falling: assessment and prevention strategies for older people. J Sci Med Sport 2005;8:3542. Ù. Simmons V, Hansen PD. Effectiveness of water exercise on postural mobility in the well elderly: an experimental study on balance enhancement.

J Gerontol A Biol Sci Med Sci 1996;51: M233-8. ı. Shumway-Cook A, Woollacott M. Motor control: translation research into clinical practice. 3rd Ed. Philadelphia: Lippincott Williams & Wilkins;2007. ˆ. Lord SR, Ward JA, Williams P. Exercise effect on dynamic stability in older women: a randomized controlled trial. Arch Phys Med Rehabil 1996;77:232-6.

325

˜. Hess JA, Woollacott M, Shivitz N. Ankle force and rate of force production increase following high intensity strength training in frail older adults. Aging Clin Exp Res 2006;18:107-15. ¯. Vargas LG. Aquatic therapy : interventions and applications. WA: Idyll Arbor, Inc. 2004:5-12. ˘. Resende SM, Rassi CM, Viana FP. Effect of hydrotherapy in balance and prevention of falls among elderly women. Rev Bras Fisioter 2008; 12:57-63. Ò. Lord S, Mitchell D, Willians P. Effect of water exercise on balance and related factors in older people. Aust Physio 1993;39:217-22. ÒÒ. Douris P, Southard V, Varga C, Schauss W, Gennaro C, Reiss A. The effect of land and aquatic exercise on balance score in older adults.

J Geriatr Phys Ther 2003;26:3-6. ÒÚ. Lord SR, Matters B, George RS. The effects of water exercise on physical functioning on older people. Aust J Ageing 2006;25:36-41. ÒÛ. Devereux K, Robertson D, Briffa NK. Effects of a water-based program on women 65 years and over: a randomised controlled trial. Aust J Physiother 2005;51:102-8.

326 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Abstract Aquatic exercise to improve balance in the elderly Piyapa Keawutan Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University The control of balance relies on many factors, which are vision, vestibular sense, proprioception, muscle strength and reaction time. With increasing age, there is a progressive loss of these system functions which can contribute to balance deficits and high risk of falls. Balance disorders represent a growing public health concern due to the association with fall and fall - related injuries, particularly in regions of the world in which high proportions of the population are elderly. The lower limb muscle weakness is a major risk factor of fall in elderly. Aquatic exercise to improve balance in elderly is the alternative exercise using the water properties. Buoyancy force helps supporting the body weight, decreasing compression force on the knee joint and moving easily. The turbulence flow is the water resistance that elderly have to control the balance against it. Water environment also decreases risk of falls due to the viscosity that supports the body while falling. Therefore, the elderly have more time to control their balance. Nevertheless, more studies on the effects of aquatic exercise on balance in the elderly are needed to clarify these effects.

Key words: Balance, Elderly, Aquatic exercise

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

327

∫∑§«“¡ª√‘∑—»πå

»“ π“°—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ¢«—≠®‘µ »»‘«ß»“‚√®πå

∫∑§—¥¬àÕ „πªí®®ÿ∫—πª√–‡∑»‰∑¬‰¥â‡¢â“ Ÿà°“√‡ªìπ —ߧ¡ºŸâ ŸßÕ“¬ÿ·≈â« ·≈–®”π«πºŸâ ŸßÕ“¬ÿ¡’·π«‚π⡇æ‘Ë¡¢÷ÈπÕ¬à“ßµàÕ‡π◊ËÕß ∂“π°“√≥套߰≈à“«∑”„À⧫“¡µâÕß°“√¥â“π°“√¥Ÿ·≈·≈–§à“√—°…“欓∫“≈„πºŸâ ŸßÕ“¬ÿ‡æ‘Ë¡ Ÿß¢÷Èπ Õߧ姫“¡√Ÿâ‡°’ˬ«°—∫ ºŸâ ŸßÕ“¬ÿ∂Ÿ°»÷°…“Õ¬à“ß·æ√àÀ≈“¬ ‡æ◊ËÕ π—∫ πÿπ„À⺟⠟ßÕ“¬ÿ¡’§«“¡¡—Ëπ§ß “¡“√∂æ÷Ëßæ‘ßµπ‡Õ߉¥â∑—Èß„π¥â“π‡»√…∞°‘® ·≈– —ߧ¡ µ≈Õ¥®π¡’Õ“¬ÿ¬◊π¬“«Õ¬à“ß¡’ ÿ¢¿“楒 ¡‘µ‘∑“ߥâ“𻓠𓇪ìπÕ’°ª√–‡¥ÁπÀπ÷Ëß∑’Ë¡’§«“¡ —¡æ—π∏å„°≈♑¥ °—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ∫∑§«“¡π’ȉ¥â√«∫√«¡·π«§‘¥‡°’ˬ«°—∫»“ π“·≈– ÿ¢¿“æ ∫∑∫“∑¢Õß»“ π“∑’Ë¡’µàÕ ÿ¢¿“æ ∑—Èß„π·ßà∫«°·≈–≈∫ √«¡∑—Èß∑ƒ…Æ’ºŸâ ŸßÕ“¬ÿ∑’ˇ™◊ËÕ¡‚¬ß°—∫»“ π“ ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√»÷°…“‡°’ˬ«°—∫ºŸâ ŸßÕ“¬ÿ„π —ߧ¡‰∑¬µàÕ‰ª §” ”§—≠: »“ π“, ÿ¢¿“æ, ºŸâ ŸßÕ“¬ÿ

∫∑π” °“√‡¢â“ Ÿ à ß— §¡ºŸ â ߟ Õ“¬ÿ (aging society) „πÀ≈“ª√–‡∑»‰¥âª√“°Ø™—¥„π™à«ß∑’§Ë π√ÿπà ç√–‡∫‘¥ª√–™“°√é (baby boom generation) À√◊ÕºŸâ∑’ˇ°‘¥„π™à«ß°≈“ß»µ«√√…∑’Ë Ú (ª√–¡“≥ªï§.». Ò˘Ùˆ-Ò˘ˆÙ) ‰¥â‡√‘Ë¡‡¢â“ Ÿà«—¬‡°…’¬≥ ‚¥¬‡©æ“–„πª√–‡∑»µ–«—πµ° ∂“π°“√≥凙àππ’‰È ¡à‰¥â‡°‘¥¢÷πÈ „πª√–‡∑»∑’æË ≤ — π“·≈⫇∑à“π—πÈ „πª√–‡∑»°”≈—ßæ—≤π“∑—ßÈ À≈“°Á‡√‘Ë¡ª√– ∫°—∫ ∂“π°“√≥åπ’ȇ™àπ‡¥’¬«°—π ®“°°“√§“¥ ª√–¡“≥ æ∫«à“®”π«πºŸâ ŸßÕ“¬ÿ„πª√–‡∑»°”≈—ßæ—≤π“®– ‡æ‘Ë¡¢÷ÈπÕ¬à“ß°â“«°√–‚¥¥∂÷ß√âÕ¬≈– ÒÙ „πªï§.». ÚÛÒ ª√–‡∑»‰∑¬ ‡ªìπÕ’°ª√–‡∑»Àπ÷Ëß∑’Ë°”≈—߇º™‘≠°—∫°“√‡ªìπ —ߧ¡ºŸâ ŸßÕ“¬ÿ ´÷Ëß —¥ à«π¢ÕߺŸâ ŸßÕ“¬ÿ¡’·π«‚π⡇æ‘Ë¡¢÷Èπ ‡√◊ËÕ¬Ê ‚¥¬‡æ‘Ë¡¢÷Èπ®“°√âÕ¬≈– ¯.˜ „πªï§.». Ú ‡ªìπ √âÕ¬≈– Ò.¯ „πªï §.». ÚÒ ·≈–„πÕ’° Ù ªïµàÕ¡“ (ªï§.». Úı) ®–‡æ‘Ë¡ Ÿß∂÷ß√âÕ¬≈– ÛÚ

∂“∫—π«‘®—¬¿“…“·≈–«—≤π∏√√¡‡Õ‡™’¬ ¡À“«‘∑¬“≈—¬¡À‘¥≈

®“° ∂“π°“√≥套߰≈à“«∑”„À⺟⠟ßÕ“¬ÿ°≈“¬‡ªìπ ª√–‡¥Áπ∑’Ë∑—Ë«‚≈°„À⧫“¡ π„® ‚¥¬‡©æ“–ª√–‡¥Áπ ÿ¢¿“æ ‡π◊ËÕß®“°‡ªìπªí≠À“∑’ˇ°‘¥®“°§«“¡‡ ◊ËÕ¡µ“¡«—¬ ´÷Ë߇ªìπ ‘Ëß∑’ˉ¡à “¡“√∂À≈’°‡≈’ˬ߉¥â„πºŸâ ŸßÕ“¬ÿ ªí®®—¬µà“ßÊ ∑’Ë¡’º≈ µàÕ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ‰¥â∂Ÿ°»÷°…“Õ¬à“ß·æ√àÀ≈“¬ √«¡∑—Èß ª√–‡¥Áπ∑“ß«—≤π∏√√¡ ´÷Ëߧ«“¡·µ°µà“ß∑“ߥâ“π¿“…“ «‘∂’ ™’«‘µ ·≈–§«“¡‡™◊ËÕ¢Õß°≈ÿà¡¡’º≈µàÕ ÿ¢¿“«–¢ÕߺŸâ ŸßÕ“¬ÿ „π≈—°…≥–∑’Ë·µ°µà“ß°—πÛ »“ 𓇪ìπÕ’°ª√–‡¥ÁπÀπ÷Ëß∑“ß «—≤π∏√√¡∑’ˉ¥â√—∫§«“¡ π„®„π™à«ßÀ≈“¬∑»«√√…∑’˺à“π¡“ ¡’ß“π«‘®—¬®”π«π¡“°∑’Ë»÷°…“∂÷ßÕ‘∑∏‘æ≈¢Õß»“ π“∑’Ë¡’µàÕ ÿ ¢ ¿“æ°“¬·≈–®‘ µÙ,ı ·µà „ πª√–‡∑»‰∑¬ª√–‡¥Á π ‡√◊Ë Õ ß »“ π“¬—ß‰¡à‰¥â∂Ÿ°π”¡“‡™◊ËÕ¡‚¬ß°—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ¡“°π—° ¥—ßπ—Èπ∫∑§«“¡π’È®÷߉¥â𔇠πÕ·π«§‘¥‡°’ˬ«°—∫ »“ π“·≈– ÿ¢¿“æ ∫∑∫“∑¢Õß»“ π“∑’Ë¡’µàÕ ÿ¢¿“æ √«¡ ∑—Èß∑ƒ…Æ’‡°’ˬ«°—∫ºŸâ ŸßÕ“¬ÿ·≈–»“ π“ ‡æ◊ËÕ‡ªìπ·π«∑“ß„π °“√»÷°…“‡°’ˬ«°—∫ºŸâ ŸßÕ“¬ÿ„π —ߧ¡‰∑¬µàÕ‰ª

328 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

·π«§‘¥‡°’ˬ«°—∫»“ π“·≈– ÿ¢¿“æ (Religion and Health) ·π«§‘¥‡°’ˬ«°—∫§«“¡ —¡æ—π∏å√–À«à“ß»“ π“°—∫ ÿ¢¿“æ¡’¡“·µà ¡—¬‚∫√“≥ µ—Èß·µà„π ¡—¬∑’˧π‡√“¡—°‡™◊ËÕ„π ‡√◊ËÕß ‘Ë߇Àπ◊Õ∏√√¡™“µ‘·≈–‡™◊ËÕ«à“§«“¡‡®Á∫ªÉ«¬‡°‘¥®“°¿Ÿµ‘ º’ ªï»“® À√◊Õ§«“¡™—Ë«√⓬ º‘¥ ∫“ª »“ π“‰¥â‡¢â“¡“¡’ ∫∑∫“∑„π°“√√—°…“¥â«¬æ≈—ß·Ààߧ«“¡¥’ À√◊ÕÕ”π“®¢Õß ‡∑懮ⓠ®π°√–∑—Ë߇¡◊ËÕ°“√·æ∑¬å ¡—¬„À¡à‡¢â“¡“∫∑∫“∑¢Õß »“ π“„π¥â“π°“√√—°…“®÷ß≈¥πâÕ¬≈߈ Õ¬à“߉√°Áµ“¡∫∑∫“∑ ¢Õß»“ π“„π·ßà¡ÿ¡∑’ˇªìπ‡ ¡◊Õπ ç«—≤π∏√√¡é ¬—ߧߡ’ ∫∑∫“∑µàÕºŸ∑â ¬’Ë ¥÷ ∂◊Õ¡“µ≈Õ¥∑ÿ°¬ÿ§∑ÿ° ¡—¬ »“ π“¡’Õ∑‘ ∏‘æ≈ µàÕ‚≈°∑—»πå §«“¡§‘¥ §«“¡‡™◊ËÕ ‰ª®π∂÷ß·π«∑“ß„π°“√ ¥”√ß™’«µ‘ ¢Õß»“ π‘°™π∑’‡Ë ™◊ÕË ∂◊Õ·≈–ªØ‘∫µ— µ‘ “¡À≈—°§” Õπ ¢Õß»“ π“π—Èπʘ »“ 𓬗ß∑”Àπâ“∑’ˇªìπ‡§√◊ËÕß¡◊Õ„π°“√ §«∫§ÿ¡ —ߧ¡ (social control) §” Õπ∑“ß»“ 𓇪ìπ°Æ „Àâ ¡“™‘°ªØ‘∫—µ‘µ“¡¥â«¬§«“¡»√—∑∏“ ´÷Ë߇ªìπº≈„À⇰‘¥ °“√§«∫§ÿ¡Õ¬à“߇ªìπ√–∫∫ ·µà∑—Èßπ’ÈÕ‘∑∏‘æ≈¢Õß»“ π“∑’Ë¡’ º≈µàÕ∫ÿ§§≈Õ“®‡ªìπ‰¥â∑ß—È ‡À𒬫·πàπ·≈–À≈–À≈«¡ (strong ties and weak ties) ´÷Ëߢ÷ÈπÕ¬Ÿà°—∫√–¥—∫§«“¡¬÷¥¡—Ëπ»√—∑∏“ (religiosity) ¢Õß»“ π‘°™π„π»“ π“π—ÈπÊ ¥â«‡¡◊ËÕ‡™◊ËÕ¡‚¬ß‡√◊ËÕß»“ π“°—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ §«“¡À¡“¬¢Õß ÿ¢¿“懪ìπ ‘ßË ∑’µË Õâ ß∑”§«“¡‡¢â“„®„π‡∫◊ÕÈ ßµâπ ·¡âÕߧ尓√Õπ“¡—¬‚≈°‰¥â„À⧫“¡À¡“¬¢Õß ÿ¢¿“æ«à“‡ªìπ ¿“«–∑’Ë ¡∫Ÿ√≥å·≈–‡™◊ËÕ¡‚¬ß°—π‡ªìπÕߧå√«¡Õ¬à“ß ¡¥ÿ≈∑—Èß °“¬ ®‘µ ·≈– —ߧ¡ √«¡∑—Èß°“√ª√“»®“°´÷Ëß‚√§·≈–§«“¡ æ‘°“√¯ §”𑬓¡π’ȉ¥â„™â°—π‚¥¬∑—Ë«‰ª ·µà ”À√—∫ºŸâ ŸßÕ“¬ÿ∑’Ë √à“ß°“¬‡√‘Ë¡‡ ◊ËÕ¡‰ªµ“¡°Æ‡°≥±å¢Õß∏√√¡™“µ‘ ´÷Ë߉¡àÕ“® µâ“π∑“π„Àâ√“à ß°“¬Õ¬Ÿ„à π¿“«– ¡∫Ÿ√≥剥â·≈â«π—πÈ °“√¡’ ¢ÿ ¿“æ ¥’„πºŸâ ŸßÕ“¬ÿ‰¥â¡’°“√‡ πÕ§«“¡À¡“¬‡æ◊ËÕ„Àâ Õ¥§≈âÕß°—∫ ¿“æ√à“ß°“¬∑’ˇª≈’ˬπ·ª≈ߢÕߺŸâ ŸßÕ“¬ÿ«à“À¡“¬∂÷ß §«“¡ “¡“√∂„π°“√¡’™’«‘µÕ¬Ÿà·≈–∑”Àπâ“∑’Ë∑“ß —ߧ¡‰¥â æ÷Ëßæ“ µπ‡Õ߉¥â·≈–¡’§«“¡‡ªìπÕ‘ √–‡µÁ¡µ“¡»—°¬¿“æ ‚¥¬‰¡à ®”‡ªìπ«à“®–µâÕߪ√“»®“°‚√§˘ ∑—»π–¢Õß ÿ¢¿“æ„πºŸ â ߟ Õ“¬ÿ ®÷ß¡’‰¥âÀ≈“°À≈“¬¡ÿ¡¡Õß ‰¥â·°à Ò) ¡ÿ ¡ ¡Õß∑“ß°“√·æ∑¬å (medical perspective)Ò ¡Õß„π¡‘µ‘¢Õߧ«“¡‡ ◊ËÕ¡∑’ˇ°‘¥¢÷Èπµ“¡«—∑—Èß∑“ߥâ“π√à“ß°“¬·≈–®‘µ„® √«¡∑—Èß欓∏‘ ¿“æ∑’ˇ°‘¥¢÷Èπ °—∫√à“ß°“¬ ´÷Ëß°Á§◊Õ °“√‡°‘¥‚√§À√◊Õ§«“¡‡®Á∫ªÉ«¬ „πºŸâ Ÿß Õ“¬ÿ¡—°¡’‚√§∑’ˇ°‘¥®“°§«“¡‡ ◊ËÕ¡¢ÕßÕ«—¬«–·≈–‚√§‡√◊ÈÕ√—ß µà“ßÊ

Ú) §«“¡ “¡“√∂„π°“√∑”Àπâ “ ∑’Ë ¢ Õß√à “ ß°“(physical functioning perspective) ´÷Ëß Rowe ·≈– KahnÒÒ ‰¥â𑬓¡‰«â«à“ ‡ªìπ°“√√—°…“‰«â´÷Ëߧ«“¡ “¡“√∂ ∑“ß°“¬„π°“√∑”Àπâ“∑’˵à“ßÊ ∑’Ë®”‡ªìπµàÕ°“√¥”√ß™’«‘µ À√◊Õµ“¡∑’˧“¥À«—ß ‰¡à«à“∫ÿ§§≈π—ÈπÊ ®–¡’‚√§À√◊Õ‰¡à°Áµ“¡ °“√∑’Ë√à“ß°“¬∫“ß à«π Ÿ≠‡ ’¬Àπâ“∑’ˉª¬àÕ¡∑”„Àâ∫ÿ§§≈‰¡à “¡“√∂¥”√ß™’«‘µ‰¥âµ“¡ª√°µ‘ ÿ¢ ‡™àπ ‰¡à “¡“√∂‡¥‘π‰¥â À√◊Õ·¢π¢“‰¡à¡’·√ß ´÷Ëߧ«“¡‡ ◊ËÕ¡¢Õß√à“ß°“¬π’ȇªìπªí≠À“ ∑’Ë√⓬·√ß ”À√—∫ºŸâ ŸßÕ“¬ÿ ‡æ√“–¡’‚Õ°“ ∑”„À⇰‘¥ªí≠À“ ÿ¢¿“æÕ◊ËπÊ µ“¡¡“‰¥â ‘Ëß∑’Ë„™âª√–‡¡‘π ¡√√∂¿“æ∑“ß°“‰¥â·°à °“√ªØ‘∫—µ‘°‘®«—µ√ª√–®”«—π (Activities of Daily Living: ADLûs)ÒÚ ´÷Ëßπ‘¬¡«—¥®“°§«“¡ “¡“√∂„π°“√∑” °‘®«—µ√ª√–®”«—π¥â«¬µ—«ºŸâ ŸßÕ“¬ÿ‡Õß ‡™àπ ·ª√ßøíπ Õ“∫πÈ” ·µàßµ—« °‘π¢â“« ¢—∫∂à“¬ ¢÷Èπ∫—π‰¥ ‡ªìπµâπ Û) §«“¡ “¡“√∂„π°“√√—∫√Ÿâ (cognitive functioning perspective) Hansen-KyleÒÛ ‡ πÕ«à“°“√¡’ ÿ¢¿“æ∑’Ë¥’¢ÕߺŸâ ŸßÕ“¬ÿπ—Èπ§«√¡’§«“¡ “¡“√∂„π°“√√Ÿâ§‘¥ (cognitive function) ∑’ˇ°’ˬ«¢âÕß°—∫§«“¡®” §«“¡§‘¥ “¡“√∂ ◊ËÕ “√‚µâµÕ∫‰¥â‡¢â“„® ∑”„Àâ “¡“√∂¥”‡π‘π™’«‘µ‰¥â ¥â«¬µ—«‡ÕßÕ¬à“ß¡’§ÿ≥¿“æ ‡æ√“–°“√√—∫√Ÿâ¡’§«“¡ ”§—≠‰¡à¬‘Ëß À¬àÕπ‰ª°«à“ ¡√√∂¿“æ∑“ß°“¬∑’®Ë –™à«¬„À⺠Ÿâ ߟ Õ“¬ÿ¡ ’ ¢ÿ ¿“æ ¥’ πÕ°®“°π’ȧ«“¡ “¡“√∂„π°“√√—∫√Ÿâ¬—ß —¡æ—π∏å°—∫ªí®®—Õ◊ËπÊ Õ—π‰¥â·°à √“¬‰¥â ·≈–Õ“™’æ¢ÕߺŸâ ŸßÕ“¬ÿ ´÷Ëß™à«à߇ √‘¡„À⺟⠟ßÕ“¬ÿ¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’ °“√»÷°…“¢Õß Sterm ·≈– CarstensenÒÙ ¬◊π¬—π«à“ —ߧ¡·≈–«—≤π∏√√¡∑’·Ë «¥≈âÕ¡ µ—«ºŸâ ŸßÕ“¬ÿ‡ªìπ‡°√“–ªÑÕß°—π∑’Ë¥’ ∑’˙૬„À⧫“¡ “¡“√∂„π °“√√—∫√Ÿ‰â ¡à‡ ◊ÕË ¡≈߇√Á« ‡π◊ÕË ß®“°ºŸ â ߟ Õ“¬ÿ‰¥â¡‚’ Õ°“ ªØ‘ ¡— æ—π∏å °—∫ºŸÕâ π◊Ë „π —ߧ¡ ∑”„À⇰‘¥°“√‡√’¬π√Ÿâ ·≈–µ◊πË µ—«Õ¬Ÿµà ≈Õ¥‡«≈“ Ù) ¡ÿ¡¡Õߥâ“π°“√ª√—∫µ—« (adaptive perspective) ‡ªìπ¡ÿ¡¡Õߥâ“𧫓¡ “¡“√∂¢ÕߺŸ â ߟ Õ“¬ÿ„π°“√ª√—∫ µ—«µàÕ°“√‡ª≈’ˬπ·ª≈ß∑’ˇ°‘¥¢÷Èπ√Õ∫Ê µ—« ∑—Èß∑“ß —ߧ¡·≈– ‘Ëß·«¥≈âÕ¡ °“√ª√—∫µ—«π—∫‡ªìπ ‘Ëß ”§—≠ ”À√—∫ºŸâ ŸßÕ“¬ÿ„π °“√Õ¬Ÿà√à«¡°—∫§πµà“ß«—¬·≈– ‘Ëß·«¥≈âÕ¡∑’ˇª≈’Ë¬π‰ª ‡æ◊ËÕ ‰¡à„À⇰‘¥§«“¡¢—¥·¬âßÀ√◊Õ§«“¡‡§√’¬¥„π°“√¥”‡π‘π™’«‘µ °“√ª√—∫µ—«‰¥âÀ√◊Õ‰¡àπ—Èπ¬àÕ¡ àߺ≈°√–∑∫µàÕ ÿ¢¿“æ¢Õß ºŸâ ŸßÕ“¬ÿÒÒ ı) °“√∫√√≈ÿ®¥ÿ ¡ÿßà À¡“¬¢Õß™’«µ‘ (eudaimonic perspective) ‡°’ˬ«¢âÕß°—∫§«“¡√Ÿâ ÷°¢ÕߺŸâ ŸßÕ“¬ÿ„π‡√◊ËÕß §«“¡æ÷ßæÕ„®„π™’«‘µ §«“¡¿“§¿Ÿ¡‘„® §«“¡‡™◊ËÕ¡—Ëπ ·≈– §«“¡¡’§ÿ≥§à“ ´÷Ëߧ«“¡√Ÿâ ÷°µà“ßÊ ‡À≈à“π’È –∑âÕπ∂÷ß ÿ¢¿“æ ºŸâ ŸßÕ“¬ÿ‡™àπ°—πÒı

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

∫∑∫“∑¢Õß»“ π“µàÕ ÿ¢¿“æ ®“°°“√»÷°…“¢Õß Koenig (2000)Òˆ ∑’ˉ¥â∑” °“√∑∫∑«πß“π«‘®¬— ‡°’¬Ë «°—∫»“ π“·≈– ÿ¢¿“æ°«à“ Û, ‡√◊ËÕßæ∫«à“»“ π“¡’º≈µàÕ ÿ¢¿“æ∑—Èß∑“ߥâ“𰓬 ®‘µ ·≈– °“√„™â∫√‘°“√∑“ß°“√·æ∑¬åÕ¬à“ß™—¥‡®π πÕ°®“°π’È°“√ »÷°…“¢Õß Lee ·≈– Newbergˆ ‰¥â„Àâ¢âÕ —߇°µ«à“»“ π“ ¡’º≈µàÕ ÿ¢¿“æ∑—Èߥâ“π∫«°·≈–≈∫ (positive and negative effects of religions on health) ”À√—∫§«“¡ —¡æ—π∏å√–À«à“ß»“ π“·≈– ÿ¢¿“æπ—Èπ ®“°°“√√«∫√«¡ ‡Õ° “√æ∫«à“∫∑∫“∑¢Õß»“ π“∑’Ë¡’º≈µàÕ ÿ¢¿“扥â ∂Ÿ ° Õ∏‘∫“¬‰«âÀ≈“°À≈“¬·ßà¡ÿ¡¥—ßπ’È °“√√—∫√Ÿâ·≈–∑—»π–µàÕ ÿ¢¿“«– (perception/attitude to general well-being) »“ π“¡’º≈µàÕ§«“¡ π÷°§‘¥¢Õß∫ÿ§§≈„π‡√◊ËÕߧ«“¡æ÷ßæÕ„®„π™’«‘µ §π∑’Ëπ—∫∂◊Õ »“ π“µà“ß°—π¡’§«“¡‡ÀÁπ‡°’Ë¬«°—∫ ÿ¢¿“«–∑’˵à“ß°—π ∫“ß »“ π“ Õπ„Àâ¬Õ¡√—∫°—∫§«“¡‡ªìπ®√‘ß∑’ˇ°‘¥¢÷È𠇙à𠧫“¡ ‡ ◊ËÕ¡¢Õß√à“ß°“¬ §«“¡‡®Á∫ªÉ«¬ ·µà∫“ß»“ π“∑”„Àâ§π¡’ ∑—»π§µ‘∑’ˉ¡à¬Õ¡®”ππ·≈–欓¬“¡¥‘Èπ√πµàÕ Ÿâ ∑”„Àâ ¡’ Àπ∑“ߢÕß°“√‰ª Ÿà ÿ¢¿“«–∑’Ë¥’·µ°µà“ß°—πÒ˜,Ò¯ «‘∂’™’«‘µ·≈–惵‘°√√¡ (life style and behavior) À≈—°§” Õπ¢Õß»“ π“¡’º≈„π°“√™’Èπ”«‘∂’™’«‘µ¢Õß ∫ÿ§§≈ ‡π◊ËÕß®“°¡’ à«π„π°“√°”Àπ¥æƒµ‘°√√¡ ´÷ËßÀ≈“惵‘°√√¡ àߺ≈°√–∑∫‡™◊ËÕ¡‚¬ß¡“∂÷ß ÿ¢¿“æ„π∫—Èπª≈“™’«‘µ¥â«¬ ‡™àπ „π»“ π“æÿ∑∏·≈–Õ‘ ≈“¡¡’¢âÕÀâ“¡°“√¥◊Ë¡ ¢Õß¡÷π‡¡“Ò˘ ´÷ßË §«“¡¬÷¥¡—πË „πÀ≈—°§” Õπ¡’º≈µàÕ ÿ¢¿“æ ¢Õß∫ÿ§§≈ ∑”„Àâ™à«¬≈¥Õ—µ√“°“√‡®Á∫ªÉ«¬¥â«¬‚√§Õ—π‡π◊ËÕß ¡“®“°·Õ≈°ÕŒÕ≈åÀ√◊Õ “√‡ 浑¥Õ◊ËπÊ À√◊ՙ૬≈¥Õ—µ√“ ‡ ’ˬߵàÕ‚√§®“°°“√¡’‡æ» —¡æ—π∏å∑’ˉ¡à‡À¡“– ¡Ú À√◊Õ „π∫“ß»“ π“‡πâπ„π‡√◊ËÕߧ«“¡ –Õ“¥∫√‘ ÿ∑∏‘Ï¢Õß√à“ß°“°àÕπª√–°Õ∫æ‘∏’°√√¡ ∑”„À⇰‘¥æƒµ‘°√√¡°“√≈â“ß¡◊Õ ·≈– ™”√–≈â“ß√à“ß°“¬‡ªìπª√–®” ´÷ßË ‡ªìπ°“√ªÑÕß°—π‡™◊ÕÈ ‚√§µà“ßÊÚÒ „π∑“ß°≈—∫°—π»“ π“°Á¡’ à«π àߺ≈°√–∑∫µàÕ¿“«– ÿ¢¿“æ ‡™àπ‡¥’¬«°—π „π°√≥’∑’Ë∫ÿ§§≈¡’§«“¡√Ÿâ ÷°º‘¥ ∫“ª À√◊Õ‰¡à “¡“√∂ªØ‘ ∫— µ‘ µ— «„Àâ ‡ À¡“– ¡µ“¡§” Õπ¢Õß»“ π“ (negative religious coping) °àÕ„À⇰‘¥§«“¡‡§√’¬¥ ·≈–°√–∑∫µàÕ ÿ¢¿“殑µÚÚ,ÚÛ °“√®—¥°“√°—∫ªí≠À“ ÿ¢¿“æ (coping with health problems) »“ 𓉥â∂°Ÿ π”¡“„™â„π°“√®—¥°“√ªí≠À“ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ‡æ‘Ë¡¡“°¢÷Èπ ‡π◊ËÕß®“°‡ªìπ«—¬∑’ËÕ«—¬«–

329

µà“ßÊ ‡ ◊ÕË ¡Àπâ“∑’≈Ë ß·≈–‡®Á∫ªÉ«¬¥â«¬‚√§‡√◊ÕÈ √—ß ŸßÚÙ ∫∑∫“∑ ¢Õß»“ π“‰¥â¡’°“√«‘®—¬®”π«π‰¡àπâÕ¬∑’ˬ◊π¬—π«à“¡’º≈µàÕ ÿ¢¿“æ∑—Èß∑“ß°“¬·≈–®‘µ„®Òˆ,Úı ®“°°“√∑∫∑«πß“π «‘®—¬®”π«π Ûı ‡√◊ËÕß ‚¥¬ Seeman ·≈–§≥–Úˆ æ∫«à“ °“√∑” ¡“∏‘ · ≈–‚¬§–¡’ § «“¡ — ¡ æ— π ∏å °— ∫ °“√≈¥≈ߢÕß √–¥—∫§Õ‡≈ ‡µÕ√Õ≈·≈–ŒÕ√å‚¡π∑’Ë∑”„À⇰‘¥§«“¡‡§√’¬¥ πÕ°®“°π’Ȭ—ßæ∫«à“°“√ªØ‘∫—µ‘»“ π°‘®∑—Èß„π»“ π“§√‘ µå ·≈–»“ π“„π‚≈°µ–«—πÕÕ° (æÿ∑∏·≈–Õ‘ ≈“¡) ¬—ß —¡æ—π∏å °—∫°“√≈¥≈ߢÕߧ«“¡¥—π‚≈À‘µ·≈–™à«¬„Àâ√–∫∫¿Ÿ¡‘§ÿâ¡°—π ¢Õß√à“ß°“¬¥’¢÷Èπ¥â«¬ πÕ°®“°ªí≠À“ ÿ¢¿“æ∑“ß°“¬·≈â« »“ 𓬗 ß ¡’ à « 𠔧— ≠ µà Õ ÿ ¢ ¿“殑 µ Õ¬à “ß¡“° ®“°°“√ «‘‡§√“–ÀåÕ¿‘¡“πß“π«‘®—¬®”π«π Ù˘ ‡√◊ËÕß‚¥¬ Ano ·≈– VasconcellesÚı æ∫«à“°“√∑”°‘®°√√¡∑“ß»“ π“ ‡™àπ °“√ ‰ª‚∫ ∂å «¥¡πµå ™à«¬≈¥§«“¡‡§√’¬¥ §«“¡«‘µ°°—ß«≈ ·≈– Õ“°“√´÷¡‡»√â“ πÕ°®“°π’È°“√‡¢â“√à«¡°‘®°√√¡∑“ß»“ π“¬—ß „™â‡ªìπ¥—™π’™’È«—¥°“√‡¢â“ —ߧ¡ (social engagement) ¢ÕߺŸâ ŸßÕ“¬ÿÚ˜ ´÷Ëß¡’º≈∑“ßÕâÕ¡µàÕ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ‡π◊ËÕß®“°°“√‡¢â“°≈ÿà¡∑“ß —ߧ¡π’È∑”„À⇰‘¥§«“¡ºŸ°æ—π∑“ß —ߧ¡ (social tie) Õ—ππ”¡“´÷Ëß°“√™à«¬‡À≈◊Õ´÷Ëß°—π·≈–°—π ∑—Èß∑“ß°“¬·≈–®‘µ„® (support) ·≈–∑”„À⺟⠟ßÕ“¬ÿ¬—ß√Ÿâ ÷° «à“‡ªìπ à«πÀπ÷ËߢÕß —ߧ¡ (a sense of connectedness) ‰¡à√Ÿâ ÷°‚¥¥‡¥’ˬ«À√◊ÕÀ¥ÀŸà ™à«¬„Àâ “¡“√∂®—¥°“√°—∫§«“¡ ‡§√’¬¥À√◊Õ§«“¡«‘µ°°—ß«≈∑’ˇ°‘¥¢÷Èπ‰¥âÚ¯ °“√®—¥°“√∑“ß —ߧ¡°—∫ ÿ¢¿“溟 â ߟ Õ“¬ÿ (social organization and aging health) °≈ÿà¡»“ π“¡’°“√ ®—¥°“√∑“ß —ߧ¡µ“¡À≈—°°“√∑“ß»“ π“∑’ˇÕ◊ÈÕµàÕ ÿ¢¿“æ ¢ÕߺŸâ ŸßÕ“¬ÿ ‡™àπ °≈ÿà¡ »“ π“„π‚∫ ∂å ‚ √¡— 𠧓∑Õ≈‘ ° „Àâ°“√Õÿ¥Àπÿπ°‘®°√√¡ à߇ √‘¡ ÿ¢¿“淰ຟ⠟ßÕ“¬ÿ (°“√«—¥ §«“¡¥—π‚≈À‘µ ·≈–®—¥Õ“À“√ ÿ¢¿“æ ‡ªìπµâπ)Ú˘ À√◊Õ °≈ÿà¡™“«¡ÿ ≈‘¡¡’√–∫∫ ç´–°“µé ´÷Ë߇ªìπ√–∫∫ «— ¥‘°“√ ∑“ß»“ π“Õ¬à“ßÀπ÷Ëß∑’˙૬‡À≈◊Õ¥Ÿ·≈ºŸâ ŸßÕ“¬ÿ∑’ˉ¡à¡’ºŸâ¥Ÿ·≈ À√◊Õ¬“°®πÛ „π∑“ß°≈—∫°—𻓠𓇪ìπ ‘ßË ∑’™Ë «à ¬„À⺠Ÿâ ߟ Õ“¬ÿ ‰¥â √â“ߧÿ≥Ÿª°“√§◊π°≈—∫„Àâ·°à —ß§¡ ‚¥¬ Kark ·≈–§≥–ÛÒ æ∫«à“»“ 𓇪ìπ‡§√◊ËÕß°≈àÕ¡‡°≈“„À⺟â∑’ˬ÷¥¡—Ëπ„π»“ π“¡’ §«“¡‡ªìπ¡‘µ√ ¡Õß‚≈°„π·ß॒ ¡’®‘µÕ“ “™à«¬‡À≈◊Õ —ߧ¡ ‘ßË ‡À≈à“π’ È ßà º≈°≈—∫¥â“π∫«°µàÕ ÿ¢¿“殑µ¢ÕߺŸ â ߟ Õ“¬ÿ ‚¥∑”„À⺟⠟ßÕ“¬ÿ‰¥â¡’‚Õ°“ ªØ‘ —ߧ¡°—∫ºŸâÕ◊Ëπ ‡°‘¥§«“¡¿“§ ¿Ÿ¡‘„®®“°°“√™à«¬‡À≈◊Õ à«π√«¡ ·≈–√Ÿâ ÷°¡’§ÿ≥§à“„πµ—«‡Õß

330 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

°√≥’ µ— « Õ¬à “ ß: ∫∑∫“∑¢Õß»“ π“Õ‘ ≈“¡∑’Ë ‡ Õ◊È Õ µà Õ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ™“«¡ÿ ≈‘¡ ®“°°“√√«∫√«¡‡Õ° “√ß“π«‘®—¬∑’Ë®—¥∑”‚¥¬π—° «‘™“°“√Õ‘ ≈“¡·≈–Àπ૬ߓπµà“ßÊÛÚ,ÛÛ æ∫«à“§” Õπ ¢Õß»“ π“Õ‘ ≈“¡À≈“¬ª√–°“√∑’ˇÕ◊ÈÕµàÕ°“√¡’ ÿ¢¿“æ∑’Ë¥’ ¢ÕߺŸ â ߟ Õ“¬ÿ™“«¡ÿ ≈‘¡∑—ßÈ „π√–¥—∫∫ÿ§§≈ §√Õ∫§√—«·≈–™ÿ¡™π °≈à“«§◊ÕπÕ°®“°§” Õπ¢Õß»“ π“®–¡’º≈µàÕ°“√ªØ‘∫—µ‘ µ—«¢ÕߺŸâ ŸßÕ“¬ÿ‡Õß·≈â« ¬—ߧ√Õ∫§≈ÿ¡‰ª∂÷ß°“√ªØ‘∫—µ‘¢Õß §√Õ∫§√—«·≈–™ÿ¡™π∑’Ëæ÷ß¡’µàÕºŸâ ŸßÕ“¬ÿ¥â«¬ „π√–¥—∫∫ÿ§§≈ π—πÈ »“ 𓉥â Õπ«à“ ÿ¢¿“æ¢Õß·µà≈–§π∂◊Õ‡ªìπ çÕ–¡“π–Àåé À√◊Õ§«“¡√—∫º‘¥™Õ∫∑’Ë®–µâÕߥŸ·≈ ¡’°“√√–∫ÿ‡°’ˬ«°—∫‡√◊ËÕß Õπ“¡—¬ à«π∫ÿ§§≈ ‚¥¬‡©æ“–§«“¡ –Õ“¥∑’Ë∂◊Õ‡ªìπ√“°∞“π ¢Õߧ«“¡»√—∑∏“„π»“ π“Õ‘ ≈“¡ ‡æ√“–‡ªìπ‡ß◊ËÕπ‰¢·√° „π°“√∑”Õ‘∫“¥–ÀåµàÕÕߧåÕ—≈‡≈“–Àå (°“√∑”§«“¡ –Õ“¥ √à“ß°“¬°àÕπ≈–À¡“¥) πÕ°®“°π’Ȭ—ß√–∫ÿ∂÷ß°“√„ÀâÀ≈’°‡≈’Ë¬ß ‘Ë߇ 浑¥µà“ßÊ ‚¥¬‡©æ“– ÿ√“ ∑’ˇª√’¬∫‡ ¡◊Õπ‡Àß◊ËÕÀ√◊Õ πÈ”¢Õß™“«π√° à«π‡√◊ËÕßÕ“À“√‰¥â°”Àπ¥„ÀâÕ‘ ≈“¡‘°™π √—∫ª√–∑“πÕ“À“√∑’ˇªìπŒ“≈“≈ ( –Õ“¥·≈–‰¥â √— ∫ Õπÿ ¡— µ‘ ®“°ÕߧåÕ—≈‡≈“–Àå) ·≈–µÕ¬¬’∫—π (¡’ª√–‚¬™πåµàÕ√à“ß°“ª√“»®“°π–≠‘ À√◊Õ ‘Ëß‚ ‚§√°µà“ßÊ) ”À√—∫°“√¥Ÿ·≈ ¥â“π ÿ¢¿“殑µπ—È𧫓¡¬÷¥¡—Ëπ„π»“ π“°Á‡ªìπ·π«∑“ßÀπ÷Ëß „π°“√√—°…“ ÿ¢¿“殑µ ‡™àπ °“√∑”≈–À¡“¥ ∑”∑“π À¡—Ëπ ¢Õæ√®“°ÕߧåÕ—≈‡≈“–Àå ‰¡à查®“À¬“∫§“¬À√◊Õ¥à“∑Õ ‰¡à ∑”º‘¥ª√–‡«≥’ ·≈– √â“ߧ«“¡‡¥◊Õ¥√âÕπ„ÀⷰຟâÕ◊ËπÛÙ ”À√—∫∫∑∫“∑¢Õߧ√Õ∫§√—«µàÕ°“√¥Ÿ·≈ºŸâ ŸßÕ“¬ÿ π—Èπ »“ π“Õ‘ ≈“¡√–∫ÿ‡Õ“‰«â™—¥‡®πÛÙ ´÷Ë߇ªìπÀ≈—°§” Õπ ∑’§Ë ≈⓬§≈÷ß°—∫»“ π“Õ◊πË Ê ∑’ Ë Õπ„Àâ≈°Ÿ °µ—≠ꟷ≈–µÕ∫·∑π §ÿ≥∫ÿæ°“√’Ûı ¥—߇™àπ „Àâ≈Ÿ°‡§“√æ·≈–∑”¥’µàÕæàÕ·¡à ‡¡◊ËÕ æàÕ·≈–·¡à‡¢â“ Ÿà«—¬™√“µâÕß„Àâ°“√¥Ÿ·≈¥â«¬§«“¡πÕ∫πâÕ¡ ÕàÕπ‚¬π ‰¡à∑”„ÀâæàÕ·¡à¢ÿàπ‡§◊Õß„® ·≈– Õπ„Àâ‡ÀÁπ«à“∫“ª ∑’ˬ‘Ëß„À≠à§◊Õ °“√Õ°µ—≠ꟵàÕæàÕ·¡à ·≈–‡ªìπ∫“ª∑’Ë “¡“√∂ ‡∑’¬∫‡§’¬ß‰¥â°—∫°“√¬° ‘ËßÕ◊Ëπ‡∑’¬∫‡§’¬ßÕ—≈‡≈“–Àå ·≈–°“√ ¶à“§π ‡ªìπµâπÛÚ „π —ߧ¡¡ÿ ≈‘¡»“ 𓇪ìπ·°àπ°≈“ß∑’ËÀ≈àÕÀ≈Õ¡ „Àâ§π„π«—≤π∏√√¡¡ÿ ≈‘¡‡Õ◊ÈÕÕ“∑√·≈–¥Ÿ·≈´÷Ëß°—π·≈–°—π ‚¥¬‡©æ“–°—∫ºŸâ ŸßÕ“¬ÿ´÷Ëß∂◊Õ«à“‡ªìπ∫ÿ§§≈∑’ËÕàÕπ·Õ ¡’§«“¡ “¡“√∂·≈–‚Õ°“ Õ—π®”°—¥ ¡§«√∑’Ë®–‰¥â√—∫°“√¥Ÿ·≈·≈– „À⧫“¡ ”§—≠¡“°°«à“ºŸÕâ π◊Ë §” Õπµà“ßÊ ¢Õß»“ π“Õ‘ ≈“¡ Õπ„À♓«¡ÿ ≈‘¡™à«¬‡À≈◊Õ‡Õ◊ÈÕ‡øóôÕ ª≈¥‡ª≈◊ÈÕߧ«“¡∑ÿ°¢å ¬“°¢Õ߇æ◊ËÕπ ¡“™‘° √â“ß∫√√¬“°“»∑’Ë “¡“√∂∑”„À⇰‘¥ §«“¡ ÿ¢·≈–§«“¡ —¡æ—π∏å∑’Ë¥’µàÕ°—π §π„π§√Õ∫§√—«∑’˵âÕß ¥Ÿ·≈ºŸâ ŸßÕ“¬ÿ∂◊Õ‡ªìπÀπâ“∑’ˇ©æ“– à«π™ÿ¡™π°ÁµâÕß„Àâ°“√

¥Ÿ·≈ºŸ â ߟ Õ“¬ÿ‡™àπ‡¥’¬«°—π·≈–∂◊Õ«à“‡ªìπÀπâ“∑’‡Ë ™‘ß —ߧ¡ À“° ≈–‡≈¬®–∂Ÿ° Õ∫ «π®“°ÕߧåÕ—≈‡≈“–Àå º≈∫“ª®–µ°Õ¬Ÿà °—∫∑ÿ°§π„π™ÿ¡™π∑’Ë≈–‡«âπ¿“√–‡™‘ß —ߧ¡ÛÙ

º≈°√–∑∫¢Õß»“ π“∑’Ë¡’µàÕ ÿ¢¿“æ ®“°°“√√«∫√«¡º≈ß“π«‘®—¬∑’ˇ°’ˬ«¢âÕß°—∫»“ π“ ·≈– ÿ¢¿“ææ∫«à“ ¡’√“¬ß“π∑’Ëæ∫º≈„π¥â“π∫«°¡“°°«à“ ¥â“π≈∫ Õ“∑‘ß“π«‘®—¬∑’Ëæ∫«à“»“ π“¡’§«“¡ —¡æ—π∏å°—∫°“√ ≈¥≈ߢÕßÕ—µ√“µ“¬ ‚¥¬°“√»÷°…“¢Õß Helm ·≈–§≥–Ûˆ æ∫«à“ °“√∑”°‘®°√√¡∑“ß»“ π“„πºŸ â ߟ Õ“¬ÿ ‡™àπ °“√‰ª‚∫ ∂å «¥¡πµå ¡’§«“¡ —¡æ—π∏å°—∫Õ“¬ÿ§“¥‡©≈’ˬ∑’ˇæ‘Ë¡¢÷Èπ À√◊Õ ®“°°“√»÷°…“¢Õß Van Ness, Kasl ·≈– JonesÛ˜ ∑’Ëæ∫«à“ºŸâÀ≠‘ß·Õø√‘°—πÕ‡¡√‘°—π∑’˪ɫ¬‡ªìπ¡–‡√Á߇µâ“π¡·µà ‰¡à‰¥âæ÷Ëßæ‘ß»“ π“¡“°π—°¡—°¡’™’«‘µ√Õ¥®“°‚√§π’ȉ¥â‰¡àπ“π πÕ°®“°π’È»“ π“¬—ß¡’ à«π„π°“√™à«¬≈¥·≈–ªÑÕß°—π°“√ ‡®Á∫ªÉ«¬¥â«¬‚√§µà“ßÊ ‡™à𠧫“¡¥—π‚≈À‘µ ŸßÛ¯ §«“¡ ®”‡ ◊ÕË ¡Û˘ ‡ªìπµâπ °“√¬÷¥¡—πË „π»“ π“¬—ß¡’º≈µàÕ惵‘°√√¡ ¢Õß∫ÿ§§≈´÷Ëߙ૬ªÑÕß°—π‰¡à„À⇰‘¥‚√§·≈–§«“¡‡®Á∫ªÉ«¬¢÷È𠇙àπ °“√„™â “√‡ 浑¥Ù ¥◊Ë¡‡À≈â“ Ÿ∫∫ÿÀ√’ËÙÒ ·≈–°“√ ÕÕ°°”≈—ß°“¬ÙÚ πÕ°®“°π’ºÈ ≈¢Õß»“ π“∑’æË ∫√“¬ß“π¡“° ∑’Ë ÿ¥ §◊Õ º≈∑“ߥâ“π ÿ¢¿“殑µ ´÷Ëß¡’ß“π«‘®—¬®”π«π¡“° ¬◊π¬—π«à“°“√ «¥¡πµå ∑”°‘®°√√¡∑“ß»“ π“™à«¬≈¥§«“¡ ‡§√’¬¥ «‘µ°°—ß«≈ ¡’º≈∑“ߥâ“π∫«°µàÕ ÿ¢¿“殑µÙÛ,ÙÙ,Ùı à«πº≈„π∑“ß≈∫π—Èπ¡’√“¬ß“π°“√»÷°…“‰¡à¡“°π—° „π®”π«ππ’È°“√»÷°…“¢Õß Neal ·≈– BastidaÙˆ æ∫«à“¡’ ºŸ â ߟ Õ“¬ÿ™“«·Õø√‘°π— Õ‡¡√‘°π— ∫“ß°≈ÿ¡à ∑’‡Ë °Á∫ß”§«“¡‡®Á∫ª«¥ À√◊ Õ ∑πµà Õ §«“¡‰¡à ∫“¬„®‚¥¬‰¡à ∫ Õ°À√◊ Õ ¢Õ§«“¡™à « ‡À≈◊Õ®“°§√Õ∫§√—«À√◊Õ‡æ◊ËÕπ ‡æ√“–‡™◊ËÕ«à“§«“¡‡®Á∫ª«¥ À√◊Õ§«“¡∑ÿ°¢å„®‡À≈à“π—Èπ‡ªìπ‡§√“–Àå°√√¡À√◊Õ∫“ª §«√ √—∫¡◊Õ°—∫ ‘Ëß∑’ˇ°‘¥¢÷ÈπÕ¬à“ß ß∫ ´÷ËßÕ“®∑”„Àâ ‡ °‘ ¥ §«“¡ ‡§√’¬¥À√◊Õ‰¡à‰¥â√—∫°“√™à«¬‡À≈◊Õ∑’ˇÀ¡“– ¡ À√◊Õ°“√»÷°…“ ∑’Ëæ∫«à“¢âÕÀâ“¡µ“¡§” Õπ∑“ß»“ π“∫“ßÕ¬à“ßÕ“® √â“ß µ√“∫“ª (stigma) „Àâ°—∫‚√§∫“ß‚√§ ‡™àπ ‚√§µ‘¥‡™◊ÈÕ∑“ß ‡æ» —¡æ—π∏å ‡Õ¥ å ´÷Ëß¡’º≈„À⺟âªÉ«¬‰¡à “¡“√∂· «ßÀ“°“√ √—°…“∑’‡Ë À¡“– ¡Ù˜ πÕ°®“°π’»È “ π“Õ“® àߺ≈µàÕ ÿ¢¿“æ „π∑“ßÕâÕ¡ µ“¡·π«§‘¥¢Õß·Õπ‡¥Õ√å —πÙ¯ ∑’ˇ πÕ ¡¡µ‘∞“π«à“ °≈ÿࡧπ∑’ˉ¡à‰¥âπ—∫∂◊Õ»“ π“À≈—°¢Õß —ߧ¡ π—ÈπÊ Õ“®∂Ÿ°·¬°ÕÕ°®“°§π°≈ÿà¡„À≠à (social isolation) ´÷ËßÀ¡“¬∂÷ßÕ“®∑”„Àâ‰¡à‰¥â√—∫‚Õ°“ Õ¬à“߇∑à“‡∑’¬¡°—∫§π °≈ÿà¡„À≠à„π°“√‡¢â“∂÷ß∫√‘°“√ ÿ¢¿“æ ·≈–‚Õ°“ µà“ßÊ ∑’Ë ‡Õ◊ÈÕµàÕ°“√¡’ ÿ¢¿“楒

331

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

∑ƒ…Æ’‡°’ˬ«°—∫ºŸâ ŸßÕ“¬ÿ·≈–»“ π“ (Gerontology Theory and Religion) „π°“√«‘ ®— ¬ ‡æ◊Ë Õ »÷ ° …“Õ‘ ∑ ∏‘ æ ≈¢Õß»“ π“∑’Ë ¡’ µà Õ ÿ¢¿“æ¢ÕߺŸ â ߟ Õ“¬ÿππ—È ¡’À≈“¬∑ƒ…Æ’∑‡’Ë ™◊ÕË ¡‚¬ß∫√‘∫∑µà“ßÊ Õ—π‡ªìπ«—≤π∏√√¡∑’Ë¡’º≈µàÕ«‘∂’™’«‘µ·≈– ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ „π∫∑§«“¡π’È𔇠πÕ∑ƒ…Æ’∑’ˉ¥â√—∫°“√查∂÷ß„π°“√»÷°…“ ‡°’¬Ë «°—∫ºŸ â ߟ Õ“¬ÿÕ¬à“ß°«â“ߢ«“ß Õß∑ƒ…Æ’ ‚¥¬°“√𔇠πÕ ‡πâ π‰ª∑’Ë°“√ª√–¬ÿ°µå∑ƒ…Æ’¥—ß°≈à“«„π°“√»÷°…“∫∑∫“∑ ¢Õß»“ π“µàÕ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ

Disengagement theoryÙ˘ ‡ªì π ∑ƒ…Æ’ ∑’Ë §‘ ¥ §â π‚¥¬π—°‚§√ß √â “ ßÀπâ “ ∑’Ë π‘ ¬ ¡ Cumming ·≈– Henry „π∑»«√√… Ò˘ˆı ´÷Ëß¡Õß«à“ ∫ÿ§§≈®–∂Ÿ°≈¥∫∑∫“∑À√◊ÕµâÕߺàÕß∂à“¬Àπâ“∑’Ë∑“ß —ߧ¡≈ß ‡π◊ËÕß®“°°“√‡¢â“ Ÿà«—¬™√“ ´÷Ëß°“√∑’Ë∫ÿ§§≈µâÕߪ≈¥ª≈àÕ∫∑∫“∑Àπâ“∑’˵à“ßÊ π—Èπ ‡°‘¥¢÷ÈπÕ¬à“߇ªìπ≈”¥—∫¢—Èπµ“¡Õ“¬ÿ ∑’ˇæ‘Ë¡¢÷Èπ (aging process) ∑—Èßπ’ȇπ◊ËÕß®“°∫ÿ§§≈®–µâÕß √—°…“ ¡¥ÿ≈„π°“√¥”√ß™’«‘µ∑’Ë®–µâÕß°â“«‰ª Ÿà«“√– ÿ¥∑â“¢Õß™’«‘µ (lifeûs final stage) µ“¡·π«§‘¥∑ƒ…Æ’π’ȇ¡◊ËÕ ª√–¬ÿ°µå‡¢â“°—∫ª√–‡¥Áπ‡√◊ËÕß»“ π“„π·ßà∑’ˇªìπ à«πÀπ÷ËߢÕß «—≤π∏√√¡∑’ËÀ≈àÕÀ≈Õ¡«‘∂’™’«‘µ¢Õß∫ÿ§§≈ ®–∑”„Àâ¡Õß °√–∫«π°“√ª≈àÕ¬«“ߢÕߺŸâ ŸßÕ“¬ÿ∑’Ë¡’ “√–¢Õß¿Ÿ¡‘À≈—ß∑“ß «—≤π∏√√¡‡¢â“¡“‡°’ˬ«¢âÕß ‡™àπ - »“ π“¡’∫∑∫“∑„π°“√ª≈¥ª≈àÕ¬∫∑∫“∑À√◊Õ Àπâ“∑’Ë„π°“√¥”‡π‘π™’«‘µºŸâ ŸßÕ“¬ÿÕ¬à“߉√ ·≈–ºŸâ ŸßÕ“¬ÿ„π ™à«ßÕ“¬ÿ‡¥’¬«°—π·µàπ—∫∂◊Õ»“ π“µà“ß°—π À√◊Õ¡’¿Ÿ¡‘À≈—ß∑“ß «—≤π∏√√¡∑’˵à“ß°—π¡’°“√ª≈¥ª≈àÕ¬∫∑∫“∑‡À≈à“π—Èπµà“ß°—π À√◊Õ‰¡à ·≈–¡’√Ÿª·∫∫‡ªìπÕ¬à“߉√ - ·≈–°“√ª≈¥ª≈àÕ¬¥—ß°≈à“«¡’Õ∑‘ ∏‘æ≈¢Õß»“ π“ ‡¢â“¡“¡’ à«π„π°“√‡ª≈’ˬπ·ª≈ßπ’ȥ⫬À√◊Õ‰¡à - πÕ°®“°π’È°“√ª≈àÕ¬«“ߢÕߺŸâ ŸßÕ“¬ÿ∑’ˇ°‘¥¢÷È𠉥â≈–«“ߧà“π‘¬¡ À√◊Õ·π«ª√–惵‘ªØ‘∫—µ‘∑’ˇªìπ∏√√¡‡π’¬¡ ªØ‘∫—µ‘¢Õß»“ 𓉪¥â«¬À√◊Õ‰¡à ·π«§‘¥π’È “¡“√∂π”¡“„™â„π°“√«‘‡§√“–Àå∫∑∫“∑ Àπâ“∑’Ë∑’˺Ÿâ ŸßÕ“¬ÿ‡§¬∑” ·≈–‡¡◊ËÕ‡¢â“ Ÿà«—¬™√“¡’∫∑∫“∑„¥∫â“ß ∑’˵âÕߪ≈àÕ¬«“ß≈ßµ“¡«—¬ ‡¡◊ËÕ„¥ Õ¬à“߉√ ·≈–°“√ª≈àÕ¬«“ß π’ È ßà º≈¥â“π∫«°À√◊Õ≈∫µàÕ¿“«– ÿ¢¿“æ·≈–°“√¥Ÿ·≈ ÿ¢¿“æ ¢ÕߺŸâ ŸßÕ“¬ÿ ´÷Ëß∫∑∫“∑Àπâ“∑’˵à“ßÊ ‡™◊ËÕ«à“ à«πÀπ÷Ëß∂Ÿ° °”À𥂥¬«—≤π∏√√¡∑“ß»“ π“

Continuity theoryıÒ ∑ƒ…Æ’§«“¡µàÕ‡π◊ËÕ߇ªìπ∑ƒ…Æ’∑’Ë¡’§«“¡¬◊¥À¬ÿàπ ‡Õ◊ÈÕµàÕ°“√»÷°…“ºŸâ ŸßÕ“¬ÿ∑’Ë¡’«‘∂’™’«‘µ∑’Ë·µ°µà“ß°—π·≈–‡πâ𠧫“¡µàÕ‡π◊ËÕß ‚¥¬‰¡à¡ÿàß»÷°…“µ—¥µÕπ‡©æ“–‡¡◊ËÕ∫ÿ§§≈‡¢â“ Ÿà«—¬ ŸßÕ“¬ÿ·≈⫇∑à“π—Èπ ‡æ√“–‡ªìπ°“√µ—¥‡Õ“™à«ß™’«‘µ∑’˺à“π ¡“¢ÕߺŸâ ŸßÕ“¬ÿÕÕ°‰ª ·π«§‘¥π’ȉ¡à‰¥â¡Õß·∫∫·¬° à«π ‡™◊ËÕ«à“™à«ß«—¬„π™’«‘µ∑’˺à“π¡“¡’ à«π§«“¡ ”§—≠·≈– àߺ≈ µàÕ‡π◊ËÕß¡“®π∂÷ß«—¬ ŸßÕ“¬ÿ ∑ƒ…Æ’π’È®÷ß„™â»÷°…“惵‘°√√¡∑’Ë ºà“π¡“µ≈Õ¥∑—Èß™à«ß™’«‘µ¢ÕߺŸâ ŸßÕ“¬ÿ (a life course perspective) ‡™◊ÕË «à“ºŸ â ߟ Õ“¬ÿ¬ß— §ß¥”√߉«â´ß÷Ë °‘®°√√¡ 惵‘°√√¡ ∫ÿ§≈‘°¿“æ µ≈Õ¥®π§«“¡ —¡æ—π∏åµà“ßÊ ∑’ˇ§¬‰¥â∑”¡“°àÕπ Àπâ“π’È ·≈–¬—ߧß欓¬“¡∑’Ë®–¥”√ß«‘∂’ªØ‘∫—µ‘¥—ß°≈à“«‡¡◊ËÕ ºà“π‡¢â“ Ÿà«—¬ ŸßÕ“¬ÿ¥â«¬ ´÷Ëß¡’ªí®®—¬∑—Èß¿“¬„π·≈–¿“¬πÕ° Õ—π‡°’Ë¬«‡π◊ËÕß¡“®“°°“√‡ªìπ ¡“™‘°¢Õß»“ π“∑’Ë “¡“√∂„™â Õ∏‘∫“¬§«“¡§‘¥·≈–惵‘°√√¡¢ÕߺŸâ ŸßÕ“¬ÿ ªí®®—¬¿“¬„π ª√–°Õ∫¥â«¬ ∫ÿ§≈‘°≈—°…≥– à«π∫ÿ§§≈ §«“¡§‘¥ §«“¡‡™◊ËÕ ´÷ßË ‡ªìπ ‘ßË ∑’‡Ë ™◊ÕË «à“®–§ßÕ¬Ÿ‰à ª®π™—«Ë ™’«µ‘ ·≈– ‘ßË ‡À≈à“π’®È –‡ªìπ æ◊Èπ∞“πµàÕ§«“¡§‘¥·≈–°“√ªØ‘∫—µ‘„π«—¬™√“¥â«¬ à«πªí®®—¿“¬πÕ° ‰¥â·°à §«“¡ —¡æ—π∏åµà“ßÊ (relationships) ·≈– ∫∑∫“∑∑“ß —ߧ¡¢ÕߺŸâ ŸßÕ“¬ÿ (social roles) ´÷Ëß¡’ à«π„π °“√°”Àπ¥°“√¥”‡π‘π™’«‘µ¢ÕߺŸâ ŸßÕ“¬ÿ‡™àπ°—πıÚ ‚≈°∑—»πå·≈–惵‘°√√¡°“√ªØ‘∫—µ‘∑’ˉ¥âª≈Ÿ°Ωíß¡“ ®“°«—≤π∏√√¡¢Õß°≈ÿà¡ ´÷Ë ß »“ π“°Á ‡ ªì π à « πÀπ÷Ë ß ¢Õß «—≤π∏√√¡∑’ËÀ≈àÕÀ≈Õ¡§π∑’ËÕ¬Ÿà¿“¬„µâ§«“¡‡™◊ËÕ¢Õß»“ π“ π—πÈ Ê ‰¥â ßà º≈·°à∫§ÿ §≈´÷ßË ‡ªìπ ¡“™‘°¢Õß°≈ÿ¡à µ—ßÈ ·µà«¬— ‡¥Á° «—¬√ÿàπ «—¬ºŸâ„À≠à ·≈–µàÕ‡π◊ËÕß¡“®π∂÷ß«—¬™√“ ‡™àπ «—≤π∏√√¡ °“√°‘πÕ“À“√¢Õß°≈ÿà¡ °“√¥◊Ë¡ ÿ√“ ‡À≈à“π’ȬàÕ¡ àߺ≈µàÕ ÿ¢¿“懡◊ËÕ‡¢â“ Ÿà«—¬ ŸßÕ“¬ÿ ‡ªìπµâπ

√ÿª ®“°‡Õ° “√·≈–ß“π«‘®—¬µà“ßÊ ∑’ˉ¥â√«∫√«¡π” ‡ πÕ„π∫∑§«“¡π’ȇÀÁπ‰¥â«à“ »“ π“¡’§«“¡‡°’ˬ«¢âÕß°—∫ ÿ¢¿“æ¢ÕߺŸâ ŸßÕ“¬ÿ ‚¥¬¡’Õ‘∑∏‘æ≈µàÕ√–∫∫§‘¥ °“√√—∫√Ÿâ ·≈–∑—»π–µàÕ ÿ¢¿“æ ´÷ßË ‡™◊ÕË ¡‚¬ß‰ª∂÷ß«‘∂™’ «’ µ‘ ·≈–惵‘°√√¡ ∑’ªË Ø‘∫µ— ‘ °“√¬÷¥¡—πË „π»“ π“ (subjective religiosity) ·≈– °“√∑”°‘®°√√¡∑“ß»“ π“æ∫«à“ à«π„À≠ࡺ’ ≈∫«°µàÕ ÿ¢¿“æ °“¬·≈–®‘µ„® °“√»÷°…“∫∑∫“∑¢Õß»“ π“®÷߇ªìπÕ’°¡‘µ‘ Àπ÷Ëß∑’Ë®–™à«¬°àÕ„À⇰‘¥Õߧ姫“¡√Ÿâ‡æ◊ËÕ𔉪‡ªìπ·π«∑“ß„π °“√¥Ÿ·≈ºŸâ ŸßÕ“¬ÿ„πª√–‡∑»∑’Ë¡’·π«‚π⡇æ‘Ë¡¡“°¢÷Èπ‡√◊ËÕ¬Ê „Àâ “¡“√∂¥”√ß™’ «‘ µ Õ¬Ÿà „ π — ß §¡‰¥â Õ ¬à “ ß¡’ §ÿ ≥ ¿“æ·≈–¡’ »—°¥‘Ï»√’

332 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

‡Õ° “√Õâ“ßÕ‘ß Ò. Li RM, Iadarola AC, Maisano CC, editors.

