Content-Jan50 - dms.moph.go.th · PDF fileQuality for Dengue Hemorrhagic Fever Patients in Sakon Nakhon Province Pornchai Channgam, M.D. Pailin Nadsantia, M.Ns. 16 Home Exercise Program

“√∫—≠

«“√ “√ °√¡°“√·æ∑¬åBULLETIN OF THE DEPARTMENT OF MEDICAL SERVICES

Contents

Vol. 32 No. 1 January-March 2007ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550

Àπâ“Page

π‘æπ∏åµâπ©∫—∫

°“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß ‚√ßæ¬“∫“≈ °≈π§√

æ‘™“µ‘ ¥≈‡©≈‘¡¬ÿ∑∏π“ æ.∫.

ªî¬πÿ™ ∫ÿ≠°Õß æ¬.¡.

æ√π‘¿“ „§√∫ÿµ√ æ∫.¡.

°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°Õ¬à“ßµàÕ‡π◊ËÕß„π®—ßÀ«—¥ °≈π§√

æ√™—¬ ®—π∑√åß“¡ æ.∫.

‰æ≈‘π π—¥ —π‡∑’¬– æ¬.¡.

°“√ àß‡ √‘¡ ¡√√∂¿“æ°“√À“¬„®„πºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß·≈–À≈—ß°“√‡ √‘¡‚ª√·°√¡ÕÕ°°”≈—ß°“¬∑’Ë∫â“π

«‘æ—≤πå ƒ…Æ’™—¬°ÿ≈ æ.∫.

‡æÁ≠»√’ · à¡â“ æ.«.

°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬‡∑§π‘§°“√‡ªî¥·º≈¢π“¥‡≈Á°„π‚√ßæ¬“∫“≈™ÿ¡™π

∏’√æ≈ ™≈‡¥™ æ.∫.

°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡‡À¡“– ¡ ”À√—∫°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°À√◊Õ‰¡à? °“√»÷°…“§«∫§ÿ¡·∫∫ ÿà¡¥â«¬°“√‡ª√’¬∫‡∑’¬∫„πµ—«Õ¬à“ß‡¥’¬«°—π

°ƒ…Æ“ ∂¡¬“∫—µ√ æ.∫.

ORIGINAL ARTICLES

1 Development of Continual Health Care Systemsat Sakon Nakhon Hospital, 2006

Pichat Dolchalermyuthana, M.D.

Piyanut Boonkong

Pornnipa Kributra

9 Development of Continuing ManagementQuality for Dengue Hemorrhagic Fever Patientsin Sakon Nakhon Province

Pornchai Channgam, M.D.

Pailin Nadsantia, M.Ns.

16 Home Exercise Program for RespiratoryRehabilitation Among Chronic ObstructivePulmonary Disease Cases

Wipat Saliddeechaikool, M.D.

Pensri Saema

25 Minilaparotomy Cholecystectomy in DistrictHospital

Therapol Chonladej, M.D.

31 Is Visual Inspection with Acetic (VIA)Appropriate for Cervical Cancer Screening? :Randomized Controlled Trial with CrossoverDesign

Krissada Tomyabatra, M.D.

“√∫—≠


Contents


Àπâ“Page

39 Heparin Free-Saline Drip Technique in Hemo-dialytic Patients with High Risk of Bleeding

Boonraksa Laonapaporn B.Ns.

Nathana Spilles, M.Ns.

Jitrada Duangkhong B.Ns.

Sumonkarn Lapkittichareonchai B.Ns.

Sulaiporn Lungbuppha B.Ns.

Piroj Yingwatanadej M.D.

Jayanton Patumanond D.Sc.

47 Intrapartum Symphysis - Fundal HeightMeasurement in Prediction of Both LowBirthweight and Big Baby

Kachornsilp Pongsawatkul

55 Stool Occult Blood Test for Screening andEarly Detection Colorectal Cancer

Wutthi Sumetchotimaytha, M.D.

Thiravud Khuhaprema, M.D.

Saipan Khunpakdee, M.D.

Ram Rangsin, M.D., Ph.D.

67 Breast Cancer Treatment with Breast-conserving Surgery and Post OperativeRadiation in Ubonratchathani Cancer Center

Pongsatorn Supaatakorn, M.D.

°“√„™â Heparin-Free Saline Drip Technique¢≥–øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰µ‡∑’¬¡„πºŸâªÉ«¬∑’Ë¡’¿“«–‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ°

∫ÿ≠√—°…“ ‡À≈à“π¿“æ√ æ¬.∫.

π—π∑π“ ™ªî≈‡≈ æ¬.¡.

®‘µ√¥“ ¥â«ß§ß æ¬.∫.

ÿ¡π°“≠®πå ≈“¿°‘µµ‘‡®√‘≠™—¬ æ¬.∫.

ÿ‰≈æ√ ≈—ß∫ÿªº“ æ¬.∫.

‰æ‚√®πå ¬‘Ëß«—≤π‡¥™ æ.∫.

™¬—πµ√å∏√ ª∑ÿ¡“ππ∑å «∑.¥.

°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥‡æ◊ËÕ„™â„π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ ·≈–∑“√°·√°‡°‘¥πÈ”Àπ—°¡“°

¢®√»‘≈ªá ºàÕß «— ¥‘Ï°ÿ≈, æ.∫.

°“√µ√«®§—¥°√Õß¡–‡√Áß≈”‰ â„À≠à√–¬–‡√‘Ë¡·√°¥â«¬«‘∏’°“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑’Ëªπ°—∫Õÿ®®“√–

«ÿ≤‘ ÿ‡¡∏‚™µ‘‡¡∏“ æ.∫.

∏’√«ÿ≤‘ §ŸÀ–‡ª√¡– æ.∫.

“¬ªÉ“π ¢ÿπ¿—°¥’ æ.∫.

√“¡ √—ß ‘π∏ÿå æ.∫., ª√.¥.

°“√√—°…“¡–‡√Áß‡µâ“π¡¥â«¬°“√ºà“µ—¥ ß«π‡µâ“π¡·≈–°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥ »Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’

æß»∏√ »ÿ¿Õ√√∂°√ æ.∫.

“√∫—≠


Contents


Àπâ“Page

æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áß≥ »Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’

∏’√æ≈ ‡®π«‘∑¬“

™≈‘¬“ «“¡–≈ÿπ

Õπÿ™µ√“ «√√≥‡ «°

°ÿ≈∏‘¥“ °ÿ≈ª√–±’ªí≠≠“

‚ ¿‘µ ∑—∫∑‘¡À‘π

æ—™π’ ‡∑æ“Õ¿‘√—°…å

§«“¡·¡àπ¬”„π°“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡¥â«¬¿“æ∂à“¬√—ß ’ ·≈–§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß ≥ »Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’

πÈ”∑‘æ¬å À¡—Ëπæ≈»√’ æ.∫.

»√’¬“ «‘‡»…π—π∑å «∑.∫.

°“√»÷°…“·∫∫≈Õß°‘®Ÿµ‘πÕ≈ „π°“√À“§«“¡ —¡æ—π∏å¢ÕßÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ°—∫¿“«– ÷¡‡»√â“

º°“«≈’ æÿà¡ ÿ∑—»πå «∑.¡.

®√√¬“ ¿—∑√Õ“™“™—¬ «∑.¥.

¬ß¬ÿ∑∏ »‘√‘ª°“√ æ.∫.

Õÿ¥¡ ≈—°…≥«‘®“√¬å æ.∫.

º≈¢Õß‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß

«‘™≠å ‘√‘‚√®πåæ√ æ.∫.

71 Health Promotion Behaviors in Cancer Patientat Ubonratchathani Cancer Center

Dhirapol Chenvidhuya

Chaliya Wamaloon

Anuttra Wunnasaweqa

Kultida Kulprateepanya

Sopit Tubtimhin

Patchanee Thepa-apirak

77 Accuracy for Detection Breast Cancer withMammography and Ultrasound at UdonthaniRegional Cancer Center

Namtip Mulpolsri, M.D.

Sriya Wisetnan, M.Sc.

86 Longitudinal Study of Chronic Musculo-skeletalPain in Relation to Depression

Pakavalee Poomsu-tat, M.Sc.

Junya Pattaraachachai, D.Sc.

Yongyuth Siripakarn, M.D.

Udom Laksanavicharn, M.D.

93 Cost Implication of Dyspnea ManagementProgram on Patients with Chronic ObstructivePulmonary Disease in Fang Hospital, ChiangMai

Wich Sirirojporn, M.D.

“√∫—≠


Contents


Àπâ“Page

§«“¡ —¡æ—π∏åªí®®—¬ à«π∫ÿ§§≈·≈–æƒµ‘°√√¡ ÿ¢¿“æ°—∫‚√§°√–¥Ÿ°æ√ÿπ¢ÕßºŸâπ”™ÿ¡™π∑’ËÕ“¬ÿ 40ªï¢÷Èπ‰ª „π‡¢µ‡∑»∫“≈‡¡◊Õß ®—ßÀ«—¥∫ÿ√’√—¡¬å

¡™—¬ Õ—»« ÿ¥ “§√ æ.∫.

°“√ª√–‡¡‘π°“√„™â¬“∑√“ ∑Ÿ´Ÿ·¡∫„π ∂“∫—π¡–‡√Áß·Ààß™“µ‘

Õ¡√√—µπå «‘®‘µ√≈’≈“ ¿.∫.

°“√≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√®“°‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬ ŸßÕ“¬ÿ

ÿ§π∏“ ªí∑¡ ‘ßÀå ≥ Õ¬ÿ∏¬“ æ.∫.

æƒµ‘°√√¡°“√¥Ÿ·≈µπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß „π‡¢µ‡∑»∫“≈‡¡◊Õß ®—ßÀ«—¥©–‡™‘ß‡∑√“

«‘‰≈≈—°…≥å «‘√‘¬–æ—π∏ÿå æ¬.∫.

¬ÿæ‘π Àß…å«–™‘π «∑.¡.

100 Relationships of Individual Factors and HealthBehaviors to Osteoporosis among CommunityLeader Aged Over Forty Years Old in Muni-cipality Area Buriram Province

Somchai Auswasudsakorn

109 Drug Use Evaluation of Trastuzumab inNational Cancer Institute

Amornrat Vijitleela, B.Pharm.

118 Visual Impairment Reduction in CommonElderly Eye DiseasesSukhontha Pattamasingh Na Ayuthaya, M.D.

127 Self-caring Behavior among HypertensionCases in Muang Chachoengsao Municipality,Chachoengsao Province

Vilailak Viriyapun, B.N.

Yuphin Hongwachin, M.Sc.

Vol. 32 No. 1 January-March 2007

1Bulletin of the Department of Medical Services


°“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß‚√ßæ¬“∫“≈ °≈π§√æ‘™“µ‘ ¥≈‡©≈‘¡¬ÿ∑∏π“ æ.∫.ªî¬πÿ™ ∫ÿ≠°Õß æ¬.¡.æ√π‘¿“ „§√∫ÿµ√ æ∫.¡.‚√ßæ¬“∫“≈ °≈π§√

Abstract Development of Continual Health Care Systems at Sakon Nakhon Hospital, 2006Dolchalermyuthana .P, Boonkong P., Kributra P.Sakon Nakhon Hospital

Bull Dept Med Serv 2006; 31:1-8.

Objective of this study was to develop quality and potential of chronic disease patient carelatency, continualy supervise among continual health care center, patient department, primary health careunit. Result of development of continual health care system were 1) Established the continual health carecentre, having the nurse to affiliate for liaison both inside and outside the hospital 2) Developed the assessmentof patient and discharge plan forms. 3) Developed 24 care map & home care pathway such as MI, HI, DM,CVA etc. 4) Developed the referral form and evaluation form 5) call center service for problem solving andinformation. There were 202 clients had received the care from nearby primary health care unit/hospitalhouse. Satisfaction level ranges from very satisfactory up to the most satisfaction, no miss appointment case,no complication after discharge, no readmission within 28 days of discharge and there were 3 last stagepatients died at home. Effective continual health care by means of coverage from hospital to home by multidisplinary team both inside and outside the hospital, with good cooperate from continual health care wouldprovide patient with knowledge, skill and confident in taking care of oneself, can discharge to patient very fastand no complication found after that.

Key words: continual health care, systems development

‡√◊ËÕß¬àÕ «—µ∂ÿª√– ß§å‡æ◊ËÕæ—≤π“§ÿ≥¿“æ·≈–»—°¬¿“æ°“√¥Ÿ·≈ºŸâªÉ«¬‚√§‡√◊ÈÕ√—ß„Àâ‡°‘¥°“√¥Ÿ·≈Õ¬à“ßµàÕ‡π◊ËÕß√–À«à“ß»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß ÀÕºŸâªÉ«¬ ∂“π∫√‘°“√ ÿ¢¿“æ√–¥—∫ª∞¡¿Ÿ¡‘·≈–™ÿ¡™π ‚¥¬§«“¡√à«¡¡◊Õ¢Õß∑’¡ À “¢“«‘™“™’æ „™â°√–∫«π°“√¡’ à«π√à«¡¢Õß∑ÿ°Àπà«¬ß“π∑’Ë‡°’Ë¬«¢âÕß º≈°“√»÷°…“ æ∫«à“ °“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß‚¥¬ 1) ®—¥µ—Èß»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß ¡’æ¬“∫“≈ª√–®”»Ÿπ¬åœ ‡ªìπºŸâª√– “πß“πÀ≈—°∑—Èß„π·≈–πÕ°‚√ßæ¬“∫“≈ 2) æ—≤π“·∫∫ª√–‡¡‘π ¿“æºŸâªÉ«¬·≈–·∫∫∫—π∑÷°°“√‡µ√’¬¡®”Àπà“¬ 3) æ—≤π“·ºπ°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À—«„®¢“¥‡≈◊Õ¥, §«“¡¥—π‚≈À‘µ Ÿß, ‡∫“À«“π ‡ªìπµâπ4) æ—≤π“„∫ àßµàÕ ·≈–·∫∫ª√–‡¡‘π ÿ¢¿“æ‡æ◊ËÕ°“√¥Ÿ·≈µàÕ‡π◊ËÕß 5) ª√÷°…“ªí≠À“∑“ß‚∑√»—æ∑å‰¥âµ≈Õ¥ 24 ™—Ë«‚¡ß ºŸâ√—∫∫√‘°“√®”π«π202 √“¬ æ∫«à“ à«π„À≠àªÉ«¬¥â«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·≈–∫“¥‡®Á∫∑’Ë‰¢ —πÀ≈—ß √Õß≈ß¡“§◊Õ ‚√§‡∫“À«“π ∑ÿ°√“¬‰¥â√—∫°“√¥Ÿ·≈®“° ∂“π∫√‘°“√„°≈â∫â“π √–¥—∫§«“¡æ÷ßæÕ„® à«π„À≠àÕ¬Ÿà„π√–¥—∫¡“°∂÷ß¡“°∑’Ë ÿ¥ ¡“µ√«®µ“¡π—¥∑ÿ°√“¬ ‰¡àæ∫¿“«–·∑√°´âÕπ¿“¬À≈—ß®”Àπà“¬ ‰¡à¡’°“√°≈—∫¡“√—°…“´È” ¿“¬„π 28 «—πÀ≈—ß®”Àπà“¬ ·≈– ºŸâªÉ«¬√–¬– ÿ¥∑â“¬‡ ’¬™’«‘µ∑’Ë∫â“π®”π«π3 √“¬ °“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß∑’Ë¡’ª√– ‘∑∏‘¿“æ ¥”‡π‘π°“√Õ¬à“ß§√Õ∫§≈ÿ¡µ—Èß·µà·√°√—∫®π∂÷ß®”Àπà“¬°≈—∫∫â“π ‚¥¬∑’¡ À “¢“«‘™“™’æ∑—Èß„π·≈–πÕ°‚√ßæ¬“∫“≈ ¡’»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß∑”°“√‡™◊ËÕ¡‚¬ß‡æ◊ËÕ„Àâ‡°‘¥°“√ª√– “πß“π∑’Ë¥’∑”„ÀâºŸâªÉ«¬¡’§«“¡√Ÿâ ∑—°…– ·≈–§«“¡¡—Ëπ„®„π°“√¥Ÿ·≈ ÿ¢¿“æ “¡“√∂®”Àπà“¬ºŸâªÉ«¬‰¥â‡√Á«·≈–‰¡àæ∫¿“«–·∑√°´âÕπÀ≈—ß®”Àπà“¬

§” ”§—≠: °“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß °“√æ—≤π“√–∫∫

2

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

°“√‡µ√’¬¡§«“¡æ√âÕ¡¢ÕßºŸâ √—∫∫√‘°“√·≈–§√Õ∫§√—«„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß °àÕπ®”Àπà“¬ ÕÕ°®“°‚√ßæ¬“∫“≈‡ªìπ ‘Ëß®”‡ªìπ·≈– ”§—≠∑’Ë‚√ßæ¬“∫“≈µâÕß®—¥∫√‘°“√„Àâ·°àºŸâªÉ«¬ ‚¥¬«“ß·ºπ°“√¥Ÿ·≈√–¬–¬“«∑’Ë∑”„Àâ‡°‘¥°“√¥Ÿ·≈Õ¬à“ßµàÕ‡π◊ËÕß ‡À¡“– ¡µ“¡ ¿“æªí≠À“¢ÕßºŸâªÉ«¬·µà≈–√“¬1 ‡æ◊ËÕ¡ÿàß‡πâπ„Àâ‡°‘¥º≈≈—æ∏å∑’Ë¥’ ¿“«– ÿ¢¿“æ·≈–§ÿ≥¿“æ™’«‘µ¢Õßª√–™“™π‡ª√’¬∫‡ ¡◊Õπ‰¥â√—∫∫√‘°“√∑’Ë¡’§ÿ≥¿“æ2

®“° ∂‘µ‘°“√„Àâ∫√‘°“√¢Õß‚√ßæ¬“∫“≈ °≈π§√æ∫«à“ºŸâªÉ«¬‚√§‡√◊ÈÕ√—ß ‰¥â·°à ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß‡∫“À«“π §«“¡¥—π‚≈À‘µ Ÿß ¡’Õ—µ√“°“√æ—°√—°…“µ—«„π‚√ßæ¬“∫“≈‡ªìπ‡«≈“π“π ·≈– °≈—∫¡“√—°…“ È” Ÿß3 àßº≈°√–∑∫µàÕºŸâªÉ«¬ §√Õ∫§√—«·≈–¡’§à“„™â®à“¬ Ÿß º≈¢Õß‚√§°àÕ„Àâ‡°‘¥§«“¡æ‘°“√ ®”‡ªìπµâÕß‰¥â√—∫°“√¥Ÿ·≈µàÕ‡π◊ËÕß

®“°°“√«‘‡§√“–Àå ∂“π°“√≥å°àÕπ°“√æ—≤π“√–∫∫æ∫«à“ ¢“¥°“√ª√– “π°“√¥Ÿ·≈√–À«à“ß∑’¡ À “¢“«‘™“™’æ ¢“¥°“√¡’ à«π√à«¡§‘¥ √à«¡∑”√–À«à“ßºŸâ„™â∫√‘°“√°—∫∑’¡ ÿ¢¿“æ ¢“¥‡°≥±å„π°“√ àßµàÕ‡æ◊ËÕ°“√¥Ÿ·≈µàÕ‡π◊ËÕß §«“¡æ÷ßæÕ„®¢ÕßºŸâ„™â·≈–ºŸâ„Àâ∫√‘°“√Õ¬Ÿà„π√–¥—∫æÕ„™â ®“° ∂“π°“√≥å¥—ß°≈à“«‚√ßæ¬“∫“≈ °≈π§√ ®÷ßµâÕß°“√æ—≤π“√–∫∫°“√¥Ÿ·≈

ÿ¢¿“æµàÕ‡π◊ËÕß ‚¥¬¡’«—µ∂ÿª√– ß§å‡æ◊ËÕæ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æ·°àºŸâªÉ«¬Õ¬à“ßµàÕ‡π◊ËÕß

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√·∫∫¡’ à«π√à«¡ ‚¥¬°“√ª√–¬ÿ°µå«ß®√°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√¢Õß‡§¡¡‘ ·≈–·¡°·∑°°“√å∑4 ∑’¡»÷°…“ª√–°Õ∫¥â«¬ ºŸâªÉ«¬ºŸâ¥Ÿ·≈ ∑’¡ À “¢“«‘™“™’æ ·≈–§≥–ºŸâ»÷°…“ √à«¡∑”§«“¡‡¢â“„® ∂“π°“√≥å·≈–ªí≠À“„π°“√ªØ‘∫—µ‘ß“πÀ“«‘∏’°“√À√◊Õ·π«∑“ß·°âªí≠À“ π”‰ª∑¥≈ÕßªØ‘∫—µ‘√«¡∂÷ß –∑âÕπ°“√ªØ‘∫—µ‘·≈–«“ß·ºπª√—∫ª√ÿß®π‰¥â·π«∑“ß°“√ªØ‘∫—µ‘∑’Ë‡À¡“– ¡

°“√¥”‡π‘π°“√·∫àß‡ªìπ 2 ¢—ÈπµÕπ §◊Õ¢—Èπ‡µ√’¬¡°“√ ‡µ√’¬¡µ—«∑’¡·≈–ºŸâ∑’Ë¡’ à«π

‡°’Ë¬«¢âÕß‚¥¬Ωñ°∑—°…–°“√‡°Á∫¢âÕ¡Ÿ≈‡™‘ß§ÿ≥¿“æ ´÷Ëß§≥–ºŸâ»÷°…“ ª√–°Õ∫¥â«¬ ·æ∑¬å æ¬“∫“≈ª√–®”ÀÕºŸâªÉ«¬ ·≈–°≈ÿà¡ß“π‡«™°√√¡ —ß§¡ π—°°“¬¿“æ∫”∫—¥‡¿ —™°√ π—°‚¿™π“°“√ π—°®‘µ«‘∑¬“ ®”π«π 26 §π®—¥ª√–™ÿ¡ ‡™‘ßªØ‘∫—µ‘°“√ ‡µ√’¬¡Õÿª°√≥å·≈–»÷°…“π”√àÕß

¢—ÈπªØ‘∫—µ‘°“√ ·∫àß°“√¥”‡π‘π°“√‡ªìπ 3 √–¬–§◊Õ √–¬–∑’Ë 1 √–¬–‡√’¬π√Ÿâ √–¬–∑’Ë 2 √–¬–‡ √‘¡æ≈—ßÕ”π“® ·≈–√–¬–∑’Ë 3 √–¬–æ÷ßæÕ„® √“¬≈–‡Õ’¬¥¥—ß√Ÿª∑’Ë 1

√Ÿª∑’Ë 1 ·ºπ°“√»÷°…“‡æ◊ËÕæ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß¢Õß‚√ßæ¬“∫“≈ °≈π§√

√–¬–∑’Ë 3 ‡°‘¥§«“¡æ÷ßæÕ„®π”æ“ Ÿà§«“¡¬—Ëß¬◊π

√–¬–∑’Ë 1 °“√‡√’¬π√Ÿâª√–‡¡‘π·≈–«‘‡§√“–Àå ∂“π°“√≥å

√–¬–∑’Ë 2 °“√‡ √‘¡æ≈—ßÕ”π“®ª√– “π·π«§‘¥ æ‘™‘µªí≠À“

ª√—∫°‘®°√√¡·≈–æ—≤π“√Ÿª·∫∫

√Ÿª·∫∫∑’Ë‡À¡“– ¡‚¥¬ ‡ª√’¬∫‡∑’¬∫ ∂“π°“√≥å°àÕπ·≈–À≈—ß°“√∑¥≈Õßª√—∫√Ÿª·∫∫

1. ‡™‘ßª√‘¡“≥ ‡ª√’¬∫‡∑’¬∫ µ—«™’È«—¥∑“ß§≈‘π‘§·≈–µ—«™’È«—¥‡©æ“–‚√§2. ‡™‘ß§ÿ≥¿“æ ª√–‡¡‘π§«“¡æ÷ßæÕ„®¢ÕßºŸâ„™â·≈–ºŸâ√—∫∫√‘°“√3. √ÿª√Ÿª·∫∫∑’Ë‡À¡“– ¡ªí≠À“Õÿª √√§·≈–¢âÕ‡ πÕ·π–

Learning stage Empowering stage Appreciate stage

ª√–‡¡‘π —ß‡°µ —¡¿“…≥å‡™‘ß≈÷° π∑π“°≈ÿà¡

/«‘‡§√“–Àå¢âÕ¡Ÿ≈ ∑’¡ ÿ¢¿“æ ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈ √à«¡°—π∑ÿ°¢—ÈπµÕπ

Content analysis ∑’¡ºŸâ»÷°…“ : Facilitator



°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈ ‚¥¬„™â ∂‘µ‘‡™‘ßæ√√≥π“·≈–°“√«‘‡§√“–Àå‡π◊ÈÕÀ“ „π¢âÕ¡Ÿ≈‡™‘ß§ÿ≥¿“æ°“√„Àâ§«“¡À¡“¬·≈– √â“ß¢âÕ √ÿª

º≈

°“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß¢Õß‚√ßæ¬“∫“≈ °≈π§√ º≈°“√»÷°…“¡’ ¥—ßπ’È

√–¬–∑’Ë 1 ª√–‡¡‘π·≈–«‘‡§√“–Àå ∂“π°“√≥å/ √–¬–

°“√‡√’¬π√Ÿâ (Learning stage)

°“√«‘‡§√“–Àå ∂“π°“√≥å°àÕπ°“√æ—≤π“√–∫∫æ∫«à“ ¥â“ππ‚¬∫“¬ ºŸâ∫√‘À“√„Àâ§«“¡ ”§—≠ ¡’π‚¬∫“¬∑’Ë™—¥‡®π

¥â“π√–∫∫°“√¥Ÿ·≈ æ∫«à“‡¡◊ËÕ√—∫ºŸâªÉ«¬‡¢â“√—∫√—°…“µ—« æ¬“∫“≈ª√–®”ÀÕºŸâªÉ«¬ª√–‡¡‘π ¿“æª∞¡π‘‡∑» „Àâ∫√‘°“√√—°…“æ¬“∫“≈µ“¡·ºπ°“√√—°…“‚¥¬‡©≈’Ë¬«—ππÕπ 5 «—π æ∫ªí≠À“ºŸâªÉ«¬‰¡àæ√âÕ¡∑’Ë®–°≈—∫∫â“π ·≈–Õ—µ√“°“√√—∫°≈—∫‡¢â“‚√ßæ¬“∫“≈¿“¬„π28 «—π ‚¥¬‰¡à‰¥â«“ß·ºπ √âÕ¬≈– 2.8 ‡π◊ËÕß®“°¡’‚√§·∑√°´âÕπ ‰¥â·°à °“√µ‘¥‡™◊ÈÕ√–∫∫∑“ß‡¥‘πÀ“¬„® °“√µ‘¥‡™◊ÈÕ√–∫∫∑“ß‡¥‘πªí “«– ·≈–·º≈°¥∑—∫ √Ÿª·∫∫°“√¥Ÿ·≈ à«π„À≠à„™â METHOD Model ¢“¥‡°≥±å„π°“√ àßµàÕ ·≈–¢“¥¬“πæ“Àπ–„π°“√‡¬’Ë¬¡∫â“π

¥â“πß∫ª√–¡“≥π—Èπ¬—ß¢“¥°“√ π—∫ πÿπ§à“„™â®à“¬„π°“√®—¥∑”·∫∫øÕ√å¡

¥â“π∫ÿ§≈“°√æ∫«à“‡®â“Àπâ“∑’Ë¡’∑—»π§µ‘∑’Ë¥’µàÕ°“√«“ß·ºπ®”Àπà“¬ºŸâªÉ«¬ ·µà¢“¥‡®â“Àπâ“∑’Ë√—∫º‘¥™Õ∫°“√ª√– “πß“π√–À«à“ßÀÕºŸâªÉ«¬°—∫™ÿ¡™πÀ√◊ÕÀπà«¬ß“πÕ◊Ëπ ¢“¥°“√¡’ à«π√à«¡§‘¥ √à«¡∑”°—∫∑’¡ ÿ¢¿“æ∑”„Àâ∑’¡‰¡à‡¢â“„®„π·π«§‘¥·≈–‰¡à∑√“∫√“¬≈–‡Õ’¬¥∑’Ë™—¥‡®π §«“¡æ÷ßæÕ„®¢ÕßºŸâ„™â·≈–ºŸâ„Àâ∫√‘°“√Õ¬Ÿà„π√–¥—∫æÕ„™â

¥â“π√–∫∫°“√¥Ÿ·≈·≈–¥â“π∫ÿ§≈“°√ Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß‡°…‘≥’·≈–§≥–5 §◊Õ ¢“¥°“√¡’ à«π√à«¡«“ß·ºπ·≈–ª√– “πß“π√–À«à“ß ºŸâªÉ«¬ºŸâ¥Ÿ·≈·≈–∑’¡ ÿ¢¿“æ °“√‡µ√’¬¡§«“¡æ√âÕ¡‡ªìπ‰ª„π≈—°…≥–°“√·°âªí≠À“‡©æ“–Àπâ“ °“√ Õπ·≈–Ωñ°∑—°…–°“√¥Ÿ·≈µπ‡Õß™â“‡°‘π‰ª ¢“¥°“√·π–π”„Àâ„™âª√–‚¬™πå®“° ∂“π∫√‘°“√„°≈â∫â“π πÕ°®“°π’È¬—ß¢“¥§«“¡‡™◊ËÕ¡‚¬ß√–À«à“ßÀÕºŸâªÉ«¬ »Ÿπ¬å ÿ¢¿“æ™ÿ¡™π ·≈– ∂“π∫√‘°“√ ÿ¢¿“æ„°≈â∫â“π ∑”„Àâ°“√µ‘¥µ“¡º≈°“√∫√‘°“√‰¡àµàÕ‡π◊ËÕß ¢“¥°“√ª√–‡¡‘πº≈≈—æ∏å º≈∑’Ëµ“¡¡“§◊ÕºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈‰¡à “¡“√∂¥Ÿ·≈µπ‡Õß‰¥â °≈—∫‡¢â“√—°…“´È” Ÿß

§≥–ºŸâ»÷°…“®÷ßπ”¢âÕ¡Ÿ≈¡“ª√–™ÿ¡«“ß·ºπ√à«¡°—π®—¥‚§√ß°“√ª√–™ÿ¡‡™‘ßªØ‘∫—µ‘°“√‡√◊ËÕß°“√«“ß·ºπ®”Àπà“¬ºŸâªÉ«¬ ‡æ◊ËÕ∑∫∑«π§«“¡√Ÿâ„Àâ·°à∫ÿ§≈“°√∑’¡ ÿ¢¿“æ ¡’ºŸâ‡¢â“√à«¡ª√–™ÿ¡®”π«π 342 §π ·≈–‰¥â√à«¡°—π°”Àπ¥·π«∑“ßªØ‘∫—µ‘°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß

√Ÿª∑’Ë 2 ‰¥Õ–·°√¡«ß®√°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√√Õ∫∑’Ë 1 (√–¬– 2 ‡¥◊Õπ : 1 .§. - 30 °.¬. æ.». 2548)

–∑âÕπ°“√ªØ‘∫—µ‘

- ‡°‘¥ —¡æ—π∏¿“æ√–À«à“ßºŸâ„™â·≈–ºŸâ„Àâ∫√‘°“√- ¡’°“√æ—≤π“µπ‡Õß„π¥â“πÕß§å§«“¡√Ÿâ‡√◊ËÕß°“√«“ß·ºπ®”Àπà“¬

ªí≠À“/Õÿª √√§

- ¢“¥∑—°…–°“√ √â“ß —¡æ—π∏¿“æ°—∫ºŸâ„™â∫√‘°“√

- ºŸâ„™â∫√‘°“√¡’®”π«π¡“°- „Àâ°“√¥Ÿ·≈‰¡à§√Õ∫§≈ÿ¡Õß§å√«¡

«“ß·ºπ «‘‡§√“–Àåªí≠À“·≈– ∂“π°“√≥å‚¥¬- SWOT Analysis √–∫∫°“√¥Ÿ·≈ªí®®ÿ∫—π- º≈°“√ Õ∫∂“¡§«“¡æ÷ßæÕ„®¢ÕßºŸâ„™â·≈–ºŸâ„Àâ∫√‘°“√

- º≈°“√ Audit chart

°≈¬ÿ∑∏å ®—¥ª√–™ÿ¡‡™‘ßªØ‘∫—µ‘°“√°“√«“ß·ºπ®”Àπà“¬

→ √à«¡°”Àπ¥·π«∑“ßªØ‘∫—µ‘°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß

ª√—∫·ºπ

- ‡æ‘Ë¡∑—°…–°“√ √â“ß —¡æ—π∏¿“æ→ æ—≤π“·π«∑“ß°“√¥Ÿ·≈ Care map/guide line/CPG

ª√—∫ ‡ª≈’Ë¬π

–∑âÕπ °“√ªØ‘∫—µ‘

4

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‚¥¬„™â«ß®√°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√ ‡¢’¬π‡ªìπ‰¥Õ–·°√¡· ¥ß√“¬≈–‡Õ’¬¥ ¥—ß· ¥ß„π√Ÿª∑’Ë 2

√–¬–∑’Ë 2 √–¬–°“√‡ √‘¡æ≈—ßÕ”π“® (Em-

powering stage) ‚¥¬°“√ª√– “π·π«§‘¥‡æ◊ËÕ·°â‰¢ªí≠À“ ‚¥¬π”¢âÕ¡Ÿ≈∑’Ë‰¥â®“°°“√«‘‡§√“–Àå ∂“π°“√≥å°“√ª√–™ÿ¡‡™‘ßªØ‘∫—µ‘°“√ °“√ —ß‡°µ·∫∫¡’ à«π√à«¡·≈–°“√ π∑π“°≈ÿà¡¡“ –∑âÕπ°“√ªØ‘∫—µ‘·≈–‡ πÕ„Àâ§≥–°√√¡°“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß‰¥â»÷°…“‡æ◊ËÕ√—∫∑√“∫ªí≠À“·≈– ∂“π°“√≥å ∑”„Àâ‰¥âÀ“·π«∑“ß„π°“√·°â‰¢ªí≠À“√à«¡°—π ªØ‘∫—µ‘µ“¡·ºπª√–‡¡‘πº≈°“√ªØ‘∫—µ‘ ‚¥¬„™â«ß®√°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√ ‡¢’¬π‡ªìπ‰¥Õ–·°√¡· ¥ß√“¬≈–‡Õ’¬¥¥—ß√Ÿª∑’Ë 3

®“°¿“æ®–æ∫«à“°“√¥”‡π‘π°“√»÷°…“„π√–¬–∑’Ë 2‰¥â‡°‘¥°“√æ—≤π“ ¥—ßπ’È

«ß√Õ∫∑’Ë 1 ∑∫∑«π·≈–∑¥≈ÕßªØ‘∫—µ‘

‡√‘Ë¡®“°®—¥µ—Èß»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß ‚¥¬¡’æ¬“∫“≈«‘™“™’æª√–®”»Ÿπ¬åœ ®”π«π 2 §π ∑”Àπâ“∑’Ëª√– “π°“√¥Ÿ·≈ √à«¡æ—≤π“·≈–®—¥À“‡Õ° “√°“√∫—π∑÷°°—∫∑’¡ ÿ¢¿“æ ‰¥â·°à ·∫∫ª√–‡¡‘π ¿“æºŸâªÉ«¬·∫∫∫—π∑÷°°“√‡µ√’¬¡®”Àπà“¬·≈–„∫ àßµàÕ ·≈–·∫∫ª√–‡¡‘π ÿ¢¿“æ‡æ◊ËÕ°“√¥Ÿ·≈µàÕ‡π◊ËÕß