Why population aging matters? A Global perspective. National institute on aging and national institutes of health [online] 2007 [cited 26 May 2009]. Available from: URL: http://www.nia.nih.gov/NR/rdonlyres/9E91407ECFE8-4903-9875-D5AA75BD1D50/0/WPAM. pdf Ú. United Nations. World Population Aging 19502050. New York: United Nations Publications; 2002. Û. Levin J. How religion influences morbidity and health: reflections on natural history, salutogenesis and host resistance. Soc Sci Med 1996;43:845-64. Ù. Benjamins MR. Religion and functional Health among the elderly: Is there a relationship and is it constant? J Aging Health 2004;16:35574. ı. Koenig GH, George LK, Hays JC, Larson DB, Cohen HJ, Blazer DB. The relationship between religious activities and blood pressure in older adults. Int J Psychiatry Med 1998;28: 189-213. ˆ. Lee BY, Newberg B. Religion and Health: A review and critical analysis. Zygon 2005;40: 443-65. ˜. Kertzer DI. Political-Economic and Cultural Explanations of Demographic Behavior. In: Situating Fertility. Anthropology and Demographic Inquire, Greenhalgh S, editor, Cambridge, Cambridge University Press; 1995:29-52. ¯. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p.

100) and entered into force on 7 April 1948.

˘. ∂“∫—π‡«™»“ µ√废⠟ßÕ“¬ÿ °√–∑√«ß “∏“√≥ ÿ¢. °“√ ¥Ÿ·≈√—°…“‚√§ºŸ â ߟ Õ“¬ÿ·∫∫ À “¢“«‘™“. °√ÿ߇∑æœ: ™ÿ¡™π À°√≥å°“√‡°…µ√·Ààߪ√–‡∑»‰∑¬; ÚıÙ:ÛÒˆ. Ò. Gilford MD. Population in the twenty-first century: Statistics for Health Policy Washington, D.C.: National Academy Press; 1988. ÒÒ. Rowe JW, Kahn RL. Successful aging. The Gerontologist 1997;37:433-40. ÒÚ. Krapp K, editor. Activities of daily living evaluation. In çEncyclopedia of Nursing & Allied Healthé. Gale Group, Inc., 2002. [online] [cited 9 July 2010]. Available from: URL: http://www.enotes.com/nursing-encyclopedia/ activities-daily-living-evaluation ÒÛ. Hansen-Kyle L. A Concept analysis of healthy aging. Nurs Forum 2005:40:45-57. ÒÙ. Stern PC, Carstensen L L, editors. Aging mind: opportunities in cognitive research. Washington, D.C.: National Academy Press; 2000. Òı. Ryff CD. Know Thyself and Become What you are: A Eudaimonic Approach to Psychological Well-being. J Happiness Stud 2006; DOI 10.

1007/s 10902-006-9019-0. [online] [cited 10 July 2010]. Available from: URL: http://www. aging.wisc.edu/pdfs/16.pdf Òˆ. Koenig GH. How religious beliefs and practices are related to stress, health and medical Services. [online] [cited 17 February 2010].

Available from: URL: http://www.hoje.org.br/ site/arq/artigos/How _Religious_Beliefs_and_ Practices_Are_Related.pdf Ò˜. Bowker D. Pain and suffering-religious perspective. In: Encyclopedia of Bioethics, Reich WT, editor, New York: Free Press; 1978: 1185-9. Ò¯. Amundsen DW. Medicine and faith in early christianity. Bull Hist Med 1982;56:326-50. Ò˘. Lyttle T. Drug based religions and contemporary drug taking. J Drug Issues 1988;18: 271-84.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Ú. Miller L, Gur M. Religiousness and sexual responsibility in adolescent girls. J Adolesc Health 2002;31:401-6. ÚÒ. Condran GA, Ellen AK. Child mortality among Jewish immigrants to the United States. J Interdiscip Hist 1991;22:223-54. ÚÚ. Trenholm P, Trent J, Compton WC. Negative religious conflict as a predictor of panic disorder. J Clin Psychol 1998;54:59-65. ÚÛ. Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious struggle as a predictor of mortality among medically ill elderly patients: A 2-Year Longitudinal Study Arch Intern Med 2001;161:1881-5. ÚÙ. Princeton Religion Research Center. Importance of religion climbing again. PRRC Emerging Trends 1994;16:1-4. Úı. Ano GG, Vasconcelles EB. Religious coping and psychological adjustment to stress: a metaanalysis. J Clin Psychol 2005;61:461-80. Úˆ. Seeman TE, Dubin LF, Seeman M. Religiosity/ spirituality and health. A critical review of the evidence for biological pathways. Am Psychol 2003;58:53-63. Ú˜. Bassuk, SS, Glass TA, Berkman LF. Social disengagement and incident cognitive decline in community-dwelling elderly persons. Ann Intern Med 1999;131:165-73. Ú¯. Strawbridge WJ, Shema SJ, Cohen RD, et al.

Religious attendance increases survival by improving and maintaining good health behaviors, mental health, and social relationships. Ann Behav Med 2001;23:68-74. Ú˘. Brown CM. Exploring the role of religiosity in hypertension management among african Americans. J Health Care Poor Underserved 2000;11:19-32. Û. °“√’¡ Õ—∫¥ÿ≈‡≈“–Àå. §Ÿà¡◊Õ¡ÿ ≈‘¡‡∫◊ÈÕßµâπ. °√ÿ߇∑æœ: . «ß»å‡ ߒˬ¡; ¡ªª. ÛÒ. Kark JD, Carmel S, Sinnreich R, Goldberger N, Friedlander Y. Psychosocial factors among

333

members of religious and secular Kibbutzim.

Is J Med Sci 1996;32:185-94. ÛÚ. ¡“§¡π—°‡√’¬π‡°à“Õ“À√—∫. §«“¡À¡“¬Õ—≈°ÿ√Õ“π‡ªìπ ¿“…“‰∑¬ ¿“§ Ú ≠´∑’Ë ÒÒ-20. °√ÿ߇∑æœ: ®‘√√—™°“√ æ‘¡æå; ÚıÛ¯:ı˜¯. ÛÛ. Õ√ÿ≥ ∫ÿ≠™¡, ∫√√≥“∏‘°“√. §≈—ß«‘™“°“√ ÿ¢¿“«–¡ÿ ≈‘¡. °√ÿ߇∑æœ: ·ºπß“π √â“߇ √‘¡ ÿ¢¿“«–¡ÿ ≈‘¡‰∑¬ »Ÿπ¬å π‚¬∫“¬‡æ◊ÕË °“√æ—≤π“ ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬; ÚıÙ˘. ÛÙ. °√–∑√«ß “∏“√≥ ÿ¢. §Ÿà¡◊Õ°“√¥Ÿ·≈øóôπøŸ ÿ¢¿“æºŸâ Ÿß Õ“¬ÿ„π™ÿ¡™π¡ÿ ≈‘¡ ”À√—∫ºŸπâ ”ª√–®”¡— ¬‘¥. °√ÿ߇∑æœ: ™ÿ¡™π À°√≥å°“√‡°…µ√·Ààߪ√–‡∑»‰∑¬; ÚııÒ. Ûı. Xing G. Filial Piety in early Buddhism.

J Buddh Ethics 2005;12. Ûˆ. Helm HM, Hays JC, Flint EP, Koenig HG, Blazer DG. Does private religious activity prolong survival? A six-year follow-up study of 3,851 older adults. J Gerontol Biol Sci Med Sci 2000;55:400-5. Û˜. Van Ness PH, Kasl SV, Jones BA. Religion, race, and breast cancer survival. Int J Psychiatry Med 2003;33:357-75. Û¯. Levin JS, Vanderpool HY. Is religion therapeutically significant for hypertension? Soc Sci Med 1989;29:69-78. Û˘. Kaufman Y, Anaki D, Binns M, Freedman M. Cognitive decline in Alzheimerûs disease: Impact of spirituality, religiosity, and QOL. Neurology 2007;68:1509-14. Ù. Stylianou S. The role of religiosity in the opposition to drug use. Int J Offender Ther Comp Criminol 2004;48:429-48. ÙÒ. Miller WR. Researching the spiritual dimensions of alcohol and other drug problems.

Addiction 1998;93:979-90. ÙÚ. Roff LL, Klemmack D, Parker M, Koenig H, Sawyer-Baker P, Allman R. Religiosity, smoking, exercise, and obesity among Southern, community-dwelling older adults. J Appl Gerontol 2005;24:337-54. ÙÛ. Maltby J, Lewis CA, Day L. Religious orientation and subjective well-being: The role of

334 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

the frequency of personal prayer. Br J Health Psychol 1999;4:363-78. ÙÙ. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York: Oxford University Press; 2001. Ùı. Mitchell J, Weatherly D. Beyond church attendance: Religiosity and mental health among rural older adults. J Cross Cult Gerontol 2000; 15:37-54. Ùˆ. Neal K, Elena B. Religion, suffering, and health among older Mexican Americans. J Aging Stud 2009;23:114-23. Ù˜. Madru N. Stigma and HIV: Does the social response affect the natural course of the epidemic? J Assoc Nurse AIDS Care 2003;14: 39-48.

Ù¯. Anderson B. Regional and cultural factors in the decline of marital fertility in Europe, in African Americans. J Health Care Poor Underserved 1986;11:19-32. Ù˘. Cumming E. Further Thoughts on the Theory of Disengagement. Int Soc Sci J 1963;15:37793. ı. Cumming E, Henry WE. Growing Old: The Process of Disengagement. New York: Basic Books, 1961. ıÒ. Hochschild AR. Disengagement Theory: A Critique and Proposal. Am Sociol Rev 1975; 40:553-69. ıÚ. Atchley RC. A continuity theory of normal aging. Gerontologist 1989;29:183-90.

Abstract Religion and health in the elderly Kwanchit Sasiwongsaroj Institute for Languages and Cultures of Asia, Mahidol University Thailand has entered into aging society and the number of elderly people tends to increase continuously.

This growth trend results in a demand for care and health expenditures. Thus, the issues on aging are extensively investigated to promote living a long and healthy life, including independence from economic and social burden.

It is well-documented that religion is closely related to health of elders. This article aims to review the current knowledge regarding the concept of religion and health, the role and positive/ negative effects of religion on health, and gerontology theory related to religion in order to provide some information for further study on aging in Thai society.

Key words: Religion Health Elderly

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

335

∫∑§«“¡ª√‘∑—»πå

°“√µ√«®«‘π‘®©—¬‚√§¡“≈“‡√’¬¥â«¬‡∑§π‘§™’««‘∑¬“√–¥—∫‚¡‡≈°ÿ≈ «’√–™—¬ ‡Õ◊ÈÕ ‘∑∏‘™—¬

∫∑§—¥¬àÕ ‚√§¡“≈“‡√’¬‡ªìπ‚√§∑’Ë°àÕ„À⇰‘¥ªí≠À“ “∏“√≥ ÿ¢Õ¬à“ß¡“°‚¥¬‡©æ“–Õ¬à“߬‘Ëß„πª√–‡∑»·∂∫‡¢µ√âÕπ√«¡∂÷ß ª√–‡∑»‰∑¬ ºŸâªÉ«¬®–¡’Õ“°“√√ÿπ·√߉¥âÀ“°‰¡à “¡“√∂µ√«®«‘π‘®©—¬™π‘¥¢Õ߇™◊ÈÕ¡“≈“‡√’¬‰¥âÕ¬à“ß∂Ÿ°µâÕß ‡π◊ËÕß®“°‡™◊ÈÕ ¡“≈“‡√’¬·µà≈–™π‘¥®–¡’§«“¡‰«µàÕ¬“∑’Ë„™â„π°“√√—°…“µà“ß°—π °“√µ√«®«‘π‘®©—¬‚√§¡“≈“‡√’¬ “¡“√∂∑”‰¥â‚¥¬°“√ µ√«®À“‡™◊ÕÈ ¡“≈“‡√’¬„π‡≈◊Õ¥¥â«¬°≈âÕß®ÿ≈∑√√»πå ´÷ßË ‡ªìπ«‘∏¡’ “µ√∞“π∑’„Ë ™â„π°“√µ√«®«‘π®‘ ©—¬ºŸªâ «É ¬√“¬∑’ Ë ß —¬«à“µ‘¥‡™◊ÕÈ ¡“≈“‡√’¬ ·µà«‘∏’π’È¡’¢âÕ®”°—¥§◊Õ ®–µâÕß¡’®”π«π‡™◊ÈÕ¡“≈“‡√’¬„π‡≈◊Õ¥¡“°æÕ®÷ß®– “¡“√∂µ√«®æ∫‰¥â √«¡∑—ÈßµâÕß¡’ §«“¡‡™’ˬ«™“≠„π°“√·¬°™π‘¥¢Õ߇™◊ÈÕ¡“≈“‡√’¬ °“√µ√«®«‘π‘®©—¬¥â«¬«‘∏’«‘∑¬“¿Ÿ¡‘§ÿâ¡°—π “¡“√∂∑”‰¥â∑—Èß°“√µ√«®À“ ·Õ𵑇®π·≈–·Õπµ‘∫Õ¥’ ´÷Ëß„À⧫“¡‰«Õ¬Ÿà∑’Ë Ò µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ ‡¡◊ËÕ∑”°“√µ√«®¥â«¬À≈—°°“√Õ‘¡¡Ÿ‚𠂧√¡“‚µ°√“æøïò °“√µ√«®«‘π‘®©—¬¥â«¬‡∑§π‘§™’««‘∑¬“√–¥—∫‚¡‡≈°ÿ≈ “¡“√∂∑”‰¥âÀ≈“¬«‘∏’ ‡™àπ ‰Œ∫√‘‰¥‡´™—Ëπ Polymerase chain reaction (PCR) ·≈– Loop-mediated isothermal amplification (LAMP) ´÷ßË „Àâ§“à §«“¡‰«Õ¬Ÿ∑à Ë’ .Ù µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ ¥—ßπ—πÈ ®–‡ÀÁπ‰¥â«“à «‘∏°’ “√µ√«®«‘π®‘ ©—¬¥â«¬«‘∏™’ «’ «‘∑¬“√–¥—∫‚¡‡≈°ÿ≈®–‡ªìπ«‘∏∑’ ¡’Ë §’ «“¡ ‰« Ÿß·≈–∂Ÿ°µâÕß·¡à𬔠·µà¬—ß¡’¢âÕ®”°—¥§◊Õ ¡’√“§“·æß °“√æ—≤π“«‘∏’°“√µ√«®«‘π‘®©—¬¥â«¬«‘∏’ LAMP ®÷߇ªìπ∑“߇≈◊Õ° Õ’°∑“ßÀπ÷Ëß∑’ËπÕ°®“°„Àâº≈§«“¡‰«„°≈⇧’¬ß°—∫ PCR ·≈â« ¬—ß®–¡’√“§“∂Ÿ°·≈–‰¡àµâÕß°“√‡§√◊ËÕß¡◊Õ∑’Ë¡’√“§“·æß „π ∫∑§«“¡ª√‘∑—»πåπ’ȉ¥â∑”°“√ √ÿªÀ≈—°°“√·≈–‡Àµÿº≈„π°“√µ√«® √«¡∑—Èß ¢âÕ¥’ ¢âÕ‡ ’¬ ¢Õß·µà≈–«‘∏’‡æ◊ËÕ„™â‡ªìπ·π«∑“ß „π°“√µ√«®«‘π‘®©—¬ ·≈–√—°…“‚√§¡“≈“‡√’¬µàÕ‰ª §” ”§—≠: ¡“≈“‡√’¬, °“√µ√«®«‘π‘®©—¬, ™’««‘∑¬“√–¥—∫‚¡‡≈°ÿ≈

∫∑π” ‚√§¡“≈“‡√’¬‡ªìπ‚√§∑’Ë°àÕ„À⇰‘¥ªí≠À“ “∏“√≥ ÿ¢ Õ¬à“ß¡“°‚¥¬‡©æ“–Õ¬à“߬‘ßË „πª√–‡∑»·∂∫‡¢µ√âÕπ (Tropical regions) „πªï §.». Ú¯ ¡’°“√√“¬ß“π«à“∑—Ë«‚≈°¡’ ºŸâªÉ«¬µ‘¥‡™◊ÈÕ ÚÙÛ ≈â“π§π (√âÕ¬≈– ¯ˆ „π·Õø√‘°“) ·≈– æ∫«à“¡’°“√‡ ’¬™’«‘µ ¯ˆÛ, §π (√âÕ¬≈– ¯˘ „π ·Õø√‘°“)Ò ‚¥¬æ∫«à“¡’Õ—µ√“°“√‡ ’¬™’«‘µ Ÿß„π‡¥Á° ∑ÿ°Ê Û «‘π“∑’ ®–¡’‡¥Á°Àπ÷Ëß§π‡ ’¬™’«‘µ®“°°“√µ‘¥‡™◊ÈÕ¡“≈“‡√’‚¥¬ “‡Àµÿ„π°“√‡ ’¬™’«µ‘ ¡—°‡π◊ÕË ß¡“®“°°“√µ‘¥‡™◊ÕÈ ¡“≈“‡√’„π ¡Õß (Cerebral malaria) ºŸâªÉ«¬¡“≈“‡√’¬

à«π„À≠àÕ“°“√®–‰¡à√πÿ ·√ß æ∫«à“¡’‡æ’¬ß√âÕ¬≈– Ò-Ú ‡∑à“π—πÈ ∑’Ë¡’Õ“°“√√ÿπ·√ß ¥—ßπ—Èπ°“√µ√«®«‘π‘®©—¬‚√§¡“≈“‡√’¬∑’Ë ∂Ÿ°µâÕß ·≈–·¡à𬔇¡◊ËÕ¡’°“√µ‘¥‡™◊ÈÕ„π√–¬–·√° ®÷ß¡’§«“¡ ”§—≠Õ¬à“ß¡“°„π°“√∑’®Ë –∫àß™’°È “√µ‘¥‡™◊ÕÈ ¡“≈“‡√’¬·µà≈–™π‘¥ ∑—ßÈ π’‡È æ◊ÕË „Àâ “¡“√∂∑”°“√√—°…“‰¥âÕ¬à“ß∂Ÿ°µâÕß·≈–∑—π∑à«ß∑’ ·≈–ªÑÕß°—π‰¡à„À⇰‘¥Õ“°“√√ÿπ·√ßÀ√◊Õ‡ ’¬™’«‘µ °“√µ√«®«‘π®‘ ©—¬‚√§¡“≈“‡√’¬ “¡“√∂∑”‰¥â‚¥¬°“√ µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬„π‡≈◊Õ¥¥â«¬°≈âÕß®ÿ≈∑√√»πå (microscopic examination) ´÷Ë߇ªìπ«‘∏’¡“µ√∞“π∑’Ë„™â„π°“√µ√«® «‘π®‘ ©—¬ºŸªâ «É ¬√“¬∑’ Ë ß —¬«à“µ‘¥‡™◊ÕÈ ¡“≈“‡√’¬ ·µà«∏‘ π’ ¡’È ¢’ Õâ ®”°—¥

‚§√ß°“√∫—≥±‘µ»÷°…“ “¢“™’«‡«™»“ µ√å §≥– À‡«™»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å

336 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

§◊Õ®–µâÕß¡’®”π«π‡™◊ÕÈ ¡“≈“‡√’¬„π‡≈◊Õ¥¡“°æÕ®÷ß®– “¡“√∂ µ√«®æ∫‰¥â √«¡∑—ÈßµâÕß¡’§«“¡‡™’ˬ«™“≠„π°“√·¬°™π‘¥ ¢Õ߇™◊ÈÕ ´÷Ëß®–¡’§«“¡ ”§—≠„π°“√√—°…“‚√§ ‡π◊ËÕß®“°‡™◊ÈÕ ¡“≈“‡√’¬·µà≈–™π‘¥ (Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae) ®–¡’§«“¡‰«µàÕ¬“∑’Ë„™â„π°“√√—°…“µà“ß°—π ·≈–‚¥¬‡©æ“–®– ¡’ªí≠À“Õ¬à“ß¡“°„π°√≥’¡’°“√µ‘¥‡™◊ÈÕ¡“≈“‡√’¬¡“°°«à“Àπ÷Ëß ™π‘¥ °“√µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬¥â«¬°≈âÕß®ÿ≈∑√√»πå¡’ Ú «‘∏’„À≠àÊ §◊Õ øî≈塇≈◊Õ¥™π‘¥Àπ“ (thick smear) °—∫ øî≈塇≈◊Õ¥™π‘¥∫“ß (thin smear) ·≈–¬âÕ¡¥â«¬ ’¬‘¡´à“ (Giemsa stain) ´÷ËߢâÕ¥’¢Õß°“√µ√«®‡™◊Èե⫬øî≈塇≈◊Õ¥ ™π‘¥Àπ“§◊Õ∑”„Àâ‚Õ°“ „π°“√µ√«®æ∫‡™◊ÈÕ¡“≈“‡√’¬ Ÿß¢÷Èπ (ı-Ú µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√) À√◊Õ‡æ‘Ë¡§«“¡‰«„π°“√ µ√«®«‘π‘®©—¬ ·µà¡’¢âÕ‡ ’¬§◊Õ®–·¬°™π‘¥¢Õ߇™◊ÈÕ¡“≈“‡√’¬‰¥â ¬“°‡π◊ËÕß®“°®–‡ÀÁπ√Ÿª√à“ߢÕ߇™◊ÈÕ¡“≈“‡√’¬‰¥â‰¡à™—¥‡®π ´÷Ëß ·µ°µà“ß®“°°“√µ√«®·∫∫øî≈¡å ‡≈◊Õ¥™π‘¥∫“ß´÷ßË ®–¡’‚Õ°“ „π°“√µ√«®æ∫‡™◊ÈÕ‰¥âπâÕ¬°«à“·µà “¡“√∂·¬°™π‘¥¢Õ߇™◊ÈÕ ¡“≈“‡√’¬‰¥â·¡à𬔰«à“ °“√µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬¥â«¬°≈âÕß®ÿ≈∑√√»π嬗ߡ’ ¢âÕ‡ ’¬Õ¬Ÿà¡“° ‚¥¬‡©æ“–Õ¬à“߬‘Ë߇√◊ËÕߢÕߧ«“¡‰«„π°“√ ∑¥ Õ∫ (sensitivity) ®÷߉¥â¡’π—°«‘®—¬À≈“¬°≈ÿà¡æ¬“¬“¡ æ—≤π“«‘∏°’ “√µ√«®«‘π®‘ ©—¬‚¥¬«‘∏Õ’ π◊Ë Ê ‡æ◊ÕË „Àâ°“√µ√«®«‘π®‘ ©—‡™◊ÈÕ¡“≈“‡√’¬¡’§«“¡∂Ÿ°µâÕß ·¡àπ¬”¡“°¢÷Èπ ‚¥¬π”‡∑§π‘§ ∑“ߥâ“π«‘∑¬“¿Ÿ¡§‘ ¡ÿâ °—π¡“ª√–¬ÿ°µå„™â„π°“√µ√«®À“·Õ𵑇®π ‡æ◊ËÕ∫àß™’È°“√µ‘¥‡™◊Èե⫬‡∑§π‘§µà“ßÊ ‡™àπ radio-immunoassay (RIA), fluorescence-immunoassay (FIA) enzyme-immunoassay (EIA) ·≈– immuno-chromatography (ICT) ‡ªìπµâπ ·µà«‘∏’∑’ˇªìπ∑’Ëπ‘¬¡¡“°∑’Ë ÿ¥§◊Õ EIA ·≈– ICT ‡π◊ËÕß®“°‡ªìπ«‘∏’∑’Ëßà“¬·≈–‰¡àµâÕß„™â “√ ‰Õ‚´‚∑ª´÷Ë߇ªìπÕ—πµ√“¬ ·≈–√“§“‰¡à·æß ´÷Ëߧ«“¡‰«·≈– §«“¡®”‡æ“–¢Õß°“√∑¥ Õ∫®–¢÷ÈπÕ¬Ÿà°—∫·Õπµ‘∫Õ¥’∑’Ë„™â„π °“√µ√«®®—∫·Õ𵑇®π¢Õ߇™◊ÈÕ πÕ°®“°π’Ȭ—ß “¡“√∂µ√«®À“·Õπµ‘∫Õ¥’∑’Ë®”‡æ“– µàÕ‡™◊ÈÕ¡“≈“‡√’¬‰¥â¥â«¬À≈—°°“√ immunoassay ¢âÕ¥’§◊Õ ‡ªìπ«‘∏’∑’Ë¡’§«“¡‰«·≈–§«“¡®”‡æ“– Ÿß ·µà®– “¡“√∂µ√«® æ∫°“√µ‘¥‡™◊ÈÕ‰¥â™â“°«à“°“√µ√«®À“·Õ𵑇®π ‡π◊ËÕß®“°®– “¡“√∂µ√«®æ∫·Õπµ‘∫Õ¥’µàÕ‡™◊ÈÕ¡“≈“‡√’¬‰¥âÕ¬à“ßπâÕÒ-Ú —ª¥“Àå À≈—ß°“√µ‘¥‡™◊ÈÕ ´÷ËßÀ“°ºŸâªÉ«¬Õ¬Ÿà„π√–¬–∑’Ë ‡™◊ÈÕ¬—ßÕ¬Ÿà„πµ—∫ (liver stage) ‡æ◊ËÕ‡æ‘Ë¡®”π«π·≈–¬—߉¡à ·æ√à°√–®“¬‡¢â“ Ÿà°√–· ‡≈◊Õ¥ (blood stage) ®–‰¡à “¡“√∂

µ√«®æ∫‰¥â„π°√–· ‡≈◊Õ¥¥â«¬«‘∏’∑“ß°≈âÕß®ÿ≈∑√√»πå ∫“ß °√≥’∑’ˇ™◊ÈÕ¡“≈“‡√’¬Õ“»—¬Õ¬Ÿà„πµ—∫‡ªìπ‡«≈“π“π‚¥¬‰¡à‡¢â“ Ÿà °√–· ‡≈◊Õ¥ ·Õ𵑇®π¢Õ߇™◊ÈÕ®–∂Ÿ°§—¥À≈—Ëß·≈–¢—∫ÕÕ°¡“ Õ¬Ÿà„π°√–· ‡≈◊Õ¥ ´÷Ëß√à“ß°“¬¢ÕߺŸâªÉ«¬®– √â“ß·Õπµ‘∫Õ¥’ ¢÷Èπ‡æ◊ËÕ¡“µàÕµâ“π‡™◊ÈÕ¡“≈“‡√’¬ ∑”„À⧫“¡‰«„π°“√µ√«® «‘π‘®©—¬‡æ‘Ë¡¢÷Èπ ·µà°“√µ√«®À“·Õπµ‘∫Õ¥’®–¡’¢âÕ‡ ’¬§◊Õ‰¡à “¡“√∂·¬°‰¥â«à“‡ªìπ°“√µ‘¥‡™◊ÈÕ·∫∫‡©’¬∫æ≈—π (acute) ‡√◊ÈÕ√—ß (chronic) ‰¢â°≈—∫®“°√–¬–´àÕπµ—« hypnozoite (relapse) °“√°≈—∫¡’‡™◊ÈÕ„π°√–· ‡≈◊Õ¥Õ’°§√—Èß (recrudescence) À√◊Õ„π√“¬∑’ˇ§¬µ‘¥‡™◊ÈÕ¡“°àÕπ ·≈–‚¥¬‡©æ“– Õ¬à“߬‘ßË °“√µ√«®ºŸªâ «É ¬„π·À≈àß√–∫“¥ (endemic area) ´÷ßË ¡’ ° “√µ‘ ¥ ‡™◊È Õ µ≈Õ¥‡«≈“·µà Õ “®‰¡à · ¥ßÕ“°“√Õ“®®–¡’ ·Õπµ‘∫Õ¥’Õ¬Ÿàµ≈Õ¥‡«≈“ °“√µ√«®«‘π®‘ ©—¬°“√µ‘¥‡™◊ÕÈ ¡“≈“‡√’¬¥â«¬«‘∏∑’ “ß«‘∑¬“ ¿Ÿ¡‘§ÿâ¡°—π·¡â«à“®–„Àâ¡’§«“¡‰«·≈–§«“¡®”‡æ“– Ÿß ·µà°Á¡’ ¢âÕ‡ ’¬∑’Ë ”§—≠§◊Õ °“√∑¥ Õ∫¡’À≈“¬¢—ÈπµÕπ „π·µà≈–¢—Èπ µÕπµâÕß„™â‡«≈“‡æ◊ËÕ„Àâ·Õ𵑇®π·≈–·Õπµ‘∫Õ¥’∑”ªØ‘°‘√‘¬“ °—π ªí®®ÿ∫π— ®÷߉¥â¡°’ “√æ—≤π“«‘∏°’ “√µ√«®«‘π®‘ ©—¬·∫∫√«¥‡√Á« (rapid diagnostic test, RDT) ‚¥¬π”À≈—°°“√∑“ß«‘∑¬“ ¿Ÿ¡‘§ÿâ¡°—π·≈–‚§√¡“‚µ√°√“æøïò¡“√«¡°—π·≈–æ—≤𓇪ìπ«‘∏’ Õ‘¡¡Ÿ‚π‚§√¡“‚µ√°√“æøïò (immuno-chromatography, ICT) ‡æ◊ÕË µ√«®À“·Õ𵑇®π¢Õ߇™◊ÕÈ ¡“≈“‡√’¬ ‚¥¬„™â·Õπµ‘∫Õ¥’∑®’Ë ”‡æ“–°—∫·Õ𵑇®π¢Õ߇™◊ÕÈ ¡“≈“‡√’¬ ‰¥â·°à histidine rich protein (HRP)Ú ·≈– lactate dehydrogenase (LDH)Û, Ù ‡ªìπµâ𠇪ìπµ—«¥—°®—∫·Õ𵑇®π„πµ—«Õ¬à“߇≈◊Õ¥ ®“°π—Èπ·Õπµ‘∫Õ¥’∑’˵‘¥©≈“°¥â«¬‚≈À–Àπ—°À√◊Õ ’ ´÷Ëß¡—° ®–„À⺠¡°—∫µ—«Õ¬à“ß∑’µË Õâ ß°“√∑¥ Õ∫„π¢—πÈ µÕπ·√° °àÕπ ∑’Ë®–∑”°“√À¬Õ¥≈ß∫π·∂∫∑¥ Õ∫ ‚¥¬·Õπµ‘∫Õ¥’∑’˵‘¥ ©≈“°®–®— ∫ °— ∫ ·Õ𵑠‡ ®π„πµ— « Õ¬à “ ß∑¥ Õ∫·≈–®–«‘Ë ß‰ª æ√âÕ¡Ê °— π„π√Ÿª¢Õß·Õ𵑇®π-·Õπµ‘∫Õ¥’§Õ¡‡æ≈Á°´å °àÕπ∑’Ë®–∂Ÿ°¥—°®—∫¥â«¬·Õπµ‘∫Õ¥’Õ’°µ—«Àπ÷Ëß∑’ˇ§≈◊Õ∫Õ¬Ÿà ∫π·∂∫∑¥ Õ∫ ·≈–√«¡µ—«°—π®π‡°‘¥‡ªìπ·∂∫¢÷Èπ ¢âÕ¥’ ¢Õß°“√∑¥ Õ∫¥â«¬«‘∏’ ICT §◊Õ √«¥‡√Á« ·≈–‰¡àµâÕß°“√ ‡§√◊ËÕß¡◊Õ摇»…À√◊Õ¡’√“§“·æß„π°“√∑¥ Õ∫ “¡“√∂π” ‰ªª√–¬ÿ°µå„™â„πæ◊Èπ∑’Ë∑’Ë¡’°“√√–∫“¥‰¥â ´÷Ëß¡—°®–‡ªìπ∂‘Ëπ ∑ÿ√°—π¥“√·≈–‰¡à¡’‰øøÑ“„™â ·µà¡’¢âÕ‡ ’¬§◊Õ§«“¡‰« «‘∏’ ICT ®– “¡“√∂µ√«®æ∫‡™◊ÈÕ¡“≈“‡√’¬‰¥â ‡ ¡◊Ë Õ ¡’ ‡ ™◊È Õ„πµ— « Õ¬à “ ß µ√«®¡“°°«à“ Ò µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ πÕ°®“°π’È ¬—ß¡’ªí≠À“„π‡√◊ËÕߧ«“¡®”‡æ“– (specificity) ´÷ËßÕ“®„Àâ º≈∫«°ª≈Õ¡ À√◊Õ≈∫ª≈Õ¡‰¥â ‚¥¬‡©æ“–Õ¬à“߬‘ËߺŸâªÉ«rheumatitis ´÷Ëß¡’ rheumatoid factorı, ˆ ∑’Ë “¡“√∂∑”

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ªØ‘°‘√‘¬“¢â“¡™π‘¥°—∫·Õπµ‘∫Õ¥’∑’Ë„™â¥—°®—∫‰¥â Õ¬à“߉√°Áµ“¡ «‘∏’ ICT ¬—ߧ߇ªìπ«‘∏’∑’Ë¡’ª√–‚¬™πå„π°“√µ√«®‡æ◊ËÕ√—°…“ ‡∫◊ÈÕßµâπ ‡π◊ËÕß®“°√«¥‡√Á«·µà®”‡ªìπµâÕß¡’°“√æ—≤π“µàÕ‰ª À√◊Õ„™â‡ªìπ«‘∏µ’ √«®¬◊π¬—π§«∫§Ÿ‰à ª°—∫«‘∏°’ “√µ√«®¥â«¬°≈âÕß ®ÿ≈∑√√»πå™π‘¥øî≈å¡Àπ“·≈–øî≈å¡∫“ß°Á®–™à«¬≈¥Õ—µ√“°“√ „Àâº≈≈∫ª≈Õ¡·≈–∫«°ª≈Õ¡‰¥â√–¥—∫Àπ÷Ëß ®–‡ÀÁπ‰¥â«à“ª√– ‘∑∏‘¿“æ„π°“√µ√«®«‘π‘®©—¬‚√§ ¡“≈“‡√’¬¥â«¬‡∑§π‘§°“√µ√«®À“‡™◊Èե⫬°≈âÕß®ÿ≈∑√√»πå À√◊Õ‡∑§π‘§∑“ߥâ“π«‘∑¬“¿Ÿ¡§‘ ¡ÿâ °—π¥—ß∑’°Ë ≈à“«¡“·≈â«¢â“ßµâπ ¬—ß‰¡à “¡“√∂∑’®Ë –§√Õ∫§≈ÿ¡§«“¡µâÕß°“√·≈–§«“¡‡À¡“– ¡ °—∫æ◊Èπ∑’Ë∑’Ë¡’°“√√–∫“¥¢Õ߇™◊ÈÕ¡“≈“‡√’¬‰¥â ®÷߉¥â¡’°“√π” ‡∑§π‘§∑“ߥâ“π™’««‘∑¬“√–¥—∫‚¡‡≈°ÿ≈¡“ª√–¬ÿ°µå„™â‡æ◊ÕË µ√«® «‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬ ‚¥¬°“√µ√«®À“ “√æ—π∏ÿ°√√¡·∑π °“√µ√«®À“·Õ𵑇®πÀ√◊Õ·Õπµ‘∫Õ¥’ ´÷Ëߧ“¥«à“®– “¡“√∂ ‡æ‘Ë¡§«“¡‰«·≈–§«“¡®”‡æ“–¢Õß«‘∏’°“√µ√«®«‘π‘®©—¬‰¥â ‡∑§π‘§ DNA hybridization ‡ªìπ«‘∏’∑’Ë∂Ÿ°π”¡“ª√–¬ÿ°µå „™â„π°“√µ√«®«‘π‘®©—¬ ·¡â«à“®–„Àâº≈°“√∑¥ Õ∫∑’Ë¥’·µà¬—ß¡’ ¢âÕ®”°—¥∫“ߪ√–°“√„π°“√∑’Ë𔉪„™â∑¥ Õ∫„π·À≈àß√–∫“¥ ‡∑§π‘§ polymerase chain reaction (PCR) ‡ªìπ«‘∏’ ∑’Ë π‘ ¬ ¡π”¡“„™â„π°“√µ√«®«‘π‘®©—¬‚√§µà“ßÊ √«¡∂÷߇™◊ÈÕ ¡“≈“‡√’¬ ‡π◊ËÕß®“°¡’§«“¡‰«·≈–§«“¡®”‡æ“– Ÿß ‚¥¬¡’°“√ »÷°…“·≈–æ—≤π“«‘∏’ PCR ¡“ª√–¬ÿ°µå„™â°—∫°“√µ√«®‡™◊ÈÕ ¡“≈“‡√’¬ ‡™àπ conventional PCR, reverse transcription PCR, nested PCR, Real time PCR, multiplex PCR ‡ªìπµâπ πÕ°®“°π’ȇ∑§π‘§ Loop-mediated isothermal amplification (LAMP) ‡ªìπÕ’°Àπ÷ßË «‘∏∑’ π’Ë “à π„® ‡π◊ÕË ß®“° ‡ªìπ«‘∏’∑’Ëßà“¬·≈–‰¡àµâÕß°“√‡§√◊ËÕß¡◊Õ∑’Ë¡’√“§“·æ߇À¡◊Õπ°—∫ PCR ‚¥¬¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬∑’Ë„™â„π°“√µ√«®«‘π‘®©—¬¥â«‡∑§π‘§ PCR À√◊Õ LAMP ¡’À≈“¬¬’π·µà∑’Ëπ‘¬¡·≈–„Àâº≈ °“√∑¥ Õ∫¥’ ‰¥â·°à ¬’π small subunit 18S ribosomal RNA˜, ¯ ‡π◊ËÕß®“°¡’ª√‘¡“≥¡“°„π “√æ—π∏ÿ°√√¡¢Õ߇™◊ÈÕ ¡“≈“‡√’¬ ·≈– “¡“√∂‡æ‘Ë¡§«“¡‰«„π°“√∑¥ Õ∫ ‚¥¬¡’§à“ §«“¡‰«Õ¬Ÿà∑’Ë .Ù-Û µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√˘ °“√‡°Á ∫ µ— « Õ¬à “ ß ”À√— ∫ °“√µ√«®«‘ π‘ ® ©— ¬ ¥â « ¬‡∑§π‘ § ™’««‘∑¬“√–¥—∫‚¡‡≈°ÿ≈ °“√‡µ√’¬¡µ—«Õ¬à“ß®–‡ªìπ à«π ”§—≠¡“°„π°“√ µ√«®«‘π‘®©—¬ “√æ—π∏ÿ°√√¡∑’Ë„™â„π°“√µ√«®«‘π‘®©—¬¥â«¬«‘∏’ PCR “√æ—π∏ÿ°√√¡π—ÈπÕ“®®–‡ªìπÕ“√å‡ÕÁπ‡ÕÀ√◊Õ¥’‡ÕÁπ‡Õ ´÷Ëß®–¡’«‘∏’ °—¥·µ°µà“ß°—π‰ª·≈–®–µâÕߪ√“»®“° DNase ·≈– RNase ‡æ◊ÕË ªÑÕß°—π°“√¬àÕ¬ ≈“¬¢Õß “√æ—π∏ÿ°√√¡ ‚¥¬

337

µ—«Õ¬à“ß∑¥ Õ∫Õ“®®–‰¥â¡“®“°°“√‡®“–‡≈◊Õ¥®“°ª≈“¬π‘È« À√◊Õ‡ âπ‡≈◊Õ¥¥”¢ÕߺŸâªÉ«¬ À√◊ÕÕ“®„™âµ—«Õ¬à“߇≈◊Õ¥∑’ËÀ¬¥ ≈ß∫π°√–¥“…°√Õß °“√µ√«®°“√µ‘¥‡™◊ÈÕ„π¬ÿß “¡“√∂∑”‰¥â ‚¥¬°“√µ—¥ à«πªï°·≈– à«π¢“¢Õ߬ÿßÕÕ°Ò °“√‡°Á∫µ—«Õ¬à“ß „π∑’ˇ¬Áπ (-Ú Õß»“‡´≈‡´’¬ ) ·≈–·Àâß®–™à«¬≈¥‚Õ°“ °“√¬àÕ¬ ≈“¬¢Õß “√æ—π∏ÿ°√√¡‰¥â À√◊Õ„π°√≥’∑’˵âÕß àß µ√«®‡ªìπ√–¬–∑“߉°≈°ÁÕ“®„™â transport media ‡æ◊Ëՙૄπ°“√§ß ¿“æ¢Õß “√æ—π∏ÿ°√√¡‰«â À“°‰¡à “¡“√∂∑”°“√ ‡µ√’¬¡ “√æ—π∏ÿ°√√¡‰¥â∑—π∑’ „π°√≥’∑’˵—«Õ¬à“ß∑¥ Õ∫‡ªìπ ‡≈◊Õ¥µâÕß„ à “√°—π‡≈◊Õ¥·¢Áß ‡™àπ EDTA À√◊Õ heparin ·µàµâÕß„™â„πª√‘¡“≥∑’ˇÀ¡“– ¡°—∫ª√‘¡“≥‡≈◊Õ¥ ‰¡à‡™àππ—Èπ ®–¡’°“√ªπ‡ªóôÕπ„πµ—«Õ¬à“ß∑¥ Õ∫ ‡π◊ËÕß®“° “√°—π‡≈◊Õ¥ ·¢Á߇À≈à“π’ È “¡“√∂¬—∫¬—ßÈ °“√∑”ß“π¢Õ߇Õπ‰´¡å DNA polymerase ‰¥â °“√‡µ√’¬¡ “√æ—π∏ÿ°√√¡ °“√ °—¥ “√æ—π∏ÿ°√√¡¢Õ߇™◊ÈÕ¡“≈“‡√’¬ “¡“√∂ ∑”‰¥â∑ß—È °“√ °—¥¥’‡ÕÁπ‡ÕÀ√◊ÕÕ“√å‡ÕÁπ‡Õ ‚¥¬æ∫«à“„πªí®®ÿ∫π— ¡’™ÿ¥ °—¥ ”‡√Á®√Ÿª¡“°¡“¬ ‡æ◊Ëՙ૬„π°“√ °—¥„À≥⠓√ æ—π∏ÿ°√√¡∑’Ë¡’§ÿ≥¿“楒 ª√“»®“°°“√ªπ‡ªóôÕπµ—«¬—∫¬—Èß ·≈–¡’§«“¡∫√‘ ÿ∑∏‘Ï Ÿß ·µà¡—°¡’√“§“·æß∑”„Àâ°“√∑¥ Õ∫¡’ √“§“ Ÿß¢÷Èπ´÷ËßÕ“®®–‰¡à‡À¡“–°—∫∫“ߪ√–‡∑» ‡π◊ËÕß®“° ºŸâªÉ«¬¡“≈“‡√’¬ à«π„À≠à®–¡’∞“π–∑“߇»√…∞°‘®‰¡à¥’ ∑”„Àâ ‰¡à “¡“√∂‡¢â“∂÷ß«‘∏’°“√∑¥ Õ∫‰¥â ¥—ßπ—Èπ«‘∏’∑’ˇÀ¡“–°—∫°“√ °—¥ “√æ—π∏ÿ°√√¡¢Õ߇™◊ÈÕ¡“≈“‡√’¬§«√®–¡’√“§“‰¡à·æß·µà „Àâ “√æ—π∏ÿ°√√¡∑’Ë¡’§ÿ≥¿“æ·≈–¡’°“√ªπ‡ªóôÕππâÕ¬ ‡™àπ °“√µâ¡À√◊Õ°“√„™âπÈ”∑”„À⇴≈≈凡Á¥‡≈◊Õ¥·¥ß·µ°ÕÕ° ·≈– „™â “√øïπÕ≈-§≈Õ‚√øÕ√å¡ °—¥‚ª√µ’πÕÕ° °àÕπ∑’Ë®–µ° µ–°Õπ “√æ—π∏ÿ°√√¡¥â«¬·Õ≈°ÕŒÕ≈åÒ ´÷Ëßæ∫«à“ “¡“√∂ 𔉪„™â‡ªìπµ—«Õ¬à“ß„π°“√∑¥ Õ∫¥â«¬«‘∏∑’ “ß™’««‘∑¬“√–¥—∫ ‚¡‡≈°ÿ≈‰¥â Hybridization ‡∑§π‘§ hybridization ‡ªìπ«‘∏’∑’Ë„™â‚æ√∫ (probe) ∑’˵‘¥©≈“°¥â«¬ “√°—¡¡—πµ¿“æ√—ß ’ ‡Õπ‰´¡å “√ø≈Ÿ‚Õ‡√ ‡´π∑å À√◊Õ‚ª√µ’π∫“ß™π‘¥ ‡™àπ digoxigenin À√◊Õ biotin ‡ªìπµ—«µ‘¥µ“¡ ‡æ◊ËÕ„Àâ‚æ√∫®—∫°—∫¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬ (complementary) ‚¥¬‚æ√∫∑’Ë„™âÕ“®‡ªìπ‚æ√∫™π‘¥¥’‡ÕÁπ‡ÕÀ√◊Õ Õ“√å‡ÕÁπ‡Õ‰¥â ‚¥¬À≈—°°“√‚æ√∫™π‘¥Õ“√å‡ÕÁπ‡Õ®–®—∫°—∫ ¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬‰¥â¥°’ «à“‚æ√∫™π‘¥¥’‡ÕÁπ‡Õ ‡π◊ÕË ß®“°Õ“√å‡ÕÁπ‡Õ ®–®—∫°—∫Õ“√å‡ÕÁπ‡Õ‰¥â¥∑’ ’Ë ¥ÿ Õ“√å‡ÕÁπ‡Õ-¥’‡ÕÁπ‡Õ ·≈–¥’‡ÕÁπ‡Õ-

338 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

¥’‡ÕÁπ‡Õ ®–®—∫°—π‰¡à¥’√Õß≈ß¡“µ“¡≈”¥—∫ ¥—ßπ—Èπ °“√„™â ‚æ√∫™π‘¥Õ“√å‡ÕÁπ‡Õ‡æ◊ËÕµ√«®À“Õ“√å‡ÕÁπ‡Õ¢Õ߇™◊ÈÕ¡“≈“‡√’®–‡ªìπ«‘∏’∑’Ë¥’∑’Ë ÿ¥ „πªï §.». Ò˘¯ˆ Oquendo ·≈–§≥–ÒÒ ‰¥â √“¬ß“π≈”¥—∫‡∫ ¢Õß repetitive DNA §«“¡¬“« ÚÒ §Ÿà ‡∫ ´÷ËßµàÕ¡“„πªï §.». Ò˘¯˜ Holmberg ·≈–§≥–ÒÚ ‰¥â ∑”°“√∑¥ Õ∫°“√µ‘ ¥ ‡™◊È Õ ¡“≈“‡√’ ¬ ™π‘ ¥ øí ≈ ´‘ æ “√—Ë ¡„π ºŸªâ «É ¬·°¡‡∫’¬ ‚¥¬„™â‚æ√∫™π‘¥¥’‡ÕÁπ‡Õ∑’µË ¥‘ ©≈“°¥â«¬ÛÚP æ∫«à“§à“§«“¡®”‡æ“–·≈–§«“¡‰«¢Õß°“√∑¥ Õ∫‡∑à“°—∫ √âÕ¬≈– Ò ·≈– ˆ¯ µ“¡≈”¥—∫ ·µà„π°“√»÷°…“¢Õß McLaughlin ·≈–§≥–ÒÛ æ∫«à“‡¡◊ËÕµ‘¥©≈“°¥â«¬ T4 kinase æ∫«à“ “¡“√∂µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬æ∫‰¥â∑’Ë Ò, µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ ¥—ßπ—Èπ®–‡ÀÁπ‰¥â«à“«‘∏’°“√µ‘¥©≈“° °Á ® –¡’ º ≈µà Õ §«“¡‰«„π°“√∑¥ Õ∫‡™à π °— π πÕ°®“°π’È McLaughlin ·≈–§≥–ÒÙ ¬—߉¥â∑¥ Õ∫ª√– ‘∑∏‘¿“æ°—∫ ‚æ√∫∑’Ë µ‘ ¥ ©≈“°¥â « ¬‡Õπ‰´¡å æ ∫«à “ “¡“√∂µ√«®À“‡™◊È Õ ¡“≈“‡√’¬æ∫‰¥â∑’Ë Ò µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ µàÕ¡“„π ªï §.». Ò˘¯¯ Sethabutr ·≈–§≥–Òı ‰¥â∑”°“√∑¥ Õ∫ °“√µ‘¥‡™◊ÈÕ¡“≈“‡√’¬„πºŸâªÉ«¬‰∑¬ ‚¥¬„™â¥’‡ÕÁπ‡Õ —߇§√“–Àå ∑’Ë¡’§«“¡¬“« ÚÒ bp ∑’˵‘¥©≈“° 32P ¥â«¬«‘∏’ Nick translation æ∫«à“ “¡“√∂µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬æ∫‰¥â ∑’Ë Ò µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ „πªï §.». Ò˘¯¯Òˆ ‰¥â¡°’ “√√“¬ß“π≈”¥—∫‡∫ ¢Õß small subunit 18S ribosomal RNA (18S rRNA) µàÕ ¡“„πªï §.». Ò˘¯˘ Waters ·≈– McCutchanÒ˜ ‰¥â æ— ≤ π“«‘ ∏’ ° “√µ√«®«‘ π‘ ® ©— ¬ ‡™◊È Õ ¡“≈“‡√’ ¬‚¥¬„™â‚æ√∫·∫∫ ®”‡æ“– (specific probe) °—∫ 18S rRNA ´÷Ëß„À⧫“¡ ‰«·≈–§«“¡®”‡æ“– Ÿß ‚¥¬ “¡“√∂µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬‰¥â ∑—Èß Ù ™π‘¥ ¥â«¬‚æ√∫ oligonucleotide ∑’˵‘¥©≈“°¥â«ÛÚP ∑’Ë®”‡æ“–°—∫‡™◊ÈÕ¡“≈“‡√’¬·µà≈–™π‘¥æ∫«à“„Àâº≈°“√ ∑¥ Õ∫∑’Ë¥’ ‚¥¬ “¡“√∂µ√«®æ∫‰¥â·¡â«à“®–¡’‡™◊ÈÕ¡“≈“‡√’‡æ’¬ß Ò µ—«µàÕ°“√∑¥ Õ∫ °“√‡µ√’¬¡µ—«Õ¬à“ß∑”‰¥â‚¥ßà“¬‡æ’¬ßÀ¬¥‡≈◊Õ¥≈ß∫π‡¡¡‡∫√π™π‘¥‰π≈Õπ (nylon membrane) ·µà‡π◊ÕË ß®“°«‘∏¥’ ß— °≈à“«‡ªìπ«‘∏∑’ ¡’Ë ’ “√°—¡¡—πµ¿“æ√—ß ’ ®”‡ªìπµâÕß¡’ÀâÕߪؑ∫—µ‘°“√∑’Ë√Õß√—∫®÷߉¡à “¡“√∂ 𔉪ª√–¬ÿ°µå„™â‰¥â„πæ◊πÈ ∑’∑Ë ¡’Ë °’ “√√–∫“¥ µâÕß∑”°“√¢π¬â“µ—«Õ¬à“ß¡“¬—ßÀâÕߪؑ∫—µ‘°“√´÷Ëß∑”„ÀâµâÕß„™â‡«≈“µ√«®π“π ¡“°°«à“ ÚÙ ™—Ë«‚¡ß „π°“√»÷°…“¢Õß Barker ·≈–§≥–Ò¯ æ∫«à“°“√‡µ√’¬¡µ—«Õ¬à“ß “√æ—π∏ÿ°√√¡¢Õ߇™◊ÈÕ¡“≈“‡√’¬π—Èπ ¡’º≈µàÕ§«“¡‰«¢Õߪؑ°‘√‘¬“ „π°“√∑¥ Õ∫«‘∏’ hybridization π—Èπ‡ªìπ«‘∏’∑’Ë¡’À≈“¬¢—ÈπµÕπ·≈–µâÕß„™â‡«≈“ ·≈–¡—°®–