®“°π—Èπæ—≤π“·ºπ°“√¥Ÿ·≈ºŸâªÉ«¬„π‚√ß

æ¬“∫“≈ ·≈–°“√¥Ÿ·≈µàÕ‡π◊ËÕß∑’Ë∫â“π®”π«π 24 ‡√◊ËÕß‡™àπ ‚√§À—«„®¢“¥‡≈◊Õ¥ ‡∫“À«“π ·≈–Õ—¡æ“µ ‡ªìπµâπæ—≤π“√–∫∫°“√ àßµàÕ¢âÕ¡Ÿ≈ ‚¥¬æ¬“∫“≈ª√–®”»Ÿπ¬åœ¡Õ∫„∫ àßµàÕ 1 ™ÿ¥ „ÀâºŸâ¥Ÿ·≈π”‰ª¬◊Ëπ„Àâ°—∫ ∂“π∫√‘°“√„°≈â∫â“π

∑∫∑«π°“√¥Ÿ·≈ºŸâªÉ«¬ ‚¥¬„™â C3THEERR „π√“¬∑’Ë¡’ªí≠À“ —∫ âÕπ „ÀâºŸâªÉ«¬·≈– §√Õ∫§√—«/ºŸâ∑’ËµâÕß¥Ÿ·≈‡¡◊ËÕ°≈—∫‰ªÕ¬Ÿà∑’Ë∫â“π ÷Ëß à«π„À≠à‡ªìπ “¡’/¿√√¬“·≈–∫ÿµ√ Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß¢«—≠µ“·≈–§≥–6 ‰¥â¡’ à«π√à«¡µ—Èß·µà«—π·√°Ê ∑”„Àâ‡°‘¥§«“¡√à«¡¡◊Õ ·≈–‡°‘¥∑—°…–°“√¥Ÿ·≈µπ‡Õß ‚¥¬¡’æ¬“∫“≈‡ªìπºŸâª√– “πß“π æ√âÕ¡∑—Èß –∑âÕπ§”™¡®“°ºŸâ„™â∫√‘°“√„Àâ·°à∑’¡ºŸâ„Àâ∫√‘°“√ ∑”„Àâ∑’¡ºŸâ„Àâ∫√‘°“√¡’ —¡æ—π∏¿“æ°—∫ºŸâ„™â∫√‘°“√¡“°¢÷Èπ ·≈–‡°‘¥§«“¡¡—Ëπ„®„π√–∫∫°“√¥Ÿ·≈ ¥—ß§”æŸ¥¢Õß·æ∑¬å∑’Ë„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬Õ—¡æ“µ√“¬Àπ÷Ëß°≈à“««à“

ç™à«¬°—π¥Ÿ ™à«¬°—πæŸ¥ ™à«¬°—π∑” ™à«¬„Àâ¡—Ëπ„®«à“ºŸâªÉ«¬®–À“¬·≈–‰¥â°≈—∫∫â“π‡√Á«¢÷Èπé (∫—π∑÷°¿“§ π“¡, 1 ∏—π«“§¡ æ.». 2548)

®“°°“√ –∑âÕπ°“√ªØ‘∫—µ‘æ∫«à“ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈∑ÿ°§πæ÷ßæÕ„®∑’Ë‰¥â¡’ à«π√à«¡„π°“√«“ß·ºπ ¥—ß∑’Ëæ¬“∫“≈∑’Ë‰¥â¥Ÿ·≈ºŸâªÉ«¬‡∫“À«“π«—¬√ÿàπ∑’Ë°≈—∫¡“

√Ÿª∑’Ë 3 ‰¥Õ–·°√¡«ß®√°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√√Õ∫∑’Ë 2 (1 µ.§. æ.». 2548 - 31 ¡’.§. æ.». 2549)


- ¡’ —¡æ—π∏¿“æ°—∫ºŸâ„™â∫√‘°“√¡“°¢÷Èπ- ºŸâ„™â∫√‘°“√¡’ à«π√à«¡„π°“√¥Ÿ·≈µπ‡Õß¡“°¢÷Èπ

- °“√„Àâ∫√‘°“√‡ªìπ∑’¡ À “¢“«‘™“™’æ


- °“√ª√– “πß“π°—∫∑’¡ ÿ¢¿“æ- ≠“µ‘‰¡à‡¢â“„®√–∫∫∫√‘°“√„À¡à §“¥À«—ß Ÿß

°≈¬ÿ∑∏å → π—∫ πÿπ„Àâ°”≈—ß„®„Àâ§”·π–π” ‡ªìπ∑’Ëª√÷°…“→ ®—¥∑”‡Õ° “√‡æ‘Ë¡→ µ‘¥µ“¡ª√–‡¡‘π„°≈â™‘¥→ –∑âÕπ§”™¡®“°ºŸâ„™â∫√‘°“√→ ∑∫∑«π°“√¥Ÿ·≈ºŸâ„™â∫√‘°“√‚¥¬„™â C3 theerr

ª√—∫·ºπ

- ª√– “πß“π°—∫∑’¡ ÿ¢¿“æ ‡√◊ËÕß∫∑∫“∑„π√–∫∫∫√‘°“√„À¡à- √à«¡°—π∑∫∑«π·π«∑“ß°“√„Àâ¢âÕ¡Ÿ≈ ®—¥µ—Èß»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß

°≈¬ÿ∑∏å

- „Àâæ¬“∫“≈ª√–®”»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕßª√– “π°“√¥Ÿ·≈Õ¬à“ßµàÕ‡π◊ËÕß

- ∑∫∑«π°“√¥Ÿ·≈ºŸâ„™â∫√‘°“√∑ÿ°√“¬ √â“ß®‘µ ”π÷°„Àâµ√–Àπ—°∂÷ß§«“¡ ”§—≠¢Õß°“√„™â·≈–ªØ‘∫—µ‘µ“¡·π«∑“ßªØ‘∫—µ‘

ª√—∫ ‡ª≈’Ë¬π

–∑âÕπ °“√ªØ‘∫—µ‘

ªØ‘∫—µ‘ + —ß‡°µ



√—°…“´È”√“¬Àπ÷Ëß°≈à“««à“ç°“√∑’Ë‰¥â„ÀâºŸâªÉ«¬·≈–≠“µ‘¡“¡’ à«π√à«¡„π°“√

¥Ÿ·≈ ÿ¢¿“æµπ‡Õßµ—Èß·µà·√°√—∫ ∑”„Àâ‡√“ π‘∑°—π¡“°°«à“‡¥‘¡ ‡¢“‰¥â‡≈à“‡√◊ËÕßÀ√◊Õªí≠À“µà“ßÊ „Àâ‡√“øíßé(∫—π∑÷°¿“§ π“¡, 21 ¡°√“§¡ 2549)

«ß√Õ∫∑’Ë 2 ≈ß¡◊ÕªØ‘∫—µ‘æ√âÕ¡æ—≤π“»—°¬¿“æ

ª√–‡¡‘π°“√ªØ‘∫—µ‘·≈– √ÿª∫∑∫“∑·≈–·π«∑“ß°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß·°à§≥–°√√¡°“√∫√‘À“√‚√ßæ¬“∫“≈„π°“√ª√–™ÿ¡ª√–®”‡¥◊Õπæƒ»®‘°“¬π æ.». 2548 ‡æ◊ËÕ„Àâ‡°‘¥§«“¡‡¢â“„®µ√ß°—πæ√âÕ¡∑—Èßª√– “πß“π°—∫À—«Àπâ“°≈ÿà¡ß“π‡æ◊ËÕ¢Õ§«“¡√à«¡¡◊Õ„π°“√ √â“ß®‘µ ”π÷°·°à∑’¡ ÿ¢¿“æ

®—¥∑”§Ÿà¡◊Õ°“√¥Ÿ·≈ ÿ¢¿“æºŸâªÉ«¬‡√◊ÈÕ√—ßÕ¬à“ßµàÕ‡π◊ËÕß ·≈–·π«∑“ß°“√«—¥º≈≈—æ∏å°“√¥Ÿ·≈„ÀâÀπà«¬ß“π≈– 1 ‡≈à¡ ‚¥¬¡’æ¬“∫“≈ª√–®”»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß∑”°“√‡°Á∫√«∫√«¡µ—«™’È«—¥º≈≈—æ∏å ‡æ◊ËÕπ”º≈°“√¥Ÿ·≈‡ πÕµàÕ§≥–°√√¡°“√∫√‘À“√¢Õß‚√ßæ¬“∫“≈

¥”‡π‘π°“√ Õ∫∂“¡§«“¡æ÷ßæÕ„®¢ÕßºŸâ„™â∫√‘°“√·≈–ºŸâ„Àâ∫√‘°“√ æ√âÕ¡∑—Èßµ√«® Õ∫°“√∫—π∑÷°‡æ◊ËÕ –∑âÕπº≈°“√ªØ‘∫—µ‘·°à∑’¡ ÿ¢¿“æ æ∫«à“¬—ß¡’ªí≠À“‡√◊ËÕß°“√„Àâ§”·π–π” ®÷ß‰¥â√à«¡°—π∑∫∑«π·π«∑“ß°“√„Àâ¢âÕ¡Ÿ≈ ‡ÀÁπ§«√„Àâª√—∫‡ªìπ°“√ ÕπÕ¬à“ß¡’·∫∫·ºπ ¡’·ºπ°“√ Õπ „™â¿“…“ßà“¬Ê ·≈–„ÀâºŸâ¥Ÿ·≈∑’Ë∑”‰¥â·≈â« Õπ‡æ◊ËÕπ ‡ πÕ∑“ß‡≈◊Õ°„π°“√¥—¥·ª≈ßÕÿª°√≥å°“√·æ∑¬å∑’Ë®–µâÕß‰ª¥Ÿ·≈µàÕ∑’Ë∫â“π∑’ËÀ“´◊ÈÕ‰¥âßà“¬ √“§“∂Ÿ° À√◊Õ¥—¥·ª≈ß‡Õß‰¥â®“°Õÿª°√≥å∑’Ë¡’Õ¬Ÿà„π∫â“π ‡™àπ „™â –π– (∑’ËπÕπ¬—¥¥â«¬πÿàπ‡ªìπ≈Õπ)·∑π∑’ËπÕπ≈¡ ™à«¬ªÑÕß°—π°“√‡°‘¥·º≈°¥∑—∫‰¥â „™â‡°â“Õ’Èæ≈“ µ‘°∑’Ë¡’æπ—°æ‘ß‡®“–√Ÿµ√ß°≈“ß ”À√—∫π—Ëß∂à“¬Õÿ®“√–·∑π‡°â“Õ’È ·µπ‡≈ ·≈–„™â‰¡âæ—π ”≈’„π°“√∑”·º≈·∑π∑’Ë§’∫ ”≈’ (forceps) ‡ªìπµâπ ‚¥¬„Àâ§«“¡√Ÿâ∑’Ë —Èπ ¡’¢—ÈπµÕπßà“¬Ê „ÀâΩñ°´È”Ê ·≈–¡’§Ÿà¡◊Õπ”‰ª∑∫∑«πµàÕ∑’Ë∫â“π ‡æ◊ËÕ„ÀâºŸâ¥Ÿ·≈‡°‘¥§«“¡¡—Ëπ„®

∑∫∑«π°“√¥Ÿ·≈ºŸâ„™â∫√‘°“√∑ÿ°√“¬‚¥¬ª√—∫‡¢â“°—∫ß“πª√–®” ‡ªìπ°“√π”°‘®°√√¡°“√∑∫∑«π°“√¥Ÿ·≈ºŸâªÉ«¬¢≥–Õ¬Ÿà„π‚√ßæ¬“∫“≈‰ªª√—∫„Àâ‡¢â“°—∫°‘®°√√¡‡¥‘¡∑’ËªØ‘∫—µ‘Õ¬Ÿà‡ªìπß“πª√–®”™à«¬„Àâ√Ÿâ ÷°«à“‰¡à

‡ªìπ¿“√– ·≈–™à«¬„Àâ‰¥â –∑âÕπ°“√¥Ÿ·≈ºŸâªÉ«¬ ‡¡◊ËÕæ∫ªí≠À“„π°“√¥Ÿ·≈ ∑’¡ µâÕß√’∫·°â‰¢ π”‰ª Ÿà °“√æ—≤π“»—°¬¿“æ°“√¥Ÿ·≈Õ¬à“ßµàÕ‡π◊ËÕß ®–‡ÀÁπ‰¥â®“°§”æŸ¥¢Õß‡¿ —™°√∑à“πÀπ÷Ëß∑’Ë°≈à“««à“

ç∑’Ëºà“π¡“‡√“µà“ß§π µà“ß∑” ‰¡à‰¥â§ÿ¬°—π ∑”‰¡à‰¥â°Á‰¡à¡’„§√√Ÿâ ‰¡à‡§¬√à«¡°—π∑∫∑«π´—°∑’ ·µà∑”·∫∫π’È¥’π– (∑∫∑«π°“√¥Ÿ·≈ºŸâªÉ«¬) ¡’ Check list„Àâ¥â«¬ –¥«°¥’ ‡¡◊ËÕ¡’ªí≠À“Õ–‰√ ‡√“‰¥â§ÿ¬°—π ™à«¬°—πª√—∫·°âé (∫—π∑÷°¿“§ π“¡, 13 °ÿ¡¿“æ—π∏å æ.». 2549)

º≈≈—æ∏å ®“°°“√ª√–‡¡‘π°“√ªØ‘∫—µ‘„π√–¬–∑’Ë 2æ∫«à“

ºŸâ¥Ÿ·≈¡’°“√æ—≤π“§«“¡ “¡“√∂„π°“√¥Ÿ·≈·≈–øóôπøŸ ¿“æ ·≈–¡’§«“¡¡—Ëπ„®„π°“√¥Ÿ·≈ºŸâªÉ«¬‡¡◊ËÕ°≈—∫∫â“π„π‡√◊ËÕß°“√®—¥∑à“πÕπ‡æ◊ËÕªÑÕß°—π·º≈°¥∑—∫ °“√ÕÕ°°”≈—ß¢âÕ °“√Ωñ°∑√ßµ—« °“√‡§≈◊ËÕπ¬â“¬°“√„ÀâÕ“À“√∑“ß “¬¬“ß °“√∑”·º≈ °“√©’¥Õ‘π´Ÿ≈‘π°“√¥Ÿ·≈∑àÕÀ≈Õ¥≈¡§Õ ‡™àπæ∫«à“ ºŸâ¥Ÿ·≈∑’ËÕ“¬ÿπâÕ¬∑’Ë ÿ¥§◊Õ ‡¥Á°À≠‘ßÕ“¬ÿ 9 ªï “¡“√∂©’¥Õ‘π´Ÿ≈‘π·°à¬“¬Õ“¬ÿ 60 ªï ∑’Ë¡’ “¬µ“‡≈◊Õπ√“ß‰¥â ‡¥Á°À≠‘ßÕ“¬ÿ 12 ªï “¡“√∂‡µ√’¬¡Õ“À“√º ¡„π°“√¥Ÿ·≈¡“√¥“∑’Ë∫â“π‰¥â‡ªìπµâπ

∑’¡ ÿ¢¿“æ‡°‘¥°“√‡√’¬π√Ÿâ√à«¡°—∫ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈·≈–‰¥âª√– “π°‘®°√√¡°“√¥Ÿ·≈‰ª®π∂÷ß∑’Ë∫â“π‚¥¬∑’¡®–‡ªìπºŸâ π—∫ πÿπ ¡“°°«à“°“√ Õπ„Àâ∑”µ“¡∑—ÈßÀ¡¥ ‡π◊ËÕß®“°ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈¡’»—°¬¿“æ‡¥‘¡∑’ËÕ“®π”¡“ª√—∫„™â„Àâ‡°‘¥ª√–‚¬™πå‰¥â ‚¥¬æ∫«à“‚¿™π“°√ª√—∫°“√ Õπ°“√∑”Õ“À“√º ¡ ®“° Õπ√“¬∫ÿ§§≈‡ªìπ Õπ√“¬°≈ÿà¡∑ÿ°«—π„π‡«≈“ 13.30 π.ª√—∫ Ÿµ√·≈–«‘∏’°“√∑”Õ“À“√‡ªìπ Ÿµ√∑’Ë„™â‡§√◊ËÕß∫¥Õ“À“√‰øøÑ“·≈– Ÿµ√„™â∂â«¬∫¥‡æ◊ËÕ„Àâ Õ¥§≈âÕß°—∫ ¿“æ·«¥≈âÕ¡®√‘ß¢ÕßºŸâªÉ«¬∑’Ë∫â“π π—°°“¬¿“æ∫”∫—¥πÕ°®“°∑”°“√¥Ÿ·≈ “∏‘µ·≈– Õπ‡æ◊ËÕøóôπøŸ ¿“æ„Àâ·°àºŸâªÉ«¬·≈â«¬—ß·π–π”°“√ª√–¬ÿ°µå°“¬Õÿª°√≥å‡æ◊ËÕªÑÕß°—π¢âÕµ‘¥‰¥â·°à √Õ°¬◊¥¢âÕ¢“∑”®“°‡™◊Õ°‰π≈ÕπºŸ°‚¬ß°—∫ºâ“¢“«¡â“

√–¬–∑’Ë 3 √–¬–‡°‘¥§«“¡æ÷ßæÕ„® (Appreciate

stage) √–¬–π’È‡°‘¥®“°°“√∑’Ë∑’¡‰¥â√à«¡°—πª√—∫·ºπ®π

6

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‰¥â√Ÿª·∫∫°“√¥Ÿ·≈∑’Ë‡À¡“– ¡ · ¥ß√“¬≈–‡Õ’¬¥¥—ß√Ÿª∑’Ë 4

„π√–¬–∑’Ë 3 æ∫«à“ ª√—∫‡ª≈’Ë¬π√Ÿª·∫∫°“√∫√‘°“√®“°°“√¥Ÿ·≈ºŸâªÉ«¬µ“¡°“√‡®Á∫ªÉ«¬∑“ß°“¬∑’Ë¡“√—°…“„π‚√ßæ¬“∫“≈ ¡“‡ªìπ√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕßµ—Èß·µà·√°√—∫®π∂÷ß∑’Ë∫â“π ‚¥¬¡’°“√ª√—∫¥â“π‚§√ß √â“ß·≈–°√–∫«π°“√¥Ÿ·≈ ÿ¢¿“æ ¥—ßπ’È