µ√«®·¬°™π‘¥¢Õ߇™◊ÈÕ¡“≈“‡√’¬‰¡à‰¥â ‚¥¬®–‡ªìπ«‘∏’∑’Ëæ—≤π“ ¢÷Èπ‡æ◊ËÕµ√«®À“¡“≈“‡√’¬™π‘¥øí≈´‘æ“√—Ë¡‡ªìπ à«π„À≠à ·≈– §«“¡‰«¢Õß°“√∑¥ Õ∫¬—߉¡à¡’ª√– ‘∑∏‘¿“楒æÕ ª√–°Õ∫ °—∫°“√æ—≤π“‡∑§π‘§ PCR ´÷Ëßßà“¬°«à“‡π◊ËÕß®“°„™â‡§√◊ËÕß ¡◊Õ‡¢â“¡“™à«¬ ∑”„Àâ«‘∏’π’ȉ¡à‡ªìπ∑’Ëπ‘¬¡„πªí®®ÿ∫—π °“√‡æ‘¡Ë ®”π«π “√æ—π∏ÿ°√√¡¥â«¬«‘∏’ polymerase chain reaction (PCR) ‡∑§π‘§ PCR ‡ªìπ‡∑§π‘§∑’Ë∂Ÿ°π”¡“ª√–¬ÿ°µå„™â„π °“√µ√«®«‘π‘®©—¬‚√§µà“ßÊ ¡“°¡“¬ ‡π◊ËÕß®“°‡ªìπ‡∑§π‘§∑’Ë „™â„π°“√‡æ‘Ë¡®”π«π¥’‡ÕÁπ‡Õ„πÀ≈Õ¥∑¥≈Õß ∑”„À⥒‡ÕÁπ‡Õ ‡ªÑ“À¡“¬∑’„Ë ™â„π°“√µ√«®«‘‡§√“–Àå¡®’ ”π«π¡“°¢÷πÈ ª√–°Õ∫ ¥â«¬ Û ¢—ÈπµÕπÀ≈—°§◊Õ Ò. Denature ‡ªìπ¢—ÈπµÕπ°“√·¬° “¬¥’‡ÕÁπ‡Õ ®“°¥’‡ÕÁπ‡Õ‡ âπ§Ÿà‡ªìπ¥’‡ÕÁπ‡Õ‡ âπ‡¥’Ë¬« ‡æ◊ËÕ„Àâ‰æ√凡Õ√å (primer) “¡“√∂‡¢â“®—∫°—∫‡∫ §Ÿà ¡ ‚¥¬„™â§«“¡√âÕπ∑’Ë Õÿ≥À¿Ÿ¡‘ª√–¡“≥ ˘Ù Õß»“‡´≈‡´’¬ ‡ªìπ‡«≈“ª√–¡“≥ Û-ˆ «‘π“∑’ ‡ªìπµ—«™à«¬„π°“√·¬° “¬ÕÕ°®“°°—π Ú. Annealing ‡ªìπ¢—ÈπµÕπ°“√∑’Ë„Àâ‰æ√凡Õ√å ´÷Ë߇ªìπµ—« ”§—≠„π°“√ √â“ß “¬¥’‡ÕÁπ‡Õ‡¢â“®—∫°—∫¥’‡ÕÁπ‡Õ ‡ªÑ“À¡“¬ ‚¥¬ à«π„À≠à®–„™âÕ≥ ÿ À¿Ÿ¡ª‘ √–¡“≥ Ùı-ˆı Õß»“ ‡´≈‡´’¬ ‡ªìπ‡«≈“ª√–¡“≥ Û-ˆ «‘π“∑’ Û. Extension ‡ªìπ¢—ÈπµÕπ°“√ √â“ß “¬¥’‡ÕÁπ‡Õ ¥â«¬‡Õπ‰´¡å heat stable DNA polymerase ‡™àπ Taq DNA polymerase ‡ªìπµâπ ¡’ “¬‰æ√凡Õ√凪ìπµ—«‡√‘Ë¡µâπ ´÷Ëß à«π„À≠à®–„™âÕÿ≥À¿Ÿ¡‘ª√–¡“≥ ˜Ú Õß»“‡´≈‡´’¬ ‡ªì𠇫≈“ª√–¡“≥ Û-ˆ «‘π“∑’ ‡¡◊Ë Õ §√∫Àπ÷Ë ß √Õ∫¥’ ‡ ÕÁ π ‡Õ‡ªÑ “ À¡“¬®–¡’ ®”π«π ‡æ‘Ë¡¢÷ÈπÀπ÷Ë߇∑à“µ—« ¥—ßπ—ÈπÀ“°∑” PCR ®”π«π√Õ∫¡“°¢÷Èπ ¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬®–‡æ‘Ë¡¢÷Èπ‡∑à“°—∫ Ún (n = ®”π«π√Õ∫) ´÷Ëß‚¥¬∑—Ë«‰ªªØ‘°‘√‘¬“ PCR ®–∑”ª√–¡“≥ Û-Ûı √Õ∫ °Á ® –∑”„À⥒‡ÕÁπ‡Õ‡ªÑ“À¡“¬®“°Àπ÷Ëß™ÿ¥‡ªìπÀ≈“¬≈â“π™ÿ¥ (Ò,˜Ù ≈â“π-ÛÙ,Ûˆ ≈â“π) ¿“¬„π‡«≈“‡æ’¬ß Ú-Û ™—Ë«‚¡ß À≈—ß®“°∑’Ë∑”ªØ‘°‘√‘¬“ PCR ®–µâÕßπ”º≈º≈‘µ∑’Ë ‰¥â‰ª∑¥ Õ∫∫π agarose gel electrophoresis ‡æ◊ËÕ ¥Ÿ·∂∫¥’‡ÕÁπ‡Õ ´÷Ëß∑”„ÀâµâÕß„™â‡«≈“„π°“√∑¥ Õ∫¡“°¢÷Èπ ¥—ßπ—Èπ®÷߉¥â¡’°“√§‘¥§âπ«‘∏’ real-time PCR §◊Õ ∑”°“√ µ‘¥µ“¡°“√‡æ‘Ë¡¢÷Èπ¢Õß “¬¥’‡ÕÁπ‡Õ‚¥¬„™â ’ø≈Ÿ‚Õ‡√ ‡´π∑å (fluorescence) ‡™àπ SYBR green ´÷Ëß®–∑”°“√«—¥°“√ ¥Ÿ¥°≈◊π· ߢÕß ’ø≈Ÿ‚Õ‡√ ‡´π∑å∑°ÿ Ê √Õ∫¢Õß°“√∑”ªØ‘°√‘ ¬‘ “

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

PCR ∑”„Àâ “¡“√∂∑√“∫º≈°“√‡æ‘Ë¡®”π«π‰¥â∑—π∑’ ‡¡◊ËÕ ®”π«π¥’‡ÕÁπ‡Õ‡æ‘¡Ë ¢÷πÈ ’ø≈Ÿ‚Õ‡√ ‡´π∑å®–®—∫¥’‡ÕÁπ‡Õ¡“°¢÷πÈ ∑”„Àâ “¡“√∂µ‘¥µ“¡¥’‡ÕÁπ‡Õ∑’ˇæ‘Ë¡®”π«π¢÷Èπ‰¥â ·µà¢âÕ‡ ’¢Õß«‘ ∏’ π’È §◊ Õ ®–‰¡à ∑ √“∫™π‘ ¥ ¢Õߥ’ ‡ ÕÁ π ‡Õ∑’Ë ‡ æ‘Ë ¡ ¢÷È π «à “ ‡ªì π ¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬À√◊Õ‡ªìπ°“√‡æ‘Ë¡¥’‡ÕÁπ‡Õ·∫∫‰¡à®”‡æ“– ‡π◊ËÕß®“° ’ø≈Ÿ‚Õ‡√ ‡´π∑å®–®—∫¥’‡ÕÁπ‡Õ‰¥â∑ÿ°™π‘¥‰¡à«à“®–¡’ ≈”¥—∫‡∫ ‡ªìπÕ¬à“߉√ ´÷Ëß “¡“√∂≈¥§«“¡‰¡à®”‡æ“–≈߉¥â √–¥—∫Àπ÷Ëß‚¥¬°“√∑”°“√«‘‡§√“–Àå melting temperature (Tm) ‡π◊ËÕß®“°°“√∑’Ë¥’‡ÕÁπ‡Õ¡’≈”¥—∫‡∫ µà“ß°—π®–¡’§«“¡ ·µ°µà“ß°—π¢ÕßÕÿ≥À¿Ÿ¡‘∑’Ë„™â„π°“√∑”„Àâ “¬¥’‡ÕÁπ‡Õ‡ âπ§Ÿà ®”π«π§√÷ßË Àπ÷ßË ·¬°ÕÕ°®“°°—πµà“ß°—π ∑”„Àâ “¡“√∂∑¥ Õ∫ ‰¥â«à“¥’‡ÕÁπ‡Õ∑’ˇæ‘Ë¡®”π«π¢÷Èπ„πªØ‘°‘√‘¬“ PCR ¡’ Tm µ√ß °—π°—∫¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬À√◊Õ‰¡à °Á®–∑”„À⧫“¡®”‡æ“–¢Õß °“√∑¥ Õ∫ Ÿß¢÷πÈ πÕ°®“°π’È ¬— ß ¡’ ° “√æ— ≤ π“Õ’ ° ¢—È π Àπ÷Ë ß ‡æ◊Ë Õ ‡æ‘Ë ¡ §«“¡®”‡æ“–‚¥¬„™â‚æ√∫‡ªìπµ—«µ‘¥µ“¡ ‚æ√∫‡ªìπ¥’‡ÕÁπ‡Õ “—ÈπÊ ∑’Ë “¡“√∂®—∫°—∫¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬∫√‘‡«≥√–À«à“ß ‰æ√凡Õ√å ıû ·≈– Ûû ‚¥¬ª≈“¬¢â“ßÀπ÷ßË ¢Õß‚æ√∫®–µ‘¥©≈“° ¥â«¬ ’ø≈Ÿ‚Õ‡√ ‡´π∑å·≈–Õ’°¢â“ßÀπ÷Ëß®–µ‘¥©≈“°¥â«¬µ—«¥Ÿ¥ °≈◊π ’ø≈Ÿ‚Õ‡√ ‡´π∑å∑’ˇ√’¬°«à“ quencher ¥—ßπ—Èπ„π°√≥’∑’Ë ‰¡à ¡’ ° “√‡æ‘Ë ¡ ®”π«π¢Õߥ’ ‡ ÕÁ π ‡Õ· ß∑’Ë ’ ø ≈Ÿ ‚ Õ‡√ ‡´π∑å ª≈àÕ¬ÕÕ°®–∂Ÿ°¥Ÿ¥°≈◊π‚¥¬ quencher ·µà∂â“¡’°“√ √â“ß “¬¥’‡ÕÁπ‡Õ¢÷Èπ ‡Õπ‰´¡å Taq DNA polymerase √â“ß ¥’‡ÕÁπ‡Õ®“°‰æ√凡Õ√å ıû ®π¡“∂÷ß∫√‘‡«≥∑’Ë‚æ√∫®—∫Õ¬Ÿà·≈– √â“ß “¬¢Õߥ’‡ÕÁπ‡ÕµàÕ‡π◊ËÕ߇¢â“¡“„π∫√‘‡«≥∑’Ë‚æ√∫®—∫Õ¬Ÿà ·≈–„™âªØ‘°‘√‘¬“ ıû-Ûû exonuclease ´÷Ë߇ªìπ§ÿ≥ ¡∫—µ‘ (activity) ∑’Ë æ ∫‰¥â „ π‡Õπ‰´¡å DNA polymerase ∑”≈“¬æ—π∏– phosphodiester ¢Õß‚æ√∫ ∑”„Àâ‡∫ ·¬° ÕÕ°®“°‚æ√∫¥â«¬ªØ‘°‘√‘¬“ ıû-Ûû exonuclease ®“°π—Èπ ‡¡◊ËÕ ’ø≈Ÿ‚Õ‡√ ‡´π∑å·≈– quencher ∑’˵‘¥Õ¬Ÿà∑’ˇ∫ ·¬° Àà“ßÕÕ°®“°°—π ∑”„Àâ “¡“√∂«—¥§à“°“√¥Ÿ¥°≈◊π· ߢÕß ’ ø≈Ÿ‚Õ‡√ ‡´π∑å∑’˪≈àÕ¬· ßÕÕ°¡“‰¥â ‚¥¬∑’ˉ¡à¡’µ—«¥Ÿ¥°≈◊π · ß quencher °Á®–∑”„Àâ∑√“∫°“√‡æ‘Ë¡®”π«π¢Õߥ’‡ÕÁπ‡Õ ‰¥â∑—π∑’·≈–‡æ‘Ë¡§«“¡®”‡æ“–¢Õߺ≈‘µº≈ PCR ∑’ˇ°‘¥¢÷Èπ ‡π◊ËÕß®“°¡’°“√‡æ‘Ë¡§«“¡®”‡æ“– Ú à«π§◊ÕπÕ°®“°∑’Ë ‰æ√凡Õ√å®–µâÕß®—∫°—∫¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬Õ¬à“ß®”‡æ“–·≈â« ‚æ√∫®–µâÕß®—∫°—∫¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬Õ¬à“ß®”‡æ“–‡™àπ°—π ∑”„Àâ‡æ‘Ë¡§«“¡®”‡æ“–¢Õß real-time PCR ¡“°¬‘Ëߢ÷Èπ ®–‡ÀÁπ‰¥â«à“‚¥¬À≈—°°“√«‘∏’ PCR “¡“√∂‡æ‘Ë¡ §«“¡‰«„Àâ°—∫µ√«®«‘π‘®©—¬‚√§‰¥â ·µà„π∑“ß°≈—∫°—πÀ“°¡’ °“√ªπ‡ªóôÕπÀ√◊Õ¡’°“√µ°§â“ß (carry over) ¢Õߺ≈º≈‘µ

339

∑’ˇ°‘¥®“°°“√∑” PCR (PCR product) ®–∑”„À⇰‘¥º≈ ∫«°ª≈Õ¡‰¥â ¥—ßπ—Èπ®÷ßµâÕß¡’°“√‡ΩÑ“√–«—ß·≈–ªÑÕß°—π°“√ ªπ‡ªóôÕπÀ√◊Õµ°§â“ß „π°√≥’∑’ˇ°‘¥ªí≠À“ªπ‡ªóôÕπÀ√◊Õ µ°§â“ߢÕߺ≈‘µº≈∑’ˇ°‘¥®“° PCR ·≈–∑”„À⇰‘¥º≈∫«° ª≈Õ¡ “¡“√∂ªÑÕß°—π·≈–·°â‰¢‰¥â‚¥¬„™â‡Õπ‰´¡å UNG ´÷Ëß ‡ªìπ‡Õπ‰´¡å∑’Ë∑”Àπâ“∑’˵—¥ uracil ÕÕ° ∑”„Àâ “¬¢Õߥ’‡ÕÁπ‡Õ ∑’Ë¡’ uracil ‡ªìπ à«πª√–°Õ∫∂Ÿ°∑”≈“¬°àÕπ∑’Ë®–‡√‘Ë¡∑” ªØ‘°‘√‘¬“ PCR ¥—ßπ—ÈπÀ“°„™â‡∫ dUTP ·∑π dTTP „π °“√∑”ªØ‘°√‘ ¬‘ “ PCR º≈º≈‘µ¥’‡ÕÁπ‡Õ∑’‰Ë ¥â®–¡’ dUTP ·∑π∑’Ë dTTP ·≈–À“°∑”°“√‡µ√’¬¡µ—«Õ¬à“ßµ√«®‚¥¬„ à‡Õπ‰´¡å UNG º≈‘µº≈¥’‡ÕÁπ‡Õ∑’ˇ°‘¥®“° PCR ∑’˵°§â“ßÀ√◊Õªπ ‡ªóôÕπ°Á®–∂Ÿ°∑”≈“¬·≈–‡À≈◊Õ‡©æ“–¥’‡ÕÁπ‡Õ‡ªÑ“À¡“¬∑’Ë¡“ ®“°‡™◊ÈÕ∑¥ Õ∫‡∑à“π—Èπ∑’Ë®–∂Ÿ°‡æ‘Ë¡®”π«πµàÕ‰ª „π°“√∑”ªØ‘°‘√‘¬“ PCR π—Èπ∫“ߧ√—Èß„Àâº≈≈∫ ª≈Õ¡‰¥â„π°√≥’∑’Ë¡’ “√¬—∫¬—Èß (inhibitor) °“√∑”ß“π¢Õß ‡Õπ‰´¡å Taq DNA polymerase ªπ‡ªóôÕπÕ¬Ÿà„πµ—«Õ¬à“ß ‡≈◊Õ¥ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß heme ´÷Ëß¡’∏“µÿ‡À≈Á°‡ªìπ à«π ª√–°Õ∫ ®– “¡“√∂√∫°«πªØ‘°√‘ ¬‘ “ PCR ‰¥â„π°√≥’∑¡’Ë °’ “√ ªπ‡ªóôÕπ®“°¢—ÈπµÕπ«‘∏’°“√ °—¥ “√æ—π∏ÿ°√√¡ À√◊Õ°“√„™â “√°—π‡≈◊Õ¥·¢Áßµ—«‡™àπ EDTA ®– “¡“√∂¬—∫¬—È߇Õπ‰´¡å Taq DNA polymerase ‰¥â ‚¥¬°“√®—∫°—∫ magnesium ´÷Ë߇ªìπ‚§·øµ‡µÕ√å¢Õ߇Õπ‰´¡å Taq DNA polymerase ∑”„Àâ ‡ °‘ ¥ ªØ‘ °‘ √‘ ¬ “‰¥â‰¡à¥’ πÕ°®“°π’È„π°√≥’∑’˺ŸâªÉ«¬‚√§ ¿Ÿ¡‘§ÿâ¡°—π∫°æ√àÕß∑’ˇ°‘¥®“°°“√µ‘¥‡™◊ÈÕ HIV ´÷Ëß¡’§«“¡ ®”‡ªìπ®–µâÕß∑“𬓵â“π‰«√— ™π‘¥∑’ˇªìπÕπ“≈Õ§¢Õ߇∫ (base analog) ∑”„Àâ°“√∑¥ Õ∫¥â«¬«‘∏’ PCR „Àâº≈≈∫ ª≈Õ¡‰¥â‡™àπ°—π ‚¥¬ “¡“√∂·°â‰¢‰¥â‚¥¬°“√‡®◊Õ®“ßµ—«Õ¬à“ß ´÷ßË ®–‡ªìπ°“√‡®◊Õ®“ßµ—«¬—∫¬—ßÈ µà“ßÊ „Àâª√‘¡“≥§«“¡‡¢â¡¢âπ¢Õß µ—«¬—∫¬—ÈßπâÕ¬≈ß·≈–‰¡à√∫°«πÀ√◊Õ¬—∫¬—Èߪؑ°‘√‘¬“ PCR ‰¥â °“√µ√«®«‘π®‘ ©—¬‡™◊ÕÈ ¡“≈“‡√’¬¥â«¬«‘∏’ polymerase chain reaction (PCR) °“√µ√«®«‘π‘®©—¬‚√§¡“≈“‡√’¬¥â«¬‡∑§π‘§ PCR ®”‡ªìπµâÕß¡’°“√ÕÕ°·∫∫‰æ√凡Õ√å‡æ◊ËÕ„Àâ®”‡æ“–°—∫¥’‡ÕÁπ‡Õ À√◊ÕÕ“√å‡ÕÁπ‡Õ‡ªÑ“À¡“¬ ‰¥â·°à small subunit 18S ribosomal rRNA gene (18S rRNA) ´÷Ëßæ∫«à“ 18S rRNA gene ¡’®”π«π™ÿ¥¡“°·≈–¡’≈”¥—∫‡∫ §ß∑’ˉ¡à§àÕ¬‡ª≈’Ë¬π ·ª≈ß ´÷Ëß∑”„Àâ “¡“√∂ÕÕ°·∫∫‰æ√凡Õ√å∑’Ë®”‡æ“–‰¥â ∑”„Àâ ‚Õ°“ „π°“√µ√«®À“‡™◊ÈÕæ∫¡’¡“°¢÷Èπ „πªï §.». Ò˘˘Û Snounou ·≈–§≥–˜ ‰¥â√“¬ß“π«‘∏’°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ ¡“≈“‡√’¬¥â«¬«‘∏’ nested PCR ´÷Ëß “¡“√∂√–∫ÿ™π‘¥¢Õ߇™◊ÈÕ

340 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

¡“≈“‡√’¬‰¥â∑—Èß Ù ™π‘¥ ‚¥¬‰æ√凡Õ√å®”π«π ı §Ÿà §Ÿà·√°‡ªìπ ‰æ√凡Õ√å∑¡’Ë §’ «“¡®”‡æ“–°—∫®’π — ·≈–Õ’° Ù §Ÿ¡à §’ «“¡®”‡æ“– °—∫¡“≈“‡√’¬·µà≈–™π‘¥ ‰¥â·°à P. falciparum, P. vivax, P. malariae ·≈– P. ovale ´÷Ëß∑”„À≥âº≈º≈‘µ PCR ¢π“¥ Úı §Ÿà‡∫ (P. falciparum) ÒÚ §Ÿà‡∫ (P. vivax) ÒÙÙ §Ÿà‡∫ (P. malariae) ·≈– ¯ §Ÿà‡∫ (P. ovale) ·≈–∑”°“√Õà“πº≈‚¥¬¥Ÿ·∂∫¥’‡ÕÁπ‡Õ∫π agarose gel electrophoresis º≈°“√∑¥ Õ∫æ∫«à“¡’§«“¡‰«∑’®Ë ”π«π Ò µ—« πÕ°®“°π’Ȭ—ß “¡“√∂µ√«®À“°“√µ‘¥‡™◊ÈÕ¡“≈“‡√’¬·∫∫º ¡ „π°√≥’∑’˵‘¥‡™◊ÈÕ¡“°°«à“Àπ÷Ëß™π‘¥ ´÷ËßÀ“°¥Ÿ®“°øî≈塇≈◊Õ¥ ∫“ߧ√—ÈßÕ“®®–‰¡à “¡“√∂∫àß™’ȉ¥â ·µàæ∫«à“®“°°“√µ√«® ¥â«¬«‘∏’ PCR π’È ¡’°“√‡°‘¥º≈≈∫ª≈Õ¡·≈–º≈∫«°ª≈Õ¡ ‰¥â„π —¥ à«π ı/Ò˘ˆ ·≈– Òˆ/Ò˘ˆ µ“¡≈”¥—∫ „πªï §.». Úˆ Johnston ·≈–§≥–Ò˘ ‰¥â ∑”°“√»÷°…“¬◊π¬—π¥â«¬«‘∏’‡¥’¬«°—π°—∫ Snounou (Ò˘˘Û) æ∫«à“‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫«‘∏’°“√¥Ÿ¥â«¬°≈âÕß®ÿ≈∑√√»π凡◊ËÕ ¬âÕ¡øî≈塇≈◊Õ¥¥â«¬ ’¬‘¡´à“æ∫«à“ «‘∏’ nested PCR „Àâ §«“¡‰«·≈–§«“¡®”‡æ“– Ÿß°«à“«‘∏°’ “√¥Ÿ¥«â ¬°≈âÕß®ÿ≈∑√√»πå æ∫«à“¡’ ˜ √“¬®“°∑—ÈßÀ¡¥ ˜˜ √“¬∑’Ë„Àâº≈≈∫ª≈Õ¡‡¡◊ËÕ µ√«®¥â«¬«‘∏’°≈âÕß®ÿ≈∑√√»πå·µà„Àâº≈∫«°°—∫ nested PCR πÕ°®“°π’È°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬¥â«¬«‘∏’ nested PCR ®– “¡“√∂µ√«®æ∫°“√µ‘¥‡™◊ÈÕ¡“°°«à“Àπ÷Ëß™π‘¥ (mixed infection) ‰¥â¡“°°«à“«‘∏’°≈âÕß®ÿ≈∑√√»πå ´÷Ëß®– ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ„π°“√√—°…“‰¥â πÕ°‡Àπ◊Õ®“° 18S rRNA gene ·≈⫬—ß¡’°“√ »÷°…“‚¥¬„™â¬’πÕ◊ËπÊ ®“°‡™◊ÈÕ¡“≈“‡√’¬ ‡™àπ circumsporozoite gene, 21 bp repeat sequence, ring-infected erythrocyte surface antigen (pf155/RESA) ·≈– dihydrofolate reductase (DHFR) ·µà¡’¢âÕ®”°—¥§◊Õ “¡“√∂µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬‰¥â∫“ß™π‘¥‡∑à“π—Èπ ·≈–‡¡◊ËÕ ‡ª√’¬∫‡∑’¬∫°—∫«‘∏’°“√µ√«®¥â«¬°≈âÕß®ÿ≈∑√√»πå·≈â«„Àâ§à“ §«“¡‰«µË”°«à“®÷߉¡à‡ªìπ∑’Ëπ‘¬¡π”¡“„™âÚ „πªï §.». Ò˘˘˘ Tham ·≈–§≥–ÚÒ ‰¥â∑”°“√∑¥ Õ∫§«“¡‰«„π°“√µ√«® «‘ π‘ ® ©— ¬‚√§¡“≈“‡√’¬¥â«¬«‘∏’ multiplex PCR ‚¥¬„™â ‰æ√凡Õ√å∑’Ë®”‡æ“–°—∫ mitochondria cytochrome C oxdiase subunit I (cox I) ¢Õß·µà≈– ªï™’Ë æ∫«à“¡’ ª√– ‘∑∏‘¿“楒 §«“¡‰«„πµ√«®À“‡™◊ÈÕ¡“≈“‡√’¬∑’Ë “¡“√∂ µ√«®æ∫‰¥â§◊Õ .Ò µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ µàÕ¡“„πªï §.». ÚÙ Fabre ·≈–§≥–ÚÚ ‰¥â∑”°“√∑¥ Õ∫¥â«¬«‘∏’ real-time PCR ·≈–„™â ’ SYBR green I ‡ªìπµ—«µ‘¥µ“¡ æ∫«à“„Àâ§à“§«“¡‰«µË”≈ߧ◊Õ “¡“√∂µ√«®æ∫‰¥â§◊Õ .Ûı

µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ µàÕ¡“‰¥â¡’°“√∑¥ Õ∫°“√µ√«® «‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬¥â«¬«‘∏’ real-time PCR µàÕ¡“Õ’° À≈“¬§√—Èß‚¥¬„™â ’ø≈Ÿ‚Õ‡√ ‡´π∑å ‚æ√∫ ‰æ√凡Õ√å ∑’Ë®”‡æ“– °—∫¬’πµà“ßÊ ¢Õ߇™◊ÈÕ¡“≈“‡√’¬ ·µàæ∫«à“ª√– ‘∑∏‘¿“æ „π °“√∑¥ Õ∫·≈–§«“¡‰«‰¡à·µ°µà“ßÕ¬à“ß™—¥‡®π®“°«‘∏’ conventional PCR ¢Õß Snounou˘ ¥—ßπ—Èπ°“√µ√«®«‘π‘®©—‚¥¬«‘∏’ real-time PCR ´÷ËßπÕ°®“°‰¡à„Àâº≈‡ªìπ∑’Ëπà“ æÕ„®·≈â« ¬—ßæ∫«à“¡’√“§“·æß·≈–®”‡ªìπµâÕß„™â‡§√◊ËÕß¡◊Õ ®”‡æ“– ”À√—∫∑¥ Õ∫´÷Ëß¡’√“§“ Ÿß¡“° ¥—ßπ—Èπ°“√µ√«® «‘π‘®©—¬¥â«¬«‘∏’ conventional PCR πà“‡ªìπ∑“߇≈◊Õ°„π °“√µ√«®«‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬¡“°°«à“«‘∏’ real-time PCR °“√µ√«®«‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬¥â«¬«‘∏’ PCR ·¡â«à“ ®–„Àâº≈°“√∑¥ Õ∫√«¥‡√Á« ·¡à𬔠·µà¬—ß¡’¢âÕ®”°—¥Õ¬Ÿà∫“ß ª√–°“√ ‡™à𠇧√◊ËÕߧ«∫§ÿ¡√Õ∫Õÿ≥À¿Ÿ¡‘ (thermal cycle) ´÷Ëß¡’√“§“·æß·¡â«à“®–∂Ÿ°°«à“‡§√◊ËÕß real-time PCR °Áµ“¡ ®÷ ߉¡à‡À¡“–°—∫°“√π”«‘∏’ PCR „π°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ ¡“≈“‡√’¬ ‡π◊ËÕß®“°ºŸâªÉ«¬ à«π„À≠à®–Õ¬Ÿà„πª√–‡∑»¬“°®π ·≈–‰¡à ¡’ ‡ §√◊Ë Õ ß¡◊ Õ ¥— ß °≈à “ «Õ¬à “ ß‡æ’ ¬ ßæÕ ”À√— ∫ ∑¥ Õ∫ πÕ°®“°π’È«‘∏’ PCR ¬—߉¡à‡À¡“–°—∫°“√𔉪„™â„π°“√µ√«® «‘π‘®©—¬∫√‘‡«≥∑’ˇªìπ·À≈àß√–∫“¥ ‡π◊ËÕß®“°µâÕß„™â‰øøÑ“ ∑”„ÀâµâÕ߇°Á∫µ—«Õ¬à“ߺŸâªÉ«¬·≈–π”¡“∑¥ Õ∫¿“¬À≈—ß ´÷Ëß °“√∑’ˉ¡à‰¥â∑¥ Õ∫∑—π∑’Õ“®∑”„Àâ “√æ—π∏ÿ°√√¡ ≈“¬µ—«‰¥â (degrade) À“°‰¡à¡√’ –∫∫°“√‡°Á∫·≈–√–∫∫°“√ ¢π àß∑’¥Ë æ’ Õ ®÷ ߉¥â¡’°“√æ—≤π“ transport media ”À√—∫°“√¢π àß µ—«Õ¬à“߇æ◊ËÕ‡°Á∫√—°…“§ÿ≥¿“æµ—«Õ¬à“ß °“√À¬¥‡≈◊Õ¥≈ß∫π °√–¥“…°√Õß∑’Ë –Õ“¥°Á‡ªìπÕ’°Àπ÷Ëß«‘∏’∑’Ë “¡“√∂π”¡“„™â‰¥â °—∫°“√‡°Á∫µ—«Õ¬à“ß¡“≈“‡√’¬·≈– “¡“√∂π”¡“ °—¥¥’‡ÕÁπ‡Õ ‰¥â¿“¬À≈—ß·≈–‡ªìπ∑’Ëπ‘¬¡„™â°—π °“√µ√«®«‘ π‘ ® ©— ¬ ‡™◊È Õ ¡“≈“‡√’ ¬ ¥â « ¬«‘ ∏’ PCR “¡“√∂µ√«®À“‡™◊ÈÕ‰¥â¥’∑’Ë ÿ¥§◊Õ°“√µ√«®À“‡™◊ÈÕ¡“≈“‡√’™π‘¥øí≈´‘æ“√—Ë¡§◊Õ .Ù µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ÚÛ ´÷ßË ¡’§«“¡‰« Ÿß¡“° „π°√≥’∑º’Ë ªŸâ «É ¬¡’‡≈◊Õ¥∑—ßÈ À¡¥√à“ß°“¬Õ¬Ÿà ı ≈‘µ√ À¡“¬§«“¡«à“§«“¡‰«„π°“√µ√«®‡∑à“°—∫ Ú, µ—«¢Õ߇™◊ÈÕ¡“≈“‡√’¬ „π°√≥’π’È∑”„À⇰‘¥·π«§‘¥ Û ª√–°“√ §◊Õ Ò. √–¥—∫¢Õß parasitemia .Ù µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ π—ÈπºŸâªÉ«¬Õ“®®–¬—߉¡à· ¥ßÕ“°“√ ´÷Ë߇ªìπ ¢âÕ¥’„π°√≥’∑’˺ŸâªÉ«¬‡ªìππ—°∑àÕ߇∑’ˬ«®“°ª√–‡∑»∑’ˉ¡à„™à ·À≈àß√–∫“¥¢Õ߇™◊ÈÕ¡“≈“‡√’¬‡¥‘π∑“߉ª¬—ß·À≈àß√–∫“¥ ·≈– ‡√‘Ë¡¡’Õ“°“√À√◊Õµ√«®§—¥°√Õß«à“¡’°“√µ‘¥‡™◊ÈÕÀ√◊Õ‰¡àÀ≈—ß ®“°‡¥‘π∑“߉ª„πæ◊Èπ∑’Ë∑’Ë¡’°“√√–∫“¥

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Ú. „π°√≥’¢Õ߇™◊ÈÕ¡“≈“‡√’¬‚¥¬‡©æ“–™π‘¥øí≈´‘æ“√—Ë¡π—Èπ®–¡’ª√“°Ø°“√≥å sequestration ‚¥¬‡™◊ÈÕ ¡“≈“‡√’¬®–‰ª‡°“–Õ¬Ÿµà “¡ºπ—ßÀ≈Õ¥‡≈◊Õ¥∑”„À⇙◊ÕÈ ¡“≈“‡√’à«πÀπ÷Ëß ‰¡àÕ¬Ÿà„πµ—«Õ¬à“߇≈◊Õ¥∑’ˇ®“–µ√«® ¥—ßπ—Èπ®–∑”„Àâ §«“¡‰«„π°“√µ√«®æ∫‡™◊Èե⫬«‘∏’ PCR ≈¥≈ß À√◊ÕºŸâªÉ«®–µâÕß¡’‡™◊ÈÕ¡“°°«à“ Ú, µ—«„π√à“ß°“¬ ´÷ËߺŸâªÉ«Õ“®®–‡√‘Ë¡· ¥ßÕ“°“√¢Õß‚√§·≈â« Û. „π°√≥’ºŸâªÉ«¬∑’ËÕ“»—¬Õ¬Ÿà„π·À≈àß√–∫“¥ ºŸâªÉ«Õ“®®–‰¡à¡’Õ“°“√·¡â«à“¡’‡™◊ÈÕ¡“≈“‡√’¬Õ¬Ÿà„π√à“ß°“¬ ¥—ßπ—Èπ „π¥â“π°“√√—°…“ºŸªâ «É ¬¡“≈“‡√’¬ °“√µ√«®«‘π®‘ ©—¬‡™◊ÕÈ ¡“≈“‡√’¥â«¬‡∑§π‘§ PCR Õ“®®–‰¡à¡’§«“¡®”‡ªìπ °“√µ√«®¥â«¬«‘∏’ RDT ´÷Ëß¡’§«“¡‰«µË”°«à“Õ“®®–‡À¡“– ”À√—∫°“√µ√«®‡æ◊ËÕ °“√√—°…“¡“°°«à“ ¥—ßπ—Èπ„π°“√µ√«®ºŸâªÉ«¬∑’Ë ß —¬«à“µ‘¥‡™◊ÈÕ¡“≈“‡√’¥â«¬«‘∏’ RDT ∑’Ë¡’§«“¡‰«Õ¬Ÿà∑’˪√–¡“≥ Ò µ—«µàÕ‡≈◊Õ¥ Ò ‰¡‚§√≈‘µ√ ®–√«¥‡√Á«·≈–¡’ª√– ‘∑∏‘¿“æ¡“°°«à“°“√ µ√«®¥â«¬«‘∏’ PCR ´÷ËßµâÕß„™â‡«≈“π“π ∑”„Àâ “¡“√∂√—°…“ ºŸâªÉ«¬‰¥â√«¥‡√Á«·≈–∑—π∑à«ß∑’ «‘∏’ PCR πà“®–‡ªìπ«‘∏’∑’Ë„™â ”À√—∫∑¥ Õ∫„πß“π«‘®—¬ √–∫“¥«‘∑¬“À√◊Õ°“√§«∫§ÿ¡‚√§ √«¡∂÷ß°“√µ√«®«‘π®‘ ©—¬ ”À√—∫°“√æ—≤π“À√◊Õ∑¥ Õ∫«—§´’π ‚√§¡“≈“‡√’¬ ´÷Ëß®”‡ªìπµâÕß„™â«‘∏’∑’Ë¡’§«“¡‰« §«“¡®”‡æ“– ·≈–∂Ÿ°µâÕß Ÿß πÕ°®“°π’ȇ∑§π‘§ real-time PCR ¡’ ª√–‚¬™πåÕ¬à“ß¡“°„π°“√𔉪„™â„π°“√µ‘¥µ“¡°“√¥◊ÕÈ ¬“¢Õß ‡™◊ÈÕ¡“≈“‡√’¬ ´÷Ëß®– “¡“√∂∫àß™’È®”π«π™ÿ¥¢Õ߬’π¥◊ÈÕ¬“‰¥â Loop-mediated isothermal amplification (LAMP) «‘∏’ loop-mediated isothermal amplification æ—≤π“‚¥¬∫√‘…—∑ Eiken Chemical Co., Ltd. ‡ªìπ«‘∏’°“√ ‡æ‘Ë¡¥’‡ÕÁπ‡Õ§≈â“¬Ê °—∫°“√∑” PCR ·µà·µ°µà“ß®“° PCR ∑’ˇªìπ°“√‡æ‘Ë¡¥’‡ÕÁπ‡Õ∑’ËÕÿ≥À¿Ÿ¡‘‡¥’¬«°—πµ≈Õ¥ªØ‘°‘√‘¬“§◊Õ ∑’ËÕÿ≥À¿Ÿ¡‘ª√–¡“≥ Ùı-ˆı Õß»“‡´≈‡´’¬ ¥â«¬‡Õπ‰´¡å Bst DNA polymerase ‚¥¬¥’‡ÕÁπ‡Õ∑’ˇ°‘¥¢÷Èπ®–‡™◊ËÕ¡µàÕ °—π‡ªì𠓬¬“«µàÕ‡π◊ËÕß°—π ‡¡◊ËÕ¡’°“√ √â“ß “¬¥’‡ÕÁπ‡Õ„π ªØ‘°‘√‘¬“®–¡’°“√„™â dNTPs ∑”„À⇰‘¥ PPi (Pyrophosphate) ·≈– PPi ∑’ˇ°‘¥¢÷Èπ®–∑”ªØ‘°‘√‘¬“°—∫ magnesium ´÷Ëß®–µ°µ–°Õπ·≈–¢ÿàπ ∑”„Àâ “¡“√∂«—¥°“√‡°‘¥ªØ‘°‘√‘¬“ ‰¥â¥â«¬‡§√◊ËÕß«—¥§«“¡¢ÿàπ ‚¥¬„™â‡«≈“„π°“√∑”ªØ‘°‘√‘¬“‡æ’¬ß Ò ™—Ë«‚¡ß ¥—ßπ—Èπ®÷ß¡’°“√π”‡∑§π‘§ LAMP ¡“ª√–¬ÿ°µå„™â °—πÕ¬à“ß·æ√àÀ≈“¬„π°“√æ—≤π“°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ°àÕ‚√§ µà“ßÊ ‚¥¬‡©æ“–Õ¬à“߬‘Ë߇™◊ÈÕ‰«√— ‡™à𠇙◊ÈÕ‰¢âÀ«—¥„À≠à H5N1ÚÙ H1N1Úı corona (SARS)Úˆ, Ú˜ ‡ªìπµâπ „π

341

°“√ √â“ß “¬¥’‡ÕÁπ‡Õ¥â«¬«‘∏’ LAMP ®–¡’‰æ√凡Õ√å Ù-ˆ µ—« ‰¥â·°à Forward Inner Primer (FIP) Forward Primer (F3) Backward Inner Primer (BIP) Backward Primer (B3) Forward Loop Primer (FLP) Backward Loop Primer (BLP) ‚¥¬‰æ√凡Õ√å FLP ·≈– BLP Õ“®®–„™âÀ√◊Õ‰¡à„™â °Á‰¥â‡π◊ÕË ß®“°‡ªìπµ—«‡√àߪؑ°√‘ ¬‘ “∑’∑Ë ”„À⇰‘¥ªØ‘°√‘ ¬‘ “ LAMP ‡√Á«¢÷Èπ ®–‡ÀÁπ‰¥â«à“ FIB ·≈– BIP ®–¡’ à«π∑’Ë “¡“√∂®—∫ ‰¥â∑—È߇ âπ sense ·≈– antisense ¥—ßπ—Èπ‡¡◊ËÕ‡°‘¥ªØ‘°‘√‘¬“ LAMP “¬¢Õߥ’‡ÕÁπ‡Õ®–‡™◊ËÕ¡µàÕ°—π‡ªìπ loop ∫√‘‡«≥ ª≈“¬¢Õߥ’‡ÕÁπ‡Õ‡ªÑ“À¡“¬∑—Èß Õߢâ“ß ·≈–®–‡™◊ËÕ¡µàÕ°—∫ ¥’‡ÕÁπ‡Õ‡ âπ∑’Ë √â“ߢ÷Èπ„À¡à ∑”„À⇰‘¥‡ªìπ¥’‡ÕÁπ‡Õ “¬¬“« ‡°’ˬ«‚¬ß°—π‰ª ‚¥¬°“√·ª≈º≈¢Õß LAMP “¡“√∂∑”‰¥â À≈“¬«‘∏‰’ ¥â·°à «—¥§«“¡¢ÿπà ¥â«¬µ“‡ª≈à“À√◊Õ‡§√◊ÕË ß«—¥§«“¡¢ÿπà (turbidity meter) ’ø≈Ÿ‚Õ‡√ ‡´π∑å SYBR green ´÷Ëß À“°‡ªìπ ’‡¢’¬« –∑âÕπ· ß®–‡ªìπº≈∫«°·≈–‡ªìπ ’ â¡„π °√≥’∑’ˇªìπº≈≈∫ πÕ°®“°π’Ȭ—ß “¡“√∂𔉪∑¥ Õ∫¥â«agarose gel electrophoresis ´÷Ëß®–‡°‘¥·∂∫¥’‡ÕÁπ‡Õ‡ªìπ ·∫∫¢—Èπ∫—π‰¥ (ladder) µ“¡§«“¡¬“«¢Õß “¬¥’‡ÕÁπ‡Õ∑’Ë √â“ߢ÷Èπ „π¢≥–∑’˺≈≈∫®–‰¡àæ∫·∂∫¢Õߥ’‡ÕÁπ‡Õ „πªï §.». Ò˘˘ˆ Poon ·≈–§≥–Ú¯ ‰¥â√“¬ß“π °“√µ√«®«‘π®‘ ©—¬‡™◊ÕÈ ¡“≈“‡√’¬™π‘¥øí≈´‘æ“√—¡Ë ¥â«¬ «‘∏’ LAMP ‚¥¬„™â‰æ√凡Õ√å∑Õ’Ë Õ°·∫∫®”‡æ“–°—∫ 18S ribosomal RNA gene ¢Õ߇™◊ÈÕ P. falciparum æ∫«à“„Àâ§à“§«“¡‰«·≈–§«“¡ ®”‡æ“–√âÕ¬≈– ˘ı ·≈– ˘˘ µ“¡≈”¥—∫ µàÕ¡“„πªï §.». Ú˜ Paris ·≈–§≥–Ú˘ ‰¥â∑”°“√æ—≤π“‡∑§π‘§ LAMP ‚¥¬„™â ‰ æ√å ‡ ¡Õ√å ∑’Ë Õ Õ°·∫∫®”‡æ“–°— ∫ histidine-rich protein encoding gene æ∫«à“„Àâ§à“§«“¡‰«·≈–§«“¡ ®”‡æ“–√âÕ¬≈– ˜ˆ.Ò ·≈– ¯˘.ˆ µ“¡≈”¥—∫ ®–‡ÀÁπ‰¥â«à“ ‚¥¬ à«π„À≠à®– “¡“√∂µ√«®À“‡™◊ÈÕ¡“≈“‡√’¬‰¥â‡æ’¬ß™π‘¥ ‡¥’¬« ¥—ßπ—ÈπµàÕ¡“„πªï §.». Ú˜ Han ·≈–§≥–Û ‰¥â æ—≤π“«‘∏’°“√µ√«®‡™◊ÈÕ¡“≈“‡√’¬∑—Èß Ù ™π‘¥ ‚¥¬„™â‰æ√凡Õ√å ∑’ËÕÕ°·∫∫®”‡æ“–°—∫ 18S ribosomal RNA gene æ∫«à“ „Àâ§“à §«“¡‰«·≈–§«“¡®”‡æ“–√âÕ¬≈– ˘¯.ı ·≈– ˘Ù.Û µ“¡ ≈”¥—∫ „πªï §.». Ú˘ Yamamura ·≈–§≥–ÛÒ ‰¥â æ—≤π“„Àâ«‘∏’°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬¥â«¬«‘∏’ LAMP ·≈–„™â°“√«‘‡§√“–Àå melting temperature √à«¡¥â«¬ æ∫«à“

342 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

„Àâ§à“§«“¡‰« Ÿß¢÷Èπ§◊Õ√âÕ¬≈– ˘˜.¯ ·≈–§«“¡®”‡æ“– √âÕ¬≈– ¯ı.˜ „πªï §.». ÚÒ Chen ·≈–§≥–ÛÚ ‰¥â √“¬ß“π°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬™π‘¥‰«·«°´å ‚¥¬„™â ‰æ√凡Õ√å∑Õ’Ë Õ°·∫∫®”‡æ“–°—∫ 18S ribosomal RNA gene ¢Õ߇™◊ÕÈ P. vivax æ∫«à“„Àâ§“à §«“¡‰«·≈–§«“¡®”‡æ“–√âÕ¬≈– ˘¯.Û ·≈– Ò µ“¡≈”¥—∫ ·≈–‡¡◊ËÕ∑”°“√‡µ√’¬¡¥’‡ÕÁπ‡Õ ®“°‡≈◊Õ¥‚¥¬«‘∏’µâ¡ (heat-treated blood) æ∫«à“¡’§«“¡ ‰«·≈–§«“¡®”‡æ“–√âÕ¬≈– ˘Û.Û ·≈– Ò µ“¡≈”¥—∫ ®–‡ÀÁπ‰¥â«à“°“√µ√«®«‘π‘®©—¬‡™◊ÈÕ¡“≈“‡√’¬¥â«¬«‘∏’ LAMP ‡ªìπ«‘∏’∑’Ë∂Ÿ°µâÕß ·¡à𬔠¡’§«“¡‰«·≈–§«“¡ ®”‡æ“–µàÕ‡™◊ÈÕ¡“≈“‡√’¬ πÕ°®“°π’Ȭ—ß¡’√“§“∂Ÿ° ·≈–‰¡à µâÕß°“√‡§√◊ËÕß¡◊Õ∑’Ë¡’√“§“·æß “¡“√∂∑¥ Õ∫‰¥â¥â«¬µ“ ´÷Ë߇À¡“– ¡°—∫°“√ª√–¬ÿ°µå„™â„π°“√µ√«®„πæ◊È π ∑’Ë · À≈à ß √–∫“¥ ‚¥¬À“°µ√«®§«∫§Ÿ°à ∫— «‘∏’ RDT ·≈–°≈âÕß®ÿ≈∑√√»πå ·≈â«®–∑”„Àâº≈°“√µ√«®¡’§«“¡‰« §«“¡®”‡æ“– ·≈–§«“¡ ·¡à𬔥’¢÷Èπ ´÷Ëß®–µâÕß∑”°“√∑¥ Õ∫µàÕ‰ª „π°“√∑¥ Õ∫ «‘∏’ LAMP Õ“®®–∑”°“√∑¥ Õ∫‰¥âßà“¬·≈–‰¡à´—∫´âÕπ ·µà Õ“®„Àâº≈∫«°ª≈Õ¡‰¥âÀ“°„™âª√‘¡“≥¢Õ߉æ√凡Õ√å¡“°‡°‘π‰ª ´÷ßË ®–µâÕß√–¡—¥√–«—ßÕ¬à“ß¡“°„π°“√‡µ√’¬¡ªØ‘°√‘ ¬‘ “„À⡧’ «“¡ ·¡à𬔷≈–∂Ÿ°µâÕß

‡Õ° “√Õâ“ßÕ‘ß Ò. World Malaria Report. Geneva 2009. Ú. Shiff CJ, Premji Z, Minjas JN. The rapid manual ParaSight-F test. A new diagnostic tool for Plasmodium falciparum infection. Trans R Soc Trop Med Hyg 1993;87:646-8. Û. Piper R, Lebras J, Wentworth L, Hunt-Cooke A, Houze S, Chiodini P, et al. Immunocapture diagnostic assays for malaria using Plasmodium lactate dehydrogenase (pLDH). Am J Trop Med Hyg 1999;60:109-18. Ù. Moody AH, Chiodini PL. Non-microscopic method for malaria diagnosis using OptiMAL IT, a second-generation dipstick for malaria pLDH antigen detection. Br J Biomed Sci 2002;59:228-31. ı. Iqbal J, Sher A, Rab A. Plasmodium falciparum histidine-rich protein 2-based immunocapture diagnostic assay for malaria: cross-reactivity with rheumatoid factors. J Clin Microbiol 2000; 38:1184-6.

ˆ. Iqbal J, Khalid N, Hira PR. Performance of rapid malaria Pf antigen test for the diagnosis of malaria and false-reactivity with autoantibodies. Adv Exp Med Biol 2003;531:135-48. ˜. Snounou G, Viriyakosol S, Zhu XP, Jarra W, Pinheiro L, do Rosario VE, et al. High sensitivity of detection of human malaria parasites by the use of nested polymerase chain reaction.

Mol Biochem Parasitol 1993;61:315-20. ¯. Snounou G, Viriyakosol S, Jarra W, Thaithong S, Brown KN. Identification of the four human malaria parasite species in field samples by the polymerase chain reaction and detection of a high prevalence of mixed infections. Mol Biochem Parasitol 1993;58:283-92. ˘. Berry A, Benoit-Vical F, Fabre R, Cassaing S, Magnaval JF. PCR-based methods to the diagnosis of imported malaria. Parasite 2008;15:4848. Ò. Snounou G. Detection and identification of the four malaria parasite species infecting humans

by PCR amplification. Methods Mol Biol 1996;50:263-91. ÒÒ. Oquendo P, Goman M, Mackay M, Langsley G, Walliker D, Scaife J. Characterisation of a repetitive DNA sequence from the malaria parasite, Plasmodium falciparum. Mol Biochem Parasitol 1986;18:89-101. ÒÚ. Holmberg M, Shenton FC, Franzen L, Janneh K, Snow RW, Pettersson U, et al. Use of a DNA hybridization assay for the detection of Plasmodium falciparum in field trials. Am J Trop Med Hyg 1987;37:230-4. ÒÛ. McLaughlin GL, Breman JG, Collins FH, Schwartz IK, Brandling-Bennett AD, Sulzer AJ, et al. Assessment of a synthetic DNA probe for Plasmodium falciparum in African blood specimens. Am J Trop Med Hyg 1987;37:2736. ÒÙ. McLaughlin GL, Ruth JL, Jablonski E, Steketee R, Campbell GH. Use of enzyme-linked syn-

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

thetic DNA in diagnosis of falciparum malaria.

Lancet 1987;1:714-6. Òı. Sethabutr O, Brown AE, Gingrich J, Webster HK, Pooyindee N, Taylor DN, et al. A comparative field study of radiolabeled and enzymeconjugated synthetic DNA probes for the diagnosis of falciparum malaria. Am J Trop Med Hyg 1988;39:227-31. Òˆ. McCutchan TF, de la Cruz VF, Lal AA, Gunderson JH, Elwood HJ, Sogin ML. Primary sequences of two small subunit ribosomal RNA genes from Plasmodium falciparum. Mol Biochem Parasitol 1988;28:63-8. Ò˜. Waters AP, McCutchan TF. Rapid, sensitive diagnosis of malaria based on ribosomal RNA. Lancet 1989;1:1343-6. Ò¯. Barker RH, Jr., Suebsaeng L, Rooney W, Wirth DF. Detection of Plasmodium falciparum infection in human patients: a comparison of the DNA probe method to microscopic diagnosis.

Am J Trop Med Hyg 1989;41:266-72. Ò˘. Johnston SP, Pieniazek NJ, Xayavong MV, Slemenda SB, Wilkins PP, da Silva AJ. PCR as a confirmatory technique for laboratory diagnosis of malaria. J Clin Microbiol 2006;44: 1087-9. Ú. Weiss JB. DNA probes and PCR for diagnosis of parasitic infections. Clin Microbiol Rev 1995; 8:113-30. ÚÒ. Tham JM, Lee SH, Tan TM, Ting RC, Kara UA. Detection and species determination of malaria parasites by PCR: comparison with microscopy and with ParaSight-F and ICT malaria Pf tests in a clinical environment. J Clin Microbiol 1999;37:1269-73. ÚÚ. Fabre R, Berry A, Morassin B, Magnaval JF. Comparative assessment of conventional PCR with multiplex real-time PCR using SYBR Green I detection for the molecular diagnosis of imported malaria. Parasitology 2004;128:1521.

343

ÚÛ. Elsayed S, Plewes K, Church D, Chow B, Zhang K. Use of molecular beacon probes for real-time PCR detection of Plasmodium falciparum and other plasmodium species in peripheral blood specimens. J Clin Microbiol 2006; 44:622-4. ÚÙ. Jayawardena S, Cheung CY, Barr I, Chan KH, Chen H, Guan Y, et al. Loop-mediated isothermal amplification for influenza A (H5N1) virus. Emerg Infect Dis 2007;13:899-901. Úı. Kubo T, Agoh M, Mai le Q, Fukushima K, Nishimura H, Yamaguchi A, et al. Development of a reverse transcription-loop-mediated isothermal amplification assay for detection of pandemic (H1N1) 2009 virus as a novel molecular method for diagnosis of pandemic influenza in resource-limited settings. J Clin Microbiol 2010;48:728-35. Úˆ. Poon LL, Leung CS, Tashiro M, Chan KH, Wong BW, Yuen KY, et al. Rapid detection of the severe acute respiratory syndrome (SARS) coronavirus by a loop-mediated isothermal amplification assay. Clin Chem 2004;50:10502. Ú˜. Hong TC, Mai QL, Cuong DV, Parida M, Minekawa H, Notomi T, et al. Development and evaluation of a novel loop-mediated isothermal amplification method for rapid detection of severe acute respiratory syndrome coronavirus. J Clin Microbiol 2004;42:195661. Ú¯. Poon LL, Wong BW, Ma EH, Chan KH, Chow LM, Abeyewickreme W, et al. Sensitive and inexpensive molecular test for falciparum malaria: detecting Plasmodium falciparum DNA directly from heat-treated blood by loop-mediated isothermal amplification. Clin Chem 2006;52:303-6. Ú˘. Paris DH, Imwong M, Faiz AM, Hasan M, Yunus EB, Silamut K, et al. Loop-mediated isothermal PCR (LAMP) for the diagnosis of

344 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

falciparum malaria. Am J Trop Med Hyg 2007;77:972-6. Û. Han ET, Watanabe R, Sattabongkot J, Khuntirat B, Sirichaisinthop J, Iriko H, et al. Detection of four Plasmodium species by genus- and species-specific loop-mediated isothermal amplification for clinical diagnosis. J Clin Microbiol 2007;45:2521-8. ÛÒ. Yamamura M, Makimura K, Ota Y. Evaluation of a new rapid molecular diagnostic system for Plasmodium falciparum combined with DNA filter paper, loop-mediated isothermal amplification, and melting curve analysis. Jpn J Infect Dis 2009;62:20-5.

ÛÚ. Chen JH, Lu F, Lim CS, Kim JY, Ahn HJ, Suh IB, et al. Detection of Plasmodium vivax infection in the Republic of Korea by loopmediated isothermal amplification (LAMP).

Acta Trop 2010;113:61-5.

Abstract Molecular diagnosis of malaria Veerachai Eursitthichai Graduate Program in Biomedical Sciences, Faculty of Allied Health Sciences, Thammasat University Malaria is an important infectious disease and causes severe public health problems in many tropical countries including Thailand. An effective diagnosis to discriminate the various Plasmodium species is needed to select the proper regimen for malarial treatment. Diagnosis of malaria by thick or thin blood films under the light microscope is the gold standard. The limitations of this technique are low sensitivity (5-20 parasites/µl) and the need for an experienced examiner able to discriminate the Plasmodium species. Diagnosis can also be based on the detection of circulating antibodies and antigens. The sensitivity of the immuno-chromatographical test (ICT) in detection of antigen is 100 parasites/µl. Nucleic acid based diagnosis, e.g., hybridization, polymerase chain reaction (PCR) or loop-mediated isothermal amplification (LAMP), can detect as little as 0.004 parasites/µl. Although the sensitivity of molecular diagnosis is very high, it requires in general expensive equipment. A favorable method which is inexpensive and effective for detection of malaria such as LAMP should be applied. In this article, the rationale, principle, advantage and disadvantage of each technique have been outlined to serve as a diagnostic guideline in the treatment of malaria.

Key words: Malaria, Diagnosis, Molecular biology

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

345

∫∑§«“¡øóôπ«‘™“

¿“«–æ‘…®“°¬“™“ ª√’¬æ√√≥ Õ√ÿ≥“°Ÿ√

∫∑§—¥¬àÕ „πªí®®ÿ∫—π∑“ß°“√·æ∑¬å¡’°“√„™â¬“™“°—πÕ¬à“ß·æ√àÀ≈“¬ ¿“«–æ‘…®“°¬“™“ (local anesthetic toxicity) ¡’º≈µàÕ∑—Èß√–∫∫ª√– “∑ à«π°≈“ß·≈–√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ‚¥¬Õ“°“√∑“ß√–∫∫ª√– “∑ ¡’µ—Èß·µà°“√‰¥â¬‘π °“√√—∫√ À√◊Õ°“√¡Õ߇ÀÁπº‘¥ª√°µ‘‰ª®π∂÷ßÕ“°“√√ÿπ·√ß ‡™àπ Õ“°“√™—° ·≈–À¡¥ µ‘‰¥â à«πÕ“°“√· ¥ß∑“ß√–∫∫ À—«„®·≈–À≈Õ¥‡≈◊Õ¥· ¥ßÕÕ°„π√Ÿª¢ÕßÀ—«„®‡µâπº‘¥®—ßÀ«– Õ—π‰¥â·°à °“√π”°√–· ‰øøÑ“º‘¥ª√°µ‘ (conduction delay) À—«„®ÀâÕß≈à“߇µâπ‡√Á«º‘¥ª√°µ‘ (ventricular tachycardia or fibrillation) À√◊Õ·¡â°√–∑—ËßÀ—«„®À¬ÿ¥‡µâπ (sinus arrest or asystole) „π∫∑§«“¡π’È®–‰¥â°≈à“«∂÷ß°≈‰°°“√‡°‘¥¿“«–æ‘…®“°¬“™“ ·≈–·π«∑“ߪؑ∫—µ‘‡¡◊ËÕ‡°‘¥¿“«–æ‘… √ÿπ·√ߥ—ß°≈à“« §” ”§—≠: ¬“™“, ¿“«–æ‘…®“°¬“™“, ¿“«–æ‘…µàÕ√–∫∫ª√– “∑, ¿“«–æ‘…µàÕ√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ lidocaine, bupivacaine, levobupivacaine

°“√©’¥¬“™“ (local anesthetics) ‡æ◊ËÕ∑”°“√ ºà“µ—¥¡’°“√„™â°—πÕ¬à“ß·æ√àÀ≈“¬„πªí®®ÿ∫—π ∑ÿ°§√—Èß∑’Ë¡’°“√ ©’¥¬“™“„ÀⷰຟâªÉ«¬π—Èπ ¡’‚Õ°“ ‡°‘¥¿“«–æ‘…®“°¬“™“ ‚¥Õ“®‡°‘¥Õ“°“√¢â“߇§’¬ß‡æ’¬ß‡≈Á°πâÕ¬ ‡™à𠇫’¬π»’√…– À√◊Õ ‡°‘¥Õ“°“√√ÿπ·√߇ªìπÕ—πµ√“¬∂÷ß™’«‘µ‰¥â Õÿ∫—µ‘°“√≥å°“√‡°‘¥ ¿“«–æ‘…®“°¬“™“„πµà“ߪ√–‡∑»æ∫‰¥âµß—È ·µà ˜.ıÒ- ÚÚ,Û µàÕ Ò, §π ¥—ßπ—Èπ®÷ߧ«√∑√“∫∂÷ß¿“«–æ‘…∑’ËÕ“®‡°‘¥ ¢÷Èπ ·≈–‡µ√’¬¡æ√âÕ¡‡æ◊ËÕ·°â‰¢¿“«–¥—ß°≈à“«‰¥â∑—π∑’

°≈‰°°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“™“Ù,ı ‚¥¬∑—Ë«‰ª ¬“™“ª√–°Õ∫¥â«¬ à«π∑’ˇªìπ ionized ·≈– nonionized form ‡¡◊ÕË ·µ°µ—« à«π∑’‡Ë ªìπ nonionized form ®–π”‚¡‡≈°ÿ≈¢Õ߬“™“´÷¡ºà“π sheath ·≈–‡¬◊ËÕÀÿâ¡ ¢Õ߇ âπª√– “∑ ‡¡◊ÕË ‰ª∂÷ß∫√‘‡«≥ membrane receptor à«π

∑’ˇªìπ ionized form ®–®—∫∑’Ë membrane receptor ¬—∫¬—Èß °“√‡°‘¥ action potential ‚¥¬¢—¥¢«“ß°“√‡¢â“‡´≈≈å¢Õß Na+ ions ®÷߉¡à‡°‘¥ depolarization ‚¥¬∑—Ë«‰ª·≈⫵—«¬“™“‡Õß¡’ pKa > ˜.Ù ¥—ßπ—Èπ∂â“ pKa ¢Õ߬“™“µË”À√◊Õ„°≈⇧’¬ß°—∫ pH ¢Õß∫√‘‡«≥∑’Ë©’¥¬“ ¬“™“®–·µ°µ—«„Àâ nonionized form ¡“° ®÷ßÕÕ°ƒ∑∏‘ω¥â ‡√Á« „π∑“ß°≈—∫°—π∂â“ pKa ¢Õ߬“™“µà“ß®“° pH ∫√‘‡«≥ π—Èπ¡“° ¬“™“·µ°µ—«„Àâ ionized form ¡“° ®–ÕÕ°ƒ∑∏‘Ï ‰¥â™â“ πÕ°®“°π’Ȭ“™“∑’Ë¡’§ÿ≥ ¡∫—µ‘„π°“√®—∫°—∫ plasma protein ‰¥â¥’ ®–ÕÕ°ƒ∑∏‘ϙⓠ·µàÕ¬Ÿà‰¥âπ“𠬓™“∑’πË ¬‘ ¡„™â¡“°„πª√–‡∑»‰∑¬ ‰¥â·°à Lidocaine (Xylocaine®, Docaine®), Bupivacaine (Marcaine®) ·≈– Levobupivacaine (Chirocaine®) §ÿ≥ ¡∫—µ‘¢Õß ¬“∑—Èß Û ™π‘¥ ‡ª√’¬∫‡∑’¬∫°—π ¥—ßµ“√“ß∑’Ë Ò

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

346 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

µ“√“ß∑’Ë Ò §ÿ≥ ¡∫—µ‘¢Õ߬“™“∑’Ë„™â∫àÕ¬„πªí®®ÿ∫—π Agents

MW pKa

Bupivacaine 288 Levobupivacaine 288 Lidocaine 234

8.1 8.1 7.9

Protein Potency Speed of Duration Maximum dose (mg/kg) CC:CNS binding(%) Onset (hr) plain with vasoconstrictor ratio 95 96 64

High High Intermediate

Slow Long 2 Slow Long 2.5 Fast Intermediate 5

3 3 7

3.7 ± 0.5 7.1 ± 1.1

MW = molecular weight CC (cardiovascular collapse) = √–¥—∫¬“„π‡≈◊Õ¥∑’Ë°àÕ„À⇰‘¥Õ“°“√‡ªìπæ‘…µàÕ√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ CNS (central nervous system) = √–¥—∫¬“„π‡≈◊Õ¥∑’Ë°àÕ„À⇰‘¥Õ“°“√‡ªìπæ‘…µàÕ√–∫∫ª√– “∑

°“√‡°‘¥æ‘…¢Õ߬“™“

°≈‰°°“√‡°‘¥æ‘…¢Õ߬“™“

æ‘…¢Õ߬“™“ ‡°‘¥®“°°“√∑’˺ŸâªÉ«¬¡’√–¥—∫¬“™“„π °√–· ‡≈◊Õ¥‰ª Ÿà ¡Õß·≈–À—«„® Ÿß®π∂÷ß√–¥—∫∑’Ë°àÕ„À⇰‘¥ æ‘…¢Õ߬“™“™π‘¥π—Èπ (toxic level) ‚¥¬∑—Ë«‰ªÕ“°“√‡√‘Ë¡ ·√°‡°‘¥®“°¬“°¥°“√∑”ß“π¢Õß ¡Õß·≈–»Ÿπ¬å§«∫§ÿ¡°“√ À“¬„® ∑”„À⺪Ÿâ «É ¬¡’Õ“°“√‡«’¬π»’√…– ≈‘πÈ ™“ ´÷¡≈ß ™—° À¡¥ µ‘ ·≈–À¬ÿ¥À“¬„® ‡¡◊ËÕ√–¥—∫¬“ Ÿß¢÷Èπ®–°¥°“√∑”ß“π¢Õß À—«„® ∑”„ÀâÀ—«„®‡µâπº‘¥®—ßÀ«–®π∂÷ßÀ—«„®À¬ÿ¥‡µâπ‰¥â ´÷Ëß °“√∑’˺ŸâªÉ«¬®–‰¥â√—∫¬“™“¡“°®π‡°‘¥æ‘…π—Èπ Õ“®‡ªìπ‰¥â®“° Ò. °“√©’¥¬“™“‡¢â“À≈Õ¥‡≈◊Õ¥·¥ß (Intraarterial injection) ‡π◊ÕË ß®“°„πÀ≈Õ¥‡≈◊Õ¥·¥ß¡’§«“¡¥—π‡≈◊Õ¥ Ÿß ‡¡◊ÕË ¡’°“√©’¥¬“™“‡¢â“À≈Õ¥‡≈◊Õ¥·¥ß‚¥¬µ√ß ∑”„À⬓™“‰ªµ“¡ °√–· ‡≈◊Õ¥‡¢â“ Ÿà ¡Õß·≈–À—«„®‰¥âÕ¬à“ß√«¥‡√Á« Ú. °“√©’¥¬“™“‡¢â“À≈Õ¥‡≈◊Õ¥¥” (Intravenous injection) ‡¡◊ÕË ¡’°“√©’¥¬“™“‡¢â“À≈Õ¥‡≈◊Õ¥¥” ¬“™“∫“ß à«π ®–∂Ÿ°∑”≈“¬ (metabolized) ∑’˵—∫ ª√–°Õ∫°—∫·√ߥ—π„π À≈Õ¥‡≈◊Õ¥¥”‰¡à Ÿß¡“°‡À¡◊Õπ„πÀ≈Õ¥‡≈◊Õ¥·¥ß®÷ß∑”„Àâ ¬“™“‰ª Ÿà ¡Õß·≈–À—«„®™â“°«à“ ·≈–ª√‘¡“≥πâÕ¬°«à“ Û. °“√©’¥¬“™“∑’ˇπ◊ÈÕ‡¬◊ËÕ·≈–°≈â“¡‡π◊ÈÕ (Soft tissue injection) À≈—ß®“°©’¥¬“™“∑’˺‘«Àπ—ß ‡π◊ÈÕ‡¬◊ËÕÀ√◊Õ°≈â“¡‡π◊ÈÕ ¬“™“®–∂Ÿ°¥Ÿ¥´÷¡‡¢â“ Ÿà°√–· ‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” °“√ ‡°‘¥æ‘…¢Õ߬“™“®“°«‘∏’π’ȵâÕßÕ“»—¬‡«≈“„π°“√¥Ÿ¥´÷¡¬“ ‡¢â“ Ÿà°√–· ‡≈◊Õ¥ ª√‘¡“≥¬“∑’Ë∂Ÿ°¥Ÿ¥´÷¡‡√Á«À√◊ՙⓢ÷ÈπÕ¬Ÿà °—∫∫√‘‡«≥∑’Ë©’¥ ´÷Ëß‚¥¬ª√°µ‘·≈â«®–πâÕ¬°«à“ª√‘¡“≥¬“∑’Ë©’¥ „ÀⷰສŸâ «É ¬¡“° ¥—ßπ—πÈ °“√‡°‘¥æ‘…®“°¬“™“«‘∏π’ ¡’È °— ®–‡°‘¥™â“ ·≈–‰¡à√ÿπ·√ß¡“°‡∑à“°“√©’¥¬“‡¢â“À≈Õ¥‡≈◊Õ¥‚¥¬µ√߈

®“°°“√»÷°…“¢Õß Guy Weinberg ·≈–§≥–˜ æ∫«à“‡¡◊ËÕ¬“™“‰ª∂÷߇´≈≈å¢Õß ¡Õß·≈–À—«„® ‚¡‡≈°ÿ≈¢Õß ¬“™“¡’§ÿ≥ ¡∫—µ‘‡ªìπ amphiphilic (§◊Õ¡’∑—Èß à«π∑’ˇªìπ lipophilic ·≈– hydrophilic) “¡“√∂ºà“π‡¢â“‰ª„π‡´≈≈å ·≈–√∫°«π°√–∫«π°“√√–¥—∫‡´≈≈套ߵàÕ‰ªπ’È Ò. Cellular metabolism and homeos˜,¯,˘,Ò,ÒÒ,ÒÚ tasis Ú. Cell signaling systems˜ ‚¥¬°“√¬—∫¬—Èß Na+Ò,ÒÒ,ÒÚ,ÒÛ, K+˘,Ò,ÒÒ, ·≈– Ca2+ÒÚ ion channels Û. Energy transduction pathway ‚¥¬°“√ ¬—∫¬—Èß°“√∑”ß“π¢Õß cyclic AMP˜ Ù. Metabotropic pathway (β2 receptorÒÙ, lysophosphatidateÒı) ı. G-protein modulation ∑’Ë Ca2+ ·≈– K+ channelsÒˆ,Ò˜ ˆ. Mitochondrial ATP production ‚¥¢—¥¢«“ß°“√∑”ß“π¢Õß enzyme ATP synthase ´÷Ëß∑” Àπâ“∑’ˇª≈’ˬπ ADP „À⇪ìπ ATP ∑’Ë mitochondrial inner membraneÒ¯ ˜. Endothelial nitric oxide release ∑”„À⇰‘¥ profound cardiovascular depression πÕ°‡Àπ◊Õ®“°∑’Ë°≈à“«¡“¢â“ßµâπ·≈â« ¬“™“™π‘¥ bupivacaine ¬—߬—∫¬—Èߢ∫«π°“√ carnitine-dependent mitochondrial transport ¢Õß fatty acids ∑’Ë cardiac mitochondria ∑”„Àâ°≈â“¡‡π◊ÈÕÀ—«„®‰¡à “¡“√∂π” fatty acids ‰ª„™â‡ªìπæ≈—ßß“π‰¥âÒ˘,Ú ¥—ßπ—Èπ∂Ⓡ°‘¥ bupivacaine toxicity µàÕ°≈â“¡‡π◊ÈÕÀ—«„®¢÷Èπ·≈â« °“√™à«¬™’«‘µ (cardiopulmonary resuscitation) ·≈–°“√√—°…“ ¬“™“ ‡ªìπæ‘…µ“¡ª√°µ‘®–‰¡à‰¥âº≈

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ªí®®—¬∑’Ë¡’º≈µàÕ°“√‡°‘¥æ‘…¢Õ߬“™“ÚÒ Ò. ª√‘¡“≥¬“∑—ÈßÀ¡¥∑’Ë„™â ∂â“„™âª√‘¡“≥¬“™“¡“° ª√‘¡“≥¬“∑’Ë´÷¡ºà“π‡¢â“ Ÿà°√–· ‡≈◊Õ¥¬àÕ¡¡’¡“°µ“¡ Ú. °“√º ¡¬“µ’∫À≈Õ¥‡≈◊Õ¥ ‡™àπ epinephrine ∑”„Àâ°“√¥Ÿ¥´÷¡¬“‡¢â“ Ÿà°√–· ‡≈◊Õ¥™â“≈ß Û. ª√‘¡“≥À≈Õ¥‡≈◊Õ¥∑’Ë¡“‡≈’Ȭß∫√‘‡«≥∑’Ë©’¥¬“™“ ¡’®”π«π¡“° ‡™àπ epidural space ¬“®–∂Ÿ°¥Ÿ¥´÷¡‡¢â“ °√–· ‡≈◊Õ¥‰¥â‡√Á«·≈–¡“°°«à“°“√©’¥¬“™“∑’Ë brachial plexus À√◊ Õ subcutaneous tissue À√◊ Õ °“√©’ ¥ ¬“ ™“„πµ”·Àπàß∑’ˬ“°≈—∫‡¢â“ ŸàÀ—«„®‚¥¬µ√ß ‡™àπ intercostal nerve block Ù. ¬“™“∑ÿ°™π‘¥ ¬°‡«âπ cocaine ¡’§ÿ≥ ¡∫—µ‘ ¢¬“¬À≈Õ¥‡≈◊Õ¥·µ°µà“ß°—π ´÷Ëß lidocaine ‡ªì𬓙“∑’Ë ¢¬“¬À≈Õ¥‡≈◊Õ¥‰¥â¡“°°«à“·≈–¥Ÿ¥´÷¡‰¥â‡√Á«°«à“ ∂⓬“™“ ™π‘¥„¥¡’§«“¡ “¡“√∂„π°“√≈–≈“¬„π‰¢¡—π Ÿß®–¡’√–¥—∫ ¬“„π‡≈◊Õ¥µË”‡π◊ËÕß®“° – ¡„π‰¢¡—π¡“°°«à“ ı. °“√∑’ˬ“™“∂Ÿ°∑”≈“¬‰¥â‡√Á« ¬àÕ¡¡’‚Õ°“ ‡°‘¥ æ‘…πâÕ¬°«à“ ˆ. Õ“¬ÿ ·≈– ¿“æ√à“ß°“¬¢ÕߺŸâªÉ«¬ ‡™à𠇥Á° ∑“√° ¡’‚Õ°“ ‡°‘¥æ‘…¢Õ߬“™“¡“°°«à“ ‡π◊ÕË ß®“°¬“µâÕß·¬àß bilirubin ®—∫°—∫ plasma protein ºŸªâ «É ¬‚√§µ—∫ √â“ß plasma protein ‰¥âπâÕ¬°«à“ª√°µ‘ ®÷߇À≈◊Õ¡’ free form ¢Õ߬“¡“° à«π„πºŸâ ŸßÕ“¬ÿ¡’ volume of distribution ·≈– clearance ¢Õ߬“≈¥≈ß®÷ߧ«√≈¥ª√‘¡“≥¬“™“∑’Ë„™â„π§√—ÈßµàÕ‰ª·≈–‡«âπ √–¬–Àà“ߢÕß°“√„À⬓π“π¢÷Èπ ˜. ¬“∑’ˬ—∫¬—Èß°“√∑”ß“π¢Õß enzymes ∑’Ë„™â„π °“√∑”≈“¬¬“Õ◊Ëπ (mixed function oxidases) ·≈–≈¥ hepatic blood flow ‡™àπ cimetidine ·≈– propanolol ®–∑”„Àâ metabolism ¢Õ߬“™“≈¥≈ß à«π¬“¥¡ ≈∫‡Õß °Á≈¥ hepatic blood flow ‡™àπ°—π ®÷ß àߺ≈„Àâ°“√∑”≈“¬“™“≈¥≈ߥâ«Õ“°“√·≈–Õ“°“√· ¥ß‡¡◊ËÕ‡°‘¥æ‘…®“°¬“™“˜ √–¬–‡√‘Ë¡·√° (early phase) à«π„À≠à‡ªìπÕ“°“√ ∑“ß√–∫∫ª√– “∑ ‰¥â·°à Õ“°“√‰¥â¬‘π·≈–‡ÀÁπ¿“溑¥ª√°µ‘ (visual or auditory disturbances) ‡«’¬π»’√…– (lightheadedness, dizziness) ≈‘Èπ·≈–√‘¡Ω望°™“ (numbness of tongue or lips with or without metallic taste) 查 ‰¡à™—¥ (slurred speech) ßà«ß´÷¡(drowsiness) ‡¡◊ËÕ√–¥—∫ ¬“„π‡≈◊Õ¥ Ÿß¢÷Èπ ºŸâªÉ«¬Õ“®¡’Õ“°“√°√– —∫°√– à“¬ (agita-

347

tion) nystagmus °≈â“¡‡π◊ÈÕ°√–µÿ° (myoclonus) Õ“® ‡°‘¥Õ“°“√™—° (seizures/convulsion) ‰¥â À“°√–¥—∫¬“„π ‡≈◊Õ¥ Ÿß∂÷ß√–¥—∫∑’Ë¡’º≈µàÕÀ—«„®·≈–À≈Õ¥‡≈◊Õ¥ ºŸâªÉ«¬®– ‡√‘Ë¡¡’Õ“°“√∑“ß√–∫∫À—«„®·≈–À≈Õ¥‡≈◊Õ¥ ‰¥â·°à À—«„®‡µâπ ‡√Á« (tachycardia) §«“¡¥—π‚≈À‘µ Ÿß¢÷Èπ (hypertension) µàÕ¡“À—«„®‡µâπ™â“ (bradycardia) §«“¡¥—π‚≈À‘µ≈¥µË” °«à“ª√°µ‘ (hypotension) À—«„®‡µâπº‘¥®—ßÀ«– (brady/ tachyarrhythmias) ®π∂÷ß ventricular tachycardia or fibrillation ·≈– asystole „π∑’Ë ÿ¥

¢âÕ·π–π”°“√√—°…“æ‘…®“°¬“™“Õ¬à“ß√ÿπ·√ß Ò. „ÀâÕÕ°´‘‡®π·≈–™à«¬À“¬„®∑—π∑’ (rapid provision of oxygenation and ventilation) ‡π◊ËÕß®“° ¿“«–§“√å∫Õπ‰¥ÕÕ°‰´¥å§—Ëß (hypercapnia) °“√¢“¥ ÕÕ°´‘‡®π (hypoxia) ·≈–¿“«–‡≈◊Õ¥‡ªìπ°√¥ (metabolic acidosis) ®–‡ √‘¡„ÀâÕ“°“√‡°‘¥æ‘…®“°¬“™“√ÿπ·√߬‘ßË ¢÷πÈ ˜,¯ Ú. °√≥’∑º’Ë ªŸâ «É ¬™—° §«∫§ÿ¡Õ“°“√™—°‚¥¬°“√„™â¬“ thiopentone À√◊Õ¬“°≈ÿà¡ benzodiazepines ‡π◊ËÕß®“° °“√™—°∑”„À⇰‘¥¿“«– metabolic acidosis˜,¯ Û. ‡¡◊ËÕ‡°‘¥æ‘…¢Õ߬“™“µàÕ√–∫∫À—«„®·≈–À≈Õ¥ ‡≈◊Õ¥ ºŸâªÉ«¬Õ¬Ÿà„π¿“«– low cardiac output ·≈–Õ“®¡’ ¿“«–À—«„®‡µâπº‘¥®—ßÀ«– ®÷ߧ«√„À⬓™à«¬‡æ‘Ë¡ cardiac output „π°≈ÿà¡ inotropes, vasopressors ‡™àπ epinephrine, ephedrine À√◊Õ norepinephrine ·≈– antiarrhythmics ‡™àπ amiodarone µ“¡≈”¥—∫˜,¯

¢âÕ§«√√–«—ß„π°“√„™â epinephrine, amiodarone ·≈– phenytoin˜,ÚÚ ‡π◊ËÕß®“° epinephrine ‡ªìπ vasopressors ∑’Ë Õ“®∑”„À⇰‘¥À—«„®‡µâπº‘¥®—ßÀ«–‰¥â ¥—ßπ—ÈπÀ“°‡°‘¥¿“«– À—«„®‡µâπº‘¥®—ßÀ«– §«√√’∫„Àâ°“√√—°…“ Õ“®„Àâ vasopressin 40 units ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” √à«¡°—∫À√◊Õ·∑π epinephrine °√≥’æ‘®“√≥“‡≈◊Õ°„™â amiodarone „π°“√√—°…“¿“«–À—«„® ‡µâπº‘¥®—ßÀ«–§«√„ÀâÕ¬à“ß√–¡—¥√–«—ß ‡π◊ÕË ß®“° amiodarone ‡ªìπ potent inhibitor ¢Õß ion channel àߺ≈„À⇰‘¥ myocardial depression ª√–°Õ∫°—∫‡ªìπ¬“∑’ÕË Õ°ƒ∑∏‘πÏ “π Õ“®∑”„À⇰‘¥ cardiovascular collapse πÕ°®“°π’È„π °“√§«∫§ÿ¡Õ“°“√™—° À“°„™â phenytoin Õ“®‡ √‘¡Õ“°“√ ‡ªìπæ‘…®“°¬“™“‰¥â

348 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

·π«∑“ß„À¡à¢Õß°“√√—°…“¿“«–æ‘…®“°¬“™“ ‚¥¬‡©æ“–µàÕ°≈â“¡‡π◊ÈÕÀ—«„® ‰¥â·°à Ò. Lipid infusion hypothesis Ò.Ò °“√„Àâ lipid ‡¢â“‰ª„π√à“ß°“¬‡ªìπ°“√ ‡æ‘Ë¡ª√‘¡“≥ fatty acids ‡¢â“ Ÿà‡´≈≈å¢Õß°≈â“¡‡π◊ÈÕÀ—«„® ´÷Ëß Õ“®™à«¬„Àâ°√–∫«π°“√ fatty acid transport ¥’¢÷Èπ ‚¥°“√‡æ‘Ë¡ substrate ¢Õߪؑ°‘√‘¬“‡¢â“‰ª¯,Ò˘ Ò.Ú °“√„Àâ lipid infusion ‡¢â“‰ª„π°√–· ‡≈◊Õ¥∑”„À⇰‘¥ lipid plasma phase À√◊Õ lipid sink ‚¥plasma lipid droplets ∑’ˇ°‘¥¢÷Èπ “¡“√∂Àÿâ¡‚¡‡≈°ÿ≈¢Õß bupivacaine ∑’Ë≈Õ¬Õ¬Ÿà„π plasma ‰¥â„πÕ—µ√“ à«π Ò droplet µàÕ bupivacaine ÒÚ ‚¡‡≈°ÿ≈˜,¯,ÚÒ,ÚÛ Ò.Û °“√„Àâ lipid infusion “¡“√∂≈¥°“√ √∫°«π nitric oxide pathway ¢Õß bupivacaine °“√„Àâ lipid infusion “¡“√∂‡æ‘Ë¡Õ—µ√“°“√√Õ¥™’«‘µ (survival rate) „πÀπŸ ·≈–‡æ‘Ë¡ª√‘¡“≥¬“ bupivacaine ∑’˵âÕß„™â ∑”„À⇰‘¥ asystole „πÀπŸ‰¥âÚÙ „πªï §.». Úˆ Rosenblatt ·≈–§≥–Úı ·≈– Litz ·≈–§≥–Úˆ ‰¥â√“¬ß“𧫓¡ ”‡√Á® „π°“√™à«¬™’«µ‘ ºŸªâ «É ¬∑’ÀË «— „®À¬ÿ¥‡µâπ·≈–À—«„®‡µâπº‘¥®—ßÀ«–

®“°¿“«–æ‘…®“°¬“™“µ“¡≈”¥—∫ ‚¥¬„™â Ú% lipid emulsion Ú. Glucose & insulin infusionÚ˜ Ú.Ò °“√„Àâ glucose √à«¡°—∫ insulin ™à«‡√àß„À⧫“¡¥—π‡≈◊Õ¥ cardiac output ·≈–§≈◊Ëπ‰øøÑ“À—«„® °≈—∫¡“‡ªìπª√°µ‘‡√Á«¢÷Èπ‡π◊ËÕß®“° insulin ‡æ‘Ë¡ª√‘¡“≥ K+ ‡¢â“‡´≈≈å «π∑“ß°—∫ K+ ∑’ËÕÕ°®“°‡´≈≈å¥â«¬ƒ∑∏‘Ï¢Õß bupivacaine ¥—ßπ—Èπ®÷ߙ૬·°â‰¢¿“«– myocardial repolarization ‰¥â‡√Á«¢÷Èπ πÕ°®“°π’È insulin ¬—ߙ૬„π°“√ √—°…“ ¡¥ÿ≈¢Õß·§≈‡´’¬¡„π√à“ß°“¬ °“√‡ªî¥·≈–ªî¥¢Õß sodium channels ·≈–‡æ‘Ë¡°“√À≈—Ëß catecholamines ®“° ¿“«–πÈ”µ“≈„π‡≈◊Õ¥µË” Ú.Ú Energy-related mechanismÚ¯ ‚¥ª√°µ‘·≈â«°≈â“¡‡π◊ÕÈ À—«„®„™â‰¢¡—π‡ªìπæ≈—ßß“π∂÷ß √âÕ¬≈– ¯ ¥—ßπ—Èπ∂Ⓣ¡à “¡“√∂„™â¢∫«π°“√ fatty acids metabolism „π°≈â“¡‡π◊ÈÕÀ—«„® À—«„®®–‡ª≈’Ë¬π¡“„™âæ≈—ßß“π®“°§“√å‚∫‰Œ‡¥√µ·∑π ´÷Ë߉¥â·°à glucose °“√„Àâ glucose √à«¡°—∫ insulin ®–‡æ‘Ë¡·π«‚πâ¡„π°“√„™âæ≈—ßß“π®“° glycolytic pathway ´÷Ë߉¥â·°à pyruvate ¡“‡ªìπæ≈—ßß“π·∑π‰¥â

√Ÿª∑’Ë Ò °“√√—°…“ cardiac arrest ‚¥¬°“√„™â lipid emulsion

349

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Û. Propofol Û.Ò ‡ªìπ lipid-based carrier ‚¥¬ “¡“√∂ ®—∫‚¡‡≈°ÿ≈¢Õß bupivacaine ‰¥â‡™àπ‡¥’¬«°—∫ lipid Õ◊ËπÚ˘ Û.Ú ®“°°“√»÷°…“¢Õß Guy Weinberg˜ ·≈– Heavner ·≈–§≥–Û æ∫«à“ propofol “¡“√∂ §«∫§ÿ¡Õ“°“√™—°‰¥â¥’°«à“ thiopentone Û.Û Propofol ¡’§ÿ≥ ¡∫—µ‘‡ªìπ antioxidant ®÷ßÕ“®™à«¬„Àâ‡π◊ÈÕ‡¬◊ËÕµà“ßÊ øóôπµ—«®“°¿“«– hypoxia ‰¥â

·µà propofol ¡’º≈°¥°≈â“¡‡π◊ÈÕÀ—«„® Õ“®∑”„Àâ cardiac output ≈¥≈߉¥âÚ˘ „πªï §.». Ú˜ ∑“ß ¡“§¡ «‘ —≠≠’·æ∑¬å·Ààß À√“™Õ“≥“®—°√·≈–‰Õ√å·≈π¥å (The Association of Anaesthetists of Great Britain & Ireland (AAGBI))ÛÒ ‡ πÕ·π«∑“ß°“√√—°…“¿“«–‡ªìπ æ‘…Õ¬à“ß√ÿπ·√ß®“°¬“™“¥—ß√Ÿª∑’Ë Ò ·≈–µ“√“ß∑’Ë Ú ·≈– Û

µ“√“ß∑’Ë Ú Immediate management ● ● ● ● ● ● ●

Stop injecting the LA Call for help Maintain airway Give 100% oxygen and ensure adequate ventilation Confirm or establish intravenous access Control seizures: benzodiazepine, thiopental or propofol in small incremental doses Assess cardiovascular status

µ“√“ß∑’Ë Û Management of cardiac arrest associated with LA injection ● ● ●

Start CPR using standard protocols Manage arrhythmias Prolonged resuscitation maybe necessary ➝ Consider the use of cardiopulmonary bypass if available ➝ Consider treatment with lipid emulsion

πÕ°®“°§”·π–π”°“√„Àâ lipid infusion ¢Õß ·π«∑“ߪؑ∫µ— π‘ ·’È ≈â« Guy Weinberg ‰¥â‡ πÕ°“√√—°…“¥â«lipid infusion ‚¥¬·π–π”„Àâ„™â Ú% lipid emulsion Ò ml/kg ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¡“°°«à“ Ò π“∑’ „π¢≥–∑’Ë∑” chest compression ·≈–„Àâ´È”Õ’° Ò ml/kg ∑ÿ° Û-ı π“∑’ ‰¡à‡°‘π Û ml/kg ®“°π—Èπ‡ª≈’ˬπ‡ªìπÀ¬¥µàÕ‡π◊ËÕß .Úı ml/kg/min ®π hemodynamic recover ‚¥¬‰¡à·π–π” „Àâ„™â propofol ·∑π Ú% lipid emulsion ·µà„™â propofol ‡æ◊ËÕ§«∫§ÿ¡Õ“°“√™—°®“° bupivacaine overdose ·∑π˜

√ÿª ¿“«–æ‘…®“°¬“™“ ∑’Ë√ÿπ·√߇ªìπÕ—πµ√“¬∂÷ß·°à™’«‘µ ¡’‚Õ°“ ‡°‘¥„π∑ÿ°§√—Èß∑’Ë¡’°“√©’¥¬“™“„ÀⷰຟâªÉ«¬ ¥—ßπ—Èπ ·æ∑¬å·≈–∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑ÿ°§π§«√¡’§«“¡√Ÿâ §«“¡ √–¡—¥√–«—ß„π°“√„™â¬“™“ ¡’°“√‡ΩÑ“√–«—ß ‡µ√’¬¡„Àâ°“√√—°…“

¿“«–·∑√°´âÕπ∑’ËÕ“®‡°‘¥¢÷Èπ‰¥âÕ¬à“ß∑—π∑à«ß∑’¥â«¬·π«∑“ß „À¡à¢Õß°“√√—°…“¿“«–æ‘…®“°¬“™“Õ¬à“ß√ÿπ·√ßµàÕ°≈â“¡ ‡π◊ÈÕÀ—«„®¥â«¬ lipid infusion ™à«¬„À⺟âªÉ«¬¡’‚Õ°“ √Õ¥ ™’«‘µ®“°æ‘…¢Õ߬“™“¡“°¢÷Èπ

‡Õ° “√Õâ“ßÕ‘ß Ò. Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious complications related to regional anesthesia: Results of a prospective survey in France. Anesthesiology 1997;87:47986. Ú. Brown DL, Ransom DM, Hall JA, Leicht CH, Schroeder DR, Offord KP. Regional anesthesia and local anesthetic-induced systemic toxicity: Seizure frequency and accompanying cardio-

350 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

vascular changes. Anesth Analg 1995;81:32128. Û. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: A prospective study. Anesthesiology 2001;95:87580. Ù. Lagan G, McLure HA. Review of local anesthetic agents. Current Anaesthesia & critical care 2004;15:247-54. ı. ¡™“¬ Õ¡√‚¬∏‘π. ¬“™“‡©æ“–∑’Ë „π Õ—ß°“∫ ª√“°“√√—µπå, «√¿“ ÿ«√√≥®‘π¥“, ∫√√≥“∏‘°“√. µ”√“«‘ —≠≠’«‘∑¬“. æ‘¡æå§√—Èß∑’Ë Û. °√ÿ߇∑æ¡À“π§√: °√ÿ߇∑懫™ “√; ÚıÙ¯: ˆˆ-˜˜. ˆ. Mulroy MF. Systemic toxicity and cardiotoxicity from local anesthetics: Incidence and preventive measures. Reg Anesth Pain Med 2002;27:55661. ˜. Weinberg GL. Current concepts in resuscitation of patients with local anesthetic cardiac toxicity.

Reg Anesth Pain Med 2002;27:568-75. ¯. Renehan EM, Enneking FK, Varshney M, Richard P, Dennis DM, Morey TE. Scavenging nanoparticles: An emerging treatment for local anesthetic toxicity. Reg Anesth Pain Med 2005; 30:380-84. ˘. Valenzuela C, Delpon E, Tamkun MM, Tamargo J, Snyders DJ. Stereoselective block of a human cardiac potassium channel (Kvl.5) by bupivacaine enantiomers. Biophys J 1995;69:418-27. Ò. Clarkson CW, Hondeghem LM. Mechanism for bupivacaine depression of cardiac conduction: Fast block of sodium channels during the action potential with slow recovery from block during diastole. Anesthesiology 1985;62:396-405. ÒÒ. Castle NA. Bupivacaine inhibits the transient outward K+ current but not the inward rectifier in rat ventricular myocytes. J Pharmacol Exp Ther 1990;255:1038-46. ÒÚ.Xiong Z, Strichartz GR. Inhibition by local anesthetics of Ca2+ channels in rat anterior

pituitary cells. Eur J Pharmacol 1998;363:8190. ÒÛ. Valenzuela C, Snyders D, Bennet P, Tamargo J, Hondeghem L. Stereoselective block of cardiac sodium channel by bupivacaine in guinea pig ventricular myocytes. Circulation 1995;92: 3014-24. ÒÙ. Butterworth JF, Brownlow RC, Leith JP, Prielipp RC, Cole LR. Bupivacaine inhibits cyclic-3û,5ûadenosine monophosphate production: A possible contributing factor to cardiovascular toxicity. Anesthesiology 1993;79:88-95. Òı. Nietgen GW, Chan CK, Durieux ME. Inhibition of lysophosphatidate signaling by lidocaine and bupivacaine. Anesthesiology 1997;86:1112-9. Òˆ. Xiong Z, Bukusoglu C, Strichartz GR. Local anesthetics inhibit the G protein-mediated modulation of K+ and Ca2+ currents in anterior pituitary cells. Mol Pharmacol 1999;55:1508. Ò˜. Zhou W, Arrabit C, Choe S, Slesinger PA. Mechanism underlying bupivacaine inhibition of G protein-gated inwardly rectifying K+ channels. Proc Natl Acad Sci USA 2001;98: 6482-7. Ò¯. Dabadie P, Bendriss P, Erny P, Mazat JP. Uncoupling effects of local anesthetics on rat liver mitochondria. FEBS Lett 1987;226:77-82. Ò˘. Weinberg GL, Palmer JW, VadeBoncouer TR, Zuechner MB, Edelman G, Hoppel CL. Bupivacaine inhibits acylcarnitine exchange in cardiac mitochondria. Anesthesiology 2000;92:523-8. Ú. Weinberg GL, Ripper R, Murphy P, Edelman LB, Hoffman W, Strichartz GR, and Feinstein DL. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart. Reg Anesth Pain Med 2006;31:296-303. ÚÒ. Singh P, Lee JS. Cardiovascular and central nervous system toxicity of local anesthetics.

Seminars in Anesthesia, Periop Med Pain 1998; 17:18-23.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ÚÚ. Groban L, Butterworth J. Lipid reversal of bupivacaine toxicity: Has the silver bullet been identified? Reg Anesth Pain Med 2003;28: 167-9. ÚÛ. Weinberg GL, Ripper R, Feinstein DL, Hoffman W. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Reg Anesth Pain Med 2003;28:198-202. ÚÙ. Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik M. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology 1998;88:1071-5. Úı. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB. Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest. Anesthesiology 2006;105:217-8. Úˆ. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a patient with ropivacaineinduced asystole after axillary plexus block using lipid infusion. Anaesthesia 2006;61:8001.

351

Ú˜. Cho HS, Lee JJ, Chung IS, Shin BS, Kim JA, Lee KH. Insulin reverses bupivacaine-induced cardiac depression in dogs. Anesth Analg 2000; 91:1096-1102. Ú¯. Weinberg GL, VadeBoncouer T. Improved energetics may explain the favorable effect of insulin infusion on bupivacaine cardiotoxicity.

Anesth Analg 2001;92:1075-6. Ú˘. De La Cruz JP, Villalobos MA, Sedeno G, Sanchez De La Cuesta F. Effect of propofol on oxidative stress in an in vitro model of anoxia-reoxygenation in the rat brain. Brain Res 1998;800:136-44. Û. Heavner JE, Arthur J, Zou J, McDaniel K, Tyman Szram B, Rosenberg PH. Comparison of propofol with thiopentone for treatment of bupivacaine-induced seizures in rats. Br J Anaesth 1993;71:715-9. ÛÒ. The Association of Anaesthetists of Great Britain and Ireland. Guidelines for the management of severe local anesthetic toxicity, 2007. Available at www.aagbi.org/publications/guidelines/ docs/latoxicity07.pdf. Last accessed May 1, 2010.

Abstract Local anesthetic toxicity Preeyaphan Arunakul Department of Anesthesia, Faculty of Medicine, Thammasat University Local Anesthetics have been widely used in every hospitals and clinics. Its toxicity can lead to central nervous system and cardiovascular disturbances with the clinical manifestations such as drowsiness, agitation, or even seizure and unconsciousness, and fatal cardiac toxicity as severe arrhythmias and contractile dysfunction.

Arrhythmias include conduction delay, ranging from bundle branch block and prolonged PR interval to ventricular tachycardia or fibrillation or even sinus arrest and asystole.

Severe local anesthetic toxicity is mechanistically complex. A review of chemistry and molecular actions of local anesthetics and guidelines for the treatment of severe local anesthetic toxicity are discussed in this article.

Key words: Local anesthetic, Local anesthetic toxicity, Lidocaine, Bupivacaine, Levobupivacaine, Cardiovascular toxicity

352 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ª°‘≥°–

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

emphysema Ò. ¿“«–‡π◊ÕÈ ‡¬◊ÕË ¡’Õ“°“» π. 欓∏‘ ¿“æ∑’¡Ë Õ’ “°“» – ¡„π‡π◊ÈÕ‡¬◊ËÕÀ√◊ÕÕ«—¬«– Ú. ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß π. ¿“æ∂ÿß≈¡ªÕ¥ ‚ªÉßæÕß¡’¢π“¥∂ÿß≈¡∑’ªË ≈“¬À≈Õ¥≈¡ΩÕ¬¢¬“„À≠à¢÷Èπ ‡√’¬°™π‘¥µà“ßÊ µ“¡µ”·Àπàß∑’ˇªìπ §¡¡. pulmonary emphysema alveolar duct emphysema ¿“«–∑àÕ∂ÿß≈¡ ªÕ¥‚ªÉßæÕß π. °“√‚ªÉßæÕߢÕß∑àÕ∂ÿß≈¡ªÕ¥„πºŸâ ŸßÕ“¬ÿ ‚¥¬¡“°¡’Õ“°“√πâÕ¬À√◊Õ‰¡à¡’Õ“°“√ atrophic emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕ߇ÀµÿΩÉÕ π. §¡¡. senile emphysema bullous emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕߢ¬“¬ π. °“√¡’‚æ√ßÕ“°“»¢π“¥„À≠àÕ—π‡¥’¬«À√◊Õ À≈“¬Õ—π¿“¬„πªÕ¥ ‡ªìπ√–¬–√ÿπ·√ߢÕß¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕß centriacinar emphysema; centrilobular emphysema ¿“«–∂ÿß≈¡ªÕ¥ à«π°≈“ß‚ªÉßæÕß π. ¿“«– ∂ÿß≈¡ªÕ¥‚ªÉßæÕß™π‘¥Àπ÷ßË ∑’¡Ë °’ “√‚ªÉßæÕß∑’√Ë –¥—∫À≈Õ¥≈¡ ΩÕ¬°àÕπ∂÷ߪ“°∂ÿß≈¡ chronic hypertrophic emphysema ¿“«– ∂ÿß≈¡ªÕ¥‚ªÉßæÕß∑—«Ë ‡√◊ÕÈ √—ß π. ∂ÿß≈¡ªÕ¥‚ªÉßæÕß™π‘¥Àπ÷ßË ¡’ ° “√‚ªÉßæÕßÕ“°“»„π∑—Ë « ∂ÿ ß ≈¡Õ¬à “ ß ¡Ë” ‡ ¡Õ §¡¡. panacinar emphysema; panlobular emphysema

compensating emphysema; compensatory emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß™¥‡™¬ π. ¿“æ ∂ÿß≈¡ªÕ¥æÕßµ—«‡°‘π·∑π∑’Ë à«πÀ¥·ø∫ ‡π◊ËÕß®“°°≈’∫ ªÕ¥øÿ∫·ø∫, µ—¥ªÕ¥ÕÕ°∫“ß à«π, ªÕ¥¡’æ—ߺ◊¥ À√◊Õ ¿“«–∑’˪ե à«πÕ◊Ëπ≈¥ª√‘¡“µ√≈ß congenital lobar emphysema ¿“«–∂ÿß≈¡ ªÕ¥‚ªÉßæÕ߇©æ“–°≈’∫·µà°”‡π‘¥ π. °“√¡’∂ÿß≈¡ªÕ¥æÕß ‡°‘π¢π“¥ ¡—°‡°‘¥∑’˪ե°≈’∫∫π∑”„ÀâÀ“¬„®≈”∫“° cutaneous emphysema ¿“«–„µâÀπ—ß¡’Õ“°“» π. °“√¡’Õ“°“»·∑√°„π‡π◊ÈÕ‡¬◊ËÕ„µâÀπ—ß ‡Àµÿ¡’°“√∫“¥‡®Á∫ ¢Õß∑√«ßÕ° ¡—°√à«¡°—∫¡’≈¡„π™àÕß∑√«ßÕ°·≈–≈¡„πª√–®—π Õ° §¡¡. subcutaneous emphysema cystic emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ‡ªìπ∂ÿß π. §¡¡. bullous emphysema diffuse emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ·æ√à°«â“ß π. §¡¡. panacinar emphysema distal acinar emphysema ¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕß à«πª≈“¬ π. ∂ÿß≈¡ªÕ¥‚ªÉßæÕß™π‘¥Àπ÷Ëß æ∫ ‡©æ“–∑’Ë∂ÿß≈¡„π∫√‘‡«≥ à«πª≈“¬µ“¡ºπ—ß√–À«à“ß°≈’∫ªÕ¥ ª√“°Ø‡ªìπ‡¡Á¥æÕß„µâº‘«‡¬◊ËÕÀÿ⡪ե ectatic emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ∫√‘‡«≥°«â“ß π. §¡¡. panacinar emphysema false emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕ߇∑Á® π. ¿“æ «‘√Ÿª¢Õß∑√«ßÕ° ‡À¡◊Õπ°√≥’∑’Ë¡’¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕß√ÿπ·√ß ‚¥¬∑’˪եՓ®ª√°µ‘À√◊Õº‘¥ª√°µ‘°Á‰¥â

».πæ.Õ√√∂ ‘∑∏‘Ï ‡«™™“™’«– ∑’˪√÷°…“*, ».¥√.πæ. ¡™—¬ ∫«√°‘µµ‘ ª√–∏“π°√√¡°“√, √».πæ.°âÕ߇°’¬√µ‘ °Ÿ≥±å°—π∑√“°√ °√√¡°“√, ».∑æ≠.„®πÿ™ ®ß√—°…å °√√¡°“√, ».æ≠.©«’«√√≥ ∫ÿπ𓧠°√√¡°“√, πæ.∑Õߥ’ ™—¬æ“π‘™, ».§≈‘𑧠æ≠.§ÿ≥‰∏«¥’ ¥ÿ≈¬®‘𥓠°√√¡°“√, π“ßπ—¬π“ «√“Õ—»«ª°µ‘ °√√¡°“√, ».πæ.π‘æπ∏å æ«ß«√‘π∑√å °√√¡°“√, ».πæ.∫√√®ß ¡‰À «√‘¬– °√√¡°“√, √».¥√.ª√’¬“ ≈’ÃÀ°ÿ≈ °√√¡°“√, ».πæ.ª√–‡ √‘∞ ∑Õ߇®√‘≠ °√√¡°“√, ».πæ.¥√.‡√◊Õπ ¡≥– °√√¡°“√, √».æ≠.«“≥’ «‘ ÿ∑∏å‡ √’«ß»å °√√¡°“√, ».¥√.æ≠.»»‘∏√ ºŸâ°ƒµ‘¬“§“¡’ °√√¡°“√, ».πæ. ¡æ≈ æß»å‰∑¬ °√√¡°“√, ».πæ. —≠≠“ ÿ¢æ“≥‘™π—π∑å °√√¡°“√, ».πæ. “‚√®πå «√√≥惰…å °√√¡°“√, √».πæ.Õ‘»√“ߧå πÿ™ª√–¬Ÿ√ °√√¡°“√, πæ.‰æ±Ÿ√¬å ¡ÿ∑√ ‘π∏ÿ °√√¡°“√, æÕ.πæ. ÿ√®‘µ ÿπ∑√∏√√¡ °√√¡°“√, √».¿≠.Õ√≈—°…≥“ ·æ√—µ°ÿ≈ °√√¡°“√, π. . ¡∑√ß »°ÿπµπ“§ °√√¡°“√, π. .≈—°¢≥“«√√≥ Õπ—π∏«—™ °√√¡°“√.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

focal emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ‡©æ“–∑’Ë π. ∂ÿß≈¡ªÕ¥‚ªÉßæÕ߇ÀµÿÀ“¬„®„π∫√√¬“°“»¡’ ΩÿÉπ ¡’°“√‚ªÉßæÕß∑’˪≈“¬À≈Õ¥≈¡·≈–À≈Õ¥≈¡ΩÕ¬ §¡¡. focal dust emphysema focal dust emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕ߇©æ“–∑’ˇÀµÿΩÿÉπ π. §¡¡. focal emphysema gastric emphysema ¿“«–ºπ—ß°√–‡æ“–Õ“À“√ ¡’Õ“°“» π. ¿“«–∑’ºË π—ß°√–‡æ“–Õ“À“√¡’Õ“°“»‡°‘¥∫√‘‡«≥ √Õ¬·º≈À√◊Õ®“°°≈‰°Õ◊Ëπ ¿“æ√—ß ’∑’ˇÀÁπ§≈⓬√“¬°√–‡æ“– Õ“À“√Õ—°‡ ∫¡’Õ“°“»∑’˺π—ß generalized emphysema ¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕß∑—Ë« π. §¡¡. panacinar emphysema glass blowerûs emphysema ¿“«–∂ÿß≈¡ ªÕ¥‚ªÉßæÕßπ—°‡ªÉ“·°â« π. ∂ÿß≈¡ªÕ¥‚ªÉßæÕß„ππ—° ‡ªÉ“·°â«®“°µâÕß Ÿ¥≈¡‡¢â“ªÕ¥·≈–„™â·√߇ªÉ“¡“° hypoplastic emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕ߇Àµÿ‡®√‘≠æ√àÕß π. ¿“æ∂ÿß≈¡ªÕ¥‚ªÉßæÕß®“°æ—≤π“ °“√º‘¥ª√°µ‘ Õ“®‡ªìπ∑’ Ë «à πÀπ÷ßË ¢Õ߇π◊ÕÈ ªÕ¥, ∑—ßÈ °≈’∫ À√◊Õ ∑—ßÈ ªÕ¥ idiopathic unilobar emphysema ¿“«–∂ÿß ≈¡ªÕ¥‚ªÉßæÕß°≈’∫‡¥’¬«‰¡à∑√“∫‡Àµÿ π. °≈ÿà¡Õ“°“√∑’Ë¡’ ∂ÿß≈¡ªÕ¥‚ªÉßæÕß°≈’∫‡¥’¬« ∑”„À⇰‘¥Õ“°“√À“¬„®≈”∫“° ·≈–Õ“°“√‡¢’¬«§≈È” infantile lobar emphysema ¿“«–∂ÿß≈¡ ªÕ¥‚ªÉßæÕß∑—Èß°≈’∫„π∑“√° π. §¡¡. congenital lobar emphysema interlobular emphysema ¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕßÀ«à“ß°≈’∫ π. §¡¡. distal acinar emphysema interstitial emphysema ¿“«–‡π◊ÈÕ‡¬◊ËÕ·∑√° ¡’Õ“°“» π. °“√¡’Õ“°“»·∑√°„π‡π◊ÕÈ ‡¬◊ÕË ‡°’¬Ë «æ—π¢Õߪե, „πª√–®—πÕ°À√◊Õ‡π◊ÈÕ‡¬◊ËÕ„µâÀπ—ß ‡Àµÿ¡’°“√©’°¢“¥À√◊Õ·µ° ¢Õß∑“ßÀ“¬„®À√◊Õ∂ÿß≈¡ªÕ¥®“°°“√Õÿ¥°—πÈ „πÀ≈Õ¥≈¡ΩÕÀ√◊Õ∫“¥·º≈∑–≈ÿºπ—ß∑√«ßÕ°À√◊Õ‡π◊ÈÕªÕ¥ intestinal emphysema ¿“«–ºπ—ß≈”‰ â¡Õ’ “°“» π. °“√¡’∂ÿßÕ“°“»ºπ—ß∫“ß·∑√°„πºπ—ß≈”‰ â™—Èπ„µâ‡¬◊ËÕ‡≈◊ËÕ¡ À√◊Õ™—Èπ„µâ‡¬◊ËÕ‡¡◊Õ° ‰¡à∑√“∫ “‡Àµÿ lobar emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ‡©æ“–°≈’∫ π. °“√¡’∂ÿß≈¡ªÕ¥‚ªÉßæÕß∫“ß°≈’∫¢Õߪե localized obstructive emphysema ¿“«– ∂ÿß≈¡ªÕ¥‚ªÉßæÕ߇ÀµÿÕ¥ÿ °—πÈ ‡©æ“–∑’Ë π. °“√¡’∂ßÿ ≈¡ªÕ¥ ‚ªÉßæÕ߇©æ“–°≈’∫À√◊Õ à«π¢Õߪե®“°¡’À≈Õ¥≈¡Õÿ¥°—Èπ ‡©æ“–·Ààß

353

mediastinal emphysema ¿“«–ª√–®—πÕ°¡’ Õ“°“» π. °“√¡’Õ“°“»„πª√–®—πÕ°´÷ßË Õ“®°”°—¥°“√À“¬„® ·≈–°“√‰À≈‡«’¬π‡≈◊Õ¥ ·≈–Õ“®π”‰ª Ÿà¿“«–™àÕßÕ°À√◊Õ∂ÿß Àÿâ¡À—«„®¡’Õ“°“» Õ“®‡ªìπº≈®“°∫“¥‡®Á∫À√◊Õ欓∏‘ ¿“æ À√◊ÕÕ“®∑”¢÷Èπµ“¡«‘∏’‡æ◊ËÕ°“√«‘π‘®©—obstructive emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕ߇ÀµÿÕ¥ÿ °—πÈ π. ∂ÿß≈¡ªÕ¥¡’≈¡Õ—¥‡°‘π‡Àµÿ®“°À≈Õ¥≈¡ Õÿ¥°—Èπ≈—°…≥–≈‘Èπ‡ªî¥∑“߇¥’¬«∑”„Àâ°“√À“¬„®ÕÕ°¢—¥¢âÕß panacinar emphysema; panlobular emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß∑—«Ë , ¿“«–∂ÿß≈¡ªÕ¥∑—«Ë °≈’∫¬àÕ¬‚ªÉßæÕß π. §¡¡. chronic hypertrophic emphysema paracicatricial emphysema ¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕߢâ“ß·º≈‡ªìπ π. ¿“æ∂ÿß≈¡ªÕ¥‚ªÉßæÕߢâ“ß√Õ·º≈‡ªìπ„πªÕ¥ paraseptal emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕߢâ“ߺπ—ß°—Èπ π. §¡¡. distal acinar emphysema pulmonary emphysema ¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕß π. §¡¡. emphysema §«“¡À¡“¬∑’Ë Ú pulmonary interstitial emphysema ¿“«– ‡π◊ÕÈ ‡¬◊ÕË ·∑√°¢Õß∂ÿß≈¡ªÕ¥¡’Õ“°“» π. ¿“«–‡°‘¥„π∑“√° §≈Õ¥°àÕπ°”À𥇪ìπ à«π„À≠à ´÷Ëß¡’≈¡√—Ë«®“°∂ÿß≈¡ªÕ¥ ‡¢â“‰ª„π™àÕß«à“ß√–À«à“߇π◊ÕÈ ‡¬◊ÕË ¡—°‡ªìπ√à«¡°—∫°“√¡’‚√§ªÕ¥ À√◊Õ¡’°“√„™â‡§√◊ËÕߙ૬À“¬„® senile emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ‡Àµÿ™√“ π. ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß„πºŸ â ߟ Õ“¬ÿ®“°°“√‡ ◊ÕË ¡ ·≈–æÕßµ—«¢Õß∂ÿß≈¡ªÕ¥ skeletal emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉßæÕß ‡Àµÿ‚§√ß°√–¥Ÿ° π. §¡¡. false emphysema small-lunged emphysema ¿“«–∂ÿß≈¡ªÕ¥ ‚ªÉßæÕ߇ÀµÿªÕ¥ΩÉÕ π. §¡¡. atrophic emphysema subcutaneous emphysema ¿“«–„µâÀπ—ß¡’ Õ“°“» π. §¡¡. cutaneous emphysema surgical emphysema ¿“«–‡π◊ÈÕ‡¬◊ËÕ„µâÀπ—ß¡’ Õ“°“»‡Àµÿ»≈— ¬°√√¡ π. °“√¡’Õ“°“»·∑√°„π‡π◊ÕÈ ‡¬◊ÕË „µâÀπ—ß À≈—ßÀ—µ∂°“√»—≈¬°√√¡ traumatic emphysema ¿“«–‡π◊ÕÈ ‡¬◊ÕË ¡’Õ“°“» ‡Àµÿ∫“¥‡®Á∫ π. °“√¡’Õ“°“»·∑√°„π‡π◊ÈÕ‡¬◊ËÕ‡æ√“–‰¥â√—∫ ∫“¥‡®Á∫ unilateral emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕߢâ“߇¥’¬« π. ¿“«–∂ÿß≈¡‚ªÉßæÕß„πªÕ¥¢â“߇¥’¬« Õ“® ‡ªìπ·µà°”‡π‘¥ À√◊Õ‡ªìπ¿“¬À≈—ß

354 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

vesicular emphysema ¿“«–∂ÿß≈¡ªÕ¥‚ªÉß æÕ߇ªìπ∂ÿß„ π. §¡¡. panacinar emphysema emphysematous Ò. - Õ“°“»„π‡π◊ÈÕ‡¬◊ËÕ «. ‡°’ˬ«°—∫ ¿“æÀ√◊Õº≈ ®“°¡’Õ“°“» – ¡„π‡π◊ÈÕ‡¬◊ËÕ À√◊ÕÕ«—¬«– Ú. - ∂ÿß≈¡ªÕ¥‚ªÉßæÕß «. ‡°’ˬ«°—∫À√◊Õ‰¥â√—∫ º≈®“°∑’Ë¡’∂ÿß≈¡ªÕ¥‚ªÉßæÕß empiric Ò. - ‡™‘ߪ√– ∫°“√≥å «. §¡¡. empirical Ú. ºŸâ¡’∑—°…–®“°ª√– ∫°“√≥å π. ·æ∑¬å ‡«™ªØ‘∫—µ‘ºŸâ¡’∑—°…–®“°ª√– ∫°“√≥å empirical - ‡™‘ ß ª√– ∫°“√≥å «. ∫πæ◊È π ∞“π¢Õß ª√– ∫°“√≥å empiricism Ò. ª√– ∫°“√≥å𬑠¡ π. §«“¡‡™◊ÕË ¡—πË „πª√– ∫°“√≥å °“√∑”‡«™ªØ‘∫—µ‘‡™‘ߪ√– ∫°“√≥å Ú. ∑ÿ√‡«™°√√¡ π. °“√·Õ∫Õâ“ߧ«“¡ “¡“√∂ ·≈–ª√– ∫°“√≥å°“√«‘π‘®©—¬·≈–∫”∫—¥‚√§ emplastic Ò. - ¬÷¥µ‘¥ «. ‡°’ˬ«°—∫°“√¬÷¥µ‘¥À√◊Õ‡À𒬫 Ú. ¬“√–ß—∫∂à“¬ π. ¬“∑”„Àâ∑âÕߺŸ° emporiatrics ‡«™»“ µ√å°“√‡¥‘π∑“ß π. ·¢πߢÕ߇«™»“ µ√凢µ√âÕπ«à“¥â«¬°“√«‘π‘®©—¬ ∫”∫—¥ ·≈– ªÑÕß°—π‚√§‡°‘¥°—∫ºŸ‰â ª Ÿ®à ¥ÿ À¡“¬Õ’°·ÀàßÀπ÷ßË ∑’‰Ë °≈ ÕÕ°‰ª §¡¡. travel medicine emprosthotonos °“√™—°‡°√ÁßÀ≈—ßµ÷ß π. °“√™—°°√–µÿ° ‡°√Áß‚¥¬»’√…–·≈–‡∑⓬◊Ëπ‰ª¢â“ßÀπâ“·≈–≈”µ—«‡°√Áß µ÷ß §¡¡. episthotonos emprosthotonus π. §¡¡. emprosthotonos empyema Ò. Ωï π. ‚æ√ß∑’Ë¡’ÀπÕß Ú. Ωï‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥ π. ‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥¡’ÀπÕß empyema articuli Ω◊ËÕ∫ÿ¢âÕ π. ‡¬◊ËÕ∫ÿ¢âÕ Õ—°‡ ∫¡’ÀπÕß empyema benignum Ωà√“â ¬ π. §¡¡. latent empyema empyema of the chest Ωï∑√«ßÕ° π. §¡¡. empyema §«“¡À¡“¬∑’Ë Ú empyema of gallbladder Ωï∂ÿßπÈ”¥’ π. ∂ÿß πÈ”¥’Õ—°‡ ∫‡©’¬∫æ≈—π¡’ÀπÕß

interlobar empyema ΩïÀ«à“ß°≈’∫ªÕ¥ π. ÀπÕß„π™àÕ߇¬◊ËÕÀÿ⡪ե¢—ßÕ¬Ÿà√–À«à“ß°≈’∫ªÕ¥ latent empyema Ωï·Ωß π. Ωï‚æ√߇¬◊ËÕÀÿâ¡ ªÕ¥∑’ˉ¡à¡’Õ“°“√ loculated empyema Ωï‚æ√߇¬◊ËÕÀÿ⡪ե¢—ß π. ÀπÕß„π‚æ√߇¬◊ËÕÀÿ⡪ե∑’Ë¢—߇ªìπÀâÕß metapneumonic empyema Ωï‚æ√߇¬◊ËÕÀÿâ¡ ªÕ¥À≈—ߪե∫«¡ π. ÀπÕß„π™àÕ߇¬◊ÕË Àÿ¡â ªÕ¥‡°‘¥À≈—ß®“° ‚√§ªÕ¥∫«¡∑ÿ‡≈“·≈â« empyema necessitatis Ωï‚æ√߇¬◊ËÕÀÿ⡪ե ·µ°∑“ßÕ° π. Ωï‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥∑’·Ë µ°‡Õß¡’ÀπÕ߉À≈ÕÕ° ºà“πºπ—ßÕ° parapneumonic empyema Ωï‚æ√߇¬◊ËÕÀÿâ¡ ªÕ¥·∑√°´âÕπªÕ¥∫«¡ π. Ωï‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥∑’‡Ë ªìπ¿“«– ·∑√°´âÕπ‚√§ªÕ¥∫«¡ empyema of pericardium Ωï∂ÿßÀÿâ¡À—«„® π. ∂ÿßÀÿâ¡À—«„®Õ—°‡ ∫‡ªìπÀπÕß pulsating empyema Ωï‚æ√߇¬◊ËÕÀÿ⡪ե‡µâ𠇪ìπ®—ßÀ«– π. ÀπÕß„π™àÕ߇¬◊ËÕÀÿ⡪ե∑’Ë¢¬—∫µ“¡®—ßÀ«– À—«„®‡µâπ ‡ÀÁπ‰¥â∑’˺π—ßÕ° putrid empyema Ωï‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥‡πà“‡À¡Áπ π. ÀπÕß„π™àÕ߇¬◊ËÕÀÿ⡪ե∑’ˇπà“‡ªóòÕ¬¡’°≈‘Ëπ‡À¡Áπ synpneumonic empyema Ωï‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥ √à«¡ªÕ¥∫«¡ π. Ωï‚æ√߇¬◊ËÕÀÿ⡪ե‡°‘¥„π™à«ßªÕ¥Õ—°‡ ∫ thoracic empyema Ωï∑√«ßÕ° π. §¡¡. empyema of the chest tuberculous empyema Ωï«—≥‚√§‚æ√߇¬◊ËÕ Àÿ⡪ե π. Ωï‚æ√߇¬◊ËÕÀÿ⡪ե‡°‘¥®“°‡™◊ÈÕ«—≥‚√§ empyemic Ò. - Ωï «. ‡°’ˬ«°—∫‚æ√ßÀπÕß Ú. - Ωï‚æ√߇¬◊ÕË Àÿ¡â ªÕ¥ «. ‡°’¬Ë «°—∫À√◊Õ¡’ÀπÕß„π ‚æ√߇¬◊ËÕÀÿ⡪ե empyesis Ò. º◊ËπÀπÕß π. º◊Ëπ‡¡Á¥ÀπÕß Ú. ‚√§º◊ËπÀπÕß π. ‚√§∑’Ë¡’º◊Ëπ‡¡Á¥ÀπÕß empyocele Ωï –¥◊Õ π. ¿“«–¡’ÀπÕߢ—ß∑’Ë –¥◊Õ emtricitabine ‡Õ¡‰∑√‰´∑“∫’π π. “√ —߇§√“–Àå𑫧≈’ ‚Õ‰´¥å§≈⓬‰´‚∑´’𠇪ìπµ—«¬—∫¬—Èß∑√“π §√‘ª‡∑ ¬âÕπ∑“ß „™â°π‘ ∫”∫—¥‚√§µ‘¥‡™◊ÕÈ ‰«√— ¿Ÿ¡§‘ ¡ÿâ °—π‡ ◊ÕË ¡ emulgent - °≈—Ëπ°√Õß «. °√–∫«π°“√√’¥§—ÈπÀ√◊Õ∑”„Àâ ∫√‘ ∑ÿ ∏‘Ï