‚§√ß √â“ß¥â“π∫ÿ§≈“°√

∑’¡ºŸâ„Àâ∫√‘°“√ ∑—Èß„π‚√ßæ¬“∫“≈·≈–πÕ°‚√ßæ¬“∫“≈ ª√–°Õ∫¥â«¬ ∑’¡ À “¢“«‘™“™’æ ¡’æ¬“∫“≈ª√–®”»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß ∑”Àπâ“∑’Ëª√– “π°“√¥Ÿ·≈∑—Èß„π·≈–πÕ°‚√ßæ¬“∫“≈

ºŸâ„™â∫√‘°“√ ‰¥â·°à ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈ ºŸâªÉ«¬‚√§‡√◊ÈÕ√—ß ºŸâæ‘°“√ ºŸâªÉ«¬√–¬– ÿ¥∑â“¬ ∑’Ë¡’§à“¥—™π’ BarthelADL πâÕ¬°«à“ 50 §–·ππ ·≈–ºŸâªÉ«¬∑’ËµâÕß„™âÕÿª°√≥å∑“ß°“√·æ∑¬å∑’Ë∫â“π

°√–∫«π°“√¥Ÿ·≈ ÿ¢¿“æ ¡’°“√¥”‡π‘π°“√ 3

√–¬– §◊Õ√–¬–∑’Ë 1 √–¬–‡µ√’¬¡§«“¡æ√âÕ¡ (√–¬–∑’Ë

ºŸâªÉ«¬ºà“πæâπ¿“«–«‘°ƒµ‘À√◊Õ„π√–À«à“ß«—π∑’Ë 1-2À≈—ß√—∫‡¢â“√—°…“) ¥”‡π‘π°“√«“ß·ºπ®”Àπà“¬ µ“¡·ºπ°“√¥Ÿ·≈„ÀâºŸâªÉ«¬·≈–§√Õ∫§√—«¡’ à«π√à«¡

√–¬–∑’Ë 2 √–¬–Ωñ°∑—°…– (√–À«à“ß«—π∑’Ë 3-5À≈—ß√—∫‡¢â“√—°…“) ‡ªìπ°“√‡µ√’¬¡§«“¡æ√âÕ¡°àÕπ®”Àπà“¬‡æ◊ËÕ„ÀâºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈‰¥â√—∫°“√æ—≤π“∑—°…–‚¥¬∑’¡ À “¢“«‘™“™’æªØ‘∫—µ‘µ“¡·ºπ°“√¥Ÿ·≈ ·≈–¡’ ◊ËÕ‡æ◊ËÕ„™âª√–°Õ∫°“√„Àâ§«“¡√Ÿâ ‡™àπ·ºàπæ—∫ ‡√◊ËÕß°“√„ÀâÕ“À“√∑“ß “¬¬“ß °“√¥Ÿ·≈∑àÕÀ≈Õ¥≈¡§Õ °“√‡µ√’¬¡Õ“À“√º ¡ ·≈–°“√¥Ÿ·≈ºŸâªÉ«¬§“ “¬ «πªí “«– ‡ªìπµâπ ª√–‡¡‘π§«“¡ “¡“√∂‡ªìπ√–¬–Ê‡¡◊ËÕæ√âÕ¡·æ∑¬å®”Àπà“¬ ·≈– àßµàÕ‰ª ∂“π∫√‘°“√ ÿ¢¿“æ„°≈â∫â“π

√–¬–∑’Ë 3 √–¬–∫√‘°“√ ÿ¢¿“æ∑’Ë∫â“π (§√—Èß∑’Ë 1¿“¬„π —ª¥“Àå∑’Ë 1 À≈—ß®”Àπà“¬ºŸâªÉ«¬·≈–§√—ÈßµàÕ‰ªµ“¡ ¿“æªí≠À“·≈–§«“¡µâÕß°“√¢ÕßºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈) ‚¥¬∫ÿ§≈“°√ª√–®” ∂“π∫√‘°“√ ÿ¢¿“æ„°≈â∫â“π¡’æ¬“∫“≈ª√–®”»Ÿπ¬åœ ‡ªìπºŸâª√– “π°“√¥Ÿ·≈ „™â‡§√◊Õ¢à“¬„π™ÿ¡™π‡¢â“¡“¡’ à«π√à«¡ ·≈– ®—¥∫√‘°“√„Àâ

√Ÿª∑’Ë 4 ‰¥Õ–·°√¡«ß®√°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√√Õ∫∑’Ë 3 (1 ‡¡.¬. - 30 ¡‘.¬. æ.». 2549)


- ‰¥â√–∫∫°“√¥Ÿ·≈ºŸâªÉ«¬∑’Ë‡ªìπÕß§å√«¡§√Õ∫§ÿ¡™—¥‡®π¡“°¢÷Èπ

- —¡æ—π∏¿“æ√–À«à“ßºŸâ„Àâ°—∫ºŸâ„™â∫√‘°“√¡’¡“°¢÷Èπ- ª√–‡¡‘πªí≠À“·≈–§«“¡µâÕß°“√¢ÕßºŸâ„™â∫√‘°“√‰¥â‡√Á«·≈–§√Õ∫§≈ÿ¡¡“°¢÷Èπ

- °“√∑”ß“π‡ªìπ√–∫∫¡’§«“¡√—∫º‘¥™Õ∫¡“°¢÷Èπ- ºŸâ„™â∫√‘°“√‰¥â√—∫°“√¥Ÿ·≈‡Õ“„®„ àÕ¬à“ßµàÕ‡π◊ËÕßµ—Èß·µà·√°√—∫®π°≈—∫¡“µ√«®µ“¡π—¥

- æ—≤π“µπ‡Õß„π¥â“πÕß§å§«“¡√Ÿâ‡√◊ËÕß°“√«“ß·ºπ®”Àπà“¬∑—°…–°“√ ◊ËÕ “√ °“√„™â°√–∫«π°“√æ¬“∫“≈


- ºŸâ√à«¡«‘®—¬∑’Ë‡ªìπºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈¡’¿“«–‡§√’¬¥‡∫◊ËÕÀπà“¬- Õ—µ√“°”≈—ß‰¡à‡æ’¬ßæÕ ¿“√–ß“π¡“°‡°‘π

ª√—∫·ºπ

∑∫∑«π·≈–ª√—∫ª√ÿß·ºπ°“√¥Ÿ·≈æ—≤π“√–∫∫°“√¡Õ∫À¡“¬ß“π·∫∫ CM

°≈¬ÿ∑∏å

- √â“ß§«“¡æ÷ßæÕ„®‚¥¬°“√„Àâ°”≈—ß„®¢÷Èπ·π–„Àâ‡ÀÁπ§ÿ≥§à“°“√ªØ‘∫—µ‘

- –∑âÕπ§”™¡¢ÕßºŸâ„™â∫√‘°“√µ‘¥µ“¡·≈–ª√–‡¡‘πº≈µàÕ‡π◊ËÕß„Àâ¡’ à«π√à«¡„π°“√§‘¥·≈–µ—¥ ‘π

- ºŸâ∫√‘À“√°√–µÿâπ‡µ◊Õπ- Õ”π«¬§«“¡ –¥«°

ª√—∫ ·ºπ

–∑âÕπ °“√ªØ‘∫—µ‘

ªØ‘∫—µ‘ + —ß‡°µ

√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß‚√ßæ¬“∫“≈ °≈π§√



§”ª√÷°…“∑“ß‚∑√»—æ∑åµ≈Õ¥ 24 ™—Ë«‚¡ß ®”Àπà“¬®“°°“√¥Ÿ·≈µàÕ‡π◊ËÕß‡¡◊ËÕ¥Ÿ·≈µπ‡Õß‰¥â

®“°°“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æÕ¬à“ßµàÕ‡π◊ËÕß∑’Ë‡°‘¥¢÷Èπ„π√–¬–∑’Ë 3 ¡’¥—ßπ’È

º≈≈—æ∏åµàÕºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈

ºŸâªÉ«¬‚√§‡√◊ÈÕ√—ß ®”π«π 202 √“¬ ∑ÿ°√“¬‰¥â√—∫°“√«“ß·ºπ®”Àπà“¬ àßµàÕ ·≈–µ‘¥µ“¡‡¬’Ë¬¡∫â“π‚¥¬∑’¡ À “¢“«‘™“™’æ „π√“¬∑’Ë¡’°“√‡®Á∫ªÉ«¬ —∫´âÕπ65 √“¬ º≈¢Õß°“√¥Ÿ·≈Õ¬à“ß‡ªìπ√–∫∫∑”„ÀâºŸâªÉ«¬¡’Õ“°“√¥’¢÷Èπ √–¬–«—ππÕπ‚√ßæ¬“∫“≈≈¥≈ß ¡“µ√«®µ“¡π—¥∑ÿ°√“¬ ‰¡àæ∫¿“«–·∑√° âÕπ¿“¬À≈—ß®”Àπà“¬·≈–‰¡à¡’°“√°≈—∫‡¢â“√—°…“´È”¿“¬„π 28 «—π¥â«¬‚√§‡¥‘¡(µ“√“ß∑’Ë 1)

®“°°“√ª√–‡¡‘π§«“¡æ÷ßæÕ„®¢ÕßºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈„π°“√„Àâ∫√‘°“√ æ∫«à“ √–¥—∫§«“¡æ÷ßæÕ„®‡æ‘Ë¡¢÷Èπ ‡π◊ËÕß®“°‰¥â√—∫∫√‘°“√µ“¡§«“¡µâÕß°“√ ‰¥â¡’ à«π√à«¡„π°“√ «“ß·ºπ°“√¥Ÿ·≈µπ‡Õß ‰¥â√—∫§”·π–π”™à«¬‡æ‘Ë¡°”≈—ß„® ™à«¬·°âªí≠À“ ¥—ß∑’ËºŸâ¥Ÿ·≈∑’Ë√à«¡«‘®—¬°≈à“««à“

ç¡’ªí≠À“°Á∂“¡‰¥â ·≈â«‡¢“ Õπ„Àâ√Ÿâ∑ÿ° ‘Ëß∑’ËµâÕß°≈—∫‰ª¥Ÿ§π‰¢â Õ¬“°„Àâ¡’·∫∫π’È µ—Èßπ“π·≈â« §π‰¢â®–‰¥â°≈—∫∫â“π‡√Á«Êé (∫—π∑÷°¿“§ π“¡, 13 æƒ…¿“§¡æ.». 2548)

º≈≈—æ∏åµàÕºŸâ„Àâ∫√‘°“√·≈–‚√ßæ¬“∫“≈

°“√ª√–‡¡‘π§«“¡æ÷ßæÕ„®¢Õß∑’¡ ÿ¢¿“æ ∑ÿ°§πæ÷ßæÕ„®°—∫√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß∑’Ë‰¥â¡’ à«π√à«¡„π°“√ª√—∫ª√ÿß ‡ªìπ°“√ √â“ß§«“¡‡¢â“„®Õ—π¥’

µàÕ°—π ∑”„Àâª√– “π°“√¥Ÿ·≈°—∫∑’¡ ÿ¢¿“æ ™à«¬≈¥§«“¡´È”´âÕπ ·≈–‰¥â™à«¬°—πªÑÕß°—π·≈–·°â‰¢ªí≠À“

‚√ßæ¬“∫“≈‡°‘¥√–∫∫°“√¥Ÿ·≈µàÕ‡π◊ËÕß∑’Ë‡À¡“– ¡ ∑”„Àâ≈¥√–¬–«—ππÕπ ‚√ßæ¬“∫“≈ ·≈–ºŸâªÉ«¬‰¡à°≈—∫¡“√—°…“´È”¥—ß· ¥ß„πµ“√“ß∑’Ë 1

«‘®“√≥å

°“√æ—≤π“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß¢Õß‚√ßæ¬“∫“≈ °≈π§√¡’√–¬–°“√ª√—∫‡ª≈’Ë¬πµ“¡«ß®√°“√»÷°…“ 3 √–¬– ¥—ßπ’È

«ß®√∑’Ë 1 √–¬–‡¢â“„® ¿“æªí≠À“·≈–√à«¡°—πÀ“√Ÿª·∫∫„À¡à ¿“¬À≈—ß®—¥ª√–™ÿ¡‡™‘ßªØ‘∫—µ‘°“√‡√◊ËÕß°“√«“ß·ºπ®”Àπà“¬ºŸâªÉ«¬ ¡’°“√æ—≤π“√Ÿª·∫∫°“√«“ß·ºπ®”Àπà“¬‚¥¬°“√¡’ à«π√à«¡¢Õß∑’¡ ÿ¢¿“æ°—∫ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈ æ—≤π“·∫∫øÕ√å¡°“√∫—π∑÷°∑’Ë “¡“√∂„™â‰¥â°—∫ºŸâªÉ«¬∑ÿ°‚√§·≈–∑ÿ°ÀÕºŸâªÉ«¬ ·≈–√à«¡°—π®—¥∑”·π«∑“ß°“√ªØ‘∫—µ‘‡æ◊ËÕ°“√¥Ÿ·≈ºŸâªÉ«¬

«ß®√∑’Ë 2 √–¬–ª√—∫/∑¥≈Õß„™â√Ÿª·∫∫„À¡à ®—¥µ—Èß»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß ¡’æ¬“∫“≈ª√–®”»Ÿπ¬åœ‡ªìπºŸâª√– “πß“πÀ≈—°∑—Èß„π·≈–πÕ°‚√ßæ¬“∫“≈ ¡’°“√√à«¡°—π·≈°‡ª≈’Ë¬π‡√’¬π√Ÿâ√–À«à“ß∑’¡‡æ◊ËÕæ—≤π“·∫∫∫—π∑÷°‡æ◊ËÕ°“√¥Ÿ·≈µàÕ‡π◊ËÕß ·≈–‡æ‘Ë¡∫√‘°“√„Àâ§”ª√÷°…“∑“ß‚∑√»—æ∑åµ≈Õ¥ 24 ™—Ë«‚¡ß

«ß®√∑’Ë 3 √–¬–ª√—∫°‘®°√√¡·≈–æ—≤π“√Ÿª·∫∫∑’Ë‡À¡“– ¡‡æ◊ËÕ„Àâ‡°‘¥§«“¡æ÷ßæÕ„® ∑”„Àâ‡°‘¥°√–∫«π°“√∑”ß“π‡æ◊ËÕ„ÀâºŸâ„™â∫√‘°“√‰¥â√—∫°“√¥Ÿ·≈∑’ËµàÕ‡π◊ËÕß

µ“√“ß∑’Ë 1 µ—«™’È«—¥°“√¥Ÿ·≈ºŸâªÉ«¬µàÕ‡π◊ËÕß‚¥¬√«¡°àÕπ·≈–À≈—ß°“√æ—≤π“√–∫∫

µ—«™’È«—¥ ‡°≥±å °àÕπ À≈—ß §«“¡·µ°µà“ß

ºŸâªÉ«¬‰¥â√—∫°“√«“ß·ºπ®”Àπà“¬ (√âÕ¬≈–) 80 33.91 100 +66.09

Õ—µ√“§«“¡æ÷ßæÕ„® (√âÕ¬≈–) 85 79.43 90.38 +10.95

Re-admission „π 28 «—π (√âÕ¬≈–) ≈¥≈ß 2.82 0 2.82

√–¬–«—ππÕπ‚√ßæ¬“∫“≈‡©≈’Ë¬ («—π) ≈¥≈ß 5 3.71 1.39

Õ—µ√“·øÑ¡¢âÕ¡Ÿ≈ºŸâªÉ«¬∑’Ë¡’°“√∫—π∑÷°§√∫∂â«π (√âÕ¬≈–) 80 49.22 70.20 +20.28

8

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

®“°°√–∫«π°“√∑”ß“πæ∫«à“√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß¢Õß‚√ßæ¬“∫“≈ °≈π§√¡’°√–∫«π°“√¥Ÿ·≈§√Õ∫§≈ÿ¡µ—Èß·µà·√°√—∫®π∂÷ß®”Àπà“¬°≈—∫∫â“π‚¥¬∑’¡ À “¢“«‘™“™’æ∑—Èß„π·≈–πÕ°‚√ßæ¬“∫“≈‚¥¬¡’»Ÿπ¬å¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß∑”°“√‡™◊ËÕ¡‚¬ß‡æ◊ËÕ„Àâ‡°‘¥°“√ª√– “πß“π∑’Ë¥’ ´÷Ëß‡ªìπ ‘Ëß®”‡ªìπ·≈– ”§—≠ Õ¥§≈âÕß°—∫ ¢âÕ§âπæ∫®“°ß“π»÷°…“∑’Ë ª“√å‡∫≈(Sparbel) ·≈– ·Õπ‡¥Õ√å —π (Anderson)7 ‰¥â∑∫∑«π·≈–¬◊π¬—π«à“À“°¿“¬„πÕß§å°√¡’√–∫∫°“√ª√– “πß“π∑’Ë¥’√–À«à“ß∫ÿ§≈“°√„π∑’¡ ®–™à«¬„Àâ°“√¥”‡π‘πß“π‡æ◊ËÕ°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß¡’ª√– ‘∑∏‘¿“æ

¢âÕ‡ πÕ·π–°“√¥Ÿ·≈ ÿ¢¿“æºŸâªÉ«¬‡√◊ÈÕ√—ß„Àâ‰¥â§ÿ≥¿“æπ—Èπ

§«√¡’°“√∑”ß“π√à«¡°—π√–À«à“ß∑’¡ ÿ¢¿“æ°—∫ºŸâªÉ«¬·≈–ºŸâ¥Ÿ·≈ ‡æ◊ËÕ‡ªìπ°“√·≈°‡ª≈’Ë¬π∑—Èß¥â“π§«“¡√Ÿâ ·≈–ª√– ∫°“√≥å∑’Ë¡’§«“¡·µ°µà“ß°—π