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

emulsifier “√∑”Õ‘¡—≈™—π π. “√∑”„À⇪ìπÕ‘¡—≈™—π emulsify ∑”Õ‘¡—≈™—π °. ∑”„À⇪ìπÕ‘¡—≈™—π emulsion Õ‘¡—≈™—π π. ¢Õ߇À≈«º ¡ “√ Ú ™π‘¥∑’Ë√«¡ ‡ªìπ‡π◊ÈÕ‡¥’¬«°—π‰¡à‰¥â ¢Õ߇À≈«™π‘¥Àπ÷Ëß°√–®“µ—«‡ªìπ‡¡Á¥‡≈Á°Ê Õ¬Ÿà„π¢Õ߇À≈«Õ’°™π‘¥Àπ÷Ëß ‡™àπ πÈ”π¡ mineral oil emulsion Õ‘¡—≈™—ππÈ”¡—π·√à π. “√‡À≈«∑’˪√–°Õ∫¥â«¬πÈ”¡—π·√à, Õ–‡§‡™’¬, πÈ”‡™◊ËÕ¡, «“π‘≈≈‘π, ·Õ≈°ÕŒÕ≈å ·≈–πÈ”∫√‘ ÿ∑∏‘Ï „™â‡ªìπ¬“√–∫“oil-in-water emulsion Õ‘¡—≈™—ππÈ”¡—π„ππÈ” π. Õ‘¡—≈™—π∑’ËπÈ”¡—π°√–®“¬µ—«‡ªìπ‡¡Á¥‡≈Á°Ê Õ¬Ÿà„ππÈ” water-in-oil emulsion Õ‘¡—≈™—ππÈ”„ππÈ”¡—π π. Õ‘¡—≈™—π∑’ËπÈ”°√–®“¬µ—«‡ªìπ‡¡Á¥‡≈Á°Ê Õ¬Ÿà„ππÈ”¡—π emulsive - Õ‘¡—≈™—π «. (Ò) ∑”‡ªìπÕ‘¡—≈™—π‰¥â; (Ú) ∑” ‡ªìπÕ‘¡—≈™—π‰¥âßà“¬; (Û) ·¬°πÈ”¡—πÕÕ°‰¥â¿“¬„µâ ·√ߥ—π emunctory Ò. - ¢—∫∂à“¬ «. ‡°’ˬ«°—∫°“√¢—∫∂à“¬À√◊ÕøÕ°≈â“ß Ú. Õ«—¬«–¢—∫∂à“¬ π. Õ«—¬«–¢—∫∂à“¬À√◊Õ∑àÕ∑“ß ¢—∫∂à“en bloc ∑—Èß°√–∫‘ «. À¡¥∑—Èß°âÕπ en plaque - ‡ªìπ·ºàπ «. Õ¬Ÿà„π√Ÿª·ºàπÀ√◊Õ®“π enëdoëplasëmic - ‡Õπ‚¥æ≈“´÷¡ «. ‡°’¬Ë «°—∫‡Õπ‚¥æ≈“´÷¡ enamel Ò. Õ’π“‡¡≈ π. (Ò) º‘«‡≈’Ë¬π«“«¢Õß°√–‡∫◊ÈÕß ¥‘π‡º“ ‚≈À– À√◊Õ¿“™π–¥‘π‡º“; (Ú) º‘« ‡§≈◊Õ∫‡√’¬∫·¢Áß¡—π«“« Ú. ‡§≈◊Õ∫øíπ π. §¡¡. dental enamel dental enamel ‡§≈◊Õ∫øíπ π. º‘«πÕ°¢Õßøí𠇪ìπ à«π·¢Áß∑’Ë ÿ¥„π√à“ß°“¬ ª√–°Õ∫¥â«¬‡°≈◊Õ·§≈‡´’¬¡ ‡°◊Õ∫∑—ßÈ À¡¥ dwarfed enamel ‡§≈◊Õ∫øíπ∫“ß π. §¡¡. nanoid enamel hereditary brown enamel ‡§≈◊Õ∫øíπ ’ πÈ”µ“≈°√√¡æ—π∏ÿå π. ‡§≈◊Õ∫øíπ∫“ß ‡ª√“– ¡’√Õ¬ ’πÈ”µ“≈ ‡°‘¥®“°æ—≤π“°“√‡§≈◊Õ∫øíπ‰¡à ¡∫Ÿ√≥å ‡Àµÿ‚§√‚¡‚´¡º‘¥ ª√°µ‘ ¥Ÿ amelogenesis imperfecta hypoplastic enamel ‡§≈◊Õ∫øíπæ√àÕ߇®√‘≠ π. ‡§≈◊Õ∫øíπ‡®√‘≠º‘¥ª√°µ‘´÷Ë߇ªìπ°“√æ—≤𓇧≈◊Õ∫øíπ‰¡à ¡∫Ÿ√≥å·∫∫Àπ÷Ëß §¡¡. amelogenesis imperfecta mottled enamel ‡§≈◊Õ∫øíπ°√– π. ‡§≈◊Õ∫øíπ ‰¡à ¡∫Ÿ√≥å‡√◊ÈÕ√—ß ≈—°…≥–‡ªìπ≈“¬®“°§«“¡∫°æ√àÕߢÕß

355

°“√¡’·§≈‡´’¬¡‡°“–°≈“¬‡ªìπ ’πÈ”µ“≈ ¡’ Õÿ ∫— µ‘ ° “√≥å „ π ∑âÕß∂‘πË ∑’πË È”¥◊¡Ë ¡’ “√ø≈ŸÕÕ√’π Ÿß æ∫„π‡¥Á°™à«ßøíπ·∑âßÕ° nanoid enamel ‡§≈◊Õ∫øíπ∫“ß π. §¡¡. dwarfed enamel enameloblast ‡´≈≈å √â“߇§≈◊Õ∫øíπ π. §¡¡. adaman toblast enameloblastoma ‡π◊ÕÈ ßÕ°‡´≈≈å √â“߇§≈◊Õ∫øíπ π. §¡¡. ameloblastoma enameloma ‰¢à¡ÿ°‡§≈◊Õ∫øíπ π. ªÿÉ¡‡§≈◊Õ∫øíπ ∑’ˉ¡à„™à‡π◊ÈÕßÕ° æ∫µ√ߪ≈“¬‡¥◊Õ¬‡§≈◊Õ∫øíπ∑’Ëßà“¡√“°øíπ À√◊Õ∑’˺‘«√“°øíπ Õ“®‡ªìπ‡§≈◊Õ∫øíπ≈â«π À√◊Õ¡’„¬ΩÕ¬¢Õß ‡π◊ÈÕ‡¬◊ËÕ„π·≈–¢Õ߇π◊ÈÕøíπ√à«¡¥â«enameloplasty º‘«‡§≈◊Õ∫øíπ π. °“√·µàߺ‘«‡§≈◊Õ∫øíπ ‡æ◊ËÕ≈∫√àÕß·≈–µ”Àπ‘ enamelum ‡§≈◊Õ∫øíπ π. §¡¡. dental enamel enanthem º◊πË ‡¬◊ÕË ‡¡◊Õ° π. º◊πË ‡°‘¥∫πº‘«‡¬◊ÕË ‡¡◊Õ° §¡¡. enanthema enanthema π. §¡¡. enanthem enanthematous - º◊πË ‡¬◊ÕË ‡¡◊Õ° «. ‡°’¬Ë «°—∫À√◊Õ¡’≈°— …≥– ¢Õߺ◊Ëπ‡¬◊ËÕ‡¡◊Õ° enantiobiosis ¿“«–ªØ‘ªí°…å™’æ π. ¿“«–∑’Ë ‘Ëß¡’™’«‘µ´÷Ëß Õ¬Ÿ√à «à ¡°—π‡ªìπªØ‘ª°í …åµÕà æ—≤π“°“√¢Õß°—π·≈–°—π enarthritis ¢âÕµàÕ™π‘¥À—«°≈¡Õ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ¢âÕµàÕ™π‘¥À—«°≈¡ enarthrodial - ¢âÕµàÕ‡∫â“ «. ‡°’ˬ«°—∫¢âÕµàÕ™π‘¥À—«°≈¡ enarthrosis ¢âÕµàÕ‡∫â“ π. ¢âÕµàÕ™π‘¥ª≈“¬°√–¥Ÿ°¢âÕ¢â“ß Àπ÷ßË ‡ªìπ∑√ß°≈¡‡§≈◊ÕË π‰À«„π‡∫⓪≈“¬°√–¥Ÿ°Õ’° ¢â“ßÀπ÷ßË encanthis ªÿÉ¡‡π◊ÈÕÀ—«µ“ π. °âÕπ‡π◊ÈÕ‡≈Á° ’·¥ß∫π√Õ∑∫‡¬◊ËÕµ“·≈–‡π◊ÈÕ¥â“π„πÀ—«µ“ encapsulated - Õ¬Ÿà„π ‘ËßÀÿâ¡ «. ´÷ËßÕ¬Ÿà¿“¬„π ‘ËßÀÿâ¡ encapsulation Ò. °“√ÀàÕÀÿâ¡ π. °“√‡¢â“Õ¬Ÿà¿“¬„π∂ÿßÀÿâ¡ Ú. °√–∫«π°“√¡’∂ÿßÀÿâ¡ π. °√–∫«π°“√∑“ß √’√«‘∑¬“∑’≈Ë Õâ ¡¥â«¬‡¬◊ÕË Àÿ¡â Õ—π‰¡à„™à‡π◊ÕÈ ‡¬◊ÕË ¢Õß à«ππ—Èπ encapsuled §¡¡. encapsulated encarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ π. §¡¡. endocarditis encephalalgia Õ“°“√ª«¥ ¡Õß π. §«“¡√Ÿâ ÷°‡®Á∫ª«¥ „π»’√…– ‡π◊ËÕß®“°æ¬“∏‘ ¿“æ∑’Ë ¡Õß

356 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

encephalatrophy ¿“«– ¡ÕßΩÉÕ π. °“√¡’ ¡ÕßΩÉÕ≈’∫ encephalic Ò. - ¡Õß «. ‡°’ˬ«°—∫ ¡Õß Ú. - „π°–‚À≈° «. Õ¬Ÿà„π°–‚À≈°»’√…– encephalitic - ¡ÕßÕ—°‡ ∫ «. ‡°’ˬ«°—∫À√◊Õ‡ªìπº≈®“° °“√Õ—°‡ ∫¢Õß ¡Õß encephalitis ¡ÕßÕ—°‡ ∫ «. °“√Õ—°‡ ∫¢Õß ¡Õß encephalitogen “√°àÕ ¡ÕßÕ—°‡ ∫ π. ‘ßË °àÕ¿“«– ¡Õß Õ—°‡ ∫ encephalitogenic - °àÕ ¡ÕßÕ—°‡ ∫ «. ‡°’ˬ«°—∫°“√ ∑”„Àâ ¡ÕßÕ—°‡ ∫ encephalization °√–∫«π°“√æ—≤π“¢Õß ¡Õß π. °√–∫«π°“√æ—≤𓇪≈◊Õ° ¡Õß„À≠à„Àâ√—∫Àπâ“∑’Ë ¢Õß»Ÿπ¬åª√– “∑ à«π≈à“ß (‰¢ —πÀ≈—ß) encephalocele ‚√§ ¡Õ߇≈◊ËÕπ π. ¿“«–∑’Ë à«π ¡Õß·≈– ‡¬◊ÕË Àÿ¡â ¬◊πË ºà“π™àÕß°–‚À≈°»’√…– Õ“®‡ªìπ·µà°”‡π‘¥ ¿“¬À≈—ß∫“¥‡®Á∫ À√◊Õ¿“¬À≈—ß»—≈¬°√√¡ basal encephalocele ‚√§ ¡Õ߇≈◊ËÕπ∫√‘‡«≥ ∞“π°–‚À≈° π. ¿“«– ¡Õ߬◊Ëπ„π∫√‘‡«≥∞“π°–‚À≈°»’√…– frontal encephalocele ‚√§ ¡Õ߇≈◊ËÕπ∫√‘‡«≥ Àπ⓺“° π. ¿“«– ¡Õ߬◊Ëπ„π∫√‘‡«≥°√–¥Ÿ°Àπ⓺“° occipital encephalocele ¡Õ߇≈◊ËÕπ∫√‘‡«≥ ∑⓬∑Õ¬ π. ¿“«– ¡Õ߬◊Ëπ„π∫√‘‡«≥°√–¥Ÿ°∑⓬∑Õencephalocystocele ‚√§ ¡Õ߇≈◊ËÕπ‡¢â“∂ÿßπÈ” π. ¿“«– ¡Õ߇≈◊ÕË π‡¢â“‰ªÕ¬Ÿ„à π∂ÿß “√πÈ”À≈àÕ ¡Õ߉¢ —πÀ≈—ß §¡¡. hydroencephalocele encephalodialysis ¿“«– ¡Õßπà«¡ π. §¡¡. encephalomalacia encephalodysplasia ¡Õ߇®√‘≠º‘¥ª√°µ‘ π. ¡Õß ‡®√‘≠º‘¥ª√°µ‘·µà°”‡π‘¥ encephalography °“√∂à“¬¿“æ√—ß ’ ¡Õß π. °“√∂à“¿“æ√—ß ’ ¡Õ߇æ◊ÕË · ¥ß‚æ√ß ¡ÕßÀ≈—ߥŸ¥ “√πÈ” À≈àÕ ¡Õ߉¢ —πÀ≈—ßÕÕ°·≈–©’¥Õ“°“»À√◊Õ “√∑÷∫ √—ß ’‡¢â“‰ª encephaloid - §≈⓬ ¡Õß π. §≈⓬ ¡ÕßÀ√◊Õ‡π◊ÕÈ ¡Õß encephalolith π‘Ë« ¡Õß π. °âÕππ‘Ë«„π ¡Õß encephaloma ‡π◊ÈÕßÕ° ¡Õß π. (Ò) ‡π◊ÈÕ ¡Õß∫«¡ À√◊Õ‡π◊ÈÕßÕ° ¡Õß; (Ú) ™◊ËÕ‡¥‘¡¢Õß medullary carcinoma encephalomalacia ¿“«– ¡Õßπà«¡ π. ¡ÕßÕàÕππà«¡ ‡Àµÿ‡π◊ÈÕ ¡Õßµ“¬®“°¢“¥‡≈◊Õ¥

encephalomeningitis ¡Õß·≈–‡¬◊ÕË Àÿ¡â ¡ÕßÕ—°‡ ∫ π. °“√Õ—°‡ ∫‡¬◊ÕË Àÿ¡â ¡Õß·≈– ¡Õß §¡¡. cerebromeningitis encephalomeningocele ‡¬◊ÕË Àÿ¡â ¡Õß·≈– ¡Õ߇≈◊ÕË π π. §¡¡. encephalocele encephalomeningopathy ‚√§ ¡Õß·≈–‡¬◊ËÕÀÿâ¡ π. ‚√§ ¡Õß·≈–‡¬◊ËÕÀÿâ¡ ¡Õß∑’ˉ¡à‰¥â‡°‘¥®“°°“√Õ—°‡ ∫ encephalometer ¡“µ√ ¡Õß π. ‡§√◊ËÕß¡◊Õµ√«®À“ µ”·Àπàß à«π ¡Õß encephalomyelitis ¡Õß·≈–‰¢ —πÀ≈—ßÕ—°‡ ∫ π. °“√ Õ—°‡ ∫¢Õ߉¢ —πÀ≈—ß·≈– ¡Õß encephalomyelocele ‰¢ —πÀ≈—ß·≈– ¡Õ߇≈◊ËÕπ π. §«“¡º‘¥ª√°µ‘¢ÕßøÕ√“‡¡π·¡°π—¡·≈–‰¡à¡’·ºàπ °√–¥Ÿ°ª°·≈–®–ßÕ¬°√–¥Ÿ° —πÀ≈—ß à«π§Õ ·≈–¡’ °“√‡≈◊ÕË π¢Õ߇¬◊ÕË Àÿ¡â ¡Õß ‡π◊ÕÈ ¡Õß ·≈–‰¢ —πÀ≈—ß encephalomyeloneuropathy ‚√§ ¡Õ߉¢ —πÀ≈—ß·≈– ‡ âπª√– “∑ π. 欓∏‘ ¿“æ∑—Èß∑’Ë ¡Õß ‰¢ —πÀ≈—ß ·≈–‡ âπª√– “∑ à«π√Õ∫ encephalomyelopathy ‚√§ ¡Õß·≈–‰¢ —πÀ≈—ß π. 欓∏‘ ¿“æ∑’Ë ¡Õß·≈–‰¢ —πÀ≈—ß encephalomyeloradiculitis ‚√§ ¡Õ߉¢ —πÀ≈—ß·≈– √“°ª√– “∑Õ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ¡Õß ‰¢ —πÀ≈—ß ·≈–√“°ª√– “∑ encephalomyeloradiculopathy ‚√§ ¡Õ߉¢ —πÀ≈—ß ·≈–√“°ª√– “∑ π. 欓∏‘ ¿“æ∑’ Ë ¡Õß ‰¢ —πÀ≈—ß ·≈–√“°ª√– “∑ encephalomyopathy ‚√§ ¡Õß·≈–°≈â“¡‡π◊ÈÕ π. 欓∏‘ ¿“æ∑’Ë ¡Õß·≈–°≈â“¡‡π◊ÈÕ encephalon ¡Õß„À≠à π. à«π¢Õß√–∫∫ª√– “∑°≈“ß ¿“¬„π°–‚À≈°»’√…– ª√–°Õ∫¥â«¬ ¡Õß à«πÀπâ“ à«π°≈“ß ·≈– à«π∑â“encephalonarcosis ¿“«–´÷¡‡´“‡Àµÿ ¡Õß π. Õ“°“√ ‡ß’¬∫ß—π‡Àµÿ‚√§ ¡Õß encephalopathic - ‚√§ ¡Õß «. ‡°’ˬ«°—∫‚√§ ¡Õß encephalopathy ‚√§ ¡Õß π. ‚√§ ¡Õ߇ ◊ËÕ¡ ¿“æ AIDS encephalopathy ‚√§ ¡Õ߇Àµÿ‡Õ¥ å π. ‚√§ ¡Õß≈ÿ°≈“¡‡Àµÿ‚√§µ‘¥‡™◊ÕÈ ‰«√— ¿Ÿ¡§‘ ¡ÿâ °—π‡ ◊ÕË ¡„π§π ™π‘¥∑’Ë Ò ‡°‘¥§«“¡º‘¥ª√°µ‘∑“ߪ√‘™“π °“√‡§≈◊ÕË π‰À« ·≈– 惵‘°√√¡ §¡¡. AIDS dementia complex, HIV encephalopathy

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

anoxic encephalopathy ‚√§ ¡Õߢ“¥ ÕÕ°´‘‡®π π. ‚√§ ¡Õ߇Àµÿ¿“«–æ√àÕßÕÕ°´‘‡®π®“°°“√ ‰À≈‡«’¬π‡≈◊Õ¥≈¥≈ß À√◊Õ√–¥—∫ÕÕ°´‘‡®π„π‡≈◊Õ¥µË”≈ß „π √“¬¢“¥ÕÕ°´‘‡®ππâÕ¬Ê ¡’Õ“°“√º‘¥ª√°µ‘∑“ß µ‘ªí≠≠“ °“√¡Õ߇ÀÁπ ·≈–°”≈—ß°“¬ „π√“¬¢“¥ÕÕ°´‘‡®π√ÿπ·√ß®“° À—«„®À¬ÿ¥‡µâπÀ√◊Õ∑“ßÀ“¬„®Õÿ¥µ—π ¡ÕßÕ“®∂Ÿ°∑”≈“¬∂“«√ ¿“¬„π‡«≈“ ı π“∑’ §¡¡. hypoxic encephalopathy biliary encephalopathy ‚√§ ¡Õ߇ÀµÿπÈ”¥’ π. ‚√§ ¡Õ߇Àµÿ‡≈◊Õ¥¡’∫≈‘ √‘ ∫Ÿ π‘ „π‡≈◊Õ¥¡“° ‡°‘¥°“√µ‘¥ ’πÈ” ¥’„π‡π◊ÈÕ ¡Õß∑”„À⇰‘¥°“√∑”≈“¬ ¡Õß bilirubin encephalopathy ‚√§ ¡Õ߇Àµÿ ∫‘≈‘√Ÿ∫‘π π. §¡¡. biliary encephalopathy boxerûs encephalopathy; boxerûs traumatic encephalopathy ‚√§ ¡Õßπ—°¡«¬ π. ‚√§ ¡Õß ‡°‘¥®“°‰¥â√∫— ∫“¥‡®Á∫„π°“√™°¡«¬ ¡’Õ“°“√‡™◊ÕË ß™â“∑“ß ¡Õß ∫“ߧ√—Èß¡’Õ“°“√ —∫ 𠧫“¡®”‡ ◊ËÕ¡ Õ“®°≈“¬‡ªìπ‚√§ ¡Õ߇ ◊ËÕ¡‰¥â hepatic encephalopathy ‚√§ ¡Õ߇Àµÿµ—∫ π. ¿“«–·∑√°´âÕπ®“°‚√§µ—∫√–¬–√ÿπ·√ß Õ“®æ∫‰¥â¿“¬À≈—ß ∑”»—≈¬°√√¡∑”∑“ß≈—¥‡™◊ËÕ¡À≈Õ¥‡≈◊Õ¥¥”æÕ√å∑—≈°— ∫ ∑à Õ ‡≈◊Õ¥¥” ¡’Õ“°“√‡ª≈’ˬπ·ª≈ß∑“ߧ«“¡√Ÿâ ÷°µ—«∑’ËÕ“®√ÿπ·√ß ¡“°∂÷ߢ—Èπ‚§¡à“ HIV encephalopathy, HIV-related encephalopathy ‚√§ ¡Õ߇Àµÿ‡Õ™‰Õ«’ π. §¡¡. AIDS encephalopathy hypernatremic encephalopathy ‚√§ ¡Õß ‡Àµÿ‡≈◊Õ¥¡’‚´‡¥’¬¡‡°‘π π. ‚√§ ¡Õ߇≈◊Õ¥ÕÕ°√ÿπ·√ß®“° ¿“«–ÕÕ ‚¡≈“√‘µ’ Ÿß‡°‘π∑’ˇªìπº≈®“°¿“«–‡≈◊Õ¥¡’‚´‡¥’¬¡ ¡“°‡°‘π·≈–¿“«–¢“¥πÈ” hypertensive encephalopathy ‚√§ ¡Õ߇Àµÿ §«“¡¥—π‡≈◊Õ¥ Ÿß π. ‚√§ ¡Õß∑’ˇ°‘¥„π¿“«–§«“¡¥—π‡≈◊Õ¥ Ÿß√⓬·√ß ¡’Õ“°“√ª«¥À—« ™—°·≈–À¡¥ µ‘ hypoglycemic encephalopathy ‚√§ ¡Õß ‡Àµÿ‡≈◊Õ¥¡’πÈ”µ“≈πâÕ¬ π. ‚√§ ¡Õ߇π◊ÕË ß®“°‡≈◊Õ¥¡’πÈ”µ“≈ πâÕ¬¡“° ‡™àπ ‚√§‰°≈‚§‡®π – ¡ ¿“«–°“√ √â“ßÕ‘π´Ÿ≈‘π ¡“°‡°‘π À√◊Õ‰¥â√—∫Õ‘π´Ÿ≈‘π‡°‘π¢π“¥ hypoxic encephalopathy ‚√§ ¡Õßæ√àÕß ÕÕ°´‘‡®π π. §¡¡. anoxic encephalopathy lead encephalopathy ‚√§ ¡Õ߇Àµÿµ–°—Ë« π. ‚√§ ¡Õ߇π◊ËÕß®“°°“√°‘π “√µ–°—Ë« æ∫„π‡¥Á°‡≈Á°¡’Õ“°“√ Õ“‡®’¬π ‡ß’¬∫ß—π ™—°°√–µÿ° ‚§¡à“ ·≈–‡ ’¬™’«‘µ

357

myoclonic encephalopathy of childhood ‚√§ ¡Õß°≈â“¡‡π◊ÈÕ°√–µÿ°„π‡¥Á° π. ‚√§ ¡Õ߉¡à∑√“∫ “‡Àµÿ‡√‘Ë¡„π‡¥Á°Õ“¬ÿ Ò-Û ªï ¡’Õ“°“√°≈â“¡‡π◊ÈÕ≈”µ—«·≈– ·¢π¢“°√–µÿ°√—« ≈Ÿ°µ“°√–µÿ° ∑à“‡¥‘π‡ª–ª– ·≈–Õ“°“√ —Ëπ ¢≥–®–∑”°“√ punch-drunk encephalopathy ‚√§ ¡Õß ‡Àµÿ‡¡“À¡—¥ π. §¡¡. boxerûs dementia saturnine encephalopathy ‚√§ ¡Õ߇Àµÿ æ‘…µ–°—Ë« π. §¡¡. lead encephalopathy uremic encephalopathy ‚√§ ¡Õ߇Àµÿ¬Ÿ‡√’π. ‚√§ ¡Õßæ∫„πºŸªâ «É ¬‡≈◊Õ¥§—ßË “√æ‘…®“°‰µ‡ ◊ÕË ¡ ¡’Õ“°“√ ßà«ßßÿπ ÕàÕπ≈â“ ‰¡à¡’ ¡“∏‘ Àßÿ¥Àß‘¥ §«“¡√Ÿâ ÷° —∫ π ·≈– ∫“ߧ√—ÈßÕ“®™—° encephalopathy ‚√§ ¡Õ߇ ◊ËÕ¡ ¿“æ π. encephalopuncture À—µ∂°“√‡®“– ¡Õß π. °“√‡®“– ¡Õ߇æ◊ËÕ°“√«‘π‘®©—¬À√◊Õ°“√∫”∫—¥‚√§ encephalopyosis Ωï„π ¡Õß π. °“√‡°‘¥ÀπÕßÀ√◊Õ‚æ√ß ÀπÕß„π ¡Õß encephalorachidian - ¡Õß·≈–‰¢ —πÀ≈—ß π. §¡¡. cerebrospinal encephaloradiculitis ‚√§√“°ª√– “∑ ¡ÕßÕ—°‡ ∫ π. ‚√§∑’ˇ°‘¥®“°°“√Õ—°‡ ∫¢Õß√“°ª√– “∑ ¡Õß encephalorrhagia °“√µ°‡≈◊Õ¥„π ¡Õß π. °“√¡’‡≈◊Õ¥ ÕÕ°„π ¡ÕßÀ√◊Õ®“° ¡Õß ‚¥¬‡©æ“–√Õ∫À≈Õ¥ ‡≈◊Õ¥ΩÕ¬„π ¡Õß encephalosclerosis ‚√§ ¡Õß°√–¥â“ß π. ‚√§∑’ˇ°‘¥®“° °“√·¢Áßµ—«¢Õ߇π◊ÈÕ ¡Õß encephaloscope °≈âÕß àÕß ¡Õß π. ‡§√◊ËÕß¡◊Õ àÕßµ√«® ‚æ√ß„π‡π◊ÈÕ ¡Õß ‡™àπ ‚æ√ßÀπÕß encephaloscopy °“√ àÕßµ√«® ¡Õß π. °“√„™â°≈âÕß àÕßµ√«®À√◊Õµ√«® Õ∫ ¡Õß encephalosepsis ¿“«– ¡Õßµ‘¥‡™◊ÈÕ π. ‚√§∑’ˇ°‘¥®“° ‡π◊ÈÕ ¡Õßµ‘¥‡™◊ÈÕµ“¬‡πà“ encephalosis ‚√§ ¡Õß π. §¡¡. encephalopathy encephalospinal - ¡Õß√à«¡‰¢ —πÀ≈—ß π. §¡¡. cerebrospinal encephalothlipsis ¿“«– ¡Õß∂Ÿ°∫’∫Õ—¥ π. ‚√§‡Àµÿ ‡π◊ÈÕ ¡Õß∂Ÿ°∫’∫Õ—¥ encephalotome ‡§√◊ÕË ß¡◊Õºà“ ¡Õß π. ‡§√◊ÕË ß¡◊Õ„™â„π°“√ ºà“ ¡Õß encephalotomy »—≈¬°√√¡ºà“ ¡Õß π. °“√ºà“‡π◊ÈÕ ¡Õß

358 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

enchondral - °√–¥Ÿ°ÕàÕπ «. §¡¡. endochondral enchondroma ‡π◊ÈÕßÕ°ª≈“¬°√–¥Ÿ°ÕàÕπ π. ‡π◊ÈÕßÕ° °√–¥Ÿ°ÕàÕπ™π‘¥‰¡à√“â ¬ ‡°‘¥∑’∫Ë √‘‡«≥‡¡∑“‰ø´‘ ¢Õß °√–¥Ÿ° §¡¡. true chondroma enchondromatosis ¿“«–°√–¥Ÿ°ÕàÕπßÕ°À≈“¬·Ààß π. ¿“«–¡’°âÕπ‡π◊ÈÕ°√–¥Ÿ°ÕàÕπßÕ°∫√‘‡«≥‡¡∑“‰ø´‘ ¢Õß°√–¥Ÿ°À≈“¬·Ààß ∑”„À⺑«°√–¥Ÿ° à«ππ—Èπ∫“ß ·≈–≈”°√–¥Ÿ°∫‘¥‡∫’Ȭ« Õ“®°≈“¬‡ªìπ¡–‡√Áß enchondromatous - ‡π◊ÕÈ ßÕ°ª≈“¬°√–¥Ÿ°ÕàÕπ «. ‡°’¬Ë « °—∫‡π◊ÈÕßÕ°ª≈“¬°√–¥Ÿ°ÕàÕπ enchondrosarcoma ¡–‡√Áß°√–¥Ÿ°ÕàÕπ¿“¬„π π. ¡–‡√Áß °√–¥Ÿ°ÕàÕπ∑’ßË Õ°Õ¬Ÿ¿à “¬„π à«π°≈“ß°√–¥Ÿ° · ¥ß Õ“°“√ª«¥≈÷°·µà¡—°‰¡àª√“°Ø°âÕπ„Àâ‡ÀÁπ §¡¡. central condrosarcoma enchondrosis ¿“«–°√–¥Ÿ°ÕàÕπßÕ° π. (Ò) °“√ßÕ° ‡°‘π¢Õß°√–¥Ÿ°ÕàÕπ; (Ú) §¡¡. enchondroma encolpism ¬“„ à™àÕߧ≈Õ¥ π. ¬“∑’Ë„™â‡ÀπÁ∫À√◊Õ„ à∑“ß ™àÕߧ≈Õ¥ encopresis °“√°≈—ÈπÕÿ®®“√–‰¡àÕ¬Ÿà π. Õ“°“√Õÿ®®“√–√“¥ ‡Àµÿ°≈—Èπ‰¡àÕ¬Ÿà encranius ·Ω¥µ‘¥°—π·Ωß„π°–‚À≈° π. ·Ω¥µ—«‡∫’¬π ·Ωß„π°–‚À≈°·Ω¥µ—«„À≠à encyopyelitis °√«¬‰µ¢¬“¬™à«ß¡’§√√¿å π. ¿“«–∑àÕ‰µ À√◊Õ°√«¬‰µæÕߢ¬“¬™à«ß¡’§√√¿å√«à ¡°—∫Õ“°“√∫«¡ πÈ” ·µà¡—°‰¡à¡’≈—°…≥–¢Õß°“√Õ—°‡ ∫ encysted - Õ¬Ÿà„π∂ÿß «. ´÷ËßÀÿâ¡Õ¬Ÿà¿“¬„π∂ÿß encystment °“√ √â“ß∂ÿßÀÿâ¡ π. °√–∫«π°“√À√◊Õ¿“«–∑’Ë ¡’∂ÿßÀÿâ¡ end plate ·ºàπª≈“¬ π. à«πª≈“¬∑’ˇªìπ·ºàπ motor end plate ·ºàπª≈“¬ª√– “∑‡§≈◊ÕË π‰À« π. à«πª≈“¬·°πª√– “∑‡§≈◊ËÕπ‰À«‡ªìπ·ºàπ√Ÿª®“π Õ¬Ÿà µ‘¥°—∫°≈â“¡‡π◊ÈÕ≈“¬ ‡°‘¥‡ªìπ√Õ¬µàÕª√– “∑√à«¡°≈â“¡‡π◊ÈÕ endadelphos ·Ω¥µ‘¥·Ωß„π√à“ß π. ·Ω¥µ—«‡∫’¬πÕ¬Ÿà„π √à“ßÀ√◊Õ„π‡π◊ÈÕßÕ°·Ω¥µ—«„À≠à endangiitis ºπ—ß™—Èπ„πÀ≈Õ¥‡≈◊Õ¥Õ—°‡ ∫ π. °“√Õ—°‡ ∫ ¢Õߺπ—ß™—Èπ„πÀ≈Õ¥‡≈◊Õ¥ §¡¡. endoangiitis endaortic - ¥â“π„π‡ÕÕÕ√嵓 «. ‡°’ˬ«°—∫¥â“π„π¢Õß ‡ÕÕÕ√嵓 endaortitis ‡¬◊ËÕ∫ÿ‡ÕÕÕ√嵓՗°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ‡¬◊ËÕ∫ÿ‡ÕÕÕ√嵓

bacterial endaortitis ‡¬◊ËÕ∫ÿ‡ÕÕÕ√嵓՗°‡ ∫ ‡Àµÿ·∫§∑’‡√’¬ π. °“√‡°‘¥ ‘ËßßÕ°∫π‡¬◊ËÕ∫ÿ‡ÕÕÕ√嵓‡Àµÿµ‘¥ ‡™◊ÕÈ ·∫§∑’‡√’endarterectomy °“√§«â“π‡¬◊ÕË ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ß π. °“√ µ—¥µ–°√—πÀπ“∑’ˇ¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ßÕÕ° carotid endarterectomy °“√§«â“π‡¬◊ÕË ∫ÿÀ≈Õ¥ ‡≈◊Õ¥·¥ß·§√Õ∑‘¥ π. °“√µ—¥µ–°√—πÀπ“∑’‡Ë ¬◊ÕË ∫ÿÀ≈Õ¥‡≈◊Õ¥ ·¥ß·§√Õ∑‘¥‡æ◊ËÕªÑÕß°—π°“√‡°‘¥‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß common femoral endarterectomy °“√§«â“𠇬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ßøï¡Õ√—≈√à«¡ π. °“√µ—¥µ–°√—πÀπ“ ∑’ˇ¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ßøï¡Õ√—≈√à«¡‡æ◊ËÕ·°â‰¢°“√¢“¥‡≈◊Õ¥ ¢Õߢ“ transluminal endarterectomy °“√§«â“𠇬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ß®“°¿“¬„π π. °“√µ—¥µ–°√—πÀπ“ ∑’ˇ¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ß‚¥¬ Õ¥Õÿª°√≥åµ—¥ºà“πÀ≈Õ¥ «π ∑“ßÀ≈Õ¥‡≈◊Õ¥ endarterial - „πÀ≈Õ¥‡≈◊Õ¥·¥ß «. ‡°’ˬ«°—∫¿“¬„π À≈Õ¥‡≈◊Õ¥·¥ß endarteritis ‡¬◊ÕË ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ßÕ—°‡ ∫ π. °“√Õ—°‡ ∫ ¢Õ߇¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ß endarterium ‡¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ß π. ‡¬◊ËÕ∫ÿ™—Èπ„π¢Õß À≈Õ¥‡≈◊Õ¥·¥ß endarteropathy ‚√§‡¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ß π. ‚√§∑’Ë ‡¬◊ËÕ∫ÿ™—Èπ„πÀ≈Õ¥‡≈◊Õ¥·¥ß digital endarteropathy ‚√§‡¬◊ÕË ∫ÿÀ≈Õ¥‡≈◊Õ¥ ·¥ßπ‘È« π. ‚√§∑’ˇ¬◊ËÕ∫ÿ™—Èπ„πÀ≈Õ¥‡≈◊Õ¥·¥ß¢Õßπ‘È« endaural - „πÀŸ «. ‡°’ˬ«°—∫¿“¬„πÀŸ endbud ªÿÉ¡ª≈“¬À“ß π. §¡¡. caudal eminence end-bulb ªÿÉ¡ª≈“¬ª√– “∑ π. à«πª≈“¬ª√– “∑∑’Ë¡’ ‘ËßÀÿâ¡ §¡¡. encapsulated nerve ending endchondral - „π°√–¥Ÿ°ÕàÕπ «. §¡¡. endochondral endeictic - ¡’Õ“°“√ «. ‡°’ˬ«°—∫À√◊Õ¡’Õ“°“√ endemia ‚√§ª√–®”∂‘Ëπ π. ‚√§∑’ˇ°‘¥‡©æ“–„π∑âÕß∂‘Ëπ ∫“ß·Ààß endemial - ª√–®”∂‘Ëπ «. §¡¡. endemic endemic - ª√–®”∂‘Ëπ «. ‡°‘¥À√◊Õæ∫∫àÕ¬„πª√–™“°√ À√◊Õ„π∑âÕß∂‘Ëπµ≈Õ¥‡«≈“ endepidermis ‡π◊ÈÕ‡¬◊ËÕ∫ÿº‘« π. ‡π◊ÈÕ‡¬◊ËÕ∑’Ë∫ÿº‘«¿“¬„πÀ√◊Õ ¿“¬πÕ°Õ«—¬«–À√◊Õ√à“ß°“¬ §¡¡. epithelium endergonic „™âæ≈—ßß“π «. ‡°’ˬ«°—∫°“√¥Ÿ¥°≈◊πæ≈—ßß“π ‚¥¬‡©æ“–∑“߇§¡’∑µ’Ë Õâ ß„™âæ≈—ßß“π„π°“√∑”ªØ‘°√‘ ¬‘ “

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

enderon - ‡π◊ÈÕ„µâº‘« π. ‡π◊ÈÕ‡¬◊ËÕ„µâÀπ—ßÀ√◊Õ„µâ‡¬◊ËÕ‡¡◊Õ° ∑’Ë·¬°‰¥â™—¥®“°‡π◊ÈÕ‡¬◊ËÕ∫ÿº‘« enderonic - ‡π◊ÕÈ „µâº«‘ «. ‡°’¬Ë «°—∫‡π◊ÕÈ ‡¬◊ÕË „µâÀπ—ßÀ√◊Õ„µâ ‡¬◊ËÕ‡¡◊Õ° end-foot à«πªÉÕߪ≈“¬ª√– “∑ π. à«πªÉÕß∑’˪≈“¬„ª√– “∑µàÕ°—∫‡´≈≈åª√– “∑ §¡¡. bouton terminal ending Ò. µÕπª≈“¬ π. µÕπ∑⓬À√◊Õ∑’ Ë π‘È ÿ¥À√◊Õ®ÿ¥®∫ Ú. ª≈“¬ª√– “∑ π. ª≈“¬‡ âπ„¬ª√– “∑ §¡¡. nerve ending annulospiral endings ª≈“¬ª√– “∑«ß‡°≈’¬« π. ª≈“¬‡ âπ„¬ª√– “∑√—∫§«“¡√Ÿâ ÷°‡ªìπ√Ÿª√‘∫∫‘Èπ¡â«πÀÿâ¡∑’Ë °≈“ß„¬°≈â“¡‡π◊ÈÕ encapsulated nerve ending ª≈“¬ª√– “∑ ¡’ ‘ËßÀÿâ¡ π. ª≈“¬‡ âπ„¬ª√– “∑√—∫§«“¡√Ÿâ ÷°∑’ˇ âπ„¬¡’ ‘Ëß Àÿ⡵àÕ®“°‡¬◊ËÕÀÿâ¡„¬ª√– “∑ epilemmal endings ª≈“¬ª√– “∑™‘¥°≈â“¡‡π◊ÕÈ π. ª≈“¬‡ âπ„¬ª√– “∑√—∫§«“¡√Ÿâ ÷°„π°≈â“¡‡π◊ÈÕ≈“¬ à«π ∑’Ë —¡º— °—∫‡ âπ„¬°≈â“¡‡π◊ÈÕ free nerve ending ª≈“¬ª√– “∑‡ª≈◊Õ¬ π. Àπ૬ª√– “∑√—∫§«“¡√Ÿ â °÷ ∑’‡Ë âπ„¬ª√– “∑·∫àßµ—«‡ªìπ·¢πß ΩÕ¬·≈– ‘Èπ ÿ¥≈ßÕ¬à“߉√⇬◊ËÕÀÿâ¡ grape endings ª≈“¬ª√– “∑æ«ßÕßÿπà π. ª≈“‡ âπ„¬ª√– “∑„π°≈â“¡‡π◊ÈÕ∑’Ë‚ªÉßæÕß≈—°…≥–æ«ßÕßÿàπ nonencapsulated nerve ending ª≈“ª√– “∑‡ª≈◊Õ¬ π. §¡¡. free nerve ending primary endings ª≈“¬ª√– “∑ª∞¡¿Ÿ¡‘ π. §¡¡. annulospiral endings endoabdominal - „π∑âÕß «. ¿“¬„π™àÕß∑âÕß endoangiitis ‡¬◊ÕË ∫ÿÀ≈Õ¥‡≈◊Õ¥Õ—°‡ ∫ π. §¡¡. endangiitis endoaortitis ‡¬◊ËÕ∫ÿ‡ÕÕÕ√嵓՗°‡ ∫ π. §¡¡. endaortitis endoappendicitis ‡¬◊ËÕ∫ÿ‰ ⵑËßÕ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ‡¬◊ËÕ‡¡◊Õ°∫ÿ‰ ⵑËß endoarteritis ‡¬◊ËÕ∫ÿÀ≈Õ¥‡≈◊Õ¥·¥ßÕ—°‡ ∫ π. §¡¡. endarteritis endobacillary - „π∫“´‘≈≈— «. ¿“¬„πµ—«∫“´‘≈≈— endobiotic - ‡∫’¬π„𰓬 π. ‡°’ˬ«°—∫°“√Õ¬Ÿà·∫∫µ—«‡∫’¬π „π‡π◊ÈÕ‡¬◊ËÕ¢ÕߺŸâ∂Ÿ°‡∫’¬π endoblast - ‡π◊ÈÕ‡¬◊ËÕ™—Èπ„π π. §¡¡. endoderm

359

endoblastic - ‡π◊ÈÕ‡¬◊ËÕ™—Èπ„π «. §¡¡. endodermal endobronchial - „πÀ≈Õ¥≈¡ «. ¿“¬„πÀ≈Õ¥≈¡ endobronchitis ‡¬◊ËÕ∫ÿÀ≈Õ¥≈¡Õ—°‡ ∫ π. °“√Õ—°‡ ∫ ¢Õ߇¬◊ÕË ∫ÿÀ≈Õ¥≈¡ endocardial - ‡¬◊ËÕ∫ÿÀ—«„® «. ‡°’ˬ«°—∫‡¬◊ËÕ∫ÿÀ—«„® endocardiopathy ‚√§‡¬◊ËÕ∫ÿÀ—«„® π. ‚√§¢Õ߇¬◊ËÕ∫ÿÀ—«„® endocarditic - ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ «. ‡°’ˬ«°—∫‡¬◊ËÕ∫ÿÀâÕß À—«„®Õ—°‡ ∫ endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿ À—«„® ¡—°¡’ ‘ËßßÕ°∫πº‘«‡¬◊ËÕ∫ÿæ∫¡“°∑’Ë≈‘ÈπÀ—«„® ·µàÕ“®‡ªìπ∑’˵”·ÀπàßÕ◊Ëπ‰¥â ‡ªìπ‚√§ª∞¡¿Ÿ¡‘À√◊Õ Õ“®‡ªìπ¿“«–·∑√°´âÕπ√à«¡°—∫‚√§Õ◊Ëπ bacterial endocarditis ‡¬◊ÕË ∫ÿÀ«— „®Õ—°‡ ∫‡Àµÿ ·∫§∑’‡√’¬ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡Àµÿµ‘¥‡™◊ÈÕ·∫§∑’‡√’¬™π‘¥ µà“ßÊ Candida endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡Àµÿ ·§π¥‘¥“ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡Àµÿµ‘¥‡™◊ÈÕ√“°≈ÿà¡·§π¥‘¥“ constrictive endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ ∫’∫√—¥ π. §¡¡. Löffler endocarditis fungal endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡Àµÿ√“ π. §¡¡. mycotic endocarditis infectious endocarditis; infective endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫µ‘¥‡™◊ÈÕ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ ‡Àµÿµ‘¥‡™◊ÈÕ®ÿ≈‘π∑√’¬å ‚¥¬‡©æ“–·∫§∑’‡√’¬·≈–√“·∫à߇ªìπ ™π‘¥‡©’¬∫æ≈—π·≈–°÷Ë߇©’¬∫æ≈—π Löffler endocarditis; Löffler fibroplastic parietal endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡≈‘øøá‡≈Õ√å π. ‡¬◊ÕË ∫ÿÀ«— „®Õ—°‡ ∫∫’∫√—¥√à«¡°—∫¿“«–‡≈◊Õ¥¡’‡¡Á¥‡≈◊Õ¥¢“« Õ’‚Õ´‘‚πøî≈¡“° ¡’‡ âπ„¬‡À𒬫¢Õ߇¬◊ËÕ∫ÿÀ—«„®Àπ“µ—« ∑”„Àâ ‡°‘¥¿“«–À—«„®≈⡇À≈«‡≈◊Õ¥§—Ëß malignant endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ ™π‘¥√⓬ π. §¡¡. infective endocarditis mural endocarditis ‡¬◊ËÕ∫ÿºπ—ßÀ—«„®Õ—°‡ ∫ π. °“√Õ—°‡ ∫∑’ˇ¬◊ËÕ∫ÿºπ—ßÀ—«„® ‰¡à‰¥â‡ªìπ∑’Ë≈‘ÈπÀ√◊Õ à«π∑’Ë ‚¬ß°—∫≈‘πÈ À—«„® mycotic endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡Àµÿ √“ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫®“°√“™π‘¥µà“ßÊ ∑’Ëæ∫∫àÕ¬‰¥â·°à ·§π¥‘¥“ ·Õ ‡æÕ√宑≈— ·≈–Œ‘ ‚∑æ≈“ ¡“ native valve endocarditis ‡¬◊ËÕ∫ÿ≈‘ÈπÀ—«„® Õ—°‡ ∫ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫µ‘¥‡™◊ÈÕ™π‘¥‡ªìπ∑’Ë≈‘ÈπÀ—«„®

360 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

parietal endocarditis ‡¬◊ËÕ∫ÿºπ—ßÀ—«„®Õ—°‡ ∫ π. §¡¡. mural endocarditis prosthetic valve endocarditis ‡¬◊ËÕ∫ÿ≈‘Èπ À—«„®‡∑’¬¡Õ—°‡ ∫ π. ‡¬◊ÕË ∫ÿÀ«— „®Õ—°‡ ∫µ‘¥‡™◊ÕÈ ∑’≈Ë π‘È À—«„®‡∑’¬¡ rheumatic endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ √Ÿ¡“µ‘° π.‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫µ’∫√à«¡°—∫‚√§‰¢â√Ÿ¡“µ‘° °“√ Õ—°‡ ∫Õ“®‡ªìπ∑’˺π—ßÀ—«„®À√◊Õ¡—°‡ªìπ∑’Ë≈‘ÈπÀ—«„®∑—ÈßÕ—π septic endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫µ‘¥‡™◊ÈÕ π. §¡¡. infective endocarditis syphilitic endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ ‡Àµÿ´‘øî≈‘ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫‡Àµÿ´‘øî≈‘ ≈ÿ°≈“¡®“°√Õ‚√§∑’‡Ë ÕÕÕ√嵓 tuberculous endocarditis ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫ ‡Àµÿ«—≥‚√§ π. ‡¬◊ËÕ∫ÿÀ—«„®Õ—°‡ ∫≈ÿ°≈“¡®“°«—≥‚√§°≈â“¡ ‡π◊ÈÕÀ—«„®À√◊Õ«—≥‚√§¢â“«øÉ“ß endocardium ‡¬◊ËÕ∫ÿÀ—«„® π. ‡¬◊ËÕ∫ÿ¥â“π„πÀâÕßÀ—«„®·≈– ‡¬◊ËÕ‡°’ˬ«æ—π∑’Ë√Õß√—∫ ∑’Ë¡’‡ âπ„¬¬◊¥À¬ÿàπ ‡ âπ„§Õ≈≈“‡®π ·≈–°≈â“¡‡π◊ÈÕ‡√’¬∫ endoceliac - „π‚æ√ß°“¬ «. Õ¬Ÿà„π‚æ√ߢÕß≈”µ—« endocellular - „π‡´≈≈å «. Õ¬Ÿà„π‡´≈≈å endocervical - „π§Õ¡¥≈Ÿ° «. ‡°’ˬ«°—∫¿“¬„π§Õ¡¥≈Ÿ° endocervicitis ‡¬◊ËÕ∫ÿ§Õ¡¥≈Ÿ°Õ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ‡¬◊ËÕ∫ÿ„π§Õ¡¥≈Ÿ° endocervix Ò. ‡¬◊ËÕ∫ÿ„π§Õ¡¥≈Ÿ° π. ‡¬◊ËÕ‡¡◊Õ°∑’Ë∫ÿ„π™àÕß§Õ ¡¥≈Ÿ° Ú. ™àÕߧա¥≈Ÿ° π. ™àÕß„π§Õ¡¥≈Ÿ°∑’‡Ë ªî¥µ‘¥µàÕ °—∫‚æ√ß¡¥≈Ÿ° endochondral - „π°√–¥Ÿ°ÕàÕπ «. Õ¬Ÿà„π À√◊Õ‡°‘¥„π °√–¥Ÿ°ÕàÕπ endocolitis ‡¬◊ËÕ∫ÿ≈”‰ â„À≠àÕ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ‡¬◊ËÕ∫ÿ‡¡◊Õ°¢Õß≈”‰ â„À≠à endocommensal µ—«Õ‘ßÕ“»—¬„𰓬 π. ‘Ëß¡’™’«‘µ∑’ËÕ“»—Õ¬Ÿà„𰓬 ‘Ëß¡’™’«‘µÕ◊Ëπ‚¥¬‰¡à‡∫’¬π endocorpuscular - „π‡¡Á¥‡≈◊Õ¥ «. Õ¬Ÿà¿“¬„π‡¡Á¥‡≈◊Õ¥ endocranial - „π°–‚À≈° «. Õ¬Ÿà¿“¬„π°–‚À≈°»’√…– endocranitis ‡¬◊ËÕ∫ÿ°–‚À≈°Õ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õß ‡¬◊ËÕ∑’Ë∫ÿ¥â“π„π°–‚À≈°»’√…– endocranium ‡¬◊ËÕ∫ÿ°–‚À≈° π. ‡¬◊ËÕ™—ÈππÕ°¢Õ߇¬◊ËÕÀÿâ¡ ¡ÕߥŸ√“

endocrine Ò. - ‡Õπ‚¥‰§√πå «. ‡°’¬Ë «°—∫Õ«—¬«–·≈–‚§√ß √â“ß ‰√â∑Õà ∑’ªË ≈àÕ¬ ‘ßË §—¥À≈—ßË ‡¢â“ Ÿ‡à ≈◊Õ¥À√◊ÕπÈ”‡À≈◊Õß ‚¥¬µ√ß Ú. - ‡°’ˬ«°—∫ŒÕ√å‚¡π «. endocrinologist ·æ∑¬å‡Õπ‚¥‰§√πå, π—°«‘∑¬“‡Õπ‚¥‰§√πå π. ·æ∑¬åÀ√◊ÕºŸâ‡™’ˬ«™“≠«‘∑¬“µàÕ¡‰√â∑àÕ endocrinology Ò. «‘∑¬“‡Õπ‚¥‰§√πå π. °“√»÷°…“‡°’¬Ë «°—∫ŒÕ√å‚¡π, √–∫∫µàÕ¡‰√â∑àÕ ·≈–∫∑∫“∑¢ÕߌÕ√å‚¡π¢Õß √à“ß°“Ú. Õπÿ “¢“‚√§√–∫∫‡Õπ‚¥‰§√πå π. ·¢πߢÕß »“ µ√å∑«’Ë “à ¥â«¬°“√«‘π®‘ ©—¬·≈–°“√∫”∫—¥‚√§„π √–∫∫‡Õπ‚¥‰§√πå endocrinopathic ‚√§√–∫∫‡Õπ‚¥‰§√πå «. ‡°’ˬ«°—∫ À√◊Õ ‡ªìπ‚√§√–∫∫‡Õπ‚¥‰§√πå endocrinopathy - ‚√§√–∫∫‡Õπ‚¥‰§√πå π. ‚√§‡°‘¥ ®“°§«“¡‰¡à ¡¥ÿ≈„π√–∫∫‡Õπ‚¥‰§√πå endocrinosis ‚√§√–∫∫‡Õπ‚¥‰§√πå π. §¡¡. endocrinopathy endocyst ‡¬◊ÕË ™—πÈ „π∂ÿßµ—«µ◊¥ π. ‡¬◊ÕË ™—πÈ „π∂ÿßµ—«ÕàÕπµ—«µ◊¥ endocytosis °“√®—∫‡¢â“‡´≈≈å π. °“√∑’ˇ´≈≈åπ”«— ¥ÿ®“° ‘Ëß·«¥≈âÕ¡‚¥¬«‘∏’µ≈∫≈âÕ¡¥â«¬‡¬◊ËÕÀÿâ¡æ≈“ ¡“ endoderm ‡π◊ÈÕ‡¬◊ËÕ™—Èπ„π π. ‡π◊ÈÕ‡¬◊ËÕ™—Èπ„π ÿ¥¢Õ߇π◊ÈÕ‡¬◊ËÕ ‡ÕÁ¡∫√‘‚Õ Û ™—Èπ ∑’Ë„Àâ°”‡π‘¥‡´≈≈凬◊ËÕ∫ÿ§ÕÀÕ¬, ∑“ßÀ“¬„® (¬°‡«âπ®¡Ÿ°), ∑“߇¥‘πÕ“À“√, °√–‡æ“– ªí “«– ·≈–∑àÕªí “«– endodermal ‡π◊ÈÕ‡¬◊ËÕ™—Èπ„π «. ‡°’ˬ«°—∫À√◊Õ‰¥â®“°‡π◊ÈÕ‡¬◊ËÕ ™—Èπ„π ÿ¥ endodontics »“ µ√å§≈Õß√“°øíπ π. ∑—πµ·æ∑¬»“ µ√å ‡°’ˬ«°—∫ ¡ÿØ∞“π, °“√ªÑÕß°—π, °“√«‘π‘®©—¬ ·≈– °“√∫”∫—¥‚√§À√◊Õ∫“¥‡®Á∫∑’‡Ë π◊ÕÈ ‡¬◊ÕË ‚æ√ßøíπ √“°øíπ ·≈–ª≈“¬√“°øíπ endodontist ∑—πµ·æ∑¬å§≈Õß√“°øíπ π. ∑—πµ·æ∑¬å ºŸâ‡™’ˬ«™“≠«‘™“§≈Õß√“°øíπ §¡¡. endodontologist endodontium ‡π◊ÈÕ‡¬◊ËÕ‚æ√ßøíπ π. ‡π◊ÈÕ‡¬◊ËÕ„π‚æ√ßøíπ∑’Ë Õÿ¥¡¥â«¬À≈Õ¥‡≈◊Õ¥·≈–ª≈“¬ª√– “∑ ¡’Àπâ“∑’Ë √â“ß À≈àÕ‡≈’È¬ß √—∫§«“¡√Ÿâ ÷° ·≈–ª°ªÑÕßøíπ

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

endodontologist ∑—πµ·æ∑¬å§≈Õß√“°øíπ π. §¡¡. endodontist endodontology «‘∑¬“§≈Õß√“°øíπ π. «‘™“«à“¥â«¬°“√»÷°…“ ∑—πµ ÿ¢¿“æ·≈–‚√§¢Õ߇π◊ÈÕ‡¬◊ËÕ‚æ√ßøíπ ªí®®ÿ∫—π „™â„𧫓¡À¡“¬°«â“ß°«à“§”«à“ endodontics ·µà ∫“ߧ√—Èß°Á„™â§”∑—Èß Õß„π§«“¡À¡“¬‡¥’¬«°—π endoectothrix √“„π·≈–πÕ°‡ â㧭 π. √“∑’Ë √â“ß ªÕ√å ∑—Èß¿“¬„π·≈–¿“¬πÕ°‡ â㧭 endoenteritis ‡¬◊ËÕ∫ÿ≈”‰ âÕ—°‡ ∫ π. °“√Õ—°‡ ∫¢Õ߇¬◊ËÕ ‡¡◊Õ°∫ÿ≈”‰ â endoenzyme ‡Õπ‰´¡å„π‡´≈≈å π. ‡Õπ‰´¡å∑’ËÕ¬Ÿà¿“¬„π ‡´≈≈å·≈–‚¥¬ª√°µ‘‰¡à°√–®“¬ÕÕ°πÕ°‡´≈≈剪 Ÿà ¿“¬πÕ° endoergic Ò. - ¥Ÿ¥°≈◊πæ≈—ßß“π, - æ≈—ßß“π¿“¬„π «. §¡¡. endergonic Ú. - ¥Ÿ¥°≈◊𧫓¡√âÕπ, - §«“¡√âÕπ¿“¬„π «. §¡¡. endothermic endoesophagitis ‡¬◊ËÕ∫ÿÀ≈Õ¥Õ“À“√Õ—°‡ ∫ π. °“√ Õ—°‡ ∫¢Õ߇¬◊ËÕ∫ÿÀ≈Õ¥Õ“À“√

361

endogamous - º ¡æ—π∏ÿå„π°≈ÿࡇ¥’¬«°—π «. ‡°’ˬ«°—∫ °“√º ¡æ—π∏ÿåÀ√◊Õ ¡√ „𠓬æ—π∏ÿ凥’¬«°—π endogamy Ò. °“√º ¡„𠓬æ—π∏ÿå π. °“√º ¡‡™◊ÈÕ∑’ˉ¥â®“° æ—π∏ÿ°√√¡ “¬‡¥’¬«°—π Ú. °“√ ¡√ „π°≈ÿà¡ π. °“√ ¡√ °—πÕ¬Ÿà¿“¬„π ª√–™“§¡ æ◊Èπ∑’Ë À√◊Õ °≈ÿà¡ endogastric - „π°√–‡æ“–Õ“À“√ «. Õ¬Ÿà À√◊Õ‡°‘¥„π °√–‡æ“–Õ“À“√ endogastritis ‡¬◊ËÕ∫ÿ°√–‡æ“–Õ“À“√Õ—°‡ ∫ π. °“√ Õ—°‡ ∫¢Õ߇¬◊ËÕ‡¡◊Õ°∫ÿ°√–‡æ“–Õ“À“√ endogenetic - ‡°‘¥„π «. §¡¡. endogenous endogenic - ‡Àµÿ„π «. §¡¡. endogenous endogenous Ò. - ‡®√‘≠®“°¿“¬„π «. ‡°’¬Ë «°—∫°“√‡®√‘≠ßÕ°ß“¡ ®“°¢â“ß„π Ú. - æ—≤π“¿“¬„π «. ‡°’ˬ«°—∫°“√æ—≤π“À√◊Õ °”‡π‘¥¢÷πÈ ¿“¬„πµ—« À√◊Õ‡°‘¥®“°‡Àµÿ¿“¬„πµ—«

362 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ª°‘≥°–

»—æ∑å —∫ π : species: ™π‘¥ À√◊Õ ™π‘¥æ—π∏ÿå? ¡™—¬ ∫«√°‘µµ‘*, æ√√…“ ‰∑√ß“¡** ¿Ÿ¡‘À≈—ß »—æ∑å∫—≠≠—µ‘∑’Ë„™â·µ°µà“ß : species - »—æ∑å«‘∑¬“»“ µ√å √“™∫—≥±‘µ¬ ∂“π(Ò°) : ™π‘¥, ªï™’ å ; - »—æ∑å·æ∑¬»“ µ√å ·≈–»—æ∑å«‘∑¬“»“ µ√å ‘Ëß·«¥≈âÕ¡(Ú): ™π‘¥æ—π∏ÿå. strain - »—æ∑å«‘∑¬“»“ µ√å √“™∫—≥±‘µ¬ ∂“π(Ò¢) : “¬‡™◊ÈÕ, “¬æ—π∏ÿå.

- »—æ∑å·æ∑¬å Õ—ß°ƒ…-‰∑¬ ©∫—∫ √“™∫—≥±‘µ¬ ∂“π æ.». Úı¯(Û): “¬ (‡™◊ÈÕ‚√§). ¢âÕ¡Ÿ≈ª√–°Õ∫ : ™π‘¥ π. - æ®π“πÿ°√¡©∫—∫√“™∫—≥±‘µ¬ ∂“π æ.». ÚıÙÚ(Ù°) : Õ¬à“ß ‡™àπ ¡’ Ú ™π‘¥; ®”æ«° ‡™àπ §π™π‘¥π’È. ™π‘¥ π. - New Model Thai-English Dictionary(ı) : kind, sort, category, variety, type. §¡¡. Õ¬à“ß, ª√–‡¿∑, æ«°. (¢âÕ —߇°µ : ‰¡à¡’ §”Õ—ß°ƒ… species „𧫓¡À¡“¢Õß™π‘¥) (ˆ°) ®”æ«°, ™π‘¥, ª√–‡¿∑, ‡∑◊Õ°, kind Õ¬à“ß. (ˆ¢) sort ™π‘¥, ª√–‡¿∑, ®”æ«°. (ˆ§) ª√–‡¿∑, ≈”¥—∫™—Èπ. category (ˆß) type ™π‘¥, ®”æ«°. variety(ˆ®) ‘Ëß∑’˪√–°Õ∫¥â«¬¢ÕßÀ≈“¬™π‘¥.

* ”π—°«‘∑¬“»“ µ√å √“™∫—≥±‘µ¬ ∂“π **°Õß«‘∑¬“»“ µ√å √“™∫—≥±‘µ¬ ∂“π

«‘«‘∏(Ù¢) «. µà“ßÊ °—π; ‡™àπ variety = «‘«‘∏æ—π∏ÿå (ºŸâ‡¢’¬π). (Ù§) π. ‘ßË ∑’¡Ë ≈’ °— …≥–‡ªìπ‡ â𬓫, ‚¥¬ª√‘¬““À¡“¬∂÷ß ‘ßË ∑’¡Ë ≈’ °— …≥–§≈⓬§≈÷ß ‡™àππ—πÈ ‡™à𠓬°“√∫‘π ; ≠“µ‘∑’Ë ◊∫¡“®“°µâπ «ß»åÀ√◊Õµâπ °ÿ≈‡¥’¬«°—π ·≈â«·¬°‡ªìπ °ÿ≈¬àÕ¬ÕÕ°‰ª = “¬æ—π∏ÿå (Õ. strain - ºŸâ‡¢’¬π). (Ùß) π. æ«°æâÕß, ‡™◊ÈÕ “¬, «ß»å«“π; ‡∑◊Õ° æ—π∏ÿå ‡∂“, ‡À≈à“°Õ; ‡™◊ÈÕ ‡™àπ æ—π∏ÿ¢å â“«. (˜) Species a taxonomic categories subordinate to a genus (or subgenus), and superior to a subspecies or variety, composed of individuals possessing common characters distinguishing them from other categories of individuals of the same taxonomic level. In taxonomic nomenclature, species are designated by the genus name followed by a Latin or Latinized adjective or noun. (¢âÕ —߇°µ: ®“°§”Õ∏‘∫“¬¢âÕπ’È species ‡ªìπ™π‘¥ „π≈”¥—∫™—Èπæ—π∏ÿå¢Õß ‘Ëß¡’™’«‘µ∑—ÈßÀ≈“¬∑—Èߪ«ß) ¢âÕ¬ÿµ‘ : Õ“»—¬¢âÕ¡Ÿ≈∑’ËÕâ“ß¡“¢â“ßµâπ ®–‡ÀÁπ«à“ species ¡’ 𗬧«“¡À¡“¬µ√ß°—∫™π‘¥æ—π∏ÿå ¡“°°«à“ ™π‘¥ (kind, type œ≈œ) ∑’‡Ë ªìπ§”∑—«Ë ‰ª ∑’‰Ë ¡à∫ßà ∫Õ°∂÷ßæ—π∏ÿ¢å Õß ‘ßË ¡’™«’ µ‘ .

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

‡Õ° “√Õâ“ßÕ‘ß Ò. »—æ∑å«‘∑¬“»“ µ√å Õ—ß°ƒ… - ‰∑¬ ‰∑¬ - Õ—ß°ƒ… ©∫—∫ √“™∫—≥±‘µ¬ ∂“π æ‘¡æå§√—Èß∑’Ë ı (·°â‰¢‡æ‘Ë¡‡µ‘¡). °√ÿ߇∑æœ : À®°. Õ√ÿ≥°“√æ‘¡æå; ÚıÙˆ. Àπâ“ Ú¯¯(°), Ú˘ı(¢). Ú. ¡™—¬ ∫«√°‘µµ‘. ¡µ‘°“√ª√–™ÿ¡ §≥–®—¥∑”æ®π“πÿ°√¡ »—æ∑å·æ∑¬»“ µ√å ·≈–»—æ∑å ‘Ëß·«¥≈âÕ¡; ÚııÚ (¬—ß ‰¡à‰¥âæ‘¡æ出¬·æ√à). Û. æ®π“πÿ°√¡»—æ∑å·æ∑¬å Õ—ß°ƒ… - ‰∑¬ ©∫—∫√“™∫—≥±‘µ¬ ∂“π; Úı¯ Àπâ“ ÚÛÒ. Ù. æ®π“πÿ°√¡ ©∫—∫√“™∫—≥±‘µ¬ ∂“π æ.». ÚıÙÚ. æ‘¡æå§√—ßÈ ∑’Ë Ò. °√ÿ߇∑æœ : π“π¡’∫§ÿä åæ∫— ≈‘‡§™—πË å; ÚıÙˆ. Àπâ“ ÛÙÙ(°), Ò¯(¢), ÒÒ˜˘(§), ˜¯Ò(ß)

363

ı. Õ ‡ ∂∫ÿµ√. New Model Thai - English Dictionary. æ‘¡æå§√—ßÈ ∑’Ë Ù. ‡≈à¡∑’Ë Ò (° - ∫). °√ÿ߇∑æœ : ‰∑¬«—≤π“æ“π‘™; ÚıÚÙ. Àπâ“ Ú¯Ú. ˆ. Õ ‡ ∂∫ÿµ√. New Model English - Thai Dictionary (Revised Edition). °√ÿ߇∑æœ : æ√’¡“ æ—∫∫≈‘™™‘ß ®”°—¥; ÚıÙ¯, Àπâ“ ÙÙ (°), ˜ˆ˜(¢), ÒÒ¯(§), ¯ˆ¯(ß), ¯˘ı(®). ˜. Dorlandûs Illustrated Medical Dictionary. 31st Edition. Philadelphia: Saunders; 2007. p. 1767.

364 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ª°‘≥°–

∫—≠™’‡Õ° “√ ‘Ëßæ‘¡æå∑“ß«‘™“°“√ ‡√◊ËÕß ç¿“«–‚≈°√âÕπé „πª√–‡∑»‰∑§≥–°√√¡°“√®—¥∑”æ®π“πÿ°√¡»—æ∑å ‘Ëß·«¥≈âÕ¡ √“™∫—≥±‘µ¬ ∂“π „πªí®®ÿ∫—π ç¿“«–‚≈°√âÕπé °”≈—߇ªìπ‡√◊ËÕß∑’Ë π„® °—π∑—ßÈ „π«ß«‘™“°“√·≈–ª√–™“™π∑—«Ë ‰ª ‚¥¬∑’°Ë √√¡°“√„π§≥– ®—¥∑”æ®π“πÿ°√¡»—æ∑å ‘Ëß·«¥≈âÕ¡¢Õß√“™∫—≥±‘µ¬ ∂“π ‡°’ˬ«¢âÕß‚¥¬µ√ß„π‡√◊ËÕßπ’È ®÷ß¡’§«“¡§‘¥«à“ ¡§«√∑’Ë®–√«∫ √«¡‡Õ° “√ ‘Ëßæ‘¡æå∑“ß«‘™“°“√„πª√–‡∑»‰∑¬¥â“π¿“«– ‚≈°√âÕπ·≈–¿Ÿ¡‘Õ“°“»‡ª≈’ˬπ·ª≈ß ®—¥æ‘¡æ凪ìπ∫—≠™’ ‡Õ° “√‡æ◊ËÕ„™â‡ªìπ·À≈àßÕâ“ßÕ‘ß ”À√—∫π—°«‘™“°“√‰∑¬ ·µà ‡π◊Ë Õ ß®“°µ√–Àπ— ° «à “ ∫— ≠ ™’ ∑’Ë π”‡ πÕ„π∫∑§«“¡π’È ¬— ߉¡à §√Õ∫§≈ÿ¡‡Õ° “√∑’¡Ë ∑’ ß—È À¡¥ ®÷ߢÕ√‘‡√‘¡Ë „À⇪ìπ∫—≠™’‡∫◊ÕÈ ßµâπ °√–µÿâπ®Ÿß„®∑à“π∑’Ë¡’¢âÕ¡Ÿ≈ ç¿“«–‚≈°√âÕπé ∑’ˉ¡àª√“°Ø„π ∫∑§«“¡π’È ‰¥â°√ÿ≥“ à߇հ “√‰ª∑’˧≥–°√√¡°“√®—¥∑” æ®π“πÿ°√¡»—æ∑å ß‘Ë ·«¥≈âÕ¡œ ‡æ◊ÕË ®—¥æ‘¡æå∫≠ — ™’‡Õ° “√œ„Àâ ¡∫Ÿ√≥凪ìπª√–‚¬™πå·°àπ—°«‘™“°“√ ‘Ëß·«¥≈âÕ¡‰∑¬µàÕ‰ª °≈‘Ëπª√–∑ÿ¡ ªí≠≠“ªîß Ò. °“√ª≈àÕ¬·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å®“°√â“πÕ“À“√ ·≈–‚√ß·√¡„π‡¢µ‡∑»∫“≈π§√‡™’¬ß„À¡à. «“√ “√«‘®¬— ¿“«–·«¥≈âÕ¡ ÚııÚ;Û:Û˘ıÚ. °âÕ߇°’¬√µ‘ °Ÿ≥±å°—π∑√“°√ Ò. §«“¡√Ÿâ‡°’ˬ«°—∫‚Õ‚´π°—∫¿“«–‚≈°√âÕπ ∏√√¡»“ µ√凫™ “√ Úıı;˜:Ò˘˜-¯. ®ß√—°…å º≈ª√–‡ √‘∞ Ò. Minimizing greenhouse gas emission through integrated waste management : case studies in Thailand.

«“√ “√√“™∫—≥±‘µ¬ ∂“π (©∫—∫¿“…“Õ—ß°ƒ…) ÚııÚ;Ò:ÒÚÙ-Ûı. ®—π∑√å‡æÁ≠ ™ÿ¡· ß Ò. º≈¢Õß·§¥‡¡’¬¡∑’Ë¡’µàÕ°“√ª≈¥ª≈àÕ¬·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å ·≈–·°ä ¡’‡∏π·≈–√Ÿª∑“ß ‡§¡’. «“√ “√«‘®¬— ¿“«–·«¥≈âÕ¡ ÚııÚ;Û:ˆ˘¯. ™π– πƒ¡“π Ò. ª√–‡∑»‰∑¬√âÕπ¢÷Èπ «“√ “√‚√ß欓∫“≈»√’ ß— «“≈¬å ÚııÚ;Ò¯:ÛÙ. ™ÿ≈’¡“» ∫ÿ≠‰∑Ò. º≈¢Õß·§¥‡¡’¬¡∑’Ë¡’µàÕ°“√ª≈¥ª≈àÕ¬·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å·≈–·°ä ¡’‡∏π·≈–√Ÿª∑“߇§¡’. «“√ “√«‘®¬— ¿“«–·«¥≈âÕ¡ ÚııÚ;Û:ˆ˘¯. ‡¥™“ ∫ÿ≠§È” Ò. À≈—ߧ“‡¢’¬«°—∫¿“«–‚≈°√âÕπ «“√ “√°“√·æ∑¬å·ºπ‰∑¬·≈–°“√·æ∑¬å∑“ß ‡≈◊Õ° ÚııÚ;˜:ı-Òˆ. ∑«’ §ÿªµå°“≠®π“°ÿ≈ Ò. Methane emission from rice field: the effect of rice varieties, growth stage of rice, and cultural practices in Thailand 4th Annual IRRI-EPA-UNDP Planning

».¥√.‡ªïò¬¡»—°¥‘Ï ‡¡π–‡»«µ ∑’˪√÷°…“, ».¥√.πæ. ¡™—¬ ∫«√°‘µµ‘ ª√–∏“π°√√¡°“√, ».¥√.®ß√—°…å º≈ª√–‡ √‘∞ °√√¡°“√, √».¥√.™—¬æ—π∏ÿå √—°«‘®—¬ °√√¡°“√, ».‡¥™“ ∫ÿ≠§È” °√√¡°“√, ¥√.∑«’ §ÿªµå°“≠®π“°ÿ≈ °√√¡°“√, ¥√.‡∫≠®≈—°…≥å °“≠®π‡»√…∞å °√√¡°“√, ».¥√.æ√™—‘∑∏‘»√—≥¬å°ÿ≈ °√√¡°“√, π“ßæ√∑‘æ¬å ªíòπ‡®√‘≠ °√√¡°“√, √».¥√.æ‘æ—≤πå æ—≤πº≈‰æ∫Ÿ≈¬å °√√¡°“√, π“¬‰æ±Ÿ√¬å «√√≥æß…å °√√¡°“√, º».¥√.‰æ√—™ “¬«‘√ÿ≥æ√ °√√¡°“√, π“ß “« ¡∑√ß »°ÿπµπ“§ °√√¡°“√, ».πæ. ¡æ≈ æß»å‰∑¬ °√√¡°“√, ¥√. ¡√—µπå ¬‘π¥’æ‘∏ °√√¡°“√, ».¥√. “¬™≈ ‡°µÿ…“ °√√¡°“√, ».πæ. “‚√®πå «√√≥惰…å °√√¡°“√, π“ß “« ÿªí≠≠“ ™¡®‘𥓠°√√¡°“√, √».¥√.Õ√«√√≥ »‘√‘√—µπåæ‘√‘¬– °√√¡°“√, ·≈–º».¥√.‡Õ◊ÈÕ¡æ√ ¡—™¨‘¡«ß»å °√√¡°“√.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Meeting of Methane Emissions from Rice Fields, Chonburi, Thailand, 1995; 11 pages. Ú. Sustainable development of rice ecosystem with the balance of local wisdom and the reduction of greenhouse gases in Thailand. Proceedings of the 17th World Congress of Soil Science Confronting New Realities in the 21st Century. Queen Sirikit National Convention Center, Bangkok, Thailand; 2002. πƒ¡≈ «√√§åªí≠≠“‡≈‘» Ò. ¿“«–‚≈°√âÕπ°—∫º≈°√–∑∫ ÿ¢¿“æ «“√ “√°√¡°“√·æ∑¬å ÚıÙ˘;ÛÒ:Ò-Ù. ‡∫≠®≈—°…≥å °“≠®π‡»√…∞å Ò. ª√–‡∑»‰∑¬√âÕπ¢÷ÈπÀ√◊Õ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ÒˆÙı. ‡ªïò¬¡»—°¥‘Ï ‡¡π–‡»«µ Ò. ¿“«–‚≈°√âÕπ°—∫ ÿ¢¿“æ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ Úıı;Ò:ÚÚÛ. Ú. «‘°ƒµ°“√≥å‚≈°√âÕπ°—∫ªí≠À“ ÿ¢¿“æ «“√ “√√“™∫—≥±‘µ¬ ∂“π Úıı;ÛÚ:¯Ú¯Û¯. Û. Õ√‘¬ —® Ù °—∫ªí≠À“‚≈°√âÕπ «“√ “√°“√·æ∑¬å·ºπ‰∑¬·≈–°“√·æ∑¬å∑“ß ‡≈◊Õ° ÚııÚ;˜:Ú˜-˘. Ù. ‚≈°√âÕπ : “‡Àµÿ º≈°√–∑∫ ·≈–·π«∑“ß ·°â‰¢. «“√ “√√“™∫—≥±‘µ¬ ∂“π ÚııÚ;ÛÙ: ııˆ-˘. æ—™√’ · ß®—π∑√å Ò. º≈¢Õß·§¥‡¡’¬¡∑’Ë¡’µàÕ°“√ª≈¥ª≈àÕ¬·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å·≈–·°ä ¡’‡∏π·≈–√Ÿª∑“߇§¡’. «“√ “√«‘®¬— ¿“«–·«¥≈âÕ¡ ÚııÚ;Û:ˆ˘¯. 摉≈æ√ ∫ÿ≠¬Õ Ò. ¿“«–‚≈°√âÕπ : §«“¡®√‘ß™ÁÕ°‚≈° “√ “∏“√≥ ÿ¢ ÿ√π‘ ∑√å ÚııÒ;˜/¯:ÒÚ-ÒÛ.

365

æŸπæ‘¿æ ‡°…¡∑√—æ¬å Ò. ¿“«–‚≈°√âÕπ·≈–º≈°√–∑∫ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÛ;Ù:Ò˜Ú¯˜. ‰æ±Ÿ√¬å «√√≥æß…å Ò. æ≈—ßß“π· ßÕ“∑‘µ¬å≈¥¿“«–‚≈°√âÕπ. ∏√√¡»“ µ√凫™ “√ ÚııÛ;Ò:Ûˆ¯-˜ ‰æ√—™ “¬«‘√ÿ≥æ√ Ò. ¿“«–‚≈°√âÕπ®“°·°ä ‡√◊Õπ°√–®° ∏√√¡»“ µ√凫™ “√ ÚııÒ;¯:¯Ú-ı. √—ß √√§å ªÿ…ª“§¡ Ò. ‡¡◊ËÕ‚≈°√âÕπ¢÷Èπ°—∫°“√‡°‘¥‚√§ “√»‘√‘√“™ ÚıÛ˘;Ù¯:ÒÒÛ˜-˘. «√‡™…∞ ‡µã™–√—° Ò. ª√–‡∑»‰∑¬√âÕπ¢÷Èπ «“√ “√‚√ß欓∫“≈»√’ ß— «“≈¬å ÚııÚ;Ò¯:ÛÙ. «√“ߧ≥“ ™ÿµ‘¥”√ßæ—π∏ÿå Ò. Minimizing greenhouse gas emission through integrated waste management : case studies in Thailand. «“√ “√√“™∫—≥±‘µ¬ ∂“π (©∫—∫¿“…“Õ—ß°ƒ…) ÚııÚ;Ò:ÒÚÙ-Ûı. »ÿ¿ ÿ¢ ª√–¥—∫»ÿ¢ Ò. Õ‘∑∏‘æ≈¢Õßæ—π∏ÿ¢å “â «·≈–°“√‡®√‘≠‡µ‘∫‚µ¢Õß ¢â“«µàÕ°“√ª≈àÕ¬°ä“´¡’‡∑π®“°°“√ª≈Ÿ°¢â“«™π‘¥ π“ «π. ‡Õ° “√°“√ª√–™ÿ¡∑“ß«‘™“°“√§√—ßÈ ∑’Ë Ù ¡À“«‘∑¬“≈—¬‡°…µ√»“ µ√å °√ÿ߇∑æ¡À“π§√; ÚıÙı Àπâ“ Ûı-ˆ. Ú. ∫∑∫“∑¢Õßæ—π∏ÿå¢â“«µàÕ°“√ª≈àÕ¬°ä“´¡’‡∑π ·≈–°“√ª≈Ÿ°¢â“«„πÕ𓧵. ‡Õ° “√°“√ª√–™ÿ¡ ∑“ß«‘™“°“√§√—Èß∑’Ë ÙÒ ¡À“«‘∑¬“≈—¬‡°…µ√»“ µ√å °√ÿ߇∑æ¡À“π§√; ÚıÙˆ Àπâ“ ÙÛ¯ÙÙ. ¡™—¬ ∫«√°‘µµ‘ Ò. ‡¡◊ËÕ‚≈°√âÕπ¢÷Èπ°—∫°“√‡°‘¥‚√§ “√»‘√‘√“™ ÚıÛ˘;Ù¯:ÒÒÛ˜-˘. Ú. ¿Ÿ¡Õ‘ “°“»·ª√ª√«π/‚≈°√âÕπ¢÷πÈ °—∫°“√‡°‘¥‚√§ „π : ¡™—¬ ∫«√°‘µµ‘, ®ÕÀåπ æ’. ≈Õø∑— , °ƒ…Æ“ »√’ ”√“≠ (∫√√≥“∏‘°“√). µ”√“‡«™»“ µ√å ‘ßË ·«¥≈âÕ¡©∫—∫‡©≈‘¡æ√–‡°’¬√µ‘ ˜Ú

366 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

æ√√…“¡À“√“™“. °√ÿ߇∑æœ: ”π—°æ‘¡æå°√ÿ߇∑æ ‡«™ “√; ÚıÙÚ. Àπâ“ ÒÒˆı-˜Ò. Û. ¿“«–‚≈°√âÕπ°—∫º≈°√–∑∫ ÿ¢¿“æ «“√ “√°√¡°“√·æ∑¬å ÚıÙ˘;ÛÒ:Ò-Ù. Ù. §«“¡√Ÿâ‡°’ˬ«°—∫‚Õ‚´π°—∫¿“«–‚≈°√âÕπ ∏√√¡»“ µ√凫™ “√ Úıı;˜:Ò˘˜-¯. ı. ¿“«–‚≈°√âÕπ°—∫ ÿ¢¿“æ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ Úıı;Ò:ÚÚÛ. ˆ. ¿“«–‚≈°√âÕπ°—∫‡æ»ª√–™“°√ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÒ;Ú:ˆıÚ. ˜. ª√–‡∑»‰∑¬√âÕπ¢÷ÈπÀ√◊Õ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ÒˆÙı. ¯. ¿“«–‚≈°√âÕπ °—∫¿Ÿ¡‘Õ“°“»‡ª≈’ˬπ·ª≈ß «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ÛÚÚ. ˘. ¿Ÿ¡‘Õ“°“»‡ª≈’ˬπ·ª≈ß·≈–™’«‘µ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:Ù¯Ò. Ò. ¿“«–‚≈°√âÕπ°—∫‚√§¡“≈“‡√’«“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ıˆ˘. ÒÒ. ¿“«–‚≈°√âÕπÀ√◊Õ ¿“«–‚≈°√âÕπ? «“√ “√√“™∫—≥±‘µ¬ ∂“π ÚııÚ;ÛÙ:ÚÒı. ÒÚ. ¿“«–‚≈°√âÕπ°—∫‡æ»∑“√°·√°§≈Õ¥ «“√ “√√“™∫—≥±‘µ¬ ∂“π ÚııÚ;ÛÙ:ı. ÒÛ. °“√∫√‘‚¿§‡π◊ÈÕ«—«°—∫¿“«–‚≈°√âÕπ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÛ;Ù:Ú-Û. ÒÙ. ¿“«–‚≈°√âÕπ°—∫‡æ»∑“√°·√°§≈Õ¥ „πª√–‡∑»‰∑«“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÛ;Ù:ÙÒıÚ. Òı. ¿“«–‚≈°√âÕπ°—∫¡“≈“‡√’¬; ¢âÕ¡Ÿ≈ªí®®ÿ∫—π «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÛ;Ù:ÒˆÙı. √—𬓠‡Œßæ√–æ√À¡ Ò. ‚≈°√âÕπ°—∫‚√§√–∫“¥ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ÛˆÛ˘.

“¬™≈ ‡°µÿ…“ Ò. ¿“«–‚≈°√âÕπ : º≈°√–∑∫µàÕæ◊™ «“√ “√«‘®—¬√–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ÚÛÒÒ. Ú. °“√∫√‘‚¿§‡π◊ÈÕ«—«°—∫¿“«–‚≈°√âÕπ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÛ;Ù:Ú- Û. “‚√®πå «√√≥惰…å Ò. ¿“«–‚≈°√âÕπ®“°·°ä ‡√◊Õπ°√–®° ∏√√¡»“ µ√凫™ “√ ÚııÒ:¯:¯Ú-ı. ‘∑∏‘æß…å «√«ß»å«‘≈“» Ò. ¿“«–‚≈°√âÕπ°—∫º≈°√–∑∫µàÕ·¡≈ß «“√ “√√“™∫—≥±‘µ¬ ∂“π ÚııÚ;ÛÙ:ˆˆÛˆ. ‘√‘«—≤πå «ß…å ‘√‘ Ò. ¿“«–‚≈°√âÕπ°—∫º≈°√–∑∫µàÕ·¡≈ß «“√ “√√“™∫—≥±‘µ¬ ∂“π ÚııÚ;ÛÙ:ˆˆÛˆ. ‡ √’ »ÿ¿√“∑‘µ¬å Ò. ·°ä ‡√◊Õπ°√–®° ¿“«–‚≈°√âÕπ °“√‡ª≈’¬Ë π·ª≈ß ¿Ÿ¡‘Õ“°“» ·≈–¿—¬æ‘∫—µ‘ «“√ “√‚√ß欓∫“≈»√’ —ß«“≈¬å ÚııÚ;Ò¯: ¯-Ò. ÿ∑∏‘√—µπå °‘µµ‘æß…å«‘‡»… Ò. Potential of clean development mechanism (CDM) activities for greenhouse gases reduction at a starch-processing factory in Thailand. «‘∑¬“π‘æπ∏å¡À“∫—≥±‘µ ∂“∫—π‡∑§‚π‚≈¬’‡Õ‡™’¬ ª√–‡∑»‰∑¬; ÚııÒ. Ú. Minimizing greenhouse gas emission through integrated waste management : case studies in Thailand. «“√ “√√“™∫—≥±‘µ¬ ∂“π (©∫—∫¿“…“Õ—ß°ƒ…) ÚııÚ;Ò:ÒÚÙ-Ûı. ÿ∑—»πå ¬° â“π Ò. ¿“«–‚≈°√âÕπ°—∫¿—¬πÈ”∑à«¡ «“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:Ú˘˜˘.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ÿæ—µ√“ ∑Õß√ÿà߇°’¬√µ‘ Ò. ¿“«–‚≈°√âÕπ°—∫‚√§¡“≈“‡√’«“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÚ;Û:ıˆ˘. ‡ Æ∞«ÿ≤‘ ·°â««‘‡»… Ò. ¿“«–‚≈°√âÕπ°—∫¡“≈“‡√’«“√ “√«‘®—¬√–∫∫ “∏“√≥ ÿ¢ ÚııÚ;ıˆ˘. Õ√√∂ ‘∑∏‘Ï ‡«™™“™’«– Ò. ¿“«–‚≈°√âÕπ À√◊Õ ¿“«–‚≈°√âÕπ? «“√ “√√“™∫—≥±‘µ¬ ∂“π ÚııÚ;ÛÙ:ÚÒı. Õ√«√√≥ »‘√‘√—µπåæ‘√‘¬– Ò. ‚≈°√âÕπ «“√ “√ «∑ ÚıÛı;Ú:Ù-ı. Ú. Õ‘∑∏‘æ≈¢Õßæ—π∏ÿ¢å “â «·≈–°“√‡®√‘≠‡µ‘∫‚µ¢Õß ¢â“«µàÕ°“√ª≈àÕ¬°ä“´¡’‡∑π®“°°“√ª≈Ÿ°¢â“«™π‘¥ π“ «π ‡Õ° “√°“√ª√–™ÿ¡«‘™“°“√§√—Èß∑’Ë Ù ¡À“«‘∑¬“≈—¬‡°…µ√»“ µ√å °√ÿ߇∑æ¡À“π§√; ÚıÙı Àπâ“ Ûı-ˆ.

367 Û. ∫∑∫“∑¢Õßæ—π∏ÿ¢å “â «µàÕ°“√ª≈àÕ¬°ä“´¡’‡∑π„π Õ𓧵 ‡Õ° “√°“√ª√–™ÿ¡«‘™“°“√§√—Èß∑’Ë ÙÒ ¡À“«‘∑¬“≈—¬‡°…µ√»“ µ√å °√ÿ߇∑æ¡À“π§√; ÚıÙˆ Àπâ“ ÙÛ¯-ÙÙ. Ù. «‘°ƒµ°“√≥å‚≈°√âÕπ°—∫ªí≠À“ ÿ¢¿“æ «“√ “√√“™∫—≥±‘µ¬ ∂“π Úıı;ÛÚ:¯Ú¯Û¯. ı. ∑√—欓°√¥‘π°—∫¿“«–‚≈°√âÕπ «“√ “√Õπÿ√—°…契π·≈–πÈ” Úıı;ÚÚ(Û): ÚÚ-ÛÚ. ˆ. ¿“«–‚≈°√âÕπ°—∫∑√—欓°√¥‘π «“√ “√‚√ß欓∫“≈»√’ —ß«“≈¬å ÚııÚ;Ò¯: ÒÒ-Ú. ˜. ¿“«–‚≈°√âÕπ°—∫‡æ»∑“√°·√°§≈Õ¥„πª√–‡∑» ‰∑«“√ “√«‘®¬— √–∫∫ “∏“√≥ ÿ¢ ÚııÛ;Ù:ÙÒıÚ.

368 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ª°‘≥°–

æ≈—ßß“π· ßÕ“∑‘µ¬å≈¥¿“«–‚≈°√âÕπ ‰æ±Ÿ√¬å «√√≥æß…å ¿—¬æ‘∫—µ‘∑’ˇ°‘¥¢÷Èπ‡ªìπ¢à“«∑ÿ°«—π ∑’ˇªìπº≈®“°°“√ ‡°‘¥æ“¬ÿ√ÿπ·√ß, πÈ”∑à«¡¡À“»“≈, ·ºàπ¥‘π∂≈à¡∫àÕ¬·≈– √ÿπ·√ߢ÷Èπ, ‰øªÉ“≈ÿ°≈“¡‰¡à¬Õ¡À¬ÿ¥·≈–≈“¡‡¢â“‰ª„π∫√‘‡«≥ ∑’¡Ë º’ ÕŸâ ¬ŸÕà “»—¬ ·≈–Õ“°“»√âÕπ®—¥∑”„À⡺’ ‡Ÿâ ’¬™’«µ‘ ‡Àµÿ°“√≥å ‡À≈à“π’πÈ “à ®–‡ªìπ ‘ßË ∫Õ°‡Àµÿ∂ß÷ º≈®“°°“√‡ª≈’¬Ë π·ª≈ß ¿“æ ¿Ÿ¡Õ‘ “°“»‡æ√“–Õÿ≥À¿Ÿ¡º‘ «‘ ‚≈°√âÕπ¢÷πÈ ∂÷ß·¡â®–¡’°“√Õ∏‘∫“„Àâ‡Àµÿº≈«à“‡Àµÿ°“√≥å‡À≈à“π’ȇªìπº≈‡π◊ËÕß®“°ª√“°Ø°“√≥å ∑’ˇ°’ˬ«°—∫°√–· πÈ”„π¡À“ ¡ÿ∑√ ´÷ËßÕ“®‡ªìπ§”Õ∏‘∫“¬∑’Ë ∂Ÿ°µâÕ߇撬ß∫“ß à«π ·≈–¬—߉¡à„™à§”Õ∏‘∫“¬∑’˧√Õ∫§≈ÿ¡∂÷ß ∑’Ë ÿ¥ ‡æ√“–‰¡à‰¥âÕ∏‘∫“¬∂÷߇Àµÿ∑’ˇªìπ∑’ˇ°‘¥¢Õߪ√“°Ø°“√≥å °√–· πÈ”µà“ßÊ π—Èπ ”À√—∫ºŸâ∑’ˉ¥â√—∫º≈°√–∑∫¿—¬æ‘∫—µ‘®“° ¿“æÕ“°“»∑’°Ë ”≈—߇°‘¥¢÷πÈ ‡ªìπ¢à“«∑ÿ°«—ππ—πÈ ‡¢“Õ“®¬Õ¡√—∫ ‰¥âßà“¬°«à“«à“π’ȧ◊Õº≈°√–∑∫¢Õß¿“«–‚≈°√âÕπ ·µà ”À√—∫ ºŸâ∑’ˉ¡à‰¥â√—∫º≈°√–∑∫π—Èπ‚¥¬µ√ß Õ“®®–¬—߉¡à¬Õ¡√—∫·≈– µ√–Àπ—°«à“¿“«–‚≈°√âÕπ‰¥â‡°‘¥¢÷Èπ·≈–°”≈—ß àߺ≈∑’ˇ≈«√⓵àÕ¡πÿ…¬å ºŸâ§π¡“°¡“¬Õ“®®–µ◊Ëπµ√–Àπ° ‡™àπ ºŸâ∑’Ë¡’∑’ËÕ¬Ÿà Õ“»—¬„°≈♓¬Ωíòß∑–‡≈ª“°Õà“« ∑’Ë°”≈—ß∂Ÿ°∫ÿ°√ÿ°æ◊Èπ∑’Ë‚¥√–¥—∫πÈ”∑–‡≈ ·πàπÕπ«à“π’Ë®–‡ªìπªí≠À“∑’Ë®– àߺ≈°√–∑∫∑’Ë √ÿπ·√ßµàÕ‡π◊ÕË ß‰ª„πÕπ“§µÕ’°¬“«π“π∑’¬Ë ß— ‰¡à√®Ÿâ ¥ÿ ®∫ Õ¬à“߉√ °Áµ“¡π’‰Ë ¡à„™à‡ªìπ ‘ßË ∑’ºË §Ÿâ π®– ‘πÈ À«—ß ·µà®–µâÕߙ૬°—π·°â‰¢ „À⧫“¡√à«¡¡◊Õ ™à«¬‡À≈◊Õ „À⧫“¡ π„® „À⧫“¡ ”§—≠ µ√–Àπ—°∂÷ߪí≠À“ „ÀâÕ¬Ÿà„𧫓¡§‘¥®‘µ„® ·≈–Õ¬Ÿà„π°“√ ¥”‡π‘π™’«‘µª√–®”«—π

°“√‡°‘¥¿“«–‚≈°√âÕπ À≈— ° ∞“π®“°°“√∫— π ∑÷ ° ¢â Õ ¡Ÿ ≈ · ¥ß«à “ ª√‘ ¡ “≥ ·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å„π∫√√¬“°“»‰¥â ‡ æ‘Ë ¡ ¢÷È π Õ¬à “ ßµà Õ ‡π◊ËÕß„πÕ¥’µ‡¡◊ËÕª√–¡“≥Àπ÷Ëß√âÕ¬°«à“ªï∑’˺à“π¡“ ·≈–‡æ‘Ë¡ ¢÷ÈπÕ¬à“ß°â“«°√–‚¥¥‡¡◊ËÕ‰¡àπ“π¡“π’È „π∫√√¬“°“»ªí®®ÿ∫—π ¡’·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å¡“°°«à“ Û¯ à«πµàÕÀπ÷Ëß≈â“π

´÷ßË ‡æ‘¡Ë ¢÷πÈ ®“°‡¡◊ÕË µÕπ‡√‘¡Ë µâπ¬ÿ§Õÿµ “À°√√¡‡¡◊ÕË √âÕ¬ªï¡“·≈â« Ò à«πµàÕÀπ÷Ëß≈â“π À√◊Õ¡’°“√‡æ‘Ë¡¢÷Èπ√âÕ¬≈– Ò µàÕªï ·≈–§“¥«à“Õ’° Ò ªï¢â“ßÀπâ“®–¡’ª√‘¡“≥·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å„π∫√√¬“°“» Ÿß∂÷ß ıÙÒ-˘˜ à«πµàÕÀπ÷Ëß≈â“π à«πÒ ·≈–®“°À≈—°∞“π°“√∫—π∑÷°¢âÕ¡Ÿ≈Õÿ≥À¿Ÿ¡‘¢Õß‚≈° ·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å®÷ß∂Ÿ°æ‘®“√≥“«à“‡ªìπµâπ‡Àµÿ ”§—≠ ¢Õß°“√‡°‘¥¿“«–‚≈°√âÕπ

√Ÿª∑’Ë Ò ª√‘¡“≥·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å„π∫√√¬“°“» ®“° æ.». ÚıÛ - ÚııÛ (‡Õ° “√Õâ“ßՑ߇≈¢∑’Ë Ò) °“√‡æ‘Ë¡ª√‘¡“≥·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å¡’µâπ‡Àµÿ ”§—≠®“°°‘®°√√¡¢Õß¡πÿ…¬å π—∫µ—Èß·µà¿“¬À≈—ß°“√ªØ‘«—µ‘ Õÿµ “À°√√¡ ‰¥â¡’°“√„™â∂à“πÀ‘π®”π«π¡À“»“≈‡æ◊ËÕ‡ªì𠇙◊ÈÕ‡æ≈‘ß„π‚√ßß“πÕÿµ “À°√√¡ ·≈–π—∫µ—Èß·µà°“√ª√–¥‘…∞å ‡§√◊ÕË ß¬πµ√å π— ¥“ª¿“¬„π∑”„Àâ°“√„™â‡™◊ÕÈ ‡æ≈‘ß´“°¥÷°¥”∫√√æå ‡æ‘¡Ë ¢÷πÈ Õ¬à“ß√«¥‡√Á« ¡πÿ…¬å‡√‘¡Ë ª≈àÕ¬·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å ¢÷Èπ Ÿà∫√√¬“°“»‡æ‘Ë¡¢÷È𠵑¥µ“¡¡“¥â«¬°“√‡æ‘Ë¡¢÷Èπ¢Õß ª√–™“°√ ‡°‘¥°“√ √â“ß™ÿ¡™π‡¡◊Õß ‘Ëß°àÕ √â“ß Õ“§“√ ∂π𠬓πæ“Àπ– °≈“¬‡ªìπ ¿“æ‡¡◊Õß„À≠à¢π“¥¡À÷¡“ √Õß√—∫ ®”π«πª√–™“°√À≈“¬≈â“π§π„π·µà≈–‡¡◊Õß

°√√¡°“√„π§≥–°√√¡°“√®—¥∑”æ®π“πÿ°√¡»—æ∑å ‘Ëß·«¥≈âÕ¡ √“™∫—≥±‘µ¬ ∂“π

369

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

æ≈—ßß“π∑¥·∑π

√Ÿª∑’Ë Ú Õÿ≥À¿Ÿ¡‘‚≈° æ.». ÚÙÚÛ-ÚıÙÛ (®“°‡Õ° “√Õâ“ßՑ߇≈¢∑’Ë Ò) ‡æ◊ËÕµÕ∫ πÕßµàÕ°“√‡®√‘≠‡µ‘∫‚µ∑“߇»√…∞°‘® √Õß√—∫°“√‡æ‘Ë¡¢÷Èπ¢Õߪ√–™“°√ °“√º≈‘µ‰øøÑ“„ÀâæÕ‡æ’¬ß µàÕ°“√„™âß“π®÷߇ªìπ ‘Ëß∑’˵âÕß¡’°“√«“ß·ºπ≈à«ßÀπâ“Õ¬à“ß √Õ∫§Õ∫·≈–√—¥°ÿ¡ „πªí®®ÿ∫—π∂à“πÀ‘π πÈ”¡—π ·≈–·°ä ∏√√¡™“µ‘ ‰¥â∂Ÿ°π”¡“„™â‡ªìπ‡™◊ÈÕ‡æ≈‘ßæ◊Èπ∞“𠔧—≠„π°“√ º≈‘µ‰øøÑ“‚¥¬∑—Ë«‰ª„πª√–‡∑»µà“ßÊ º≈º≈‘µæ≈Õ¬‰¥â®“° °“√„™â‡™◊ÈÕ‡æ≈‘ß´“°¥÷°¥”∫√√æå ´÷Ëß¡’§“√å∫Õπ‡ªìπ à«π ª√–°Õ∫À≈—° §◊Õ°“√ª≈àÕ¬·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥å Ÿà ∫√√¬“°“»Õ¬à“ßµàÕ‡π◊ËÕß·≈–¡À“»“≈ µ≈Õ¥∑—Èß„πµÕπ °≈“ß«—π∑’Ë¡πÿ…¬å∑”°‘®°√√¡ ·≈–„πµÕπ°≈“ߧ◊π∑’˵âÕß°“√ · ß «à“ß „π¢≥–∑’Ë¥«ß‰ø‡ªî¥Õ¬ŸàÀπ÷Ëߥ«ßπ—Ëπ§◊Õ —≠≠“≥ ∫Õ°«à “ °”≈— ß ¡’ · °ä §“√å ∫ Õπ‰¥ÕÕ°‰´¥å ∂Ÿ ° ª≈à Õ ¬ÕÕ° Ÿà ∫√√¬“°“»‡æ‘Ë¡¢÷Èπ ·≈– ”À√—∫‡¡◊Õß„À≠àµà“ßÊ „π‚≈° ¥«ß ‰ø∑’ˇªî¥Õ¬Ÿà„πÕ“§“√∫â“π‡√◊Õπ·≈–µ“¡∂ππÀπ∑“߉¥â°≈“‡ªìπ¿“æ∑’Ë «¬ß“¡°‘πÕ“≥“∫√‘‡«≥°«â“߉°≈‡¡◊ËÕ¡Õß≈ß¡“ ®“°Àπ⓵à“߇§√◊ËÕß∫‘π ·µà ‘Ëß∑’Ë¡Õ߉¡à‡ÀÁπ„π¢≥–‡¥’¬«°—π π—Ëπ§◊Õ·°ä §“√å∫Õπ‰¥ÕÕ°‰´¥åª√‘¡“≥¡À“»“≈‡™àπ°—π∑’Ë °”≈—ß∂Ÿ°ª≈àÕ¬ÕÕ° Ÿ∫à √√¬“°“»‚¥¬‚√ßß“πº≈‘µ‰øøÑ“ ¡πÿ…¬å ‰¥âµ√–Àπ—°∂÷ߪí≠À“π’È ·µà„π¢≥–‡¥’¬«°—πµâÕ߬ա√—∫«à“ ‘Ëß ‡À≈à“π’ÈÕ¬Ÿà„π°√–∫«π°“√«‘«—≤π“°“√ ·≈–‡ªìπ‰ªµ“¡§«“¡ —¡æ—π∏å¢ÕßÕÿª ߧå·≈–Õÿª∑“𠧫“¡√Ÿâ®—°æՇ撬߇∑à“π—Èπ ∑’Ë®– “¡“√∂¬—∫¬—Èß À√◊ÕÕ¬à“ßπâÕ¬™à«¬∫√√‡∑“ªí≠À“‰¥â ¥—ßπ—Èπ°“√«‘®—¬·≈–æ—≤π“‡∑§‚π‚≈¬’‡æ◊ËÕ„™âæ≈—ßß“π∑¥·∑π ®÷߉¥â∂Ÿ°√‘‡√‘Ë¡π”¡“„™â‡æ◊Ëՙ૬·°âªí≠À“

‚¥¬π‘¬“¡·≈–π—¬∑“ߥâ“π ‘Ëß·«¥≈âÕ¡ æ≈—ßß“π ∑¥·∑π§◊Õæ≈—ßß“π®“°·À≈àß∑√—欓°√∑’‰Ë ¡à¡«’ π— À¡¥ ‰¥â·°à æ≈—ßπÈ”, æ≈—ß· ßÕ“∑‘µ¬å æ≈—ß≈¡, æ≈—ߧ≈◊Ëπ, æ≈—ßπÈ”¢÷Èπ πÈ”≈ß, æ≈—ßß“π®“°æ◊™ (‰∫‚Õ¥’‡´≈, ‡Õ∏“πÕ≈) æ≈—ßß“π ™’«¡«≈ (‡™◊ÈÕ‡æ≈‘ß®“°æ◊™), ·°ä ™’«¿“æ ·≈–æ≈—ßß“π §«“¡√âÕπ„µâ¿‘¿æ ´÷Ëß„π∫√√¥“æ≈—ßß“π‡À≈à“π’È æ≈—ßß“π®“° · ßÕ“∑‘ µ ¬å ¡’ ° “√«‘ ®— ¬ ·≈–æ— ≤ π“‡∑§‚π‚≈¬’ ‡ æ◊Ë Õ °“√º≈‘ µ ¡“°∑’Ë ÿ¥ ∑’ˇªìπ‡™àππ’ȇªìπ‡æ√“–‡Àµÿº≈ Ú ª√–°“√ ª√–°“√ ·√°·πàπÕπ«à“‡ªìπ‡æ√“–æ≈—ßß“π· ßÕ“∑‘µ¬å∑’Ë àß¡“∂÷ß‚≈° ¡’ª√‘¡“≥¡À“»“≈ ª√–°“√∑’Ë Ú ‡ªìπ‡æ√“–‡∑§‚π‚≈¬’‡æ◊ËÕ √â“߇§√◊ËÕß¡◊Õ„π°“√º≈‘µæ≈—ßß“π®“°· ßÕ“∑‘µ¬å‡ªìπº≈ ®“°°“√æ—≤π“µàÕ¬Õ¥®“°°“√ª√–¥‘…∞姑¥§âπÕÿª°√≥å “√ °÷Ëßµ—«π” ´÷Ë߇ªìπ ‘Ëß∑’Ë·æ√àÀ≈“¬„™â°—π¡“°„π™’«‘µª√–®”«—π ¢Õß¡πÿ…¬å„πªí®®ÿ∫—π

“√°÷Ëßµ—«π”º≈‘µ‰øøÑ“®“°· ßÕ“∑‘µ¬å “√°÷Ëßµ—«π”‰¡à„™à©π«π ‡™àπ·ºàπ¬“ß ·≈–‰¡à„™à µ—«π”‰øøÑ“ ‡™àπ≈«¥∑Õß·¥ß ·µà¡ ’ ¡∫—µÕ‘ ¬Ÿµà √ß°≈“ßÊ ∑”„Àâ ‡¡◊ËÕ¡’· ßµ°°√–∑∫°àÕ‡°‘¥æ“À–π”°√–· ·≈–¡’°√–· ‰À≈ºà“π π—Ëπ§◊Õ ¡∫—µ‘∑’Ë摇»…´÷Ëß “¡“√∂π”¡“ª√–¬ÿ°µå„™â ‡ªì π Õÿ ª °√≥å º ≈‘ µ æ≈— ß ß“π‰øøÑ“®“°· ßÕ“∑‘µ¬å‰¥â ¥—ß∑’Ë æ∫‡ÀÁπ‰¥â„πªí®®ÿ∫—πÕÿª°√≥åπ’È¡’≈—°…≥–‡ªìπ·ºß·ºàπ‡√’¬∫ ¡’ ’‡¢â¡·∫à߇ªìπ™àÕßµ“√“ß ∑’ˇ√’¬°«à“·ºß ÿ√‘¬– À√◊Õ‡´≈≈å · ßÕ“∑‘µ¬å ª√–‡∑»ºŸºâ ≈‘µ·ºß ÿ√¬‘ – ”À√—∫„™âº≈‘µ‰øøÑ“∑’ Ë ”§—≠ ‰¥â·°à ª√–‡∑» À√—∞Õ‡¡√‘°“ ª√–‡∑»®’π ª√–‡∑»≠’˪ÿÉπ ·≈– ª√–‡∑»µà“ßÊ „π∑«’ª¬ÿ‚√ª ”À√—∫ª√–‡∑»‰∑¬π—Èπ„π¢≥–π’È ¡’‚√ßß“πª√–°Õ∫∏ÿ√°‘®º≈‘µ·ºß‡´≈≈å· ßÕ“∑‘µ¬å Õ¬Ÿà∑’Ë ®—ßÀ«—¥©–‡™‘߇∑√“ ®—ßÀ«—¥™≈∫ÿ√’ ·≈–®—ßÀ«—¥π§√√“™ ’¡“ ∑”°“√º≈‘µ‡æ◊ËÕ®”Àπà“¬·≈– àßÕÕ° ‡æ◊ËÕ𔉪„™âº≈‘µ‰øøÑ“ ªí®®ÿ∫—πª√–‡∑»µà“ßÊ ¡’°“√·¢àߢ—π°—π Ÿß¡“°„π °“√§âπ§«â“«‘®¬— ·≈–æ—≤π“‡∑§‚π‚≈¬’‡æ◊ÕË º≈‘µ‡´≈≈å· ßÕ“∑‘µ¬å ‡æ◊ËÕ„À≥â·∫∫∑’Ë¡’ª√– ‘∑∏‘¿“æ°“√º≈‘µ°√–· ‰øøÑ“ Ÿß ·≈– ¡’µπâ ∑ÿπ„π°“√º≈‘µµË” ¡’°“√„™â‡∑§‚π‚≈¬’π“‚π ·≈–«— ¥ÿ»“ µ√å ‡æ√“–„π¢≥–∑’Ë√“§“πÈ”¡—π Ÿß¢÷Èπ ∑”„Àâ ° “√º≈‘ µ °√–· ‰øøÑ“®“°‡´≈≈å· ßÕ“∑‘µ¬å “¡“√∂‡¢â“ Ÿà°“√·¢àߢ—π‰¥â

370 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ª√– ‘∑∏‘¿“æ°“√·ª≈ß· ßÕ“∑‘µ¬å ‡ªìπæ≈—ßß“π‰øøÑ“ ¢âÕæ‘®“√≥“∑’Ë ”§—≠ ”À√—∫‡´≈≈å· ßÕ“∑‘µ¬å∑’Ë¥’¡’ Õߪ√–°“√ §◊ Õ µâ Õ ß “¡“√∂„Àâ °”‡π‘ ¥ æ≈— ß ß“π‰øøÑ “ ‰¥â ¡ “°°«à “ µà Õ °“√‰¥â √— ∫ · ß„πª√‘ ¡ “≥·≈–∫πæ◊È π ∑’Ë ∑’Ë ·πàπÕπ¢π“¥Àπ÷Ëß ·≈–µâÕß¡’µâπ∑ÿπ„π°“√º≈‘µµË”°«à“µàÕ Àπà « ¬æ≈— ß ß“π∑’Ë ‡ ´≈≈å · ßÕ“∑‘ µ ¬å ® –º≈‘ µ‰¥â „πªí®®ÿ∫—π “¡“√∂·∫à߉¥â‡ªìπÚ Ò. ‡´≈≈å∑’Ë∑”ß“π°—∫· ߉¥âÀ≈“¬§«“¡¬“«§≈◊Ëπ “¡“√∂„Àâª√– ‘∑∏‘¿“æ°“√‡ª≈’ˬπ· ßÕ“∑‘µ¬å‡ªìπæ≈—ßß“π ‰øøÑ“‰¥â Ÿß ÿ¥∂÷ß√âÕ¬≈– ÙÛ Ú. ‡´≈≈å· ßÕ“∑‘µ¬å·∫∫øî≈å¡∫“߇§≈◊Õ∫¥â«¬ “√ °÷Ëßµ—«π”∑”®“° à«πº ¡∑Õß·¥ß Õ‘π‡¥’¬¡ °—≈‡≈’ˬ¡ ·≈– ‡´‡≈‰π¥å „Àâª√– ‘∑∏‘¿“æ‰¥â Ÿß ÿ¥∂÷ß√âÕ¬≈– Ú Û. ‡´≈≈å · ßÕ“∑‘ µ ¬å “√°÷Ë ß µ— « π”´‘ ≈‘ § Õπ·∫∫ º≈÷°‡¥’ˬ«À√◊Õ·∫∫À≈“¬º≈÷° „Àâª√– ‘∑∏‘¿“æ‰¥â Ÿß ÿ¥∂÷ß √âÕ¬≈– Ú Ù. ‡´≈≈å· ßÕ“∑‘µ¬å “√°÷Ëßµ—«π”´‘≈‘§Õπ·∫∫‰¡à ‡ªìπ√Ÿªº≈÷° „Àâª√– ‘∑∏‘¿“æ‰¥â Ÿß ÿ¥¡“°°«à“√âÕ¬≈– Ò ®–‡ÀÁ π‰¥â «à “„πªí ® ®ÿ ∫— π ª√– ‘ ∑ ∏‘ ¿ “æ°“√‡ª≈’Ë ¬ π · ßÕ“∑‘µ¬å‡ªìπæ≈—ßß“π‰øøÑ“‰¥â‡æ‘Ë¡ Ÿß¢÷Èπ ®π‡À¡“– ¡ ”À√—∫°“√π”¡“„™â √â“߇ªìπ‚√ßß“π‰øøÑ“æ≈—ß· ßÕ“∑‘µ¬å ”À√—∫ª√–‡∑»‰∑¬„π¢≥–π’È “¡“√∂º≈‘µ‡´≈≈å· ßÕ“∑‘µ¬å ‰¥â∑—Èß„π·∫∫∑’Ë Û ·≈– Ù

°“√º≈‘µ‰øøÑ“„πª√–‡∑»‰∑°“√‰øøÑ“ΩÉ“¬º≈‘µ‡ªìπ√—∞«‘ “À°‘® —ß°—¥°√–∑√«ß æ≈—ßß“π ¡’Àπâ“∑’˺≈‘µ‰øøÑ“„™â¿“¬„πª√–‡∑»‰∑¬ ®—¥µ—Èߢ÷È𠵓¡æ√–√“™∫—≠≠—µ°‘ “√‰øøÑ“ΩÉ“¬º≈‘µ·Ààߪ√–‡∑»‰∑¬ æ.». ÚıÒÒ Àπâ“∑’˪√–°“√Àπ÷Ëߧ◊Õ°”Àπ¥‡ß◊ËÕπ‰¢∑’ˇ°’ˬ«°—∫ §ÿ≥¿“æ‰øøÑ“ ‡∑§π‘§∑“ß«‘»«°√√¡ ·≈–§«“¡ª≈Õ¥¿—¢Õß√–∫∫‰øøÑ“ „π°√≥’∑’ˇհ™πª√– ߧ宖‡™◊ËÕ¡‚¬ß√–∫∫ ‰øøÑ“ „πÕ¥’µ°“√º≈‘µ‡æ◊ÕË „™â‰øøÑ“‚¥¬æ≈—ßß“π· ßÕ“∑‘µ¬å ¡’¢Õ∫‡¢µ®”°—¥ „™â‡©æ“–„πæ◊Èπ∑’ˇ≈Á°Ê Õ¬ŸàÀà“߉°≈ ‰¡à¡’ √–∫∫ “¬ àß ·≈–‰¡à‡À¡“–∑’Ë®–®—¥∑” ‡æ√“–‰¡à§ÿâ¡∑ÿπ ·µà ªí®®ÿ∫—π°“√º≈‘µ‰øøÑ“‚¥¬æ≈—ßß“π· ßÕ“∑‘µ¬å “¡“√∂∑”„Àâ „™â‰øøÑ“‰¥â„π™ÿ¡™π¢π“¥„À≠à¢÷Èπ ®÷ߧ«√¡’√–∫∫°“√‡™◊ËÕ¡ µàÕ°—∫ “¬ àߢÕß°“√‰øøÑ“ΩÉ“¬º≈‘µ „π≈—°…≥–∑’Ë “¡“√∂

„™â‰øøÑ“‰¥â®“°∑—Èß Õß√–∫∫ ∂Ⓡ¡◊ËÕ‰øøÑ“®“°æ≈—ßß“π· ß Õ“∑‘µ¬åº≈‘µ‰¥â‡°‘π°“√„™âß“π„πµÕπ°≈“ß«—π ®– “¡“√∂ ®à“¬‰ø°≈—∫‡¢â“√–∫∫¢Õß°“√‰øøÑ“ΩÉ“¬º≈‘µ‰¥â ‚¥¬‡Àµÿπ’È °“√®– à ß ‡ √‘ ¡ °“√„™â æ ≈— ß ß“π∑¥·∑π·∫∫π’È ‡ æ◊Ë Õ ™à « ¬≈¥ ¿“«–‚≈°√âÕπ®÷ßµâÕß¡’°“√¥”‡π‘πß“π√à«¡¡◊Õ°—π ®÷ß®–∫√√≈ÿ «—µ∂ÿª√– ߧå

∫∑ √ÿª °“√‡ª≈’Ë ¬ π·ª≈߇æ‘Ë ¡ ¢÷È π ¢Õߪ√‘ ¡ “≥·°ä ‡√◊ Õ π °√–®°∑’Ë ”§— ≠ ™π‘ ¥ Àπ÷Ë ß §◊ Õ ·°ä §“√å ∫ Õπ‰¥ÕÕ°‰´¥å „ π ∫√√¬“°“»º‘«‚≈° Õ¥§≈âÕß —¡æ—π∏å°—∫°“√‡ª≈’ˬπ·ª≈ß ‡æ‘Ë¡¢÷Èπ¢ÕßÕÿ≥À¿Ÿ¡‘Õ“°“» ‡¡◊ËÕ¡’°“√‡æ‘Ë¡¢÷Èπ¢ÕßÕÿ≥À¿Ÿ¡‘ ¢Õß‚≈°µàÕÊ ‰ª‡™àππ’È ‡√’¬°«à“‡°‘¥¿“«–‚≈°√âÕπ º≈°√–∑∫ ∑’Ë®–‡°‘¥µ“¡¡“§◊Õ‡°‘¥ ¿“æ¿Ÿ¡‘Õ“°“»·ª√ª√«π ‡™àπ‡°‘¥ §«“¡§≈“¥‡§≈◊ÕË π¢Õß™à«ß‡«≈“°“√‡ª≈’¬Ë πƒ¥Ÿ ‡°‘¥°“√≈–≈“¢ÕßπÈ” ·¢Á ß ¢—È «‚≈°·≈–µ“¡¬Õ¥‡¢“ Ÿß µàÕ‡π◊ËÕߥ⫬°“√ ‡æ‘Ë¡¢÷Èπ¢Õß√–¥—∫πÈ”∑–‡≈ °“√‡°‘¥æ“¬ÿ∑’Ë√ÿπ·√ß·≈–¡’®”π«π ¡“°¢÷Èπ µàÕ‡π◊ËÕߥ⫬‡°‘¥πÈ”∑à«¡·≈–·ºàπ¥‘π∂≈à¡ ∑–‡≈ ∑√“¬¢¬“¬¢Õ∫‡¢µ º≈º≈‘µ®“°°“√‡°…µ√°√√¡≈¥≈ß ‡°‘¥ §«“¡Õ¥Õ¬“°·≈–‚√§√–∫“¥ º≈°√–∑∫‡π◊ËÕß®“°¿“«–‚≈°√âÕπ‡√‘Ë¡· ¥ß„Àâ‡ÀÁπ ·≈â« ·≈–®–‡°‘¥µàÕ‡π◊ËÕ߉ªÕ’°¬“«π“π„πÕ𓧵 „π∑“ß µ√ß°—π¢â“¡°“√√‘‡√‘Ë¡¥”‡π‘π°“√·°â‰¢‰¥â‡°‘¥¢÷Èπ‡™àπ‡¥’¬«°—π ¡πÿ…¬åµâÕßÀ—π¡“„À⧫“¡ ”§—≠µàÕ°“√„™âæ≈—ßß“π∑¥·∑π∑’Ë ‰¡à°àÕ‡°‘¥°“√ª≈àÕ¬·°ä ‡√◊Õπ°√–®° °“√º≈‘µ‰øøÑ“®“° æ≈—ßß“π· ßÕ“∑‘µ¬å‰¥â· ¥ß„Àâ‡ÀÁπ»—°¬¿“æ„π°“√∑’Ë®–™à«≈¥∑¥·∑π°“√„™â‡™◊ÈÕ‡æ≈‘ß´“°¥÷°¥”∫√√æå ‡π◊ËÕß®“°‡ªìπ °“√º≈‘µ‰øøÑ“∑’ˉ¡à¡’°“√ª≈àÕ¬·°ä ‡√◊Õπ°√–®°„¥Ê ‡ªìπ°“√ ™à«¬≈¥¿“«–‚≈°√âÕπ ®÷ßµâÕß„À⧫“¡ π„® π—∫ πÿπ°“√ ¥”‡π‘π°“√ ‡æ◊ÕË °àÕ„À⇰‘¥º≈ª√–‚¬™πå‚¥¬∑—«Ë °—πÕ¬à“߬ÿµ∏‘ √√¡ ‡À¡“– ¡ ·≈– ¡§«√

‡Õ° “√Õâ“ßÕ‘ß Ò. http://en.wikipedia.org/wiki/Global_warming Ú. http://en.wikipedia.org/wiki/Solar_cell