√–∫∫°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕßπ—Èπ®–µâÕß§”π÷ß∂÷ßºŸâ„™â∫√‘°“√‡ªìπ»Ÿπ¬å°≈“ß ‡ªìπÕß§å√«¡ ·≈–¡’§«“¡µàÕ‡π◊ËÕß‡™◊ËÕ¡‚¬ß®“°‚√ßæ¬“∫“≈ Ÿà∫â“π ‚¥¬°“√„™â»—°¬¿“æ∑’Ë¡’Õ¬Ÿà¡“„™â„π™’«‘µª√–®”«—π„Àâ¡“°∑’Ë ÿ¥

§«√°”Àπ¥·π«∑“ß°“√¥Ÿ·≈ºŸâªÉ«¬∑—È ß∑’Ë ‚√ßæ¬“∫“≈·≈–∑’Ë∫â“π „Àâ·°àºŸâ¥Ÿ·≈ ‚¥¬∑’¡ ÿ¢¿“æµâÕßµ√–Àπ—°∂÷ß§«“¡ ”§—≠¢Õß°“√„Àâ§”ª√÷°…“ ·≈–°“√∑∫∑«π°“√Ωñ°ªØ‘∫—µ‘

∑’¡¥Ÿ·≈ ÿ¢¿“æ∑’Ë∫â“π §«√ª√–¬ÿ°µå°“√®—¥°“√¥â“π ‘Ë ß·«¥≈âÕ¡„Àâ ‡¢â“°—∫«‘∂’™’«‘µ¢ÕßºŸâªÉ«¬·≈–§√Õ∫§√—«„Àâ¡“°∑’Ë ÿ¥ √«¡∑—Èß°“√ª√–¬ÿ°µå„™âÕÿª°√≥å∑“ß°“√·æ∑¬å ·≈–°“√®—¥∑’ËÕ¬ŸàÕ“»—¬„Àâ‡À¡“– ¡°—∫≈—°…≥–°“√‡®Á∫ªÉ«¬ ‡ªìπµâπ

°“√ ‘Èπ ÿ¥°“√¥Ÿ·≈ ÿ¢¿“æµàÕ‡π◊ËÕß¢÷ÈπÕ¬Ÿà°—∫

‡Õ° “√Õâ“ßÕ‘ß

1. ‡Õ¡Õ√ §”¿—°¥’. °“√æ—≤π“°“√«“ß·ºπ®”Àπà“¬°“√®”Àπà“¬ºŸâªÉ«¬¢Õßæ¬“∫“≈ª√–®”°“√‚√ßæ¬“∫“≈ ‡¢“ «π°«“ß ®—ßÀ«—¥¢Õπ·°àπ. √“¬ß“π°“√»÷°…“Õ‘ √–ª√‘≠≠“æ¬“∫“≈»“ µ√¡À“∫—≥±‘µ “¢“«‘™“∫√‘À“√°“√æ¬“∫“≈ ∫—≥±‘µ«‘∑¬“≈—¬ ¡À“«‘∑¬“≈—¬¢Õπ·°àπ; 2546.

2. ÿ¿’ ∫√‘∫Ÿ√≥å. °“√æ—≤π“°“√ªØ‘∫—µ‘°“√«“ß·ºπ®”Àπà“¬‚√ßæ¬“∫“≈™ÿ¡™π·ÀàßÀπ÷Ëß ®—ßÀ«—¥√âÕ¬‡ÕÁ¥. «‘∑¬“π‘æπ∏åæ¬“∫“≈»“ µ√å¡À“∫—≥±‘µ “¢“°“√æ¬“∫“≈™ÿ¡™π∫—≥±‘µ«‘∑¬“≈—¬ ¡À“«‘∑¬“≈—¬¢Õπ·°àπ; 2548.

3. »Ÿπ¬å¢âÕ¡Ÿ≈¢à“« “√. √ÿª ∂‘µ‘¢âÕ¡Ÿ≈°“√∫√‘°“√‚√ßæ¬“∫“≈ °≈π§√ ª√–®”ªï 2546-2548. °≈π§√: °≈ÿà¡ß“πæ—≤π“∫√‘°“√·≈–«‘™“°“√ ‚√ßæ¬“∫“≈ °≈π§√; 2548.

4. Kemmis SB, Mctaggart R. The action researchplanner. 3rd ed. Vicoria: Deakin University; 1988.

5. ‡°…‘≥’ ‡æ™√»√’, πßπÿ™ ∫ÿ≠¬—ß, π∑’ ‡°◊ÈÕ°Ÿ≈°‘®°“√. °“√®—¥°“√¥â“π§ÿ≥¿“æ„π°“√«“ß·ºπ®”Àπà“¬¢ÕßÀ—«Àπâ“ÀÕºŸâªÉ«¬„π‚√ßæ¬“∫“≈¡À“«‘∑¬“≈—¬ ·≈–‚√ßæ¬“∫“≈»Ÿπ¬å„π¿“§„µâ. ß¢≈“π§√‘π∑√å‡«™ “√ 2549; 24:19-26.

6. ¢«—≠µ“ ∫“≈∑‘æ¬å, “≈’ ‡©≈‘¡«√√≥æß»å, ≈—æ≥“ °‘®√ÿàß‚√®πå,»‘√‘«√√≥ æ‘√‘¬§ÿ≥∏√. °“√∑∫∑«π§«“¡√Ÿâß“π«‘®—¬∑“ß°“√æ¬“∫“≈∑’Ë‡°’Ë¬«¢âÕß°—∫ºŸâ¥Ÿ·≈ºŸâªÉ«¬√–∫∫ª√– “∑·≈–‰¢ —πÀ≈—ß „πª√–‡∑»‰∑¬ √–À«à“ßªï æ.». 2534-æ.». 2543.«“√ “√æ¬“∫“≈ ß¢≈“π§√‘π∑√å 2546; 23:1-28.

7. Sparbel KJH, Anderson MA. Integrated literature re-

view of continuity of care : Part 1, conceptual issue.

Journal of Nursing Scholarship 2000; 32:17-24.

§«“¡ “¡“√∂„π°“√¥Ÿ·≈µπ‡Õß·≈–§ÿ≥¿“æ™’«‘µ¢ÕßºŸâ„™â∫√‘°“√

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ √».¥√. ¡®‘µ ·¥π ’·°â« πæ.«—π™—¬®à“¬‡®√‘≠ ·≈– Õ.¥√.∑—¥∑√«ß ªÿ≠≠∑≈—ß§å ºŸâ∑√ß§ÿ≥«ÿ≤‘·≈–∑’Ëª√÷°…“ß“π«‘®—¬ ·≈–¢Õ∫§ÿ≥ºŸâªÉ«¬ ºŸâ¥Ÿ·≈ ∑’Ë√à«¡æ—≤π“√–∫∫°“√¥Ÿ·≈∑’Ë‡À¡“– ¡ ”À√—∫√æ. π.




°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°Õ¬à“ßµàÕ‡π◊ËÕß„π®—ßÀ«—¥ °≈π§√æ√™—¬ ®—π∑√åß“¡ æ.∫.*‰æ≈‘π π—¥ —π‡∑’¬– æ¬.¡.***°≈ÿà¡ß“π°ÿ¡“√‡«™°√√¡ ‚√ßæ¬“∫“≈ °≈π§√**°≈ÿà¡ß“π°“√æ¬“∫“≈ ‚√ßæ¬“∫“≈ °≈π§√

Abstract Development of Continuing Management Quality for Dengue Hemorrhagic FeverPatients in Sakon Nakhon ProvinceChanngam P.*, Nadsantia P.**

*Department of Pediatrics, Sakon Nakhon hospital, Sakon Nakhon 47000 Thailand**Department of Nursing , Sakon Nakhon hospital, Sakon Nakhon 47000 Thailand


The aim of this action research was to identify the problems and develop the continuingmanagement quality and referral system for dengue hemorrhagic fever patients in Sakon Nakhon province.The period of the study during 2002-2007. The target population were 39 physicians and 194 nurses from 18hospitals in Sakon Nakhon province, and 1,013 cases of dengue hemorrhagic fever patients. The study wasdivided into 2 phases, phases I was situational analysis and management assessment, and phases II composedof planning and implementation including training, annual conference of dengue hemorrhagic fever, clinicalpractice guideline for dengue hemorrhagic fever management, dengue chart record development, dead casesand interesting cases conference, hot line and dengue corner, dengue hemorrhagic fever demonstration ward,visiting and studying support for physicians and nurses, monitoring and supervision, and evaluation. Theresult revealed that the first year, there were 4 dead cases, 3 cases died from fluid over load and 1 case fromprolong shock with internal bleeding. There were high rate of an incorrected administration of intravenousfluid at the febrile period and plasma leakage or shock period, incompleted of dengue charts, delayed andincorrected plasma leakage or shock evaluations, fluid over load in the referred patients. The final resultrevealed that the dead case, the complication with fluid over load, the length of staying in hospital weredecreased whereas the completed dengue charts of referred patients, the proper administration of intravenousfluid, the proper evaluation of shock were increased. The conclusion showed that this action research has beensuccessful and benefits to improve the management and referral system for dengue hemorrhagic feverpatients. This model should be the public health policy in order to reduce mortality and complication rate ofdengue hemorrhagic fever patients.

Key words: dengue hemorrhagic fever, continuing management quality

10

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

∂“π°“√≥å‚√§‰¢â‡≈◊Õ¥ÕÕ°¢Õßª√–‡∑»‰∑¬¬—ß¡’°“√√–∫“¥√ÿπ·√ß1 ¡’Õ—µ√“ªÉ«¬·≈–Õ—µ√“ªÉ«¬µ“¬„π√–¥—∫ Ÿß®πµâÕß¡’°“√∫√√®ÿ„π·ºπæ—≤π“‡»√…∞°‘®·≈– —ß§¡·Ààß™“µ‘®π∂÷ßªí®®ÿ∫—π (©∫—∫∑’Ë 10 æ.». 2550 -æ.». 2554) ·≈–¡’‚§√ß°“√æ—≤π“«‘™“°“√·≈–‡∑§‚π‚≈¬’‡æ◊ËÕªÑÕß°—π·≈–§«∫§ÿ¡‚√§‰¢â‡≈◊Õ¥ÕÕ°‡©≈‘¡æ√–‡°’¬√µ‘Õ¬à“ßµàÕ‡π◊ËÕßµ—Èß·µàªï æ.». 25422 ‡ªìπµâπ¡“ ¬—ßæ∫«à“¡’°“√√–∫“¥∑ÿ°Ê ªï·≈–æ∫«à“¡’ºŸâªÉ«¬‡ ’¬™’«‘µ∑—Èß‡¥Á°·≈–ºŸâ„À≠à ”À√—∫®—ßÀ«—¥ °≈π§√‡ªìπæ◊Èπ∑’Ë∑’Ë¡’°“√√–∫“¥¢Õß‚√§‰¢â‡≈◊Õ¥ÕÕ°‡¥ß°’Ëµ≈Õ¥ªï ‚¥¬‡©æ“–„πªï æ.». 2545 ¡’ºŸâªÉ«¬‡¥Á°‡ ’¬™’«‘µ¡“°∂÷ß 4 √“¬¥â«¬ “‡Àµÿµà“ßÊ °—π Õ’°∑—Èß¬—ß¡’°“√√—°…“æ¬“∫“≈∑’ËÀ≈“°À≈“¬¢Õß·æ∑¬å∑—Èß„π‚√ßæ¬“∫“≈™ÿ¡™π·≈–‚√ßæ¬“∫“≈∑—Ë«‰ª„π®—ßÀ«—¥ °≈π§√ ∑’Ë‰¡à‡ªìπ·π«∑“ß‡¥’¬«°—π‡ªìπ¢âÕ∫°æ√àÕß„π°“√«‘π‘®©—¬·≈–√—°…“‚√§‰¢â‡≈◊Õ¥ÕÕ° §≥–ºŸâ«‘®—¬ ÷Ëß‡ªìπ∑’Ëª√÷°…“°“√√—°…“æ¬“∫“≈‚√§‰¢â‡≈◊Õ¥ÕÕ°¢Õß®—ßÀ«—¥ °≈π§√®÷ß‰¥â∑”°“√«‘®—¬‡æ◊ËÕÀ“√Ÿª·∫∫°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°„Àâ§√Õ∫§≈ÿ¡∑—Èß®—ßÀ«—¥Õ¬à“ßµàÕ‡π◊ËÕß

«—µ∂ÿ·≈–«‘∏’°“√

°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√·∫∫¡’ à«π√à«¡‡æ◊ËÕæ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈·≈–√–∫∫°“√ àßµàÕºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°„π®—ßÀ«—¥ °≈π§√ √–À«à“ßªïæ.». 2545 - æ.». 2550 ‡ªìπ√–¬–‡«≈“ 5 ªï ª√–™“°√°≈ÿà¡‡ªÑ“À¡“¬ª√–°Õ∫¥â«¬

ºŸâªÉ«¬‡¥Á°‚√§‰¢â‡≈◊Õ¥ÕÕ°∑’Ë√—∫‰«â√—°…“„π‚√ßæ¬“∫“≈ °≈π§√∑—ÈßÀ¡¥„πªï æ.». 2545 - æ.». 2550®”π«π 1,013 √“¬ ‡ªìπºŸâªÉ«¬∑’Ë¡“√—∫°“√√—°…“‡Õß 688√“¬ ·≈–ºŸâªÉ«¬∑’Ë√—∫°“√ àßµàÕ®“°‚√ßæ¬“∫“≈™ÿ¡™π325 √“¬

·æ∑¬å·≈–æ¬“∫“≈∑’Ë ‡°’Ë¬«¢âÕß°—∫°“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕÕ° „π‚√ßæ¬“∫“≈™ÿ¡™π·≈–‚√ßæ¬“∫“≈∑—Ë«‰ª¢Õß®—ßÀ«—¥ °≈π§√®”π«π 18 ·Ààß ‡ªìπ·æ∑¬å ®”π«π 39 §π·≈–æ¬“∫“≈ ®”π«π 194 §π

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√»÷°…“ ª√–°Õ∫¥â«¬·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫§«“¡æ√âÕ¡¥â“π ∂“π∑’Ë

§√ÿ¿—≥±å°“√·æ∑¬å∑’Ë®”‡ªìπ„π‚√ßæ¬“∫“≈™ÿ¡™π ·≈–¥â“π«‘™“°“√¢Õß·æ∑¬å æ¬“∫“≈∑’Ë‡°’Ë¬«¢âÕß°—∫°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°

‡√◊ËÕß¬àÕ °“√»÷°…“§√—Èßπ’È‡ªìπ°“√«‘®—¬‡™‘ßªØ‘∫—µ‘°“√‡æ◊ËÕæ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈·≈–√–∫∫°“√ àßµàÕºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°„π®—ßÀ«—¥ °≈π§√√–À«à“ßªï æ.». 2545 - æ.». 2550 ‚¥¬¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“ªí≠À“·≈–·π«∑“ß°“√æ—≤π“°“√«‘π‘®©—¬°“√√—°…“æ¬“∫“≈ ·≈–°“√ àßµàÕºŸâªÉ«¬ ‚¥¬»÷°…“„π·æ∑¬å 39 §π ·≈–æ¬“∫“≈ 194 §π®“°‚√ßæ¬“∫“≈∑—Ë«‰ª·≈–‚√ßæ¬“∫“≈™ÿ¡™π 18 ·Ààß„π®—ßÀ«—¥ °≈π§√ ºŸâªÉ«¬‡¥Á°‚√§‰¢â‡≈◊Õ¥ÕÕ° 1,013 √“¬ °“√»÷°…“·∫àßÕÕ°‡ªìπ 2 √–¬– √–¬–∑’Ë 1 °“√«‘‡§√“–Àå ∂“π°“√≥å·≈–ª√–‡¡‘π§«“¡æ√âÕ¡¥â“π°“√√—°…“æ¬“∫“≈ √–¬–∑’Ë 2 ¢—Èπ°“√¥”‡π‘π°“√ ‚¥¬°“√‡µ√’¬¡§«“¡æ√âÕ¡¢Õß∫ÿ§≈“°√ °“√Õ∫√¡‡æ‘Ë¡æŸπ§«“¡√Ÿâ °“√®—¥∑”§Ÿà¡◊Õ·≈–·π«∑“ß°“√√—°…“æ¬“∫“≈ °“√æ—≤π“√–∫∫∫—π∑÷°‡«™√–‡∫’¬π ®—¥ÀÕºŸâªÉ«¬°ÿ¡“√‡«™°√√¡‡ªìπÀπà«¬ “∏‘µ ®—¥µ—Èß»Ÿπ¬å hot line ·≈– dengue corner ®—¥‚§√ß°“√‰¢â‡≈◊Õ¥ÕÕ° —≠®√ π—∫ πÿπ°“√»÷°…“¥Ÿß“π¢Õß∫ÿ§≈“°√ ®—¥∑” case conference ∑∫∑«π§Ÿà¡◊Õ°“√√—°…“æ¬“∫“≈·≈–ª√—∫ª√ÿß·π«ªØ‘∫—µ‘ µ‘¥µ“¡·≈–π‘‡∑»ß“π ·≈–°“√ª√–‡¡‘πº≈ º≈°“√»÷°…“„πªï·√°æ∫«à“ ¡’ºŸâªÉ«¬‡ ’¬™’«‘µ 4 √“¬ ‡ ’¬™’«‘µ®“°¿“«–πÈ”‡°‘π 3 √“¬ ‡ ’¬™’«‘µ®“°¿“«–™ÁÕ°π“π·≈–‡≈◊Õ¥ÕÕ°¿“¬„π 1 √“¬ ¬—ß¡’·æ∑¬å®”π«π¡“°„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π√–¬–µà“ßÊ ‰¡à∂Ÿ°µâÕß ª√–‡¡‘π¿“«–æ≈“ ¡“√—Ë«À√◊Õ™ÁÕ°‰¡à∂Ÿ°µâÕß ¡’¿“«–πÈ”‡°‘π„πºŸâªÉ«¬ àßµàÕ®”π«π¡“° §«“¡ ¡∫Ÿ√≥å¢Õß·∫∫∫—π∑÷°°“√ —ß‡°µÕ“°“√‰¢â‡≈◊Õ¥ÕÕ°∑’Ë àßµàÕ‰¡à§√∫∂â«π À≈—ß°“√¥”‡π‘πß“πæ∫«à“¡’ºŸâªÉ«¬‡ ’¬™’«‘µ≈¥≈ß ¿“«–πÈ”‡°‘π„πºŸâªÉ«¬ àßµàÕ≈¥≈ß ·≈–®”π«π«—π∑’ËºŸâªÉ«¬πÕπ√—°…“„π‚√ßæ¬“∫“≈‡©≈’Ë¬≈¥≈ß∑ÿ°ªï µ“¡≈”¥—∫ §«“¡ ¡∫Ÿ√≥å¢Õß·∫∫∫—π∑÷°°“√ —ß‡°µÕ“°“√‰¢â‡≈◊Õ¥ÕÕ°∑’Ë àß¡“°—∫ºŸâªÉ«¬ àßµàÕ‡æ‘Ë¡¢÷Èπ∑ÿ°ªï®π∂÷ß√âÕ¬≈– 100 §«“¡∂Ÿ°µâÕß¢Õß°“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”‡æ‘Ë¡¢÷Èπ∑ÿ°ªï §«“¡∂Ÿ°µâÕß¢Õß°“√ª√–‡¡‘π¿“«–™ÁÕ°‚¥¬·æ∑¬å·≈–æ¬“∫“≈‡æ‘Ë¡¡“°¢÷Èπµ“¡≈”¥—∫ º≈°“√»÷°…“π’È· ¥ß„Àâ‡ÀÁπ«à“√Ÿª·∫∫°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°¢Õß®—ßÀ«—¥ °≈π§√ª√– ∫§«“¡ ”‡√Á® ´÷Ëß§«√®—¥∑”‡ªìππ‚¬∫“¬ “∏“√≥ ÿ¢‡æ◊ËÕæ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°Õ¬à“ß ¡Ë”‡ ¡Õ·≈–µàÕ‡π◊ËÕß ‡æ◊ËÕ≈¥Õ—µ√“µ“¬·≈–¿“«–·∑√°´âÕπ¢Õß‚√§‰¢â‡≈◊Õ¥ÕÕ°