371

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ª°‘≥°–

°“√∑¥ Õ∫≈¡À“¬„® Õ√√∂æ≈ ™’æ —µ¬“°√* ‡√◊Õß√Õß ™’æ —µ¬“°√** ®“° So Sethaputra New Model EnglishThai Dictionary ©∫—∫ª√—∫ª√ÿß ®—¥æ‘¡æå‚¥¬∫√‘…—∑æ√’¡“ æ—∫∫≈‘™™‘ß ®”°—¥ °√ÿ߇∑æœ æ.». ÚıÙ¯: breath n. ≈¡À“¬„® (Àπâ“ ˘Ú) test n. °“√∑¥ Õ∫ (Àπâ“ ¯Ú˘) °“√∑¥ Õ∫≈¡À“¬„® (breath test) À¡“¬∂÷ß °“√µ√«®«‘‡§√“–Àå≈ ¡À“¬„®ÕÕ°‡™‘ ß ª√‘ ¡ “≥ ‡æ◊Ë Õ · ¥ß ª√“°Ø°“√≥å·≈–ª√‘¡“≥¢Õß·°ä “√Õ‘π∑√’¬å∫“ß™π‘¥ ∑’Ë Õ“®„™â‡ªìπµ—«∫àß™’È¿“«–º‘¥ª√°µ‘¢Õß√à“ß°“¬ „πÕ¥’µµ—Èß·µà ¡—¬¢Õߌ‘ª‚ª‡§√∑’ Ò ·æ∑¬åÕ“»—¬°“√‰¥â°≈‘Ëπº≈‰¡âÀÕ¡ À«“π¢Õß “√•’‚∑π™à«¬«‘π®‘ ©—¬¿“«–•’‚∑·Õ»‘‚¥ ‘ „πºŸªâ «É ‡∫“À«“π, °≈‘Ëπ “∫§“«ª≈“„πºŸâªÉ«¬‚√§µ—∫, °≈‘Ëπªí “«– „πºŸªâ «É ¬¿“«–‰µ≈⡇À≈« ·≈–°≈‘πË ‡πà“„πºŸªâ «É ¬‚√§Ωï„πªÕ¥ À√◊Õ‚√§‚æ√ßÕ“°“»¢â“ß®¡Ÿ°Õ—°‡ ∫‡√◊ÈÕ√—ß µàÕ¡“‰¥â¡’ºŸâ„™â °“√«‘‡§√“–Àå·°ä „π≈¡À“¬„®ÕÕ° ‡™àπ Œ—¬‚¥√‡®π‡æÕ√å ÕÕ°‰´¥å ·≈–‰πµ√‘°ÕÕ°‰´¥å „π°“√«‘π‘®©—¬‚√§À≈“¬‚√§ „πªí®®ÿ∫—π¡’ºŸâπ”°“√µ√«®«‘‡§√“–Àå “√Õ‘π∑√’¬å√–‡À¬Õ◊ËπÊ Õ’°À≈“¬µ—«∑’Ë∂Ÿ°¢—∫ÕÕ°¡“„π≈¡À“¬„® ‡™àπ “√°≈ÿà¡Õ—≈‡•π ·≈–‡¡∏‘¬å≈Õ—≈‡•π ‰ª™à«¬°“√«‘π‘®©—¬‚√§ °“√µ√«®ºŸâ¥◊Ë¡ ÿ√“¢—∫√∂°Á‡ªìπ°“√∑¥ Õ∫≈¡À“¬„®·∫∫Àπ÷Ëß Õ¬à“߉√°Á¥’ ‡∑à“∑’Ë∑√“∫ °“√∑¥ Õ∫≈¡À“¬„®¬—߉¡à‰¥â„™â„π°“√µ√«® ª√–®”∑“߇«™°√√¡ ¡’‡æ’¬ß°“√„™âÕ¬à“ß°«â“ߢ«“ß„πß“π »÷°…“«‘®—„π∫∑§«“¡¢Õ߉¡‡§‘≈øî≈≈‘ª åÒ ‰¥âÕâ“߇°’ˬ«°—∫ π— ° «‘ ∑ ¬“»“ µ√å ™ÿ ¥ ·√°∑’Ë ∑”°“√µ√«®«‘ ‡ §√“–Àå · °ä „π ≈¡À“¬„®ÕÕ° «à“‡¡◊ËÕ æ.». ÚÛÚ˜ Antoine Laurent Lavoisier π—°«‘∑¬“»“ µ√凧¡’™“«Ω√—Ë߇» ·≈– Pierre Simon Laplace π—°øî ‘° å§≥‘µ»“ µ√噓«Ω√—Ë߇» ‡ªìπ π—°«‘∑¬“»“ µ√å™ÿ¥·√°∑’˵√«®·°ä „π≈¡À“¬„®ÀπŸµ–‡¿“

ºŸ‡â ¢’¬π∫∑§«“¡‡√◊ÕË ßπ’È „π∞“π–∑’‡Ë ªìπ·æ∑¬å√–∫∫°“√ À“¬„®·≈–欓∏‘·æ∑¬å¡§’ «“¡ π„®‡ªìπ摇»…µâÕß°“√∑√“∫«à“ ·°ä ™π‘¥„¥∫â“ß∑’Ë¢—∫ÕÕ°®“°√à“ß°“¬∑“ß°“√À“¬„®π—Èπ ¡’ §«“¡ —¡æ—π∏å°—∫欓∏‘ ¿“æ„π√à“ß°“¬Õ¬à“߉√ ®÷ß∑”°“√ ∑∫∑«π«√√≥°√√¡‡∑à“∑’ÀË “‰¥â®“°«“√ “√«‘™“°“√∑—ßÈ „πª√–‡∑» ·≈–µà“ߪ√–‡∑» ·≈–®“°‡«ä∫‰´µå®”π«π¡“°°«à“ Ú ™‘Èπ ‡æ◊ËÕ∑√“∫𗬥—ß°≈à“« ·µà‡π◊ËÕß®“°‡√◊ËÕßπ’È¡’ “√–¢âÕ¡Ÿ≈¡“° ®÷ߢյ—¥¡“‡ πÕ‡ªìπµÕπÊ ‚¥¬„π§√—Èßπ’È®–¢Õ‡ πÕ¢âÕ¡Ÿ≈ ‡°’ˬ«°—∫·°ä ‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®°àÕπ

‰πµ√‘° ÕÕ°‰´¥å (NO) ‰π‚µ√‡®π ‡ªìπ∏“µÿ≈”¥—∫∑’Ë ˜ —≠≈—°…≥å N ‡ªìπ Õ‚≈À– ≈—°…≥–‡ªìπ·°ä ¡’ª√“°ØÕ¬Ÿà„π∫√√¬“°“»ª√–¡“≥ √âÕ¬≈– ¯ ¡’§«“¡ ”§—≠µàÕ ‘Ëß¡’™’«‘µ ‡æ√“–‡ªìπÕß§å ª√–°Õ∫ ”§—≠¢Õß‚ª√µ’π·≈–°√¥π‘«§≈’Õ‘°Ú ‰πµ√‘°ÕÕ°‰´¥å ‡ªìπ “√∑’ Ë √â“ߢ÷πÈ „π√à“ß°“¬ª√°µ‘ µ“¡∏√√¡™“µ‘ ®“°°√¥·Õ¡‘‚π L-arginine ‚¥¬‡Õπ´—¬¡å ‰πµ√‘°ÕÕ°‰´¥å ‘¬åπ‡∑ ´÷Ëßæ∫°“√ √â“ß„π‡π◊ÈÕªÕ¥∫√‘‡«≥ ∂ÿß≈¡·≈–√–¥—∫µà“ßÊ ¢Õß∑“ßÀ“¬„® ´÷Ëß√«¡∂÷ß‚æ√ß®¡Ÿ° ·≈–‚æ√ßÕ“°“»¢â“ß®¡Ÿ° ª√‘¡“≥ à«π„À≠à¢Õß·°ä ‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ°¢Õߧπ ÿ¢¿“æª√°µ‘‡ªìπ à«π∑’Ë ‡°‘¥„π∑“ßÀ“¬„® à«πµâπ (‚æ√ß®¡Ÿ°·≈–‚æ√ßÕ“°“»¢â“ß ®¡Ÿ°)Û,Ù,ı Gustafsson ·≈–§≥–ˆ ‡ªìπ°≈ÿà¡·√°· ¥ß«à“ ‰¥âæ∫·°ä ‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ°¢Õß¡πÿ…¬å·≈– —µ«åÀ≈“¬™π‘¥‡¡◊ËÕ æ.». ÚıÛÙ ´÷Ëß∑”„Àâ¡’°“√»÷°…“µàÕ¡“ ∑—Èß„π§π ÿ¢¿“æª√°µ‘·≈–ºŸâªÉ«¬‚√§ Tsang ·≈–§≥–˜,¯ (æ.». ÚıÙÙ) ∑”°“√«‘®—¬æ∫«à“ºŸâ™“¬®’π ÿ¢¿“æª√°µ‘ ¢—∫·°ä ‰πµ√‘°ÕÕ°‰´¥åÕÕ°„π≈¡À“¬„®¡“°°«à“ºŸâÀ≠‘ß (§à“ æ’ = .Ò); ª√‘¡“≥∑’Ë¢—∫ÕÕ° —¡æ—π∏å°—∫¢π“¥√à“ß°“¬

* »Ÿπ¬å«—≥‚√§‡¢µ Ò ‡™’¬ß„À¡à, ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’Ë Ò, °√¡§«∫§ÿ¡‚√§ °√–∑√«ß “∏“√≥ ÿ¢ ** ¿“§«‘™“欓∏‘«‘∑¬“, §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à, ®—ßÀ«—¥‡™’¬ß„À¡à

372 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

·µà‰¡à —¡æ—π∏å°—∫Õ“¬ÿ ¡’√“¬ß“π«à“°√–∫«π°“√·ª√√ŸªÕ≥Ÿ ¢Õ߉πµ√‘°ÕÕ°‰´¥å¿“¬„π√à“ß°“¬ —¡æ—π∏å°—∫°”‡π‘¥æ¬“∏‘ ¢Õß‚√§√–∫∫°“√À“¬„®, ‚√§‰µ, ‚√§√–∫∫ª√– “∑«‘∑¬“ ·≈– ‚√§µ—∫ ®“°ß“π«‘®—¬¢Õß Tsang ·≈–§≥–˘ (æ.». ÚıÙı) „πºŸâªÉ«¬‚√§À≈Õ¥≈¡‚ªÉßæÕß ‰¡àæ∫√–¥—∫‰πµ√‘°ÕÕ°‰´¥å ·µ°µà“ß®“°§πª√°µ‘ ·µàæ∫√–¥—∫µË”°«à“Õ¬à“ß¡’π—¬ ”§—≠ ‡¡◊ËÕ‚√§¡’¿“«–·∑√°´âÕπ®“°°“√µ‘¥‡™◊Èե⫬ªá ‘«‚¥‚¡·π ·Õ√ÿ ®‘ ‚ π â “ º≈ß“ππ’È®÷ߧâ“π°—∫‡Àµÿº≈∑’ˇ πÕ‚¥¬°≈ÿà ¡ π—°«‘®—¬¢ÕߪÕ√å ∫“√åπ å·≈–§≥–Ò,ÒÒ (µ—Èß·µà æ.». ÚıÛ¯) «à“√–¥—∫‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ° —¡æ—π∏å°∫— °≈«‘∏“π°“√Õ—°‡ ∫ ·µàµàÕ¡“¡’§”Õ∏‘∫“¬®“°°“√∑’ˇÕÁπ´—¬¡å ¢Õß·∫§∑’‡√’¬·≈–‡™◊ÈÕ√“ “¡“√∂¬àÕ¬ ≈“¬ÕÕ°‰´¥å ¢Õß ‰π‚µ√‡®π ‰¥âÒÚ ∑”„Àâª√‘¡“≥≈¥≈ß ß“π«‘®¬— ‡√◊ÕË ß·°ä ‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ°π’È À≈—ß®“° Gustafsson ·≈–§≥–ˆ ‰¥â· ¥ß«à“æ∫·°ä π’È„π §π·≈– —µ«å‡¡◊ËÕ æ.». ÚıÛÙ °Á¡’º≈ß“πµ’æ‘¡æåÕÕ°¡“ ‡ªìπ®”π«π¡“° ¡’∑—Èß∑’Ë»÷°…“„π§π ÿ¢¿“æª√°µ‘ ·≈–„π ºŸâªÉ«¬‚√§µà“ßÊ ‚¥¬‡©æ“–„πºŸâªÉ«¬‚√§À◊¥À≈Õ¥≈¡°Á‰¡àµË” °«à“ Ù ©∫—∫ÒÛ ‚√§Õ◊Ëπ∑’Ë¡’°“√»÷°…“´÷Ëß·∫à߇ªìπ‚√§∑’Ë »÷°…“·°ä ‰πµ√‘°ÕÕ°‰´¥å„π≈¡®“°∑“ßÀ“¬„® à«πµâπ (nasal NO) ‰¥â·°à‚√§ primary ciliary dyskinesia (PCD) ∑’Ë¡’ª√‘¡“≥·°ä ‰πµ√‘°ÕÕ°‰´¥åµË”¡“°°«à“§à“„π§π ÿ¢¿“æ ª√°µ‘Ù,ÒÙ-Òˆ, cystic fibrosis (CF)Ò˜,Ò¯, allergic rhinitisÒ˘-ÚÒ, sinusitis ·≈– nasal polyposis; ·µà∑’Ë ‡ªìπª√–‚¬™πå™—¥‡®π§◊Õ°“√«‘π‘®©—¬¿“«–¢π°«—¥∑”ß“π¥âÕª∞¡¿Ÿ¡‘ à«π„π¿“«–Õ◊πË π—πÈ °“√·ª≈º≈°“√µ√«®¬—߉¡à™¥— ‡®π ”À√—∫°“√µ√«®«‘‡§√“–Àå‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ° ∑’Ë¡’ª√–‚¬™πå™—¥‡®π„π°“√µ√«®√—°…“ºŸâªÉ«¬‚√§À◊¥·≈â«ÚÚ °Á¡’º≈°“√»÷°…“„πºŸâªÉ«¬°≈ÿà¡Õ“°“√ PCD, ‚√§À≈Õ¥≈¡ ‚ªÉßæÕß, ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß, ‚√§ªÕ¥Õ‘π‡µÕ√å µ‘‡∑’¬≈, cystic fibrosis, ‚√§ªÕ¥µ‘¥‡™◊ÈÕ (‚¥¬‡©æ“–„πºŸâªÉ«¬„π ÀÕ∫√‘∫“≈ºŸâªÉ«¬Àπ—°, ºŸâªÉ«¬∂à“¬ª≈Ÿ°ªÕ¥∑’Ë¡’¿“«–µ‘¥‡™◊ÈÕ ·∑√°´âÕπÚÛ ·≈–ºŸâªÉ«¬À≈—ß»—≈¬°√√¡‡ª≈’ˬπ∑“ßÀ≈Õ¥ ‡≈◊Õ¥‚§‚√π“√’¬ÚÙ å ) ·µàπÕ°®“°‚√§À◊¥·≈â« ‚√§Õ◊Ëπ∑’Ë°≈à“« ¡“¬—߉¡à¡’¢âÕ π—∫ πÿπ°“√„™â∑’Ë·πàπÕπ ·≈–∑’ËÕâ“ß«à“°“√ µ√«®ª√‘¡“≥‰πµ√‘°ÕÕ°‰´¥å„π≈¡À“¬„®ÕÕ°„πºŸâ ªÉ « ¬„™â ‡§√◊ËÕߙ૬À“¬„®Õ“®„™â™à«¬µ‘¥µ“¡°“√¥”‡π‘π‚√§À√◊Õµ‘¥ µ“¡º≈°“√√—°…“ °Á¬—ßÕ¬Ÿà„π™à«ß°“√»÷°…“¬◊π¬—π √ÿª«à“°“√µ√«®«‘‡§√“–Àå·°ä ‰πµ√‘°ÕÕ°‰´¥å„π ≈¡À“¬„®ÕÕ°¡’º≈ª√–‚¬™πå¬π◊ ¬—π‰¥â„πºŸªâ «É ¬‚√§À◊¥À≈Õ¥≈¡ ·≈–°≈ÿà¡Õ“°“√¢π°«—¥¥âÕ¬ ¡√√∂¿“æª∞¡¿Ÿ¡‘ ·µà°“√

𔉪„™â ‡ ªì π «‘ ∏’ µ √«®ª√–®”∑“߇«™°√√¡§ß¬— ߉¡à ‡ À¡“– ‡π◊ËÕß®“°§«“¡®”‡ªìπ ·≈–§«“¡§ÿâ¡∑ÿπ ”À√—∫«‘∏’°“√µ√«® ®–¢Õ𔇠πÕ„π‚Õ°“ µàÕ‰ª

‡Õ° “√Õâ“ßÕ‘ß Ò. Phillips M. Breath tests in medicine. Scientific American July 1992. p. 74-9. Ú. æ®π“πÿ°√¡ ©∫—∫√“™∫—≥±‘µ¬ ∂“π æ.». ÚıÙÚ æ‘¡æå§√—Èß∑’Ë Ò °√ÿ߇∑æœ : π“π¡’∫ÿä§ åæ—∫≈‘‡§™—Ëπ å ; ÚıÙˆ Àπâ“ ˆ. Û. Alving K, Weizberg E, Lundberg JM. Increased amounts of nitric oxide in exhaled air of asthmatics. Eur Respir J 1993;6:1368-70. Ù. Lunberg JO, Weitzberg E, Nordvall SL, Kuylenstierna R, Lunberg JM, Alving K. Primarily nasal origin of exhaled nitric oxide and absence in Kartagenerûs syndrome. Eur Respir J 1994;7:1501-4. ı. Schedin U, Frostell C, Persson MG, Jakobsson J, Andersson G, Gustafsson LE. Contribution from upper and lower airways to exhaled endogenous nitric oxide in humans. Acta Anaesthesiol Scand 1995;39:327-32. ˆ. Gustafsson LE, Leone AM, Persson MG, Wiklund NP, Moncada S. Endogenous nitric oxide is present in the exhaled air of rabbits, guinea pigs and humans. Biochem Biophys Res Commun 1991;181:852-7. ˜. Tsang KW, Ip SK, Leung R, Tipoe GL, Chan SL, Shum IH, et al. Exhaled nitric oxide: effects of age, gender and body size. Am J Respir Crit Care Med 2001;163:A50. ¯. Tsang KW, Ip SK, Leung R, Tipoe GL, Chan SL, Shum IH, et al. Exhaled nitric oxide: the effects of age, gender and body size. Lung 2001; 179:83-91. ˘. Tsang KW, Leung R, Chin-Wan P, Chan SL, Tipoe GL, Ooi GC, et al. Exhaled and sputum nitric oxide in bronchiectasis. Chest 2002;121:8894.

373

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Ò. Barnes PJ. Nitric oxide and airway disease. Ann Med 1995;27:389-93. ÒÒ. Barnes PJ, Liew FY. Nitric oxide and asthmatic inflammation. Immunol Today 1995;16:128-30. ÒÚ. Gaston B, Ratjen F, Vaughan JW, Malhotra NR, Canady RG, Snyder AH, et al. Nitrogen redox balance in the cystic fibrosis airway: effects of antipseudomonal therapy. Am J Respir Crit Care Med 2002;165:387-90. ÒÛ. ATS Workshop Proceedings: Exhaled nitric oxide and nitric oxide oxidative metabolism in exhaled breath condensate. Proceedings of the American Thoracic Society 2006;3:131-45. ÒÙ. Narang I, Ersu R, Wilson NM, Bush A. Nitric oxide in chronic airway inflammation in children : diagnostic use and pathophysiological significance. Thorax 2002;57:586-9. Òı. Horvath I, Loukides S, Wodehouse T, Csiszer E, Cole PJ, Kharitonov SA, et al. Comparison of exhaled and nasal nitric oxide and exhaled carbon monoxide levels in bronchiectatic patients with and without primary ciliary dyskinesia. Thorax 2003;58:68-72. Òˆ. Wodehouse T, Kharitonov SA, Mackay IS, Barnes PJ, Wilson R, Cole PJ. Nasal nitric oxide measurements for the screening of primary ciliary dyskinesia. Eur Respir J 2003; 21:43-7. Ò˜. Balfour-Lynn I, Laverty A, Dinwiddle R. Reduced upper airway nitric oxide in cystic fibrosis. Arch Dis Child 1996;75:319-22. Ò¯. Lundberg JO, Nordvall SL, Weitzberg E, Kollberg H, Alving K. Exhaled nitric oxide in pediatric asthma and cystic fibrosis. Arch Dis Child 1996;75:323-6. Ò˘. Arnal JF, Didier A, Rami J, MûRini C, Charlet JP, Serrano E, et al. Nasal nitric oxide is increased in allergic rhinitis. Clin Exp Allergy 1997;27:358-62. Ú. Kharitonov S, Rajakullasingam K, OûConnor B, Durham S, Barnes PJ. Nasal nitric oxide is

increased in patients with asthma and allergic rhinitis and may be modulated by nasal glucocorticosteroids. J Allergy Clin Immunol 1997;99:58-64. ÚÒ. Martin U, Bryden K, Devoy M, Howarth P. Increased levels of exhaled nitric oxide during nasal and oral breathing in subjects with seasonal rhinitis. J Allergy Clin Immunol 1996; 97:768-72. ÚÚ. Bates CA, Silkoff PE. Exhaled nitric oxide in asthma: from bench to bedside. J Allergy Clin Immunol 2003;111:256-62. ÚÛ. Marczin N, Riedel B, Gal J, Polak J, Jacoub M. Exhaled nitric oxide during lung transplantation. Lancet 1997;350:1681-2. ÚÙ. Marczin N, Kovesi T, Royston D. Exhaled nitric oxide as a marker of lung injury in coronary bypass surgery. Br J Anaesthesia 2003; 90:101-4.

‡Õ° “√Õà“π‡æ‘Ë¡‡µ‘¡ Ò. American Thoracic Society. Recommendations for standardized procedures for the on-line and off-line measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide in adults and children - 1999. Official statement of the American Thoracic Society adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med 1999;160:2104-17. Ú. American Thoracic Society/ European Respiratory Society. ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005. Am J Respir Crit Care Med 2005;171:912-30. Û. Baraldi E, Scollo M, Zaramella C, Zanconato S, Zacchello F. A simple flow-driven method for online measurement of exhaled NO starting at the age of 4 to 5 years. Am J Respir Crit Care Med 2000;162:1828-32.

374 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Ù. Beckman JS, Beckman TW, Chen J. Apparent hydroxyl radical production by peroxynitrate: implications for endothelial injury from nitric oxide and superoxide. Proc Natl Acad Sci USA 1990;87:1620-4. ı. Beckman JS . The double-edged role of nitric oxide in brain function and superoxide-mediated injury. J Dev Physiol 1991;15:53-9. ˆ. Beghetti M, Silkoff PE, Caramori M, Holtby HM, Slutsky AS, Adatia I. Decreased exhaled nitric oxide may be a marker of cardiopulmonary bypass-induced injury. Ann Thorac Surg 1998;66:532-4. ˜. Brett SJ, Evans TW. Measurement of endogenous nitric oxide in the lungs of patients with the acute respiratory distress syndrome. Am J Respir Crit Care Med 1998;157:993-7. ¯. Brett SJ, Quinlan GJ, Mitchell J, Pepper JR, Evans TW. Production of nitric oxide during surgery involving cardiopulmonary bypass. Crit Care Med 1998;26:272-8. ˘. Busch T, Bartsch P, Pappert D, Grunig E, Hildebrandt W, Elser H, et al. Hypoxia decreases exhaled nitric oxide in mountaineers susceptible to high-altitude pulmonary edema.

Am J Respir Crit Care Med 2001;163:368-73. Ò. Byrnes CA, Dinarevic S, Busst C, Bush A, Shinebourne EA. Is nitric oxide in exhaled air produced at airway or alveolar level? Eur Respir J 1997;10:1021-5. ÒÒ. Carlin RE, McGraw DJ, Camporesi EM, Hakim TS. Increased nitric oxide in exhaled gas is an early marker of hypovolemic states. J Surg Res 1997;69:362-6. ÒÚ. Corradi M, Majori M, Cacciani GC. Increased exhaled nitric oxide in patients with satble chronic obstructive pulmonary disease. Thorax 1999;54:572-5. ÒÛ. Cremona G, Higenbottam TW, Mayoral V, Alexander G, Demoncheaux E, Borland C, et al.

Elevated exhaled nitric oxide in patients with

hepatopulmonary syndrome. Eur Respir J 1995; 8:1883-5. ÒÙ. Cucchiaro G, Tatum AH, Brown MC, Camporesi EM, Daucher JW, Hakim TS. Inducible nitric oxide synthase in the lung and exhaled nitric oxide after hyperoxia. Am J Physiol 1999;277: L636-L644. Òı. Cuthbertson BH, Stott SA, Webster NR. Exhaled nitric oxide as a marker of lung injury in coronary artery bypass surgery. Br J Anaesthesiol 2002;89:247-50. Òˆ. Delclaux C, Mahut B, Zerah-Lancner F, Delacourt C, Laoud S, Cherqui D, et al.

Increased nitric oxide output from alveolar origin during liver cirrhosis versus bromchial source during asthma. Am J Respir Crit Care Med 2002;165:332-7. Ò˜. Delen FM, Spipel JM, Osborne ML. Increased exhale nitric oxide in chronic bronchitis: comparison with asthma and COPD. Chest 2000; 117:695-701. Ò¯. Deykin A, Massaro AF, Coulston E, Drazen JM, Israel E. Exhaled nitric oxide following repeated spirometry or repeated plethysmography in healthy individuals. Am J Respir Crit Care Med 2000;161:1237-40. Ò˘. Deykin A, Massaro AF, Drazen JM, Israel E. Exhaled nitric oxide as a diagnostic test for asthma: online versus offline techniques and effect of flow rate. Am J Respir Crit Care Med 2002;165:1597-601. Ú. Djupesland PG, Chatkin JM, Qian W, Haight JS. Nitric oxide in the nasal airway: a new dimension in otorhinolaryngology. Am J Otolaryngol 2001;22:19-32. ÚÒ. Dotsch J, demirakca S, Terbrack HG. Airway nitric oxide in asthmatic children and patients with cystic fibrosis. Eur Respir J 1996;9:253740. ÚÚ. Dweik RA, Laskowski D, Abu-Soud HM, Kaneko F, Hutte R, Stuehr DJ, Erzurum SC.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

Nitric oxide synthesis in the lung: regulation by oxygen through a kinetic mechanism. J Clin Invest 1998;101:660-6. ÚÛ. Fernandez-Mondejar E, Hambraeus-Jonzon K, Roneus A, Hedenstierna G. Nitric oxide increases dramatically in air exhaled from lung rregions with occluded vessdels. Acta Anaesthesiol Scand 2003;47:312-8. ÚÙ. Gilain L, Bedu M, Jouaville L, Guichard C, Advenier D, Mom T, et al. Analysis of nasal and exhaled nitric oxide concentration in nasal polyposis. Ann Otolaryngol Chir Cervicofac 2002;119:234-42. (English abstract). Úı. Girgis RE, Gugnani MK, Abrams J, Mayes MD. Paritioning of alveolar and conducting airway nitric oxide in scleroma lung disease.

Am J Respir Crit Care Med 2002;165:158791. Úˆ. Girgis RE, Qureshi MA, Abrams J, Swerdlow P. Decreased exhaled nitric oxide in sickle cell disease: relationship with chronic lung involvement. Am J Hematol 2003;72:177-84. Ú˜. Guenard H, Varene N, Vaida P. Determination of lung capillary blood volume and membrane diffusing capacity in man by the measurements of NO and CO transfer. Respir Physiol 1987;70: 113-20. Ú¯. Hall GL, Reimann B, Wildhaber JH, Frey U. Tidal exhaled nitric oxide in healthy unsedated newborn infants with prenatal tobacco exposure.

J Appl Physiol 2002;92:59-66. Ú˘. Hamid Q, Springall DR, Riveros-Moreno V, Chanez P, Howarth P, Redington A, et al.

Induction of nitric oxide synthase in asthma.

Lancet 1993;342:1510-3. Û. Harkins MS, Fiato KL, Iwamoto GK. Exhaled nitric oxide predicts asthma exacerbation. J Asthma 2004;41:471-6. ÛÒ. Ho LP, Innes JA, Greening AP. Nitrite levels in breath condensate of patients with cystic fibrosis is elevated in contrast to exhaled nitric oxide. Thorax 1998; 53: 680-4.

375

ÛÚ. Ho LP, Innes JA, Greening AP. Exhaled nitric oxide is not elevated in the inflammatory airways diseases of cystic fibrosis and bronchiectasis. Eur Respie J 1998;12:1290-4. ÛÛ. Hogman M, Drca N, Ehrstedt C, Merilainen P. Exhaled nitric oxide partitioned into alveolar, lower airways and nasal contributions. Respir Med 2000;94:985-91. ÛÙ. Hogman M, Ludviksdottir D, Anderson SD, George S, Hakansson L, Chan HK, et al. Inhaled mannitol shifts exhaled nitric oxide in opposite directions in asthmatic and healthy subjects.

Respir Physiol 2001;124:141-50. Ûı. Hogman M, Holmkvist T, Wegener T, Emtner M, Andersson M, Hedenstrom H, Merilainen P. Extended No analysis applied to patients with CIOPD, allergic asthma and allergic rhinitis. Respir Med 2002;96:24-30. Ûˆ. Hogman M, Holmkvist T, Walinder R, Meriilainen P, Ludviksdottir D, Hakansson L, Hedenstrom H. Increased nitric oxide elimination from the airways after smoking cessation.

Clin Sci (lond) 2002;103:15-9. Û˜. Humpl T, Campbell R, Stephens D, Van Arsdell G, Benson LN, Hltby HM, et al. Levels of exhaled nitric oxide before and after surgical and transcatheter device closure of atrial septal defects in children. J Thorac Cardiovasc Surg 2002;124:806-10. Û¯. Hunt J. The informative complexity of exhaled nitrogen oxide chemistry. Thorax 2005;60:2-3. Û˘. Husain M, Adrie C, Ichinose F, Kavosi M, Zapol WM. Exhaled nitric oxide as a marker for organic nitrate tolerance. Circulation 1994; 89:2498-2502. Ù. Hyde RW, Geigel EJ, Olszowka AJ, Krasney JA, Forster RE II, Utell MJ, et al. Determination of production of nitric oxide by lower airways of humans: theory. J Appl Physiol 1997;82:1290-6. ÙÒ. Ishibe Y, Liu R, Hirosawa J, Kawamura K, Yamasaki K, Saito N. Exhaled nitric oxide

376 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

level decreases after cardiopulmonary bypass in adult patients. Crit Care Med 2000;28:3823-7. ÙÚ. Jobsis Q, Raatgeep HC, Hop WC, de Jongste JC. Controlled low flow off line sampling of exhaled nitric oxide in children. Thorax 2001; 56:285-9. ÙÛ. Jones SL, Kittelson J, Cowan JO, Flanneery EM, Hancox RJ, McLachlan CR, et al. The predictive value of exhaled nitric oxide measurements in assessing changes in asthma control.

Am J Respir Crit Care Med 2001;164:738-43. ÙÙ. Jorres RA. Modelling the production of nitric oxide within the human airways. Eur Respir J 2000;16:555-60. Ùı. Karadag B, James AL, Gultekin E. Nsal and lower airway level of nitric oxide in children with primary ciliary dyskinesia. Eur Respir J 1999;13:1402-5. Ùˆ. Kharitonov SA, Wells AU, OûConnor BJ. Elevated levels of exhaled nitric oxide in bronchiectasis. Am J Respir Crit Care Med 1995; 151:1889-93. Ù˜. Kharitonov SA, Barnes PJ. Nitric oxde in exhaled air is a new marker of airway inflammation. Monaldi Arch Chest Dis 1996;51:533-7. Ù¯. Kharitonov SA, Yates DH, Barnes PJ. Inhaled glucocorticoids decrease nitric oxide in exhaled air of asthmatic patients. Am J Respir Crit Care Med 1996;153:454-7. Ù˘. Kharitonov SA, Alving K, Barnes PJ. Exhaled and nasal nitric oxide measurements: recommendations. The European Respiratory Society Task Force. Eur Respir J 1997;10:1683-93. ı. Kharitonov SA, Barnes PJ. Exhaled markers of inflammation. Curr Opin Allergy Clin Immunol 2001;1:217-24. ıÒ. Kharitonov SA, Barnes PJ. Biomarkers of some pulmonary diseases in exhaled breath. Biomarkers 2002;7:1-32. ıÚ. Kharitonov SA, Gonio F, Kelly C, Meah S, Barnes PJ. Reproducibility of exhaled nitric

oxide measurements in healthy adults and children. Eur Respir J 2003;21:433-8. ıÛ. Kimberly B, Nejadnik B, Giraud GD. Nasal contribution to echaled nitric oxide at rest and during breath-holding in human. Am J Respir Crit Care Med 1996;153:829-36. ıÙ. Kissoon N, Duckworth LJ, Blake KV, Murphy SP, Taylor CL, DeNicola LR, et al. Exhaled nitric oxide concentrations: online versus offline values in healthy children. Pediatr Pulmonol 2002;33:283-92. ıı. Kissoon N, Duckworth LJ, Blake KV, Murphy SP, Lima JJ. Effect of beta-2 agonist treatment and spirometry on exhaled nitric oxide in healthy children and children with asthma. Pediatr Pulmonol 2002;34:203-8. ıˆ. Kovesi T, Royston D, Yacoub M, Marczin N. Basal and nitroglycerin-induced exhaled nitric oxide before and after cardiac surgery with cardiopulmonary bypass. Br J Anaestheesiol 2003;90:608-16. ı˜. Lanz MJ, Leung DY, McCormick DR, Harbeck R, Szefler SJ, White CW. Comparison of exhaled nitric oxide, serum eosinophilic catio protein, and soluble interleukin-2 receptor in exacerbations of pediatric asthma. Pediatr Pulmonol 1997;24:305-11. ı¯. Lehtimaki L, Turjanmaa V, Kankaanranta H, Saarelainen S, Hahtola P, Moilanen E. Increased bronchial nitric oxide production in patients with asthma measured with a novel method of different exhalation flow rates. Ann Med 2000;32:417-23. ı˘. Lehtimaki L, Kankaanranta H, Saarelainen S, Hahtola P, Jarvenpaa R, Koivula T, et al.

Extended exhaled NO measurement differentiates between alveolar and bronchial inflammation. Am J Respir Crit Care Med 2001;163: 1557-61. ˆ. Lehtimaki L, Kankaanranta H, Saarelainen S, Turjanmaa V, Moilanen E. Inhaled fluticasone

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

decreases bronchial but not alveolar nitric oxide output in asthma. Eur Respir J 2001;18:6359. ˆÒ. Lehtimaki L, Kankaanranta H, Saarelainen S, Hahtola P, Jarvenpaa R, Koivula T, et al.

Extended exhaled NO measurement differentiates between alveolar and bronchial inflammation. Am J Respir Crit Care Med 2001;163: 1557-61. ˆÚ. Lundberg JON, Farkas-Szallasi T, Weitzberg E, Rinder J, Lidholm J, Anggard A, et al. High nitric oxide production in human paranasal sinuses. Nature Med 1995;1:370-3. ˆÛ. Lunberg JON, Weitzberg E, Lundberg JM, Alving K. Nitric oxide in exhaled air. Eur Respir J 1996;9:2671-80. ˆÙ. Lundberg JO, Weitzberg E, Lundberg JM, Alving K. Nitric oxide in exhaled air. Eur Respir J 1996;9:2671-80. ˆı. Lundberg JO, Weitzberg E. Nasal nitric oxide in man. Thorax 1999;54:947-52. ˆˆ. Lundberg JO, Maniscalco M, Sofia M, Lundblad L, Weitzberg E. Humming, nitric oxide, and paranasal sinus obstruction. JAMA 2003;289: 302-3. ˆ˜. Marhado RF, Londhe Nerkar MV, Dweik RA, Hammel J, Janocha A, Pyle J, et al. Nitric oxide and pulmonary arterial pressures in pulmonary hypertension. Free Radic Biol Med 2004;37:1010-7. ˆ¯. Maestrelli P, Ferrazzoni S, Visentin A, Marian E, Dal Borgo D, Accordino R, et al. Measurement of exhaled nitric oxide in healthy adults.

Sarcoidosis Vasc Diffuse Lung Dis 2007;24: 65-9. ˆ˘. Mahut B, Delclaux C, Tillie-Leblond I, Gosset P, Delacourt C, Zerah-Lancner F, et al. Both inflammation and remodeling influence nitric oxide output in children with refractory asthma.

J Allergy Clin Immunol 2004;113:252-6.

377

˜. Malmstrom RE, Tornberg D, Settergren G, Liska J, Angdin M, Lundberg JO, Weitzberg E. Endogenous nitric oxide release by vasoactive drugs monitored in exhaled air. Am J Respir Crit Care Med 2003;168:114-120. ˜Ò. Maniscalco M, Weitzberg E, Sunberg J, Sofia M, Lundberg JO. Assessment of nasal and sinus nitric oxide output using single-breath humming exgalations. Eur Respir J 2003;22:3239. ˜Ú. Mattes J, Strom vanûs Graevesande K, Reining U. NO in exhaled air is correlated with markers of eosinophilic airway inflammation in corticosteroid-dependent childhood asthma. Eur Respir J 1999;13:1391-5. ˜Û. Marczin N, Riedel B, Royston D, Yacoub M. Intravenous nitrate vasodilators and exhaled nitric oxide. Lancet 1997;349:1742. ˜Ù. Maziak W, Loukides S, Culpitt S. Exhaled nitric oxide in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;157: 998-1002. ˜ı. Massaro AF, Mehta S, Lilly CM. Elevated nitric oxide concentrations in isolated lower airway gas of asthmatic subjects. Am J Respir Crit Care Med 1996;153:1510-4. ˜ˆ. Massaro AF, Drazen JM. Exhaled nitric oxide during exercise : site of release and modulation by ventilation and blood flow. J Appl Physiol 1996;80:1863-4. ˜˜. Matsumoto A, Ogura K, Hirata Y, Kakoki M, Watanabe F, Takenaka K, et al. Increased nitric oxide in the exhaled air of patients with decompensated liver cirrhosis. Ann Intern Med 1995;123:110-3. ˜¯. Mehta S, Javeshgani D, Datta P, Levy RD, Magder S. Porcine endotoxemic shock is associated with increased expired nitric oxide.

Crit Care Med 1999;27:385-93. ˜˘. Nunes H, Lebrec D, Mazmanian M, Capron F, Heller J, Tazi KA, et al. Role of nitric oxide

378 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

in hepatopulmonary syndrome cirrhotic rats. J Respir Crit Care Med 2001; 164: 879-85. ¯. Ojoo JC, Mulrennan A, Kastelik JA, Morice AH, Redington AE. Exhaled breath condensate pH and exhaled nitric oxide in allergic asthma and in cystic fibrosis. Yhorax 2005;60:22-6. ¯Ò. Ozkan M, Dweik RA, Laaskowski D, Arroliga AC, Erzurum SC. High levels of nitric oxide in individuals with pulmonary hypertension receiving epoprostenol therapy. Lung 2001;179: 233-43. ¯Ú. Palm JP, Graf P, Lunberg JO, Alving K. Characterization of exhaled nitric oxide: introducing a new reproducible method for nasal nitric oxide measurements. Eur Respir J 2000;16: 236-41. ¯Û. Paredi P, Leckie MJ, Horvath I, Allegra L, Kharitonov SA, Barnes PJ. Changes in exhaled carbon monoxide and nitric oxide levels following allergen challenge in patients with asthma. Eur Respir J 1999;13:48-52. ¯Ù. Paredi P, Kharitonov SA, Loukides S. Exhaled nitric oxide is increased in active fibrosing alveolitis. Chest 1999;115:1352-6. ¯ı. Pedroletti C, Zetterquist W, Nordvall L, Alving K. Evaluation of exhaled nitric oxide in schoolchildren at different exhalation flow rates. Pediatr Res 2002;52:393-8. ¯ˆ. Persson MG, Agvald P, Gustafsson LE. Detection of nitric oxide in exhaled air during administration of nitroglycerin in vivo. Br J Pharmacol 1994;111:825-8. ¯˜. Piacentini GL, Bodini A, Costella S, Vicentini L, Mazzi P, Sperandio S, et al. Exhaled nitric oxide and sputum eosinophil markers of inflammation in asthmatic children. Eur Respir J 1999;13:1386-90. ¯¯. Pietropaoli AP, Perillo IB, Torres A, Perkins PT, Frasier LM, Utell MJ, et al. Simultaneous measurement of nitric oxide production by conducting and alveolar airways of humans. J Appl Physiol 1999;87:1532-42.

¯˘. Riley MS, Porszasz J, Miranda J, Engelen MP, Brundage B, Wasserman K. Exhaled nitric oxide during exercise in primary pulmonary hypertension and pulmonary fibrosis. Chest 1999; 111: 45-50. ˘. Rolla G, Brussino L, Colagrande P, Dutto L, Polizzi S, Scappaticci E, et al. Exhaled nitric oxide and oxygenation abnormalities in hepatic cirrhosis. Hepatology 1997;26:842-7. ˘Ò. Rolla G, Brussino L, Colagrande P, Scappaticci E, Morello M, Bergerone S, et al. Exhaled nitric oxide and impaired oxygenation in cir rhotic patients before and after liver transplantation. Ann Intern Med 1998;129:375-8. ˘Ú. Runer T, Cervin A, Linberg S, Uddman R. Nitric oxide is a regulator of muco-ciliary activity in the upper respiratory tract. Otolaryngol Head Neck Surg 1998;107:40-6. ˘Û. Rutgers SR, van der Mark TW, Coers W. Markers of nitric oxide metabolism in sputum and exhaled air are not increased in chronic obstructive pulmonary disease. Thorax 1999; 54:576-80. ˘Ù. Salome CM, Roberts AM, Brown NJ. Exhaled nitric oxide measurements in a population sample of young adults. Am J Respir Crit Care Med 1999;159:911-6. ˘ı. Sartori C, Lepori M, Busch T, Duplain H, Hildebrandt W, Bartsch P, et al. Exhaled nitric oxide does not provide a marker of vascular endothelial function in healthy humans. Am J Respir Crit Care Med 1999;160:879-82. ˘ˆ. Schmetterer L, Strenn K, Kastner J, Eichler HG, Wolzt M. Exhaled NO during graded changes in inhaled oxygen in man. Thorax 1997;52:736-8. ˘˜. Shin HW, Rose-Gotton CM, Sufi RS, Perez F, Cooper DM, Wilson AF, et al. Flow-independent nitric oxide exchange parameters in cystic fibrosis. Am J Respir Crit Care Med 2002;165: 349-57.

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

˘¯. Shin HW, Rose-Gittron CM, Cooper DM, Hill M, George SC. Impact of high-intensity exercise on nitric oxide excghnage in healthy adults. Med Sci Sports Exerc 2003; 35: 9951003. ˘˘. Shin HW, Rose-Gottron CM, Cooper DM, Newcombe RL, George SC. Airway diffusing capacity of nitric oxide is not impacted by steroid therapy in asthma. J Appl Physiol 2004; 96:65-75. Ò. Silkoff PE, McClean PA, Slutsky AS, Furlott HG, Hoffstein E, Wakita S, et al. Marked flow-dependence of exhaled nitric oxide using a new technique to exclude nasal nitric oxide.

Am J Respir Crit Care Med 1997;155:260-7. ÒÒ. Silkoff PE, Robbins RA, Gaston B, Lunberg JO, Townley RG. Endogenous nitric oxide in allergic airway disease. J Allergy Clin Immunol 2000;105:438-48. ÒÚ. Silkoff PE, Sylvester JT, Zamel M, Permutt S. Airway nitric oxide diffusion in asthma: role in pulmonary function and bronchial responsiveness. Am J Respir Crit Care Med 2000;161:1218-28. ÒÛ. Sittipunt C, Steinberg KP, Ruzinski JT, Myles C, Zhu S, Goodman RB, et al. Nitric oxide and nitrotyrosine in the lungs of patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2001;163:503-10. ÒÙ. Soderman C, Leone A, Furst V, Persson MG. Endogenous nitric oxide in exhaled air from patients with liver cirrhosis. Scand J Gastroenterol 1997;32:591-7. Òı. St. Croix CM, Wetter TJ, Pegelow DF, Meyer KC, Dempsey JA. Assessment of nitric oxide formation during exercise. Am J Respir Crit Care Med 1999;159:1125-33. Òˆ. Stewart TE, Valenza F, Ribeiro SP, Wener AD, Volgyesi G, Mullen JB, et al. Increased nitric oxide in exhaled gas as an early marker of lung inflammation in a model of sepsis.

379

Am J Respir Crit Care Med 1995;151:7138. Ò˜. Sumino H, Sato K, Sakamaki T, Masuda H, Nakamura T, Kanda T, Nagai R. Decreased basal production of nitric oxide in patients with heart disease. Chest 1998;113;317-22. Ò¯. Tassiopoulos AK, Carlin RE, Gao Y, Pedoto A, Finck CM, Landas SK, et al. Role of nitric oxide and tumor necrosis factor on lung injury caused by ischemia/reperfusion of the lower extremities. J Vasc Surg 1997;26:647-56. Ò˘. Tornberg DC, Bjorne H, Lundberg JO, Weitzberg E. Multiple single-breath measurements of nitric oxide in the intubated patients.

Am J Respir Crit Care Med Zlung) 2003; 168:1210-5. ÒÒ. Tsuchiya M, Tokai H, Takehara Y, Haraguchi Y, Asada A, Utsumi K, Inoue M. Interrelation between oxygen tension and nitric oxide in the respiratory system. Am J Respir Crit Care Med 2000;162:1257-61. ÒÒÒ. Tworetzky W, Moore P, Bekker JM, Bristow J, Black SM, Fineman JR. Pulmonary blood flow alters nitric oxide production in patients undergoing device closure of atrial septal defects. J Am Coll Cardiol 2000;35:463-7. ÒÒÚ. van der Lee I, van den Bosch JM, Zanen P. Reduction of variability of exhaled nitric oxide in healthy volunteers. Respir Med 2002;96: 1014-20. ÒÒÛ. Vandivier RW, Eidsath A, Banks SM, Preas HL, Leighton SB, Godin PJ, et al. Downregulation of nitric oxide by ibuprofen in human volunteers. J Pharmacol Exp Ther 1999; 289:1398-403. ÒÒÙ. Weitzberg E, Lundberg JO. Nonenzymatic nitric oxide production in humans. Nitric Oxide 1998;2:1-7. Òı. Weitzberg E, Lundberg JO. Humming greatly increases nasal nitric oxide. Am J Respir Crit Care Med 2002;166:144-5.

380 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

ÒÒˆ. Wildhaber JH, Hall GL, Stick SM. Measurements of exhaled nitric oxide with the singlebreath technique and positive expiratory pressure in infants. Am J Respir Crit Care Med 1999;159:74-8. ÒÒ˜. Yoshizumi M, Perrella MA, Burnett JC Jr, Lee ME. Tumor necrosis factor downregulates an endothelial nitric oxide synthase mRNA by shortening its half-life. Circ Res 1993;73:2059.

ÒÒ¯. Zietkowski Z, Bodzenta-Lukaszyk A. Exhaled nitric oxide (NO) in patients with respiratory tract diseases. Pol Merkur Lekarski 2004;16: 115-8. (English abstract).

381

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ª°‘≥°–

Õππ—°»÷°…“·æ∑¬å¬ÿ§„À¡àÕ¬à“߉√¥’ «‘π‘∑√“ π«≈≈–ÕÕß

∫∑§—¥¬àÕ Àπ÷Ëß„πÕÿª √√§ ”§—≠¢Õß°“√®—¥°“√‡√’¬π°“√ Õπ ”À√—∫π—°»÷°…“·æ∑¬å„πªí®®ÿ∫—π§◊Õ §«“¡·µ°µà“ߢÕ߬ÿ§ ¡—¬·≈–∫ÿ§≈‘°¿“æ√–À«à“ßÕ“®“√¬å°—∫π—°»÷°…“ §«“¡·µ°µà“ߢÕ߬ÿ§ ¡—¬‡°‘¥®“°π—°»÷°…“·æ∑¬å¬ÿ§„À¡àÕ¬Ÿà„𠇮‡πÕ‡√™—Ëπ Y (‡°‘¥√–À«à“ßªï §.». Ò˘¯Ú - ÚÛ) „π√–À«à“ß∑’ËÕ“®“√¬å à«π„À≠àÕ¬Ÿà„π‡®‡πÕ‡√™—Ëπ X ·≈–‡∫∫’È∫Ÿ¡ ´÷ßË ¡’§“à π‘¬¡„π°“√„™â™«’ µ‘ µà“ß°—π ¥—ßπ—πÈ °“√®—¥°“√‡√’¬π°“√ Õπ‡æ◊ÕË „Àâ‡À¡“–°—∫√Ÿª·∫∫°“√‡√’¬π√Ÿ®â ß÷ §«√ Ò) ¡’‚§√ß √â“ß ¢Õß«‘™“Õ¬à“ß™—¥‡®π, Ú) ‡ªî¥‚Õ°“ „Àâπ°— »÷°…“‰¥â· ¥ß§«“¡§‘¥ √â“ß √√§å, Û) „À⧫“¡ ”§—≠°—∫ªí≠À“§«“¡‡§√’¬¥ ·≈– Ù) ¡’«‘™“∫—ߧ—∫‡°’ˬ«°—∫®√‘¬∏√√¡ à«πªí®®—¬‡°’ˬ«°—∫∫ÿ§≈‘°¿“ææ∫«à“ π—°»÷°…“·æ∑¬å¬ÿ§„À¡à¡’·π«‚πâ¡∂π—¥ °“√‡√’¬π‡ªìπ°≈ÿà¡·≈–¡’ªØ‘ —¡æ—π∏å°—∫ºŸâÕ◊Ëπ¡“°¢÷Èπ°«à“„πÕ¥’µ πÕ°®“°π—Èπ¬—ß∂π—¥°“√‡√’¬π√Ÿâºà“πª√– ∫°“√≥å®√‘ß ·≈–‡πâπ°“√𔉪„™â‰¥â®√‘ß¡“°¢÷Èπ ¥—ßπ—Èπ°“√ π—∫ πÿπ„ÀâÕ“®“√¬åºŸâ®—¥°“√‡√’¬π°“√ Õπ‡¢â“„®∂÷ߧ«“¡·µ°µà“߇À≈à“π’È ®÷ߙ૬ π—∫ πÿπ„Àâπ—°»÷°…“ “¡“√∂‡√’¬π√Ÿâ‰¥âÕ¬à“߇µÁ¡ª√– ‘∑∏‘¿“æ·≈– √â“ߧ«“¡‡¢â“„®´÷Ëß°—π·≈–°—π√–À«à“ß Õ“®“√¬å·≈–π—°»÷°…“¥â«§” ”§—≠: ‡®‡πÕ‡√™—Ëπ Y, π—°»÷°…“·æ∑¬å, Õ“®“√¬å, ∫ÿ§≈‘°¿“æ, ‰¡‡¬Õ√å-∫√‘° å, §“√å≈ ®ÿß „π°“√®—¥°“√‡√’¬π°“√ Õπ ”À√—∫π—°»÷°…“·æ∑¬å ªí®®—¬∑’§Ë «√§”π÷ß∂÷ßπÕ°‡Àπ◊Õ®“°§«“¡√Ÿ∑â §’Ë √Õ∫§≈ÿ¡‡°≥±å ·æ∑¬ ¿“ §◊Õ µ—«¢ÕßÕ“®“√¬åº Ÿâ Õπ·≈–µ—«¢Õßπ—°»÷°…“‡Õß ‚¥¬Õÿª √√§Õ“®‡°‘¥®“°∑—°…–°“√ Õπ¢ÕßÕ“®“√¬åÀ√◊Õ ∑—°…–°“√‡√’¬π√Ÿâ¢Õßπ—°»÷°…“ πÕ°®“°π—Èπ¬—ßÕ“®‡°‘¥®“° §«“¡·µ°µà“ß√–À«à“߬ÿ§ ¡—¬·≈–∫ÿ§≈‘°¿“æÕ’°¥â«¬ °ÿ≠·® ”§—≠∑’Ë𔉪 Ÿà°“√·°â‰¢ªí≠À“§◊Õ °“√∑”§«“¡‡¢â“„®§«“¡ ·µ°µà“ߥ—ß°≈à“«·≈–¬Õ¡√—∫„𧫓¡µà“ß√«¡∂÷߇ª≈’ˬπ„Àâ ‡ªìπ‚Õ°“ Ÿ°à “√ √â“ß·æ∑¬å¬§ÿ „À¡à∑¡’Ë ‡’ Õ°≈—°…≥凩擖µ—« ¥—ßπ—Èπ °“√∑”§«“¡‡¢â“„®‡√◊ËÕߧ«“¡·µ°µà“ß√–À«à“߬ÿ§ ¡—·≈–∫ÿ § ≈‘ ° ¿“æ®÷ ß ‡ªì π ª√–‚¬™πå µà Õ °“√‡√’ ¬ π°“√ Õπ„Àâ ‡À¡“–°—∫π—°»÷°…“·≈–™à«¬„À⇢Ⓞ®æƒµ‘°√√¡¢Õßπ—°»÷°…“ ¬ÿ§„À¡à¡“°¢÷Èπ πÕ°®“°π—Èπ¬—߇ªìπª√–‚¬™πåµàÕµ—«π—°»÷°…“ ‡Õß„π°“√∑”§«“¡‡¢â“„®µπ‡Õß·≈–π”¡“´÷ßË °“√ √â“߇հ≈—°…≥å ¢Õßµπ‡Õß√«¡∂÷ß à߇ √‘¡§«“¡¿“§¿Ÿ¡‘„®„πµπ‡ÕßÕ’°¥â«¬

Generation differences ®“°·π«§‘¥‡√◊ËÕß Generation „π¡ÿ¡¡ÕߢÕß™“µ‘ µ–«—πµ°æ∫«à“π—°»÷°…“·æ∑¬åª®í ®ÿ∫π— ´÷ßË Õ¬Ÿ„à π‡®‡πÕ‡√™—πË Y (Millennial Generation; ‡°‘¥√–À«à“ßªï §.». Ò˘¯Ú ÚÛ) ¡’·π«§‘¥∑’·Ë µ°µà“ß®“°Õ“®“√¬å´ß÷Ë Õ¬Ÿ„à π‡®‡πÕ‡√™—πË X (‡°‘¥√–À«à“ßªï §.». Ò˘ˆÒ - Ò˘¯Ò) ·≈–‡®‡πÕ‡√™—Ëπ ‡∫∫’È∫Ÿ¡ (‡°‘¥√–À«à“ßªï §.». Ò˘ÛÙ - Ò˘ˆ) ‚¥¬°“√»÷°…“ ¢Õß Wilson „πªï æ.». ÚııÒÒ æ∫«à“¡’≈—°…≥– ˜ ª√–°“√∑’Ë · ¥ß„Àâ ‡ ÀÁ 𠧫“¡·µ°µà “ ß√–À«à “ ߺŸâ ∑’Ë ‡ °‘ ¥„𠇮‡πÕ‡√™—Ëπ Y °—∫‡®‡πÕ‡√™—ËπÕ◊ËπÊ ‰¥â·°à Ò. Special - ‡®‡πÕ‡√™—Ëπ Y ®—¥‡ªìπ°≈ÿࡧπ∑’Ë¡’ ®”π«π¡“°∑’Ë ÿ¥ ¡’ ÿ¢¿“楒∑’Ë ÿ¥ ·≈–‰¥â√—∫°“√‡≈’ȬߥŸÕ¬à“ß ¥’∑’Ë ÿ¥„πª√–«—µ‘»“ µ√å¢Õß™“«Õ‡¡√‘°—πÚ ‚¥¬æàÕ·¡à¢Õß ‡¥Á°°≈ÿà¡π’ÈÕÿ∑‘»µ—«‡æ◊ËÕ≈Ÿ° ·≈–‡¥Á° à«π„À≠à¡’§«“¡ ÿ¢‡¡◊ËÕ ‰¥â„™â‡«≈“Õ¬Ÿà√à«¡°—∫§√Õ∫§√—«

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

382 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

Ú. Sheltered - ‡®‡πÕ‡√™—Ëπ Y ®—¥‡ªìπ°≈ÿࡧπ ∑’ˉ¥â√—∫°“√‡≈’ȬߥŸ¡“Õ¬à“ߪ°ªÑÕß¡“°∑’Ë ÿ¥„πª√–«—µ‘»“ µ√å ¢Õß™“«Õ‡¡√‘°—πÚ ‡π◊ËÕß®“°æàÕ·¡à à«π„À≠à‡§¬ºà“𧫓¡ ≈”∫“°„π™à«ßÀ≈—ß ß§√“¡‚≈°§√—Èß∑’Ë Ú ®÷ß欓¬“¡¥Ÿ·≈·≈– ª°ªÑÕ߇æ◊ËÕ„Àâ≈Ÿ°‡º™‘≠°—∫§«“¡¬“°≈”∫“°πâÕ¬∑’Ë ÿ¥ Û. Confident - ‡®‡πÕ‡√™—Ëπ Y ‡ªìπ°≈ÿà¡∑’Ë¡’ §«“¡ ÿ¢ ¡—Ëπ„®„πµπ‡Õß ·≈–¡ÕßÕ𓧵„π·ß॒‚¥¬‡©æ“– ‡√◊ÕË ß∞“π–°“√‡ß‘π Ù. Team-oriented - ‡®‡πÕ‡√™—Ëπ Y §ÿâπ‡§°—∫°“√∑”ß“π‡ªìπ°≈ÿ¡à ·≈–¡’∑°— …–„π°“√ª√– “πß“π°—∫ºŸÕâ π◊Ë ®÷߇√’¬π√Ÿâ®“°°“√∑”ß“π√à«¡°—∫ºŸâÕ◊Ëπ‰¥â¥’°«à“°“√‡√’¬π√Ÿâ¥â«µπ‡ÕßÛ ı. Achieving - ‡®‡πÕ‡√™—Ëπ Y ¡’‡ªÑ“À¡“¬¢Õß §«“¡ ”‡√Á®¥â“πÕ“™’æ°“√ß“πµà“ß®“°°≈ÿ¡à Õ◊πË ‚¥¬‡¡◊ÕË ‡∑’¬∫ °—∫‡®‡πÕ‡√™—Ëπ‡∫‡∫’È∫Ÿ¡ ´÷Ëß¡’§«“¡∑–‡¬Õ∑–¬“π·≈–¡’·√ß ¢—∫¥—π®“°¿“¬„𠇮‡πÕ‡√™—Ëπ Y °≈—∫‰¡à π„®‡√◊ËÕ߇À≈à“π’È ·µà ° ≈— ∫‰¥â√—∫Õ‘∑∏‘æ≈®“°·√ß∫—π¥“≈„®¿“¬πÕ°¡“°°«à“ πÕ°®“°π—Èπ¬—ß„À⧫“¡ ”§—≠°—∫·π«‚πâ¡Õ“™’æ∑’Ë®–‰¥â√—∫ §«“¡π‘¬¡„πÕ𓧵·≈–§«“¡™Õ∫ à«πµ—« ·≈–¡Õß«à“°“√ »÷°…“‡ªìπÀπ∑“ßÀπ÷Ëß„π°“√‡¥‘π∑“ß ŸàÕ“™’æ∑’˵âÕß°“√·µà ‰¡à‰¥â‡ªìπ°“√∑”„À⇰‘¥ªí≠≠“À√◊Õ‡ªìπ°“√ªØ‘√Ÿªµ—«‡Õß ˆ. Pressured - ‡π◊ËÕß®“°‡®‡πÕ‡√™—Ëπ Y ‡ÀÁπæàÕ ·¡à¢Õßµπ∑”ß“πÀπ—°·≈–欓¬“¡æ—≤π“µπ‡Õß Ÿà°“√‡ªìπ ºŸâ‡™’ˬ«™“≠„π·µà≈– “¢“ µπ‡Õß®÷ßµâÕß°“√µ—ÈßÀ≈—°ªí°∞“π „À≥⡗Ëπ§ß·≈–‡√Á«∑’Ë ÿ¥ §«“¡°¥¥—ππ’È∑”„À⇮‡πÕ‡√™—Ëπ Y ‰¡à‡§¬Õ¬Ÿπà ß‘Ë ®π‡«≈“„π·µà≈–«—π·∑∫®–‰¡àæÕ„Àâß“π‡ √Á® ·≈– µ—¥ ‘𧫓¡ ”‡√Á®„π°“√‡√’¬π¢Õßµπ‡Õß®“°°“√¡’º≈°“√ ‡√’¬π∑’Ë¥’ ˜. Conventional - §”Œ‘µ¢Õ߇®‡πÕ‡√™—πË Y §◊Õ ç§√Õ∫§√—«é ‡™àπ‡¥’¬«°—∫‡®‡πÕ‡√™—Ëπ‡∫∫’È∫Ÿ¡∑’ËŒ‘µ§”«à“ ç‡Õ‡≈’ˬπé ‡π◊ËÕß®“°‡®‡πÕ‡√™—Ëπ Y À≈“¬§π‡°‘¥„π¬ÿ§∑’Ë¡’ °“√À¬à“√â“ß¡“°·≈–¡Õ߇ÀÁ𧫓¡‡ª√“–∫“ߢÕß ∂“∫—π §√Õ∫§√—« ‡¢“®÷ߪ√“√∂π“®– √â“ߧ√Õ∫§√—«∑’Ë¡—Ëπ§ß‚¥¬‡ªìπ ΩÉ“¬ √â“ߧ«“¡ºŸ°æ—π°—∫æàÕ·¡à·≈–æ’ËπâÕß‚¥¬‡©æ“–°—∫·¡à ¢Õßµπ ‡¡◊ËÕæ‘®“√≥“®“°§«“¡·µ°µà“߇À≈à“π’È °“√®—¥°“√ ‡√’¬π°“√ Õπ®÷ߧ«√µÕ∫ πÕßµàÕ≈—°…≥–¥—ß°≈à“« ‚¥Wilson „πªï æ.». ÚııÒÒ „À⧫“¡‡ÀÁπ«à“Õ“®“√¬å§«√ Õπ‚¥Ò. ¡’‚§√ß √â“ߢÕß«‘™“, ß“π∑’Ë¡Õ∫À¡“¬, ·≈– §«“¡§“¥À«—ßµàÕº≈°“√‡√’¬πÕ¬à“ß™—¥‡®π