§” ”§—≠: ‰¢â‡≈◊Õ¥ÕÕ° §ÿ≥¿“æ°“√√—°…“æ¬“∫“≈Õ¬à“ßµàÕ‡π◊ËÕß



·∫∫∫—π∑÷°¢âÕ¡Ÿ≈‡°’Ë¬«°—∫ºŸâªÉ«¬ ¡’ 2 à«π ‰¥â·°à·∫∫∫—π∑÷°¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâªÉ«¬ ·≈–·∫∫∫—π∑÷°°“√«‘π‘®©—¬ °“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕ

‡°≥±å°“√«‘π‘®©—¬‚√§‰¢â‡≈◊Õ¥ÕÕ°¢ÕßÕß§å°“√Õπ“¡—¬‚≈°3

§Ÿà¡◊Õ·π«∑“ß°“√«‘π‘®©—¬·≈–°“√√—°…“‚√§‰¢â‡≈◊Õ¥ÕÕ°¢Õß°√–∑√«ß “∏“√≥ ÿ¢©∫—∫ªï æ.». 2542·≈– æ.». 25462,4

°“√¥”‡π‘π°“√»÷°…“ ·∫àß‡ªìπ 2 √–¬– §◊Õ√–¬–∑’Ë 1 ¢—Èπ‡µ√’¬¡°“√ ¥”‡π‘π°“√„πªï æ.».

2545 ‚¥¬«‘‡§√“–Àå ∂“π°“√≥å·≈–ª√–‡¡‘π§«“¡æ√âÕ¡‡°’Ë¬«°—∫°“√√—°…“æ¬“∫“≈‚√§‰¢â‡≈◊Õ¥ÕÕ°„π®—ßÀ«—¥ °≈π§√¥â“π«‘™“°“√ §«“¡√Ÿâ¢Õß·æ∑¬å·≈–æ¬“∫“≈ ¥â“π°“√∫√‘À“√®—¥°“√ ∂“π∑’Ë §√ÿ¿—≥±å°“√·æ∑¬å∑’Ë®”‡ªìπ„π‚√ßæ¬“∫“≈™ÿ¡™π·≈–‚√ßæ¬“∫“≈∑—Ë«‰ª ·≈–®—¥∑”·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°

√–¬–∑’Ë 2 ¢—Èπ¥”‡π‘π°“√ ¥”‡π‘π°“√√–À«à“ß ªïæ.». 2546 - æ.». 2550 ª√–°Õ∫¥â«¬ 3 ¢—ÈπµÕπ¥—ßπ’È

¢—ÈπµÕπ∑’Ë 1 °“√‡µ√’¬¡∫ÿ§≈“°√ „π√–À«à“ßªï æ.». 2545 - æ.». 2546 ‚¥¬ºŸâ«‘®—¬µ‘¥µàÕª√– “πß“π°—∫°√¡°“√·æ∑¬å ”π—°ß“πª≈—¥°√–∑√«ß “∏“√≥ ÿ¢‡æ◊ËÕ¢Õ‡ªìπÀπà«¬Õ”π«¬°“√„π°“√®—¥ª√–™ÿ¡·≈–Õ∫√¡·æ∑¬å æ¬“∫“≈∑’Ë‡°’Ë¬«¢âÕß°—∫°“√«‘π‘®©—¬√—°…“æ¬“∫“≈ ·≈– àßµàÕºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ° ‡¢µ 6 À≈—ß®“°π—Èπ ºŸâ«‘®—¬ª√–™ÿ¡·≈–·µàßµ—Èß§≥–°√√¡¥”‡π‘πß“πæ—≤π“§ÿ≥¿“æ°“√¥Ÿ·≈√—°…“‚√§‰¢â‡≈◊Õ¥ÕÕ° ®—ßÀ«—¥ °≈π§√ √à«¡°—∫ ”π—°ß“π “∏“√≥ ÿ¢®—ßÀ«—¥

¢—ÈπµÕπ∑’Ë 2 °“√∑¥≈ÕßªØ‘∫—µ‘·≈– –∑âÕπ°“√ªØ‘∫—µ‘ „π√–À«à“ßªï æ.». 2546 - æ.». 2549 ¥—ßπ’È

®—¥Õ∫√¡‡æ◊ËÕ‡æ‘Ë¡æŸπ§«“¡√Ÿâ·≈–∑—°…–·°à·æ∑¬å·≈–æ¬“∫“≈∑’Ë ”‡√Á®°“√»÷°…“„À¡à ‡æ◊ËÕ„Àâ‡¢â“„®√–∫∫°“√¥”‡π‘πß“πæ—≤π“§ÿ≥¿“æ°“√¥Ÿ·≈√—°…“‚√§‰¢â‡≈◊Õ¥ÕÕ°

°“√®—¥∑”§Ÿà¡◊Õ·≈–∑”·π«∑“ß°“√√“¬ß“π·æ∑¬å‚¥¬¡’¢âÕ∫àß™’È∑’Ë™—¥‡®π∑’Ëæ¬“∫“≈®–µâÕß√“¬ß“π·æ∑¬å ‡™àπ º≈CBC ®”π«π‡°≈Á¥‡≈◊Õ¥ °“√‡ª≈’Ë¬π·ª≈ß¢Õß§à“ Hematocrit ª√‘¡“≥ªí “«–∑’Ë

≈¥≈ßπâÕ¬°«à“ 0.5 ´’´’/°‘‚≈°√—¡/™—Ë«‚¡ß Õ“°“√·≈–Õ“°“√· ¥ß¢Õß¿“«–™ÁÕ° °“√‡ª≈’Ë¬π·ª≈ß°“√√Ÿâ µ‘µ≈Õ¥®πÕ“°“√∑âÕßÕ◊¥·πàπÕ÷¥Õ—¥ À“¬„®≈”∫“°‡ªìπµâπ ¢—ÈπµÕπ°“√ —ß‡°µ·≈–√“¬ß“π·æ∑¬å‰¥â‡À¡“– ¡∑—π‡«≈“ √–∫∫°“√ àßµàÕ‡πâπ„Àâ¡’°“√ àßDengue chart ∑ÿ°√“¬

®—¥∑” Dead case conference ∑ÿ°√“¬ ·≈–®—¥∑” Interesting case conference „π‚√ßæ¬“∫“≈™ÿ¡™π∑ÿ°·Ààß

®—¥ÀÕºŸâªÉ«¬°ÿ¡“√‡«™°√√¡„π‚√ßæ¬“∫“≈ °≈π§√‡ªìπÀπà«¬ “∏‘µ¥â“π°“√√—°…“æ¬“∫“≈‚√§‰¢â‡≈◊Õ¥ÕÕ°

æ—≤π“√–∫∫°“√∫—π∑÷°‡«™√–‡∫’¬π·≈–°“√√“¬ß“π·æ∑¬å

®—¥µ—Èß»Ÿπ¬åŒÕ∑‰≈πå (Hot line) ‰¢â‡≈◊Õ¥ÕÕ°¢Õß®—ßÀ«—¥„Àâ§”ª√÷°…“°“√√—°…“æ¬“∫“≈‚√§‰¢â‡≈◊Õ¥ÕÕ° µ≈Õ¥ 24 ™—Ë«‚¡ß ·≈– Dengue corner „π·ºπ°ºŸâªÉ«¬©ÿ°‡©‘π‚√ßæ¬“∫“≈ °≈π§√

®—¥ª√–™ÿ¡«‘™“°“√ —≠®√°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°‚¥¬„™âæ◊Èπ∑’Ë®—ßÀ«—¥ °≈π§√

π—∫ πÿπ°“√»÷°…“¥Ÿß“π¢Õß·æ∑¬å·≈–æ¬“∫“≈∑’Ë‡°’Ë¬«¢âÕß®“°‚√ßæ¬“∫“≈™ÿ¡™π

∑∫∑«π§Ÿà¡◊Õ°“√√—°…“æ¬“∫“≈·≈–ª√—∫ª√ÿß·π«ªØ‘∫—µ‘Õ¬à“ßµàÕ‡π◊ËÕß∑ÿ°ªï ‡™àπ °“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π√–¬–«‘°ƒµ‘®“°‡¥‘¡„Àâ 5 ’ ’/°‘‚≈°√—¡/™—Ë«‚¡ß ‡ªìπ 1.5 ´’´’/°‘‚≈°√—¡/™—Ë«‚¡ß ·≈–°“√„Àâ 10%Hesteril µàÕ®“° Dextran °√≥’ºŸâªÉ«¬‰¥â Dextran §√∫30 ’ ’/°‘‚≈°√—¡µ“¡·π«∑“ß¢Õß°√–∑√«ß “∏“√≥ ÿ¢4

°“√®—¥‚§√ß°“√‰¢â‡≈◊Õ¥ÕÕ° —≠®√‚¥¬¡’°ÿ¡“√·æ∑¬å‚√ßæ¬“∫“≈ °≈π§√‡ªìπÀ—«Àπâ“∑’¡‡æ◊ËÕÕ∫√¡·≈–„Àâ§”ª√÷°…“·°à∫ÿ§≈“°√„π‚√ßæ¬“∫“≈™ÿ¡™π´÷Ëß·∫àß‡ªìπ‡¢µ„Àâ –¥«°„π°“√π‘‡∑»·≈–µ‘¥µ“¡°“√¥”‡π‘πß“πµ“¡µ—«™’È«—¥ ·≈–ª√–‡¡‘π°“√ªØ‘∫—µ‘µ“¡·π«∑’Ë°”Àπ¥‰«âÕ¬à“ßµàÕ‡π◊ËÕß

µ‘¥µ“¡·≈–π‘‡∑»ß“π°“√√—°…“æ¬“∫“≈µ“¡¡“µ√∞“π°√–∑√«ß “∏“√≥ ÿ¢

¢—ÈπµÕπ∑’Ë 3 °“√ª√–‡¡‘πº≈ ¥”‡π‘π°“√„π

12

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

√–À«à“ßªï æ.». 2549-2550°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈ «‘‡§√“–Àå¢âÕ¡Ÿ≈‚¥¬„™â§à“

‡©≈’Ë¬ √âÕ¬≈–

º≈

®“°°“√«‘‡§√“–Àå ∂“π°“√≥åæ∫«à“°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‡¥Á°‰¢â‡≈◊Õ¥ÕÕ°∑’Ë àßµàÕ¡“®“°‚√ßæ¬“∫“≈™ÿ¡™π„πªï æ.». 2545 ®”π«π 54 √“¬ à«π„À≠à‰¥â√—∫ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”‰¡à∂Ÿ°µâÕß„π√–¬–æ≈“ ¡“√—Ë«À√◊Õ™ÁÕ° √Õß≈ß¡“‡ªìπ°“√„Àâ “√πÈ”‰¡à∂Ÿ°µâÕß„π√–¬–‰¢â °“√ª√–‡¡‘πæ≈“ ¡“√—Ë«À√◊Õ™ÁÕ°‰¡à∂Ÿ°µâÕßÀ√◊Õ™â“ °“√ª√–‡¡‘π‡≈◊Õ¥ÕÕ°¿“¬„π‰¡à∂Ÿ°µâÕß√âÕ¬≈– 57.4, 51.9, 50.0 ·≈– 16.7 µ“¡≈”¥—∫ ·≈–√âÕ¬≈– 50 ¡’¿“«–·∑√° âÕπ®“°°“√√—°…“ ¿“«–·∑√°´âÕπ à«π„À≠à‡ªìπ fluid overload √Õß≈ß¡“‡ªìπprolong shock, internal bleeding, severe metabolicacidosis, hepatic failure ·≈–respiratory failure§‘¥‡ªìπ√âÕ¬≈– 37.0, 3.8, 3.8, 1.8, 1.8, 1.8 µ“¡≈”¥—∫·≈–æ∫«à“¡’ºŸâªÉ«¬‡ ’¬™’«‘µ 4 √“¬

”À√—∫§«“¡æ√âÕ¡‡°’Ë¬«°—∫°“√√—°…“æ¬“∫“≈¥â“πµà“ßÊ æ∫«à“¡’§«“¡æ√âÕ¡¥â“πÕ“§“√ ∂“π∑’Ë·≈–ÀÕºŸâªÉ«¬¡’§√ÿ¿—≥±å°“√·æ∑¬å∑’Ë®”‡ªìπ§√∫ √âÕ¬≈– 100

§«“¡√Ÿâ¢Õß·æ∑¬åæ∫«à“ à«π„À≠à¡’§«“¡√Ÿâ∂Ÿ°µâÕß‡°’Ë¬«°—∫Õ“°“√¢Õß‚√§‰¢â‡≈◊Õ¥ÕÕ° √Õß≈ß¡“‡ªìπ°“√«‘π‘®©—¬ ·≈–Õ“°“√· ¥ß¢Õß¿“«–™ÁÕ° §‘¥‡ªìπ√âÕ¬≈–92.3, 59.0 ·≈– 23.1 µ“¡≈”¥—∫ ¡’°“√∑” Tourniquettest ‡æ◊ËÕª√–°Õ∫°“√«‘π‘®©—¬ √âÕ¬≈– 79.0 °“√√—°…“√–¬–‰¢â∂Ÿ°µâÕß§√∫∂â«π√âÕ¬≈– 48.7 °“√√—°…“‡∫◊ÈÕßµâπºŸâªÉ«¬™ÁÕ°∂Ÿ°µâÕß§√∫∂â«π √âÕ¬≈–74.4 À≈—°°“√æ‘®“√≥“„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∂Ÿ°µâÕß‡æ’¬ß√âÕ¬≈– 25.6 à«π„À≠à¡’§«“¡¡—Ëπ„®„π°“√√—°…“ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕÕ°Õ¬Ÿà„π√–¥—∫ª“π°≈“ß√âÕ¬≈– 76.9·≈–¡’§«“¡¡—Ëπ„®„π°“√√—°…“Õ¬Ÿà„π√–¥—∫πâÕ¬∂÷ß√âÕ¬≈–23.1

æ¬“∫“≈∑’ËªØ‘∫—µ‘ß“π„π‚√ßæ¬“∫“≈™ÿ¡™π à«π„À≠à¡’§«“¡√Ÿâ∂Ÿ°µâÕß§√∫∂â«π‡°’Ë¬«°—∫Õ“°“√·≈–Õ“°“√· ¥ß °“√∑”·≈–°“√Õà“πº≈ Tourniquet test

°“√ª√–‡¡‘π¿“«–™ÁÕ° À≈—°°“√æ¬“∫“≈√–¬–‰¢â√–¬–æ—°øóôπ ‡æ’¬ß√âÕ¬≈– 46.4, 45.4, 35.6, 56.7 ·≈–36.0 µ“¡≈”¥—∫ ·≈–¡’§«“¡¡—Ëπ„®„π°“√æ¬“∫“≈ºŸâªÉ«¬ à«π„À≠àÕ¬Ÿà√–¥—∫ª“π°≈“ß√âÕ¬≈– 78.4

ºŸâªÉ«¬‡¥Á°‚√§‰¢â ‡≈◊Õ¥ÕÕ°∑’Ë ‰¥â√—∫°“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕ„πªï æ.». 2545 - æ.». 2550¡’®”π«π 54, 45, 44, 58, 63 ·≈– 65 √“¬ µ“¡≈”¥—∫

ºŸâªÉ«¬∑’Ë‡ ’¬™’«‘µ®”π«π 4 √“¬ „πªï æ.». 2545æ∫«à“¡’ “‡Àµÿ®“° fluid overload √à«¡°—∫ respiratoryfailure 2 √“¬ fluid overload √à«¡°—∫ hepaticencephalopathy 1 √“¬ ·≈– prolong shock √à«¡°—∫internal bleeding 1 √“¬

À≈—ß°“√¥”‡π‘π°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ° æ∫«à“„πªï æ.». 2547-æ.». 2550 ¡’ºŸâªÉ«¬‡ ’¬™’«‘µ 2 √“¬ „πªï æ.». 2547 ¡’1 √“¬ ‡ ’¬™’«‘µ®“° prolong shock ‡ªìπºŸâªÉ«¬∑’Ë‰¥â√—∫¬“°≈ÿà¡·Õ ‰æ√‘π·≈–‰¥â√—∫°“√ àßµàÕ®“°‚√ßæ¬“∫“≈„π —ß°—¥°√–∑√«ß°≈“‚À¡ ®÷ß‰¥â¡’°“√ª√– “π§«“¡√à«¡¡◊Õ°“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕ°—∫‚√ßæ¬“∫“≈‡Õ°™π ·≈–‚√ßæ¬“∫“≈ —ß°—¥°√–∑√«ß°≈“‚À¡ „π®—ßÀ«—¥ °≈π§√„Àâ‡¢â“√à«¡„π°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈¥â«¬ „πªï æ.». 2550 ¡’ºŸâªÉ«¬‡ ’¬™’«‘µ 1√“¬®“°°“√µ‘¥‡™◊ÈÕ√à«¡ (co-infection) §◊Õ InfluenzaB √à«¡°—∫¡’¿“«– severe pneumonia with ARDS,Hepatorenal involvement

§«“¡ ¡∫Ÿ√≥å∂Ÿ°µâÕß¢Õß·∫∫∫—π∑÷°°“√ —ß‡°µÕ“°“√‰¢â‡≈◊Õ¥ÕÕ° (Dengue chart) ∑’Ë àß¡“°—∫ºŸâªÉ«¬‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 81.5, 91.1, 95.0, 100.0, 100.0 ·≈–100.0 µ“¡≈”¥—∫ §«“¡∂Ÿ°µâÕß¢Õß°“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π√–¬–µà“ßÊ ‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 55.0,80.0, 82.0, 82.0, 90.0 ·≈– 95.0 µ“¡≈”¥—∫ ·≈–§«“¡∂Ÿ°µâÕß¢Õß°“√ª√–‡¡‘π¿“«–™ÁÕ°‚¥¬·æ∑¬å·≈–æ¬“∫“≈‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 50.0, 80.0, 82.0, 85.0,90.0 ·≈– 92.0 µ“¡≈”¥—∫ ¿“«–πÈ”‡°‘π„πºŸâªÉ«¬∑’Ë àßµàÕ®“°‚√ßæ¬“∫“≈™ÿ¡™π≈¥≈ß‡ªìπ√âÕ¬≈– 37.0, 24.4,22.7, 3.4, 9.5 ·≈– 3.0 µ“¡≈”¥—∫ ´÷Ëßæ∫«à“„πªïæ.». 2549 ¿“«–πÈ”‡°‘π¡’‡æ‘Ë¡¡“°¢÷Èπ‡≈Á°πâÕ¬ ·≈–



≈¥≈ßÕ’°¡“°„πªï æ.». 2550 ‡π◊ËÕß®“°·æ∑¬å¬—ß‰¡à‡¢â“„®‡°’Ë¬«°—∫°“√‡æ‘Ë¡ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π√–¬–«‘°ƒµ¢≥–∑’ËºŸâªÉ«¬¬—ß‰¡à™ÁÕ° ºŸâ«‘®—¬√à«¡°—∫§≥–°√√¡°“√æ—≤π“§ÿ≥¿“æ°“√¥Ÿ·≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°®÷ß‰¥âª√—∫·π«∑“ß°“√„Àâ “√πÈ”„πÀ≈Õ¥‡≈◊Õ¥¥”Õ’°§√—Èß

·≈–Õ—µ√“°“√‡ ’¬™’«‘µ®“°‚√§‰¢â‡≈◊Õ¥ÕÕ°„π®—ßÀ«—¥ °≈π§√≈¥≈ßÕ¬à“ß™—¥‡®π®“°ªï æ.». 2545 - æ.».2550 √âÕ¬≈– 0.34, 0.0, 0.14, 0.0, 0.12 ·≈– 0.0¥—ß· ¥ß„π√Ÿª∑’Ë 1 µ“¡≈”¥—∫ à«π®”π«π«—π∑’ËºŸâªÉ«¬πÕπ√—°…“„π‚√ßæ¬“∫“≈‡©≈’Ë¬≈¥≈ß‡ªìπ 3.8, 3.5, 3.4,3.07, 2.98 ·≈– 2.9 «—π µ“¡≈”¥—∫ ¥—ß· ¥ß„π√Ÿª∑’Ë 2

«‘®“√≥å

°“√»÷°…“π’È‡ªìπ°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√∑’Ë‡πâπ°“√»÷°…“¢âÕ¡Ÿ≈·≈–π”¡“«‘‡§√“–Àåªí≠À“·≈–§«“¡‡ ’Ë¬ß∑’Ë®–‡°‘¥¢÷Èπ®“°°“√√—°…“æ¬“∫“≈¡“«“ß·ºπ ªØ‘∫—µ‘°“√·≈– –∑âÕπº≈≈—æ∏å®π‡°‘¥«ß®√°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬Õ¬à“ßµàÕ‡π◊ËÕß °“√Õ∫√¡øóôπøŸ∑“ß«‘™“°“√ °“√∑∫∑«π‡«™√–‡∫’¬π ·≈–°“√ àß‡ √‘¡„Àâ·æ∑¬å·≈–æ¬“∫“≈√à«¡°—π∑”ß“π‡ªìπ∑’¡‡ªìπ ‘Ëß∑’Ë¡’ª√–‚¬™πåÕ¬à“ß¡“°„π°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬5 ‡æ√“–‡¡◊ËÕ·æ∑¬å·≈–æ¬“∫“≈¡’§«“¡√Ÿâ §«“¡ “¡“√∂ ·≈–ª√– ∫°“√≥å¡“°¢÷Èπ®– “¡“√∂¥Ÿ·≈ºŸâªÉ«¬‰¥â¥’¬‘Ëß¢÷Èπ ™à«¬„ÀâºŸâªÉ«¬√Õ¥™’«‘µ‰¥â¡“°¢÷Èπ °“√®—¥∑”·π«∑“ß°“√√“¬ß“π·æ∑¬å‚¥¬¡’¢âÕ∫àß™’È∑’Ë™—¥‡®π ∑”„Àâæ¬“∫“≈‡ΩÑ“ —ß‡°µ‰¥âÕ¬à“ß∂Ÿ°µâÕß·≈–√“¬ß“π·æ∑¬å‰¥â‡À¡“– ¡∑—π‡«≈“ √–∫∫°“√ àßµàÕ∑’Ë‡πâπ„Àâ¡’°“√ àß dengue chart ∑ÿ°√“¬ µ≈Õ¥®π°“√®—¥√–∫∫°“√„Àâ§”ª√÷°…“‰¥â∑—Ë«∑—Èß®—ßÀ«—¥‚¥¬ºà“π»Ÿπ¬åŒÕ∑‰≈πå ‡¡◊ËÕπ”¡“«‘‡§√“–Àå‡™‘ß√–∫∫°“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕæ∫«à“‰¥âº≈≈—æ∏å‡ªìπ∑’Ëæ÷ßæÕ„®¡“° °≈à“«§◊ÕºŸâªÉ«¬‡ ’¬™’«‘µ≈¥≈ß ¿“«–πÈ”‡°‘π≈¥≈ß¿“«–·∑√°´âÕπ®“°πÈ”‡°‘π≈¥≈ß ®”π«π«—π∑’ËπÕπ√—°…“„π‚√ßæ¬“∫“≈‡©≈’Ë¬≈¥≈ß °àÕπ°“√æ—≤π“æ∫ºŸâªÉ«¬‡ ’¬™’«‘µ®“°¿“«–πÈ”‡°‘π·≈–¿“«–™ÁÕ°π“π ´÷Ëß‡ªìπ “‡Àµÿ ”§—≠∑’Ë∑”„ÀâºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°‡ ’¬™’«‘µ¥—ß‡™àπ®“°°“√»÷°…“„π ∂“∫—π ÿ¢¿“æ‡¥Á°·Ààß™“µ‘¡À“√“™‘π’∑’Ëæ∫«à“ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°‡ ’¬™’«‘µ®“°Õ—π‡π◊ËÕß¡“®“°·æ∑¬å«‘π‘®©—¬≈à“™â“·≈–°“√„Àâ “√πÈ”‰¡à∂Ÿ°µâÕß5-8 À≈—ß°“√æ—≤π“ 5 ªï „πªï æ.». 2550 ‰¡à¡’ºŸâªÉ«¬‡ ’¬™’«‘µ‡≈¬ à«πºŸâªÉ«¬‡ ’¬™’«‘µ 1 √“¬„πªïæ.». 2549 æ∫„π°“√ àßµàÕ®“°‚√ßæ¬“∫“≈∑’Ë‰¡à‰¥â‡¢â“√Ÿª∑’Ë 2 ®”π«π«—ππÕπ√—°…“‡©≈’Ë¬

4

3.5

3

2.5

2

1.5

1

0.5

02545 2546 2547 2548 2549 2550

æ.».

®”π«π«—ππÕπ√—°…“‡©≈’Ë¬

√Ÿª∑’Ë 1 √âÕ¬≈–¢Õß§«“¡ ¡∫Ÿ√≥å¢Õß Dengue chart §«“¡

∂Ÿ°µâÕß¢Õß°“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π

√–¬–µà“ßÊ §«“¡∂Ÿ°µâÕß¢Õß°“√ª√–‡¡‘π¿“«–

™ÁÕ° ¿“«–πÈ”‡°‘π·≈–ºŸâªÉ«¬‡ ’¬™’«‘µ„π®—ßÀ«—¥

°≈π§√

100

80

60

40

20

02545 2546 2547 2548 2549 2550

æ.».

§«“¡ ¡∫Ÿ√≥å¢Õß dengue chart

§«“¡∂Ÿ°µâÕß¢Õß°“√ª√–‡¡‘π¿“«–™ÁÕ°

√â Õ ¬ ≈–ºŸâ ªÉ « ¬ ‡ ’ ¬ ™’ «‘ µ „π®—ßÀ«—¥ °≈π§√

§«“¡∂Ÿ°µâÕß¢Õß°“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥

√âÕ¬≈–¢ÕßºŸâªÉ«¬ àßµàÕ‚√ßæ¬“∫“≈™ÿ¡™π∑’Ë¡’¿“«–πÈ”‡°‘π

®”π«π«—π

14

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

æ¬“∫“≈≈¥≈ß ≈¥¿“«–·∑√°´âÕππÈ”‡°‘π Õ—µ√“µ“¬≈¥≈ß §«“¡√Ÿâ¢Õß·æ∑¬å„π°“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥¥” °“√ª√–‡¡‘π¿“«–™ÁÕ° µ≈Õ¥®π√–∫∫°“√ àßµàÕ∑’Ë¡’ª√– ‘∑∏‘¿“æ¥’¢÷Èπ µ“¡≈”¥—∫ ¥—ßπ—Èπ √Ÿª·∫∫°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°Õ¬à“ßµàÕ‡π◊ËÕß ‚¥¬°“√®—¥Õ∫√¡øóôπøŸ«‘™“°“√∑ÿ°ªï °“√ª√–™ÿ¡ª√÷°…“°√≥’»÷°…“ºŸâªÉ«¬ °“√∑∫∑«π‡«™√–‡∫’¬π °“√π‘‡∑»ß“π·≈–„Àâ§”ª√÷°…“‚¥¬∑’¡°ÿ¡“√·æ∑¬å„π√–¥—∫‚√ßæ¬“∫“≈™ÿ¡™π °“√®—¥»Ÿπ¬åŒÕ∑‰≈πå‰¢â‡≈◊Õ¥ÕÕ° ®÷ß§«√‡ªìππ‚¬∫“¬¢Õß®—ßÀ«—¥·≈–π‚¬∫“¬ “∏“√≥ ÿ¢„π°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈·≈–°“√ àßµàÕºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°µàÕ‰ª

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫æ√–§ÿ≥·æ∑¬åÀ≠‘ß ÿ®‘µ√“ π‘¡¡“ππ‘µ¬å·≈–·æ∑¬åÀ≠‘ß»‘√‘‡æÁ≠ °—≈¬“≥√ÿ® ∑’Ë‰¥â∂à“¬∑Õ¥§«“¡√Ÿâ·°à∫ÿ§≈“°√ “∏“√≥ ÿ¢®—ßÀ«—¥ °≈π§√ ·≈–√à«¡∑”case conference ·≈–¢Õ¢Õ∫æ√–§ÿ≥π“¬·æ∑¬åÕ¿‘™“µ‘Õ¿‘«—≤πæ√ ºŸâÕ”π«¬°“√‚√ßæ¬“∫“≈ °≈π§√ ·≈–π“¬·æ∑¬å™√— « ÿ∏“¥“ π“¬·æ∑¬å “∏“√≥ ÿ¢®—ßÀ«—¥ °≈π§√ ∑’ËÕπÿ≠“µ„Àâ¥”‡π‘π°“√·≈–‡º¬·æ√àº≈°“√»÷°…“ ·≈–¢Õ¢Õ∫§ÿ≥·æ∑¬å æ¬“∫“≈ÀÕºŸâªÉ«¬°ÿ¡“√‡«™°√√¡ ‚√ßæ¬“∫“≈ °≈π§√ ∑’Ë√à«¡æ—≤π“§ÿ≥¿“æ°“√¥Ÿ·≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°

√à«¡¥”‡π‘π°“√ ∑”„Àâ‚√ßæ¬“∫“≈∑’Ë‰¡à‰¥â‡¢â“√à«¡¥”‡π‘π°“√‡ÀÁπ§«“¡ ”§—≠¢Õß√–∫∫°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‰¢â‡≈◊Õ¥ÕÕ° ∑”„Àâ‰¥â‡§√◊Õ¢à“¬°“√æ—≤π“§ÿ≥¿“æ °“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‰¢â‡≈◊Õ¥ÕÕ°·≈–‡§√◊Õ¢à“¬„π√–∫∫°“√ àßµàÕºŸâªÉ«¬¡“°¢÷Èπ ·≈–§√Õ∫§≈ÿ¡∑—Èß®—ßÀ«—¥ ”À√—∫ªï æ.». 2549 ¡’ºŸâªÉ«¬‡ ’¬™’«‘µ 1 √“¬®“°¿“«–µ‘¥‡™◊ÈÕ √à«¡°—∫‰¢âÀ«—¥„À≠àÕ‘πø≈Ÿ‡Õ´“∫’∑’Ë¡’ªÕ¥∫«¡√ÿπ·√ß·≈– ARDS ‰¥â¬“∑“¡‘ø≈Ÿ9,10 ‚¥¬ª√÷°…“·æ∑¬åºŸâ‡™’Ë¬«™“≠‚√§µ‘¥‡™◊ÈÕ·µàÕ“°“√‰¡à¥’¢÷Èπ¡’¿“«– multiorgan failure µ“¡¡“

®“°°“√√à«¡°—π∑∫∑«π°√≥’ºŸâªÉ«¬‡ ’¬™’«‘µ·≈–°“√∑∫∑«π«√√≥°√√¡5-7,11-14 ∑”„Àâ°ÿ¡“√·æ∑¬å∑ÿ°§πµâÕß„Àâ§«“¡√–¡—¥√–«—ß°—∫°“√√—°…“æ¬“∫“≈ ºŸâªÉ«¬¡“°¢÷Èπ ‚¥¬‡πâπÀ≈—°°“√ªØ‘∫—µ‘∑’ËµâÕß«‘π‘®©—¬„Àâ‰¥â„π√–¬–·√°15 µâÕß¡’§«“¡√Ÿâ„π°“√√—°…“¿“«–πÈ”‡°‘π´÷Ëß‡ªìπ¿“«–·∑√°´âÕπ∑’Ëæ∫‰¥â∫àÕ¬ °“√√—°…“ºŸâªÉ«¬‰¢â‡≈◊Õ¥ÕÕ°∑’Ë¡’Õ“°“√·ª≈°ÕÕ°‰ª µâÕßæ¬“¬“¡À“ “‡Àµÿ∑’ËÕ“®æ∫√à«¡°—∫°“√µ‘¥‡™◊ÈÕ‰¢â‡≈◊Õ¥ÕÕ°∑’ËÕ“®®–µ‘¥‡™◊ÈÕ°àÕπÀ√◊ÕÀ≈—ß‡¢â“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈°Á‰¥â·≈–Õ“®®–∑”„ÀâÕ“°“√·≈–Õ“°“√· ¥ß¢Õß‚√§·µ°µà“ß‰ª®“°‡¥‘¡ ´÷Ëß®–‡ªìπ∫∑‡√’¬π„π°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°√“¬µàÕÊ ‰ª‰¥â‡ªìπÕ¬à“ß¥’ Õ¬à“ß‰√°Áµ“¡Õ—µ√“µ“¬¢Õß‚√§‰¢â‡≈◊Õ¥ÕÕ°®—ßÀ«—¥ °≈π§√‰¥â≈¥≈ßÕ¬à“ß¡“°®“°√âÕ¬≈– 0.3 ‡ªìπ√âÕ¬≈– 0.0 ´÷ËßµË”°«à“‡°≥±å∑’Ë°√–∑√«ß “∏“√≥ ÿ¢ °”Àπ¥µ—«™’È«—¥‰«â∑’Ë√âÕ¬≈– 0.2 ¥—ßπ—Èπ √Ÿª·∫∫°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°Õ¬à“ßµàÕ‡π◊ËÕßπ’È®÷ß‡ªìπ√Ÿª·∫∫Àπ÷Ëß„π°“√‡æ‘Ë¡§ÿ≥¿“æ·≈–ª√– ‘∑∏‘¿“æ„π°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ° ´÷Ëß°“√∑”ß“π‡°’Ë¬«°—∫°“√æ—≤π“§ÿ≥¿“æ°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°®”‡ªìπµâÕß∑”Õ¬à“ßµàÕ‡π◊ËÕß·≈– ¡Ë”‡ ¡Õ ‡æ◊ËÕ„Àâ°“√√—°…“æ¬“∫“≈¡’ª√– ‘∑∏‘¿“æÕ—π®–‡°‘¥ª√–‚¬™πå Ÿß ÿ¥ µàÕºŸâªÉ«¬µàÕ‰ª

√ÿª

°“√»÷°…“π’È‰¥âº≈≈—æ∏å°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°∑’Ë¥’ ‰¥â·°à ®”π«π«—π∑’ËπÕπ√—°…“„π‚√ß


1. °Õß√–∫“¥«‘∑¬“ ”π—°ß“πª≈—¥°√–∑√«ß “∏“√≥ ÿ¢.√“¬ß“π°“√‡ΩÑ“√–«—ß‚√§ª√–®”ªï 2530-2550. °√ÿß‡∑æœ:°√–∑√«ß “∏“√≥ ÿ¢; 2550.