Ú. „Àâ‚Õ°“ π—°»÷°…“‰¥â· ¥ß§«“¡§‘¥ √â“ß √√§å, ¡’ à«π√à«¡„π°“√ Õπ·≈–°‘®°√√¡ ·≈–¡’∑“߇≈◊Õ°¡“°¢÷Èπ Û. „À⧫“¡ ”§—≠°—∫ªí≠À“§«“¡‡§√’¬¥ ‡™àπ ¡’ «‘™“∑’˙૬„Àâπ—°»÷°…“‡¢â“„®∑’Ë¡“¢Õߧ«“¡‡§√’¬¥·≈–®—¥°“√ °—∫§«“¡‡§√’¬¥‰¥â, ≈¥‡π◊ÈÕÀ“«‘™“∑’ˉ¡à®”‡ªìπ≈ß„Àâ‡À≈◊Õ·µà À—«¢âÕ∑’˧√Õ∫§≈ÿ¡‡π◊ÈÕÀ“ ”§—≠·≈– π—∫ πÿπ„Àâπ—°»÷°…“ ∑”§«“¡‡¢â“„®À—«¢âÕ‡À≈à“π—ÈπÕ¬à“ß≈÷°´÷Èß¡“°¢÷Èπ, ‡√’¬π‡ªìπ «‘™“¬àÕ¬Ê, ¬◊¥À¬ÿàπ«—π°”Àπ¥ àßß“π„Àâ¡“°¢÷Èπ, ¡’°“√ «“ß·ºπ®—¥°“√°—∫ª√‘¡“≥ß“π‰¥â≈à«ßÀπâ“, ¡’√–∫∫µ√«® Õ∫º≈°“√‡√’¬π¥â«¬µπ‡Õß ‡™àπ ºà“π√–∫∫ÕÕπ‰≈πå, ·≈– ®—¥°“√‡√’¬π°“√ Õπ„Àâ§≈⓬§≈÷ß°—∫°“√‡≈àπ‡°¡ §◊Õ‰¥â√—∫ §«“¡√Ÿâ, √Ÿâ ÷°ºàÕπ§≈“¬, ¡’°“√ªÑÕπ°≈—∫ (feedback) ·≈– ‰¥â√—∫º≈µÕ∫·∑π∑—π∑’ Ù. „Àâπ—°»÷°…“‡¢â“√à«¡™—Èπ‡√’¬π«‘™“∫—ߧ—∫∑’Ë°≈à“« ∂÷ß®√‘¬∏√√¡ ‡™àπ ∑”§«“¡‡¢â“„®∂÷ß∑’¡Ë “·≈–∑’‰Ë ª¢Õß®√‘¬∏√√¡, ≈¥°“√·®°‡°√¥Õ¬à“ßøÿÑ߇øÑÕ‚¥¬®”°—¥®”π«π‡°√¥ A ·≈â« À—π‰ª„À⧫“¡ ”§—≠°—∫°“√Ωñ°∑—°…–¡“°¢÷Èπ ·≈–µàÕµâ“π «—≤π∏√√¡°“√‚°ß Thielfoldt „πªï æ.». ÚıÙ˜Ù ¡’§«“¡‡ÀÁπ«à“ ª√–™“°√„π‡®‡πÕ‡√™—Ëπ Y ¡’≈—°…≥– ”§—≠ ‰¥â·°à ™◊Ëπ™¡„π §«“¡À≈“°À≈“¬, ¡Õß‚≈°„π·ß॒·≈–µ“¡§«“¡‡ªìπ®√‘ß, ¡’ §«“¡§‘¥ √â“ß √√§å·≈–™Õ∫∑”„π ‘Ëß∑’ˉ¡à‡À¡◊Õπ„§√, ™Õ∫ ª√—∫ª√ÿ߰Ƈ°≥±å‡ ’¬„À¡à, ‰¡à¬¥÷ µ‘¥°—∫ ∂“∫—π, „™âÕπ‘ ‡∑Õ√å‡πÁµ §≈àÕß·§≈à«, ‡™◊ËÕ¡—Ëπ„π‡∑§‚π‚≈¬’, ∑”ß“πÀ≈“¬Õ¬à“߉¥â Õ¬à“ß√«¥‡√Á« ·≈–¡’§√Õ∫§√—«‡ªìπ‡æ◊ËÕπ ¥—ßπ—Èπ°“√®—¥°“√ ‡√’¬π°“√ Õπ ”À√—∫‡®‡πÕ‡√™—Ëπ Y ®÷ߧ«√¡’≈—°…≥– ‰¥â·°à √â “ ß ¿“æ·«¥≈â Õ ¡∑’Ë ¡’ ‚ §√ß √â “ ß™— ¥ ‡®π·≈–∑”ß“π‚¥‡°◊ÈÕ°Ÿ≈°—π „Àâß“π‚¥¬§”π÷ß∂÷ߧ«“¡·µ°µà“ß√–À«à“ß∫ÿ§§≈, Õ“®“√¬å · ≈–π— ° »÷ ° …“¡’ ª Ø‘ — ¡ æ— π ∏å ´÷Ë ß °— π ·≈–°— π ·≈– Õ“®“√¬å§«√‡µ√’¬¡√—∫¡◊Õ°—∫°“√‡√’¬°√âÕß®“°π—°»÷°…“·≈– §«“¡§“¥À«—ß∑’Ë Ÿß¢÷Èπ¥â«¬

Personality differences ®“°·π«§‘¥‡√◊ËÕ߇®‡πÕ‡√™—Ëπ Y æ∫«à“π—°»÷°…“ ·æ∑¬å„πªí®®ÿ∫—π¡’§«“¡‡ªìπµ—«¢Õßµ—«‡Õß¡“°¢÷Èπ ¥—ßπ—Èπ °“√‡√’¬π®÷ߧ«√§”π÷ß∂÷ߧ«“¡·µ°µà“ß√–À«à“ß∫ÿ§§≈‡ ¡Õ ´÷Ë ß„π§≥–·æ∑¬»“ µ√å¡’π—°»÷°…“∑’Ë√–¥—∫ µ‘ªí≠ ≠“„°≈â ‡§’¬ß°—π¡“° ¥—ßπ—È𧫓¡·µ°µà“ß∑’Ë™—¥‡®π¡“°°«à“®÷߇ªì𠧫“¡·µ°µà“ߢÕß∫ÿ§≈‘°¿“æ Àπ÷Ëß„π∑ƒ…Æ’∫ÿ§≈‘°¿“æ∑’Ë ‡ªìπ∑’Ë√Ÿâ®—°°«â“ߢ«“ß∑’Ë ÿ¥„π‚≈°§◊Õ∑ƒ…Æ’‰∑ªá¢Õߧ“√å≈ ®ÿß (C. G. Jungûs personality type theory)ı ´÷Ë߉¥â√—∫°“√ æ—≤π“„Àâ∑”§«“¡‡¢â“„®‰¥âß“à ¬¢÷πÈ ‚¥¬ Briggs ·≈– Myersˆ,˜

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

À≈—°°“√ª√–‡¡‘π∫ÿ§≈‘°¿“浓¡∑ƒ…Æ’‰∑ªá (Personality Type Indicator) §◊Õ °“√·∫àߧ«“¡∂π—¥∑“ß ∫ÿ§≈‘°¿“æ (preferences) ÕÕ°‡ªìπ Ù §Ÿà (dichotomies) ∫àß∫Õ°∂÷ß·π«‚πâ¡°“√„™âæ≈—ßß“π, §«“¡∂𗥄π°“√√—∫√Ÿâ ¢âÕ¡Ÿ≈„À¡à, §«“¡∂𗥄π°“√ª√–¡«≈º≈¢âÕ¡Ÿ≈ ·≈–«‘∂’

383

™’«‘µ∑’Ë∂π—¥ (µ“√“ß∑’Ë Ò) ‚¥¬·µà≈–§π®–¡’§«“¡∂π—¥Õ¬à“ß „¥Õ¬à“ßÀπ÷ßË „π·µà≈–§Ÿà ¥—ßπ—πÈ ‡¡◊ÕË ª√–‡¡‘π·≈â«®–∑√“∫√À— ‰∑ªá (Type codes) ‡ªìπÕ—°…√ Ù µ—«∫àß∫Õ°∂÷߉∑ªá (Type) À√◊Õ∫ÿ§≈‘°¿“æ¢Õ߇√“µ“¡∑ƒ…Æ’‰∑ªá ´÷Ëß “¡“√∂„™â„π°“√ æ—≤π“«ÿ≤‘¿“«–∑“ßÕ“√¡≥å·≈– —ߧ¡

µ“√“ß∑’Ë Ò The basic model of mental preferences Mental preferences

√À— ‰∑ªá (Type codes) ·≈–≈—°…≥–∫ÿ§≈‘°¿“æ

E (Extraverted) I (Introverted) ● ∂π—¥°“√¥÷ßæ≈—ßß“πÕÕ°¡“®“° ‘Ëß∑’ËÕ¬Ÿà√Õ∫µ—« ● ∂π—¥°“√¥÷ßæ≈—ßß“πÕÕ°¡“®“° ‘Ëß∑’ËÕ¬Ÿà¿“¬„πµ—« ®÷ß¡—°‡¢â“À“ºŸâ§πÀ√◊Õ ‘ËßÕ◊ËπÊ √Õ∫µ—«‡æ◊ËÕ„Àâ√Ÿâ ÷° ®÷ß¡—°µâÕß°“√ 燫≈“ à«πµ—«é ¡“°‡æ◊ËÕÕ¬ŸàÕ¬à“ß °√–©—∫°√–‡©ß¢÷πÈ ß∫·≈–™“√åµæ≈—ßß“π ● ∑”°àÕ𠧑¥∑’À≈—ß ● §‘¥°àÕπ ·≈⫧àÕ¬∑” ·π«‚πâ¡°“√„™âæ≈—ßß“π ● √Ÿâ ÷°‡ª≈à“‡ª≈’ˬ«∂⓵âÕß∂Ÿ°µ—¥¢“¥®“°°“√¡’ ● √Ÿâ ÷°‡Àπ◊Õ Ë ¬·≈–À¡¥·√ß∂Ⓣ¡à¡’‡«≈“‡ªìπ à«πµ—« ªØ‘ —¡æ—π∏åÀ√◊Õæ∫ª–°—∫§πÕ◊Ëπ ‡æ’¬ßæÕ ”À√—∫§‘¥·≈–‰µ√àµ√Õß ● ‡ªî¥°«â“ßµàÕ§πÕ◊ËπÀ√◊Õ ‘ËßÕ◊ËπÊ ∑’ˇ¢â“¡“À“ ● ‰¡à§àÕ¬µÕ∫√—∫§πÀ√◊Õ ‘Ëßµà“ßÊ ∑’ˇ¢â“¡“À“ ‡°‘¥ ‡°‘¥·√ß∫—π¥“≈„®‰¥âßà“¬®“° ‘Ëß√Õ∫µ—« ·√ß∫—π¥“≈„®‰¥â≈÷°Ê ¿“¬„π ● ¡’§«“¡ ÿ¢°—∫§«“¡ —¡æ—π∏åÀ≈“°À≈“¬√Ÿª·∫∫ ● ™Õ∫°“√ ◊Õ Ë “√·∫∫µ—«µàÕµ—«·≈–§«“¡ —¡æ—π∏å ·≈–§«“¡‡ª≈’ˬπ·ª≈ß∑’ˇ°‘¥¢÷Èπ ·∫∫æ‘®“√≥“‡ªìπ√“¬Ê ‰ª S (Sensing) N (Intuitive) ● ¡’„®®¥®àÕÕ¬Ÿà°—∫ çªí®®ÿ∫—πé ·≈–æ‘®“√≥“∂÷ß ● ¡’„®®¥®àÕÕ¬Ÿ° à —∫ çÕπ“§µé ·≈–æ‘®“√≥“∂÷ß §«“¡‡ªìπ®√‘ß„πªí®®ÿ∫—𠧫“¡‡ªìπ‰ª‰¥â„πÕ𓧵 ● „™âª√– ∫°“√≥å∑’ˇ§¬‰¥â√—∫ºà“πª√– “∑ —¡º— ● „™â®‘πµπ“°“√§‘¥ ‘Ëß∑’Ëπà“®–‡ªìπ‰ª‰¥â¢÷Èπ¡“™à«∑—ÈßÀâ“„π°“√‡√’¬π√Ÿâ „π°“√‡√’¬π√Ÿâ §«“¡∂𗥄π°“√√—∫√Ÿâ¢âÕ¡Ÿ≈„À¡à ● √â“ß ‘Ëß„À¡àÊ ¢÷Èπ∫π√“°∞“π¢Õߪ√– ∫°“√≥å ● √â“ß ‘Ëß„À¡àÊ ¢÷Èπ∫π√“°∞“π¢Õߧ«“¡‡¢â“„®„π „πÕ¥’µ ∑ƒ…Æ’ ● “¡“√∂¥÷ߧ«“¡∑√ß®”¢÷Èπ¡“‡ªìπ¢âÕ¡Ÿ≈∑’Ë ● “¡“√∂¥÷ߧ«“¡∑√ß®”¢÷π È ¡“‡ªìπÀ≈—°°“√§√à“«Ê, ‡∑’ˬߵ√ß·≈–¡’√“¬≈–‡Õ’¬¥¡“° ∫√‘∫∑∑’ËÕ¬Ÿà√Õ∫Ê, À√◊Õ§«“¡‡™◊ËÕ¡‚¬ß ● ™Õ∫§«“¡™—¥‡®π, ¢âÕ¡Ÿ≈∑’ˇªìπ√Ÿª∏√√¡, ‰¡à™Õ∫ ● ™Õ∫ ‘Ëß∑’ˬ—ߧ≈ÿ¡‡§√◊Õ, ‰¡à¡’¢âÕ¡Ÿ≈™—¥‡®π À√◊Õ °“√§“¥‡¥“„π ‘Ëß∑’ˉ¡à¡’¡Ÿ≈ µâÕߧ“¥‡¥“§«“¡À¡“¬‡Õß T (Thinking) F (Feeling) ● ™Õ∫ √ÿª ‘Ëßµà“ßÊ ¥â«¬°“√ 科¥é ´÷Ë߇°‘¥®“° ● ™Õ∫ √ÿª ‘ß Ë µà“ßÊ ¥â«¬°“√ ç√Ÿ â °÷ é ´÷ßË ‡°‘¥®“°°“√ °“√∑”§«“¡‡¢â“„®®ÿ¥ª√– ߧå¢Õßß“π, „™â‡Àµÿ ∑”§«“¡‡¢â“„®¿“æ°«â“ßÊ ¢Õßß“π, „™â ≠ — ™“µ≠“≥, ·≈–º≈, §‘¥«‘‡§√“–ÀåÕ¬à“߇ªìπ√–∫∫ ¡ÿßà ‡πâπ„Àâ∑°ÿ ΩÉ“¬°≈¡‡°≈’¬« ·≈–‰¥âª√–‚¬™πå√«à ¡°—π ● §âπÀ“§«“¡®√‘ßÀ√◊ÕÕπÿ¡“πµ“¡‡Àµÿ·≈–º≈∑’§ Ë «√ ● „™â§«“¡√Ÿâ ÷° à«πµ—«À√◊Õ —߇°µº≈°√–∑∫µàÕ§π §«“¡∂π— ¥„π°“√ª√–¡«≈º≈ ®–‡ªìπ‡æ◊ËÕ„™â„π°“√µ—¥ ‘π„® Õ◊Ëπ‡æ◊ËÕ„™â„π°“√µ—¥ ‘π„® ¢âÕ¡Ÿ≈ ● ¡—°§‘¥∑” ‘Ëß„¥‚¥¬¡ÿàߺ≈ ”‡√Á®¢Õßß“πÀ√◊Õ°“√ ● ¡—°ÕàÕπ‰À«À√◊Õ§≈âÕ¬µ“¡ªØ‘°√ ‘ ¬‘ “À√◊Õ§«“¡µâÕß ∫√√≈ÿ«—µ∂ÿª√– ß§å °“√¢Õߧπ√Õ∫¢â“ß ● ™”π“≠°“√∑”ß“πµ“¡«—µ∂ÿª√– ߧåÀ√◊Õ§‘¥«‘‡§√“–Àå ● ™”π“≠°“√∑”ß“π‡æ◊Õ Ë „Àâ∑°ÿ §π‡¢â“„®°—π·≈–· ¥ß Õ¬à“߇ªìπ√–∫∫ §«“¡‡ÀÁπ∑’Ë∑ÿ°§π¡—°‡ÀÁπ¥â«● ¬Õ¡√—∫«à“§«“¡¢—¥·¬â߇ªìπ‡√◊Õ Ë ß∏√√¡™“µ‘·≈–‡ªìπ ● ‰¡à ∫“¬„®‡¡◊ËÕæ∫§«“¡¢—¥·¬âß ∂â“æ∫§«“¡‰¡à à«πÀπ÷ËߢÕߧ«“¡ —¡æ—π∏å∑’ˇ°‘¥¢÷Èπ‰¥â ≈ß√Õ¬°—π®–√Ÿâ ÷°Õ÷¥Õ—¥¢÷Èπ¡“∑—π∑’

384 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

µ“√“ß∑’Ë Ò The basic model of mental preferences (µàÕ) Mental preferences

√À— ‰∑ªá (Type codes) ·≈–≈—°…≥–∫ÿ§≈‘°¿“æ

J (Judging) ¬÷¥∂◊Õ°“√µ—¥ ‘π„®¢Õßµπ‡ªìπ∑’˵—Èß ● «“ß·ºπÕ¬à“ß≈–‡Õ’¬¥≈à«ßÀπâ“°àÕπ≈ß¡◊Õ∑” ● ¡’ ¡“∏‘°—∫ß“π∑’Ë∑”Õ¬Ÿàµ√ßÀπâ“ «‘∂’°“√¥”‡π‘π™’«‘µ (lifestyle) ● µâÕß∑”ß“π„À⇠√Á®∑’≈–Õ¬à“ß®÷ß®– “¡“√∂∑”ß“π ∑’Ë∂π—¥ µàÕ‰ª‰¥â ● ÕàÕπ‰À«µàÕ deadline ∂⓬—߉¡à∂÷ß°”Àπ¥ àß®– ∑”ß“π‰¥â¥’∑’Ë ÿ¥·≈–‰¡à‡§√’¬¥ ● ¡—°¥”‡π‘π™’«‘µµ“¡‡ªÑ“À¡“¬, °”Àπ¥ àß ·≈– µ“√“߇«≈“ ●

„π°“√‡√’¬πæ∫«à“°“√ª√–‡¡‘π∫ÿ§≈‘°¿“æ¡’§«“¡ ”§—≠Õ¬à“ß¡“°µàÕ∑—ßÈ Õ“®“√¬å·≈–π—°‡√’¬π ‚¥¬¡À“«‘∑¬“≈—·Ààß√—∞®Õ√凮’¬‰¥â ÕπÀ≈—° Ÿµ√°“√ª√–‡¡‘π∫ÿ§≈‘°¿“浓¡ ∑ƒ…Æ’‰∑ªá„Àâ°—∫π—°»÷°…“√–¥—∫ª√‘≠≠“‚∑ “¢“§√ÿ»“ µ√å ‡æ◊Ë Õ„Àâ∑”§«“¡‡¢â“√Ÿª·∫∫°“√‡√’¬π√Ÿâ¢Õßπ—°‡√’¬πª√–‡¿∑ µà“ßÊ ·≈–‡æ◊ËÕ„ÀâÕ“®“√¬å “¡“√∂®—¥°“√‡√’¬π°“√ Õπ∑’Ë ‡À¡“– ¡°—∫π—°‡√’¬π·µà≈–§π„À≥⡓°∑’Ë ÿ¥ πÕ°®“°π—Èπ ¬—ß·π–π”‡∑§π‘§°“√‡√’¬π„À≥⇵Á¡ª√– ‘∑∏‘¿“æ¢Õßπ—°‡√’¬π ‰∑ªáµà“ßÊ ¥â«¬˘ πÕ°®“°π—Èπ¬—ß “¡“√∂„™â§âπÀ“√Ÿª·∫∫ °“√‡√’¬π√Ÿâ (learning style) „ππ—°»÷°…“√–¥—∫Õÿ¥¡»÷°…“ ´÷Ë߇ªìπ∑—°…–∑’Ë ”§—≠∑’Ë ÿ¥„π°“√‡√’¬π√Ÿâ√–¥—∫ Ÿß‰¥â‡™àπ°—π¯ „π‰∑¬¡’°“√»÷°…“‚¥¬√Õß»“ µ√“®“√¬å ¥√.»√’‡√◊Õπ ·°â«°—ß«“≈ „πªï æ.». ÚıÙıÒ ‚¥¬„™â·∫∫ª√–‡¡‘π MBTI (Myers-Briggs Type Indicators) ‡æ◊ËÕ»÷°…“≈—°…≥– ∫ÿ§≈‘°¿“æ¢Õßπ—°»÷°…“ ˆ “¢“Õ“™’æ√«¡∂÷ßπ—°»÷°…“·æ∑¬å æ∫«à“ à«π„À≠àπ—°»÷°…“·æ∑¬å¡’∫ÿ§≈‘°¿“æ·∫∫ INFJ, INFP, ·≈– ISFP ¡“°∑’Ë ÿ¥µ“¡≈”¥—∫ (√âÕ¬≈– Ûı.Ù˜, Òı.ˆ˘ ·≈– Òı.ÛÛ) à«π„À≠à‡ªìπ Introverts ´÷Ëß∂π—¥ °“√‡√’¬π√Ÿâ¥â«¬µπ‡Õß (√âÕ¬≈– ¯ˆ.Ú˜) §«“¡∂𗥄π°“√ ‡√’¬π√Ÿâ ‘Ëß„À¡àÊ æ∫«à“ Sensings ´÷Ëß∂π—¥°“√‡√’¬πºà“π ª√– “∑ —¡º— ∑—Èß ı ·≈–‡πâπ°“√𔉪„™â‰¥â®√‘ßæ∫√âÕ¬≈– Ù¯.¯Ù „°≈⇧’¬ß°—∫ Intuitions (√âÕ¬≈– ıÒ.Òˆ) ´÷Ëß ∂π—¥°“√‡√’¬π‚¥¬ √â“ß°√Õ∫§«“¡§‘¥·≈–§”π÷ß∂÷ߧ«“¡ ‡ªìπ‰ª‰¥â„πÕ𓧵 à«π°“√ª√–¡«≈º≈§«“¡§‘¥·≈–°“√ µ—¥ ‘π„®æ∫«à“ à«π„À≠à‡ªìπ Feelings (√âÕ¬≈– ˜˜.Ò¯) ´÷ßË ∂π—¥°“√µ—¥ ‘π„®‚¥¬§”π÷ß∂÷ߧà“π‘¬¡ à«π∫ÿ§§≈·≈–§«“¡ ª√ÕߥÕß „π√–À«à“ß∑’Ë Thinkings æ∫√âÕ¬≈– ÚÚ.¯Ú ´÷Ëß

P (Perceiving) ● ¬◊¥À¬ÿàπ·≈–ª√—∫‡ª≈’ˬπ‰¥âµ“¡ ∂“π°“√≥å ● ≈ß¡◊Õ∑”‰ª‡≈¬·≈⫧àÕ¬«“ß·ºπ¢≥–∑”À√◊ÕÀ≈—ß ®“°∑”‰ª∫â“ß·≈â« ● ∑”ß“π‰ª¥â«¬‡≈àπ‰ª¥â«¬‰¥â ● ™Õ∫∑”ß“πÀ≈“¬Ê Õ¬à“ßæ√âÕ¡°—π‡æ◊ËÕ‰¡à„Àâ‡∫◊ËÕ ● ¡’¿Ÿ¡‘µâ“π∑“πµàÕ deadline ®–∑”ß“π‰¥â¥’∑’Ë ÿ¥ ‡¡◊ËÕ„°≈â∂÷ß°”Àπ¥ àß¡“°Ê ● ¡—°À≈’°‡≈’ˬßß“π∑’ˉ¡à¬◊¥À¬ÿàπ, ¢“¥Õ‘ √– À√◊Õ‰¡à À≈“°À≈“¬

‡ªìπ°≈ÿà¡∑’˵—¥ ‘π„®‚¥¬„™â‡Àµÿ·≈–º≈‡ªìπÀ≈—° „πªï æ.». ÚııÛ ¡’°“√ ”√«®∫ÿ§≈‘°¿“æ„ππ—°»÷°…“·æ∑¬å™—Èπªï∑’Ë Ù °àÕπ‡ªî¥¿“§‡√’¬π„π¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å®”π«π ¯ §π (√âÕ¬≈– Ò) ‚¥¬«‘π∑‘ √“ π«≈≈–ÕÕß æ∫«à“π—°»÷°…“·æ∑¬å à«π„À≠à¡’∫ÿ§≈‘°¿“æ·∫∫ ISFJ, INFJ, ·≈– ESFJ ¡“° ∑’Ë ÿ¥ (√âÕ¬≈– Ò˜.ı, ÒÛ.˜ı ·≈– ÒÚ.ı µ“¡≈”¥—∫) à«π„À≠à‡ªìπ Introverts, ·≈– Feelings (√âÕ¬≈– ˆı ·≈– ˜Ú.ı µ“¡≈”¥—∫) ‡™àπ‡¥’¬«°—∫ß“π«‘®—¬„πÕ¥’µ´÷Ëßæ∫ √âÕ¬≈– ¯ˆ.Ú˜ ·≈– ˜˜.Ò¯ µ“¡≈”¥—∫ à«π Sensings æ∫¡“°°«à“ Intuitions ‡ªìπÕ—µ√“ à«π Ú:Ò µà“ß®“°°“√ »÷°…“„πÕ¥’µ´÷Ëß„°≈⇧’¬ß°—π à«π∫ÿ§≈‘°¿“æ∑’ˉ¡àæ∫‡≈¬„π π—°»÷°…“·æ∑¬å®“°°“√»÷°…“∑—Èß Õß ‰¥â·°à ENTJ ·≈– ENTP ®“°º≈°“√»÷°…“¥—ß°≈à“« √ÿª‰¥â«à“ Ò) π—°»÷°…“ ·æ∑¬å„πªí®®ÿ∫—π·¡â à«π„À≠à¡’§«“¡∂𗥄π°“√„™âæ≈—ßß“π ·∫∫ Introverts ´÷Ëß∂π—¥°“√‡√’¬π√Ÿâ¥â«¬µπ‡Õß ·µà·π«‚πâ¡ ¢Õßπ—°»÷°…“·∫∫ Extroverts ´÷Ëß∂π—¥°“√‡√’¬π√Ÿâ‚¥¬¡’ ªØ‘ —¡æ—π∏å°—∫ºŸâÕ◊Ë𠇙àπ ‡æ◊ËÕπ, ºŸâªÉ«¬ À√◊ÕÕ“®“√¬å ¡’·π« ‚πâ¡ Ÿß¢÷Èπª√–¡“≥‡∑à“µ—« ·≈–‡¡◊ËÕæ‘®“√≥“√à«¡°—∫·π«§‘¥ ‡√◊ËÕ߇®‡πÕ‡√™—Ëπ Y æ∫«à“®–¡’·π«‚πâ¡ Ÿß¢÷Èπ‡√◊ËÕ¬Ê ‰ªÕ’° ª√–¡“≥ Òı ªï ®π ‘Èπ ÿ¥π—°»÷°…“·æ∑¬å„π‡®‡πÕ‡√™—Ëππ’È Ú) §«“¡∂𗥄π°“√‡√’¬π√Ÿâ ‘Ëß„À¡àÊ æ∫«à“¡’·π«‚π⡇ªìπ Sensings ‡æ‘Ë¡¢÷Èπ ¥—ßπ—Èπ°“√®—¥°“√‡√’¬π°“√ Õπ∑’ˇÀ¡“– °— ∫ π— ° »÷ ° …“„πªí ® ®ÿ ∫— π §◊ Õ ‡æ‘Ë ¡ ‡π◊È Õ À“‡°’Ë ¬ «°— ∫ °“√𔉪 ª√–¬ÿ ° µå „ ™â „ π™’ «‘ µ ®√‘ ß ·≈– π— ∫ πÿ π„Àâ ¡’ ° “√‡√’ ¬ π√Ÿâ ºà “ π ª√– “∑ —¡º— ‡™àπ °“√Ωñ°ªØ‘∫—µ‘„Àâ¡“°¢÷Èπ‡¡◊ËÕ‡ª√’¬∫ ‡∑’¬∫°—∫°“√ π—∫ πÿπ°“√‡√’¬π√Ÿâºà“π°“√ Õπ·∫∫∫√√¬“¬

385

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

À√◊ Õ Õà “ πÀπ— ß ◊ Õ ¥â « ¬µπ‡Õß´÷Ë ß ‡ªì 𠧫“¡∂π— ¥ ¢Õß°≈ÿà ¡ Intuitions˘,ÒÒ,ÒÚ ·≈– Û) §«“¡∂𗥄π°“√ª√–¡«≈º≈ §«“¡§‘¥·≈–µ—¥ ‘π„®æ∫«à“ à«π„À≠à‡ªìπ Feelings ¡“°°«à“ Thinkings °«à“‡∑à“µ—«‡™àπ‡¥’¬«°—∫„πÕ¥’µ · ¥ß„Àâ‡ÀÁπ«à“ °“√‡√’¬π√Ÿ„â π§≥–·æ∑¬»“ µ√å “¡“√∂À≈àÕÀ≈Õ¡„Àâπ°— »÷°…“ à«π„À≠৔π÷ß∂÷ߧ«“¡µâÕß°“√¢ÕߺŸâ§π‡ªìπÀ≈—°´÷Ë߇ªìπ §ÿ≥ ¡∫—µ‘¢Õß·æ∑¬å∑’Ë¡’§«“¡‡¡µµ“ à«π°≈ÿà¡πâÕ¬´÷Ëß∂π—¥ „π°“√µ—¥ ‘π„®‚¥¬¬÷¥‡Àµÿ·≈–º≈‡ªìπÀ≈—°°Á¡’§«“¡‡¡µµ“ ‰¥â‡™àπ°—π·µà‚¥¥‡¥àπ„π°“√§‘¥Õ¬à“߇ªìπ√–∫∫´÷Ëß “¡“√∂ √â“ßß“π«‘®—¬·≈–π«—µ°√√¡„À¡àÊ „Àâ«ß°“√·æ∑¬å‰¥â ¥—ßπ—Èπ ·π«∑“ßæ—≤π“§◊Õ π—∫ πÿπ„Àâπ°— »÷°…“·æ∑¬å°≈ÿ¡à Feelings ‰¥â‡√’¬π«‘∏°’ “√§‘¥Õ¬à“߇ªìπ√–∫∫¡“°¢÷πÈ „π√–À«à“ß∑’ Ë π—∫ πÿπ „Àâπ—°»÷°…“·æ∑¬å°≈ÿà¡ Thinkings ¡’‚Õ°“ ‡√’¬π√Ÿâ∑—°…– °“√ ◊ËÕ “√·≈–°“√‡¢â“„®®‘µ„®¢ÕߺŸâÕ◊Ëπ„Àâ¡“°¢÷Èπ Õ¬à“߉√ °Áµ“¡∫ÿ§≈‘°¿“æ·∫∫ ENTJ ·≈– ENTP ´÷ßË ‡ªìπ∫ÿ§≈‘°¿“æ ¢ÕߺŸâ π”‚¥¬∏√√¡™“µ‘‰¡àæ∫„ππ—°»÷°…“·æ∑¬å‡≈¬ §≥– ·æ∑¬»“ µ√åÕ“® π—∫ πÿπ„Àâπ°— »÷°…“°≈ÿ¡à Thinkings ·≈– Intuitions æ—≤π“µπ‡Õߢ÷Èπ‡ªìπ∫ÿ§≈‘°¿“æ∑—Èß Õß·∫∫π’ȉ¥â ‚¥¬°“√æ—≤𓧫“¡‡ªìπ Extraverts ´÷Ëß∂π—¥°“√‡¢â“ —ߧ¡ ·≈–¡’ªØ‘ ¡— æ—π∏å°∫— ºŸÕâ π◊Ë ‚¥¬°“√ π—∫ πÿπ°“√‡√’¬π·∫∫°≈ÿ¡à À√◊Õ°“√∑”°‘®°√√¡√–À«à“ߧ≥–„Àâ¡“°¢÷Èπ πÕ°®“°π—ÈπÕ“® ª√—∫‡ª≈’ˬπ«‘∂’™’«‘µ¢Õßπ—°»÷°…“°≈ÿà¡ Judgings (√âÕ¬≈– ˆÛ.˜ı) ´÷ËßµâÕß«“ß·ºπ≈à«ßÀπⓇ ¡Õ„ÀâΩñ°°“√·°âªí≠À“ ‡©æ“–Àπâ“·≈–¬◊¥À¬ÿàπ¡“°¢÷È𠇙àπ ‡æ‘Ë¡‡µ‘¡°“√‡√’¬π°“√ Õπ∑’ˇπâπ°“√·°â‰¢ªí≠À“ À√◊Õ Õ𧫓¡√Ÿâ∑’˪√“°Ø„π «“√ “√«‘™“°“√„À¡àÊ πÕ°‡Àπ◊Õ®“°°“√ Õπ‡©æ“–‡π◊ÈÕÀ“ „πµ”√“ ‡ªìπµâπ à«π«‘∂™’ «’ µ‘ ¢Õßπ—°»÷°…“°≈ÿ¡à Perceivings (√âÕ¬≈– Ûˆ.Úı) ´÷Ëß¡—°‰¡à«“ß·ºπ≈à«ßÀπâ“·≈–ª≈àÕ¬„Àâ ™’«‘µ¥”‡π‘π‰ªµ“¡∑’ˇªìπÕ“®À—π¡“Ωñ°°“√«“ß·ºπ≈à«ßÀπâ“ ∫â“ß “¡“√∂∑”‰¥â‚¥¬°”À𥇫≈“ àßß“π‡ªìπ√–¬–·≈–¡’ °“√µ‘¥µ“¡§«“¡°â“«Àπâ“Õ¬à“ß ¡Ë”‡ ¡Õ À√◊Õ°”Àπ¥„Àâ Õà“πÀ—«¢âÕ∑’˵âÕ߇√’¬π¡“°àÕπ≈à«ßÀπâ“·≈â«π”¡“Õ¿‘ª√“¬„π ÀâÕ߇√’¬π ‡ªìπµâπÒÒ,ÒÚ

√ÿª °“√®—¥°“√‡√’¬π°“√ Õπ„Àâπ—°»÷°…“·æ∑¬å¬ÿ§„À¡à ‡ªì𧫓¡∑â“∑“¬¢ÕßÕ“®“√¬åÕ¬à“ß¡“° §«“¡·µ°µà“ߢÕß ‡®‡πÕ‡√™—πË ∑”„ÀâÕ“®“√¬å·≈–π—°»÷°…“·æ∑¬å¡§’ “à π‘¬¡µà“ß°—π àߺ≈„À⧫“¡§“¥À«—ߢÕßÕ“®“√¬åÕ“®‰¡àµ√ß°—∫§«“¡‡ªìπ®√‘ß ‡™à𠧓¥À«—ß«à“π—°»÷°…“·æ∑¬å∑’Ë¥’§◊Õ§π∑’˵—Èß„®‡√’¬πÕ¬à“ß Àπ—°·≈–∑”§–·ππ‰¥â¡“° ·µà„𧫓¡‡ªìπ®√‘ß ‘ßË ∑’πË °— »÷°…“

„π‡®‡πÕ‡√™—Ë π Y µâ Õ ß°“√‰¡à „ ™à ° “√‡¢â “„®§«“¡√Ÿâ Õ ¬à “ ß ∂àÕß·∑âÀ√◊Õ‡ªìπºŸâ‡™’ˬ«™“≠‡©æ“– “¢“ ·µàµâÕß°“√‡ªìπ ·æ∑¬å∑’Ë “¡“√∂¥Ÿ·≈ºŸâªÉ«¬‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ®÷ߧ“¥ À«—ß«à“Õ“®“√¬å®–™◊Ëπ™¡§π∑’Ë¡’§«“¡√—∫º‘¥™Õ∫µàÕ°“√‡√’¬π ¡“°°«à“§π∑’ˉ¥â‡°√¥ A πÕ°®“°π—È𧫓¡·µ°µà“ߢÕß ∫ÿ§≈‘°¿“æ°Á¡’º≈µàÕ§«“¡§“¥À«—ߥ⫬ ‡™àπ Õ“®“√¬å§“¥ À«—ß«à“π—°»÷°…“§«√∑”§«“¡‡¢â“„®‡π◊ÈÕÀ“‰¥â®“°°“√∫√√¬“„πÀâÕ߇√’¬π ·µà®“°·π«‚πâ¡π—°»÷°…“∑’Ë∂π—¥°“√‡√’¬π√Ÿâ·∫∫ Sensings ¡“°¢÷Èπ∑”„Àâ∑√“∫«à“π—°»÷°…“·æ∑¬å¡’·π«‚πâ¡ ∑”§«“¡‡¢â“„®‡π◊ÈÕÀ“‰¥â®“°°“√‡√’¬π·∫∫ª√–¬ÿ°µå‡æ◊ËÕ𔉪 „™â‰¥â®√‘ß·≈–°“√‡√’¬π¿“§ªØ‘∫—µ‘¡“°¢÷È𠇪ìπµâπ À“° Õ“®“√¬å„π§≥–·æ∑¬»“ µ√å¡Õ߇ÀÁπ·π«‚πâ¡¢Õßπ—°»÷°…“ ·æ∑¬å¬ÿ§„À¡àÕ¬à“ß™—¥‡®π·≈â« °“√®—¥°“√‡√’¬π°“√ Õπ ¬à Õ ¡ π— ∫ πÿ π„Àâ π— ° »÷ ° …“ “¡“√∂‡√’ ¬ π√Ÿâ ‰ ¥â Õ ¬à “ ߇µÁ ¡ ª√– ‘∑∏‘¿“æ·≈–™à«¬„À⧫“¡ —¡æ—π∏å√–À«à“ßÕ“®“√¬å°—∫ π—°»÷°…“¥’¢÷ÈπÕ¬à“ß¡“°¥â«¬

‡Õ° “√Õâ“ßÕ‘ß Ò. Wilson M, Gerber LE. How Generational Theory Can Improve Teaching: Strategies for Working with the çMillennialsé. Currents in Teaching and Learning. 2008 Fall;1:29-44. Ú. Strauss W, Howe N. Millennials rising: The next great generation. New York: Vintage Books; 2000. Û. Twenge J. Generation me: Why todayûs young Americans are more confident, assertive, entitled-and more miserable than ever before.

New York: Free Press; 2006. Ù. Thielfoldt D, Scheef D. Generation X and The Millennials: What You Need to Know About Mentoring the New Generations [Internet]. 2004 Aug [cited 2010 May 18];Available from: http:// www.abanet.org/lpm/lpt/articles/mgt08044.html ı. Jung CG. Psychological Types. New Jersey: Princeton University Press; 1971. ˆ. Myers IB. Manual: The Myers-Briggs Type Indicator. Consulting Psychologists Press; 1962. ˜. Myers IB, McCaulley MH. Manual: A Guide to the Development and Use of the MyersBriggs Type Indicator. Consulting Psychologists Press; 1985.

386 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

¯. Gordon DL. Looking at Type and Learning Styles. FL USA: Center for Applications of Psychological Type; 1997. ˘. Brightman HJ. Student Learning and the MyersBriggs Type Indicator [Internet]. [cited 2010 May 12];Available from: http://www2.gsu.edu/ ~dschjb/wwwmbti.html Ò. »√’‡√◊Õπ ·°â«°—ß«“≈. ≈—°…≥–∫ÿ§≈‘°¿“æ¢Õßπ—°»÷°…“ ˆ “¢“Õ“™’æ (°ÆÀ¡“¬ §Õ¡æ‘«‡µÕ√å ·æ∑¬»“ µ√å ¡πÿ…¬»“ µ√å «‘»«°√√¡»“ µ√å ‡»√…∞»“ µ√å) ®“° °“√™’«È ¥— ¢Õß Myers Briggs Type Indicator (MBTI). ®ÿ≈ “√‰∑¬§¥’»÷°…“. ÚıÙı;Ò¯:Û˜-ıˆ.

ÒÒ. Kroeger O, Thuesen JM, Rutledge H. Type Talk at Work (Revised): How the 16 Personality Types Determine Your Success on the Job. Revised. New York: Delta; 2002. ÒÚ. Baron R. What Type Am I?: The Myers-Brigg Type Indication Made Easy. New York: Penguin Publishing; 1998.

Abstract How to instruct the Generation Y medical students Winitra Nuallaong Department of Psychiatry, Faculty of Medicine, Thammasat University The obstacles of instructing a medical student probably come from the Generational and personality differences between an instructor and a student. Since a current medical student is in the Generation Y while almost instructors are in the Generation X and Baby Boom, todayûs class would better develop 1) clarity in course structure, 2) significant opportunities for student initiative, 3) awareness of stress-reduction and 4) a course-long conversation on the ethical dimensions in order to match studentûs learning style. Moreover, personality difference shows a medical student prefers to participate in a group studying and learn more specific practical point. Thus, instructors would be encouraged to aware an individual difference in order to improve educational productivity as well as promote relationship with a student.

Key words: Generation Y, Medical student, Instruction, Personality, MBTI, Myers-Briggs, Carl Jung

387

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

ª°‘≥°–

π«—µ°√√¡ : ‡§√◊ËÕß∂à“ߪ“°™àÕߧ≈Õ¥ ´’ Õ“√å «’ √ÿàπ∑’Ë Ò (CRV V.1) ‡©≈‘¡æ≈ Õ—»«∏’√“ß°Ÿ√ ∫∑π”

«— ¥ÿ·≈–«‘∏’°“√»÷°…“

◊∫‡π◊ÕË ß®“°°“√ºà“µ—¥¡¥≈Ÿ°∑“ß™àÕߧ≈Õ¥„π°√≥’ ¡¥≈Ÿ°‰¡àÀ¬àÕπ (Vaginal hysterectomy, VH À√◊Õ Scarless hysterectomy, SH) µâÕß°“√æ◊Èπ∑’Ë∫√‘‡«≥™àÕߧ≈Õ¥ ¡“°æÕ§«√‡æ◊ËÕ„Àâ “¡“√∂ºà“µ—¥®π ”‡√Á®‰¥â ·µàªí®®ÿ∫—𠇧√◊Ë Õ ß¡◊ Õ ¥— ß °≈à “ «„π∑âÕßµ≈“¥‰¡à ¡’ ®”Àπà “ ¬À√◊ Õ ¡’ · µà ‰ ¡à ‡À¡“– ¡°—∫°“√ºà“µ—¥¥—ß°≈à“« ºŸâπ‘æπ∏å®÷߉¥â¥—¥·ª≈ß·≈– ª√–¥‘…∞凧√◊ÕË ß∂à“ߪ“°™àÕߧ≈Õ¥¢÷πÈ „À¡à ‡æ◊ÕË °“√ºà“µ—¥ SH ‚¥¬‡©æ“– ´÷Ëß “¡“√∂𔉪„™â„π°“√ºà“µ—¥™àÕߧ≈Õ¥°√≥’ Õ◊πË Ê ¥â«¬ ‚¥¬µ—ßÈ ™◊ÕË «à“ ´’ Õ“√å «’ (CRV = CHALERMPOLûS Retractors of vagina) √ÿàπ∑’Ë Ò (CRV V.1) ‚¥¬∑’Ë CRV V.1 ¡’ Û à«π¥—ßπ’È Ò. ‡§√◊ÕË ß∂à“ß∑“ߥâ“πÀπâ“ (Anterior) ¡’ Ú ¢π“¥ (‡≈Á°, °≈“ß) Ú. ‡§√◊ËÕß∂à“ß∑“ߥâ“π¢â“ß (Lateral) ¡’ Ú ¢π“¥ (‡≈Á°, °≈“ß) Û. ‡§√◊ËÕß∂à“ß∑“ߥâ“πÀ≈—ß (Posterior) ¡’¢π“¥ ‡¥’¬«

‰¥â¥—¥·ª≈ß·≈–ª√–¥‘…∞å CRV V.1 ¢÷Èπ ®“° ‡§√◊ËÕß∂à“ß™àÕß∑âÕߢÕß∑“ß»—≈¬°√√¡∑’ˉ¡à„™â·≈â« ·≈–‡§√◊ËÕß ∂à“ߪ“°™àÕߧ≈Õ¥∑’Ë¡’Õ¬Ÿà°àÕπ·µà‰¡à‡À¡“– ¡ ∑’Ë ∑”®“° Stainless steel ‡°√¥ 304L ∑’ˉ¡à‡ªìπ π‘¡ §«“¡Àπ“ Ú ¡¡. ‚¥¬¥—¥„À⇢⓰—∫§«“¡‚§âߢÕß™àÕߧ≈Õ¥ ‡æ◊ÕË „Àâ –¥«° °—∫°“√ºà“µ—¥·≈–™à«¬ºà“µ—¥ ‚¥¬¡’√“¬≈–‡Õ’¬¥¢Õß¡‘µ‘¥—ßπ’È Ò. ™π‘¥ Anterior - ¢π“¥‡≈Á° °«â“ß Ú ‡´πµ‘‡¡µ√, ¬“« ÚÙ.ı ‡´πµ‘‡¡µ√ - ¢π“¥°≈“ß °«â“ß Û.¯ ‡´πµ‘‡¡µ√, ¬“« Û˜ ‡´πµ‘‡¡µ√ Ú. ™π‘¥ Lateral - ¢π“¥‡≈Á° °«â“ß Û.Û ‡´πµ‘‡¡µ√, ¬“« Ú¯ ‡´πµ‘‡¡µ√ - ¢π“¥°≈“ß °«â“ß Û.¯ ‡´πµ‘‡¡µ√, ¬“« Û˜ ‡´πµ‘‡¡µ√ Û. ™π‘¥ Posterior - µ—« Retractor ‡ª≈à“ °«â“ß Û ‡´πµ‘‡¡µ√, ¬“« ÛÚ.ı ‡´πµ‘‡¡µ√, Àπ—° Ò °√—¡ - µÿâ¡πÈ”Àπ—° √Ÿªµ—¥¢«“߇ªìπ√ŸªÀ—«„® °«â“ß ı.ı ‡´πµ‘‡¡µ√, ¬“« ˜.ı ‡´πµ‘‡¡µ√, Ÿß ¯ ‡´πµ‘‡¡µ√, Àπ—° Ò.Û¯ °‘‚≈°√—¡ ‡¡◊ËÕ‡™◊ËÕ¡√«¡°—ππÈ”Àπ—°√«¡ Ò.Ù¯ °‘‚≈°√—¡ ‘È𠇪≈◊Õß§à“„™â®à“¬ª√–¡“≥ Ú,ı ∫“∑ ¥—ß√Ÿª

«—µ∂ÿª√– ߧå Ò. ‡æ◊ÕË æ—≤π“π«—µ°√√¡„π°“√ºà“µ—¥∑“ß™àÕߧ≈Õ¥ Ú. ‡æ◊ËÕ‡æ‘Ë¡ª√– ‘∑∏‘¿“æ„π°“√ºà“µ—¥ SH Û. ‡æ◊ÕË ≈¥°“√π”‡¢â“‡§√◊ÕË ß¡◊Õ·æ∑¬å®“°µà“ߪ√–‡∑»

°≈ÿà¡ß“π Ÿµ‘-π√’‡«™»“ µ√å, ‚√ß欓∫“≈πæ√—µπ√“™∏“π’, °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢

388 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

√Ÿª∑’Ë Ò Retractor ∑—ÈßÀ¡¥

√Ÿª∑’Ë Ú ‰¥âπ” CRV V.1 ∑—ÈßÀ¡¥‰ª„™â™à«¬∂à“ß™àÕߧ≈Õ¥„π°“√ºà“µ—¥ VH À√◊Õ SH √«¡ Ú √“¬ ≥ ‚√ß欓∫“≈πæ√—µπ√“™∏“π’ µ—Èß·µà‡¡…“¬π æ.». ÚııÚ - ‡¡…“¬π æ.». ÚııÛ ‚¥¬ºŸâªÉ«¬∑ÿ°√“¬‡ªìπ benign, non prolapsed uterus °≈à“«§◊Õ leiomyoma Ò √“¬, adenomyosis Û √“¬, DUB Ò √“¬, ª«¥∑âÕßπâÕ¬‡√◊ÈÕ√—ß (Chronic pelvic pain) Û √“¬, ªí≠≠“ÕàÕπ®“°‚√§¥“«πå Ú √“¬ ·≈– CIN III Ò √“¬ „πºŸâªÉ«¬∑—Èß Ú √“¬ ¡’∂÷ß Ù √“∑’ˉ¡à‡§¬§≈Õ¥∫ÿµ√

389

Thammasat Medical Journal, Vol. 10 No. 3, July-September 2010

º≈°“√»÷°…“

√ÿª

æ∫«à“°“√ºà“µ—¥ VH À√◊Õ SH ∑—Èß Ú √“¬ ‚¥°“√„™â CRV V.1 ™à«¬„Àâ°“√ºà“µ—¥ª√– ∫§«“¡ ”‡√Á® ¥â«¬¥’ ‚¥¬‰¡à¡’¿“«–·∑√°´âÕπ„¥Ê ºŸâªÉ«¬¡’§«“¡æÕ„® ‡π◊ËÕß®“°¡’§«“¡‡®Á∫ª«¥∑’ËπâÕ¬°«à“°“√ºà“µ—¥∑“ßÀπâ“∑âÕß ·∫∫¥—È߇¥‘¡À√◊Õ°“√ºà“µ—¥ àÕß°≈âÕß §à“„™â®à“¬∂Ÿ°°«à“ øóôπ µ—«‡√Á«°«à“·≈–‰¡à¡’∫“¥·º≈∑’ËÀπâ“∑âÕ߇≈¬ ‚¥¬∑’Ë CRV V.1 ™à«¬„Àâ‡ÀÁπæ◊Èπ∑’Ë°“√ºà“µ—¥‰¥â°«â“ߢ÷Èπ ºŸâ™à«¬¥÷ß√—Èßßà“¬ ∑”„Àâ °“√ºà“µ—¥ßà“¬¢÷Èπ √«¥‡√Á«¢÷Èπ·≈–ª≈Õ¥¿—¬

‡§√◊ËÕß∂à“ߪ“°™àÕߧ≈Õ¥ CRV V.1 ™à«¬„π°“√ ºà“µ—¥ SH ‰¥â¥’¬‘Ëß°«à“‡§√◊ËÕß¡◊Õ‡°à“∑’ˇ§¬¡’ ºŸâπ‘æπ∏å®–‰¥â æ—≤π“√ÿπà ∂—¥‰ª‡æ◊ÕË „Àâ‡À¡“– ¡°—∫¢π“¥√à“ß°“¬§π‰∑¬¬‘ßË ¢÷πÈ ‚¥¬À«—ß«à“°“√ºà“µ—¥∑“ß™àÕߧ≈Õ¥∑ÿ°™π‘¥‚¥¬‡©æ“– SH ®– ‰¥â°«â“ߢ«“ßÕÕ°‰ª „Àâº≈¥’∑ ’Ë ¥ÿ µ°·°àºªŸâ «É ¬∑ÿ°√“¬ ‚¥¬∑’Ë ‰¡à ‘Èπ‡ª≈◊Õ߇ߑπ∑Õß„π°“√ —Ëß´◊ÈÕ‡§√◊ËÕß¡◊Õ®“°µà“ߪ√–‡∑» Õ’°µàÕ‰ª

Abstract The Innovation : CRV V.1 Chalermpol Assawatheerangkoon Department of Obstetrics and Gynecology, Nopparat Rajathani Hospital CRV V.1 (CHALERMPOLûS Retractors of Vagina, version 1) are instruments which assist in vaginal surgery esp. Scarless Hysterectomy (SH) or Vaginal Hysterectomy (VH). SH, in non-prolapsed uterus, needs more space to succeed the operation, but all previous commercial instruments are not suitable for this operation. The author adapted some old fashioned abdominal and vaginal retractors to use in SH by with less budget (~ 2,500 Baht). All 20 patients whom SH were performed by the author, and used CRV V.1 to assist the operation. The results of operations was impressive, with less pain and less cost. There was complication. It provides good cosmetic result and had no abdominal scar.

Key words: CHALERMPOLûS Retractors of Vagina, Scarless Hysterectomy, Vaginal Hysterectomy

390 .

∏√√¡»“ µ√凫™ “√ ªï∑’Ë Ò ©∫—∫∑’Ë Û ª√–®”‡¥◊Õπ°√°Æ“§¡-°—𬓬π ÚııÛ

®¥À¡“¬∂÷ß∫√√≥“∏‘°“√

‡√’¬π ∫√√≥“∏‘°“√∏√√¡»“ µ√凫™ “√ „π©∫—∫‡¥◊Õπ‡¡…“¬π-¡‘∂ÿπ“¬π ÚııÛ ‰¥â‡ πÕ·°â§”¿“…“Õ—ß°ƒ…¢Õß∫∑∫√√≥“∏‘°“√√—∫‡™‘≠ «à“§«√„™â Invited Editorial ¡“°°«à“ Guest Editorial ·µà°æÁ ∫Õ’°„π©∫—∫π’È ™—°‰¡à·πà„®«à“º¡Õ“®·π–π”º‘¥°Á‰¥â Õ¬à“߉√°Áµ“¡ „π©∫—∫‡¡…“¬π¡‘∂ÿπ“¬π §«√„™âÀ—«¢âÕ«à“ ∫∑∫√√≥“∏‘°“√ °ÁæÕ ‡æ√“–‡ªìπ∫∑§«“¡¢Õß∫√√≥“∏‘°“√‡Õß ‰¡à‰¥â‡™‘≠¡“‡¢’¬π „π«“√ “√©∫—∫‡¥’¬«°—ππ—Èπ ¡’°“√„™â¿“…“∑’˵—¥ ‘𧫓¡º‘¥∂Ÿ°¬“° ¥—ßµ—«Õ¬à“ß - ™◊ËÕ∫∑§«“¡ 秫“¡‡§√’¬¥„ππ—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘°¡À“«‘∑¬“≈—¬∏√√¡»“ µ√åé Àπâ“ ˘ı øíߥŸ‡ªìπ ”π«π ¿“…“Õ—ß°ƒ…¡“° ·≈–§«“¡À¡“¬°Á·ª≈°Ê ∑’Ë∂Ÿ°µâÕßπà“®–‡ªìπ 秫“¡‡§√’¬¥¢Õßπ—°»÷°…“·æ∑¬å™—Èπ§≈‘π‘° ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√åé - ™◊ËÕ∫∑§«“¡‡√◊ËÕß ç≈—°…≥–‡«™°√√¡·≈–º≈°“√µ√«® “√πÈ”‰¢ —πÀ≈—ß„π‡¥Á°∑’Ë¡’¿“«–‰¢â·≈–™—°„π‚√ß欓∫“≈ ∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘é ∑’ˇÀ¡“–·≈– Õ¥§≈âÕß°—∫ “√–§«“¡„π‡π◊ÈÕ‡√◊ËÕߧ«√‡ªìπ ç≈—°…≥–‡«™°√√¡ ·≈–º≈°“√µ√«® “√πÈ”À≈àÕ‰¢ —πÀ≈—ß„π‡¥Á°¿“«–™—°‡Àµÿ‰¢â∑‚’Ë √ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘é ¥â«‡Àµÿº≈«à“»—æ∑å∫—≠≠—µ‘¢Õß spinal fluid §◊Õ “√πÈ”À≈àÕ‰¢ —πÀ≈—ß ( “√πÈ”‰¢ —πÀ≈—ßÕ“®À¡“¬∂÷ß “√πÈ”¢Õß ‰¢ —πÀ≈—ß) ·≈– febrile seizure §◊Õ¿“«–™—°‡Àµÿ‰¢â - ‚¥¬∂Ÿ°µâÕß ™◊ËÕ∫∑§«“¡§«√ —Èπ°–∑—¥√—¥ ·≈–∂Ÿ°À≈—°¿“…“¥â«¬ ¥—ßπ—Èπ™◊ËÕ∫∑§«“¡ çªí®®—¬∑’Ë¡’º≈µàÕ§«“¡ √à«¡¡◊ÕºŸâªÉ«¬‡∫“À«“πª√–‡¿∑∑’Ë Úé §«√‡ªìπ çªí®®—¬∑’Ë¡’º≈µàÕ§«“¡√à«¡¡◊Õ¢ÕߺŸâªÉ«¬‚√§‡∫“À«“πª√–‡¿∑ ∑’Ë Úé - Õà“π∫∑§«“¡‡√◊ÕË ß ç°“√µ‘¥‡™◊ÕÈ „π°√–· ‡≈◊Õ¥¢ÕߺŸªâ «É ¬‡¥Á°„π‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘é ·≈â« µâÕߢÕÕπÿ≠“µ‡ πÕ»—æ∑å∫—≠≠—µ‘∑’ˇ°’ˬ«¢âÕߥ—ßµàÕ‰ªπ’È Bacteremia (the presence of bacteria in the blood) ∫—≠≠—µ‘«à“ °“√¡’·∫§∑’‡√’¬„π‡≈◊Õ¥ À√◊Õ (¿“«–) ‡≈◊Õ¥¡’·∫§∑’‡√’¬; septicemia (systemic disease associated with the presence and persistence of pathogenic microorganisms or their toxin in the blood) ∫—≠≠—µ‘«à“‚√§ (∑—Ë«°“¬) ∑’Ë¡’‡™◊ÈÕ°àÕ‚√§À√◊Õ “√™’«æ‘…¢Õ߇™◊ÈÕ°àÕ‚√§„π‡≈◊Õ¥ À√◊Õ¿“«–‡≈◊Õ¥ µ‘¥‡™◊ÈÕ; toxemia (any condition resulting from the spread of toxins or toxic bacterial products by the blood stream) ∫—≠≠—µ‘«à“¿“«–‡≈◊Õ¥¡’ “√™’«æ‘…. ‚¥¬»—æ∑å∫—≠≠—µ‘∑’ˇ πÕ¢â“ßµâπ ®÷ߢՇ πÕ™◊ËÕ ∫∑§«“¡«à“ ç¿“«–‡≈◊Õ¥¡’‡™◊ÈÕ°àÕ‚√§„πºŸâªÉ«¬‡¥Á°¢Õß‚√ß欓∫“≈∏√√¡»“ µ√凩≈‘¡æ√–‡°’¬√µ‘é - „π«“√ “√œ ©∫—∫π’È¡’®¥À¡“¬∂÷ß∫√√≥“∏‘°“√ Ú ©∫—∫ À—«¢âÕ¿“…“Õ—ß°ƒ…„π “√∫—≠§«√‡ªìπæÀŸæ®πå§◊Õ Letters to the Editor

»“ µ√“®“√¬å 𓬷æ∑¬å “‚√®πå «√√≥惰…å §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