2. ÿ®‘µ√“ π‘¡¡“ππ‘µ¬å, »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§‰¢â‡≈◊Õ¥ÕÕ°‡¥ß°’Ë. °√ÿß‡∑æœ:°√–∑√«ß “∏“√≥ ÿ¢; 2542.

3. World Health Organization. Dengue hemorrheagic

fever: Diagnosis, treatment, prevention, and control.

2nd ed. Geneva: WHO; 2001.



4. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®, ÿ®‘µ√“ π‘¡¡“ππ‘µ¬å. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§‰¢â‡≈◊Õ¥ÕÕ°‡¥ß°’Ë©∫—∫·°â‰¢ª√—∫ª√ÿß§√—Èß∑’Ë 1 °√–∑√«ß “∏“√≥ ÿ¢. °√ÿß‡∑æœ: ‚√ßæ‘¡æå¥Õ°‡∫’È¬; 2546.

5. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®. ‡§≈Á¥(‰¡à)≈—∫‰¢â‡≈◊Õ¥ÕÕ°: DHF stateof the Arts in case management. °√ÿß‡∑æœ: °√ÿß‡∑æ‡«™ “√; 2549.

6. Õπÿ«—≤πå »ÿ¿™ÿµ‘°ÿ≈, ·≈–§≥–. ¢—ÈπµÕπ°“√∑”°‘®°√√¡æ—≤π“§ÿ≥¿“æ √Ÿª·∫∫ ”À√—∫∫√‘°“√ ÿ¢¿“æ. °√ÿß‡∑æœ:∫√‘…—∑¥’‰´√å®”°—¥; 2543.

7. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®. ¢Õ¥‡°√Á¥‰¢â‡≈◊Õ¥ÕÕ°. æ‘¡æå§√—Èß∑’Ë 1.°√ÿß‡∑æœ: °√ÿß‡∑æ‡«™ “√; 2547.

8. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®. ‰¢â‡≈◊Õ¥ÕÕ° °“√¥Ÿ·≈·≈–√—°…“: “‡Àµÿ°“√µ“¬∑’Ë ”§—≠„πºŸâªÉ«¬‚√§‰¢â‡≈◊Õ¥ÕÕ°. °√ÿß‡∑æœ:∫√‘…—∑¥’‰´√å®”°—¥; 2541.

9. ÿ√‘¬– §ŸÀ–√—µπå. π‘¬“¡‚√§µ‘¥‡™◊ÈÕª√–‡∑»‰∑¬ 2544.°√ÿß‡∑æœ: ‚√ßæ‘¡æåÕß§å°√°“√√—∫ àß ‘π§â“·≈–æ— ¥ÿ¿—≥±å;2544. Àπâ“ 150-1.

10. ¿“«æ—π∏å ¿—∑√‚°»≈, ª√–‡ √‘∞ ‡Õ◊ÈÕ«√“°Ÿ≈. ‰¢âÀ«—¥„À≠à/

‰¢âÀ«—¥π°. °√ÿß‡∑æœ: ∫√‘…—∑‚π«å‡≈®¥å‡æ√ ®”°—¥; 2549.11. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®, ÿ®‘µ√“ π‘¡¡“ππ‘µ¬å,‰æ∫Ÿ≈¬å ‡Õ°· ß»√’.

ºŸâªÉ«¬‰¢â‡≈◊Õ¥ÕÕ°∑’Ë‡ ’¬™’«‘µ∑’Ë‚√ßæ¬“∫“≈‡¥Á°ªï æ.». 2530.«“√ “√°√¡°“√·æ∑¬å 2532; 14:771-8.

12. ÿ®‘µ√“ π‘¡¡“ππ‘µ¬å. ‰¢â‡≈◊Õ¥ÕÕ°. °√ÿß‡∑æ¡À“π§√: ”π—°æ‘¡æå°√ÿß‡∑æ‡«™ “√; 2534.

13. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®. ∫∑‡√’¬π®“°¢âÕº‘¥æ≈“¥„π°“√√—°…“ºŸâªÉ«¬‰¢â‡≈◊Õ¥ÕÕ°. Thai Ped J 2004; 11:212-4.

14. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®. Managing severe dengue shocksyndrome in the ICU setting. „π: ¥ÿ ‘µ ∂“«√,®‘µ≈—¥¥“¥’‚√®πå«ß»å,π«≈®—π∑√å ª√“∫æ“≈, ∫√√≥“∏‘°“√. Currentconcepts in pediatric critical care. °√ÿß‡∑æœ: ∫’¬Õπ¥å‡Õπ‡∑Õ√å‰æ√´å; 2548.

15. »‘√‘‡æÁ≠ °—≈¬“≥√ÿ®, ‡¥«‘¥ «ÕÀåπ, ÿ®‘µ√“ π‘¡¡“ππ‘µ¬å, ·≈–§≥–. ¥—™π’∑’Ë™à«¬„π°“√«‘π‘®©—¬‚√§‰¢â‡≈◊Õ¥ÕÕ°„π√–¬–·√°„π: °√–∑√«ß “∏“√≥ ÿ¢. º≈ß“π«‘™“°“√¥’‡¥àπ °√–∑√«ß “∏“√≥ ÿ¢ ªï 2538. ‡™’¬ß√“¬: ‚√ßæ‘¡æåÕ‘π‡µÕ√åæ√‘Èπ∑å;2539. Àπâ“ 1-16.

16

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å


°“√ àß‡ √‘¡ ¡√√∂¿“æ°“√À“¬„®„πºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß·≈–À≈—ß°“√‡ √‘¡‚ª√·°√¡ÕÕ°°”≈—ß°“¬∑’Ë∫â“π«‘æ—≤πå ƒ…Æ’™—¬°ÿ≈ æ.∫.*‡æÁ≠»√’ ·´à¡â“ æ.«.***‚√ßæ¬“∫“≈‡™’¬ß¥“« Õ”‡¿Õ‡™’¬ß¥“« ®—ßÀ«—¥‡™’¬ß„À¡à**æ¬“∫“≈«‘™“™’æª√–®”§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚√ßæ¬“∫“≈‡™’¬ß¥“« Õ”‡¿Õ‡™’¬ß¥“« ®—ßÀ«—¥‡™’¬ß„À¡à

Abstract Home Exercise Program for Respiratory Rehabilitation Among Chronic ObstructivePulmonary Disease CasesSaliddeechaikool W., Saema P.

Chiangdao Hospital, Chiangdao, Chiang Mai, Thailand


Chronic obstructive pulmonary disease (COPD) is a high prevalence clinical syndrome. It is thefourth most common caused of death and the fifth of disability adjusted life years (DALYs). The objective ofthis study was comparison the result of respiratory rehabilitation indicators while before and after homeexercise program for 3 months. Selected group of patients were COPD patients in severe and very severe stage,that cannot tolerate by aerobic exercise program. Eight cases of severe and very severe COPD patients, clinicalstable, were trained for exercise program, and received dumbbell, sandbag and theraband. Exercise timemust more than 30minutes and more than 3 times per week at home. The patients were evaluated every monthuntil 3months by 6MWD (6minutes walk distances), MMRC dyspnea score, St.Gorege RespiratoryQuestionnaire (SGQ), FEV1%, BODE index. Indicators of 8 patients,be calculated to average result of group,compare between start and finish program. 6MWD start at 345.75 metre increase to 410.75 metre at finish,increase 65 metre. MMRC Score start at 3.25 points decrease to 2.13 points at finish,decrease 1.13 points.FEV1% start at 35.60% increase to 38.34%, increase 2.74%. SGQ Score start at 45.75 points decrease to 38.63points,decrease 7.13 points. BODE Index Score start at 6.25 points decrease to 4.25 points,decrease 2 points.Analysed by inferential statistic, the mean difference of 6MWD MMRC SGQ (impact) and BODE indexsignificantly improved (p-value < 0.05) Home exercise program by simple and low cost tools in 3 monthsimprove respiratory function,tolerance and sense of well-being in severe and very severe stage COPD patients.

Key words: respiratory rehabilitation, sever and very sever COPD, exercise



∫∑π”

‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß (COPD) ‡ªìπ‚√§‰¡àµ‘¥µàÕ∑’Ë¡’Õÿ∫—µ‘°“√≥å‡æ‘Ë¡¡“°¢÷ÈπÕ¬à“ßµàÕ‡π◊ËÕß ‚¥¬‡©æ“–„πª√–‡∑»∑’Ë°”≈—ßæ—≤π“®“°°“√ª√–¡“≥¢ÕßÕß§å°“√Õπ“¡—¬‚≈° „πªï æ.». 2545 §«“¡™ÿ°¢Õß‚√§π’È‚¥¬‡©≈’Ë¬ ”À√—∫ª√–™“°√∑—Ë«‰ª∑ÿ°Õ“¬ÿª√–¡“≥ 11.6/1,000„πºŸâ™“¬ ·≈– 8.77/1,000 „πºŸâÀ≠‘ß1 COPD ‡ªìπ “‡Àµÿ¢Õß°“√‡ ’¬™’«‘µ Ÿß‡ªìπ≈”¥—∫∑’Ë 4 ¢Õß‚≈° „πªï æ.». 2545 ¡’ºŸâ‡ ’¬™’«‘µ®“°‚√§π’È Ÿß∂÷ß 2.75 ≈â“π§πÀ√◊Õ√âÕ¬≈– 4.8 ¢Õß°“√‡ ’¬™’«‘µ∑—Ë«‚≈° ·≈–¬—ß‡ªìπ‚√§∑’Ë¿“√– Ÿß ´÷Ëß§”π«≥®“°º≈√«¡¢Õß®”π«πªï∑’ËÕ¬Ÿà„π¿“«–∑’Ë™à«¬‡À≈◊Õµπ‡Õß‰¡à‰¥â·≈–‡ ’¬™’«‘µ°àÕπ«—¬Õ—π§«√ (disability adjusted life years, DALYs)„π°≈ÿà¡ºŸâ∑’Ë¡’Õ“¬ÿ¡“°°«à“ 15 ªï „πªï æ.». 2533 ®–Õ¬Ÿà„π≈”¥—∫∑’Ë 5 √Õß®“°‚√§À—«„®¢“¥‡≈◊Õ¥ ‚√§´÷¡‡»√â“Õÿ∫—µ‘‡Àµÿ∫π∑âÕß∂ππ ·≈–‚√§À≈Õ¥‡≈◊Õ¥¢Õß ¡Õß1

°“√√—°…“¥â«¬°“√øóôπøŸ ¡√√∂¿“æ°“√À“¬„® ‡æ◊ËÕ™à«¬∑”„ÀâºŸâªÉ«¬À“¬„®‡Õß‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ≈¥Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬≈â“‰¥â‚¥¬ßà“¬ ™à«¬¬°√–¥—∫§ÿ≥¿“æ™’«‘µ„Àâ¥’¢÷Èπ2 √«¡∑—Èß™à«¬≈¥°“√πÕπ√—°…“„π‚√ßæ¬“∫“≈Õ—π‡π◊ËÕß¡“®“°¿“«–‚√§°”‡√‘∫‰¥â3 º≈°“√«‘‡§√“–Àå·∫∫√«∫√«¡ √“¬ß“π 6 √“¬ß“πæ∫«à“ °“√∑”°“√øóôπøŸ ¡√√∂¿“æ°“√À“¬„®À≈—ß¿“«–‚√§°”‡√‘∫„À¡àÊ ™à«¬≈¥°“√°”‡√‘∫´È”®πµâÕß°≈—∫πÕπ‚√ßæ¬“∫“≈4

°“√øóôπøŸ ¡√√∂¿“æ°“√À“¬„® ª√–°Õ∫¥â«¬Õß§åª√–°Õ∫µà“ßÊ ‰¥â·°à °“√„Àâ§«“¡√Ÿâ‡°’Ë¬«°—∫‚√§ °“√™à«¬‡≈‘°∫ÿÀ√’Ë °“√·π–π”‡√◊ËÕß‚¿™π“°“√ °“√Ωñ°°“√À“¬„®‡æ◊ËÕ∫√√‡∑“Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ °“√Ωñ°°“√‰ÕÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ·≈–Ωñ°°“√ÕÕ°°”≈—ß°≈â“¡‡π◊ÈÕ¥â«¬°“√ÕÕ°°”≈—ß°“¬

°“√Ωñ°°≈â“¡‡π◊ÈÕ¥â«¬°“√ÕÕ°°”≈—ß°“¬ π—∫‡ªìπÕß§åª√–°Õ∫ ”§—≠¢Õß°“√øóôπøŸ ¡√√∂¿“æ°“√À“¬„®·µà®“°º≈°“√ ”√«®„π™π∫∑ æ∫«à“ ºŸâªÉ«¬‰¡à‡§¬‰¥â√—∫§”·π–π”®“°·æ∑¬åÕ¬à“ß®√‘ß®—ß5 ‡π◊ËÕß®“°·æ∑¬å‡Õß¢“¥§«“¡√Ÿâ¢—Èπª√–¬ÿ°µå„™â ‰¡à “¡“√∂Õ∏‘∫“¬ºŸâªÉ«¬À√◊ÕÕ∏‘∫“¬„Àâ∑’¡‡®â“Àπâ“∑’Ë‡¢â“„®·≈–π”‰ªΩñ°ºŸâªÉ«¬‰¥â·¡âπ—°°“¬¿“æ∫”∫—¥‡ÕßÀ≈“¬§πÕ“®¬—ß‰¡à‡¢â“„®∂÷ßÀ≈—°°“√ ·≈–«‘∏’°“√∑”°“√øóôπøŸ ¡√√∂¿“æ°“√À“¬„® ”À√—∫ºŸâªÉ«¬‚√§π’È

ºŸâªÉ«¬∑’Ë§«√‰¥â√—∫°“√Ωñ°ÕÕ°°”≈—ß°≈â“¡‡π◊ÈÕ‡æ◊ËÕøóôπøŸ ¡√√∂¿“æªÕ¥ §«√‡ªìπºŸâªÉ«¬∑’Ë¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬·≈–‰¡à “¡“√∂∑”°‘®°√√¡ª√–®”«—π‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ∑—Èß∑’Ë‰¥â√—∫°“√√—°…“¥â«¬¬“¢¬“¬À≈Õ¥≈¡Õ¬à“ß‡À¡“– ¡·≈â«‚¥¬‰¡à§«√„™â§à“ ‰ª‚√‡¡µ√’¬åæ‘®“√≥“ ‡æ’¬ß¥â“π‡¥’¬«6 µ“¡§”·π–π”¢Õß‚°≈¥å(GOLD) ·π–π”„Àâ∑”°“√øóôπøŸ ¡√√∂¿“æªÕ¥µ—Èß·µà‚√§¢—Èπª“π°≈“ß®π∂÷ß¢—Èπ√ÿπ·√ß¡“°7 À“°ºŸâªÉ«¬‰¡à¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ “¡“√∂ª√–°Õ∫Õ“™’æÀ√◊Õ°‘®°√√¡

‡√◊ËÕß¬àÕ ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‡ªìπÀπ÷Ëß„π‚√§‰¡àµ‘¥µàÕ¡’Õÿ∫—µ‘°“√≥å Ÿß ‡ªìπ “‡Àµÿ°“√‡ ’¬™’«‘µ≈”¥—∫∑’Ë 4 ¢Õß‚≈° ‡ªìπ‚√§¿“√– Ÿß≈”¥—∫∑’Ë 5 °“√»÷°…“§√—Èßπ’È¡’«—µ∂ÿª√– ß§å ‡æ◊ËÕ¥Ÿº≈°“√ª√–¬ÿ°µå„™â‡§√◊ËÕß¡◊ÕÕÕ°°”≈—ß°“¬∑’Ëßà“¬ √“§“∂Ÿ° “¡“√∂π”‰ª„™âÕÕ°°”≈—ß°“¬∑’Ë∫â“π „πºŸâªÉ«¬°≈ÿà¡ COPD √–¬–√ÿπ·√ß∂÷ß√ÿπ·√ß¡“° ®”π«π 8 √“¬ ∑’Ë¡’¿“«–∑“ß§≈‘π‘°§ß∑’Ë Õπ«‘∏’°“√ÕÕ°°”≈—ß°“¬µ“¡‚ª√·°√¡æ√âÕ¡„™âÕÿª°√≥å ¥—¡‡∫≈≈å ¬“ß¬◊¥ ∂ÿß∑√“¬ ÕÕ°°”≈—ß°“¬§√—Èß≈–‰¡àπâÕ¬°«à“ 30 π“∑’·≈–µâÕß‰¡àπâÕß°«à“ 3 §√—ÈßµàÕ —ª¥“Àå ‰¥âª√–‡¡‘π 6 MWD (6-minutes walk distance) MMRC dyspnea score, St Gorege RespiratoryQuestionnaire, FEV1 ∑ÿ°‡¥◊Õπ ®π§√∫ 3 ‡¥◊Õπ π”§à“‡©≈’Ë¬¢Õß°≈ÿà¡µ—«Õ¬à“ß¡“‡ª√’¬∫‡∑’¬∫°àÕπ·≈–À≈—ß‡¢â“‚ª√·°√¡ §à“ 6MWD ®“°‡¥‘¡ 345.75 ‡¡µ√ ‡æ‘Ë¡‡ªìπ 410.75 ‡¡µ√ ‡æ‘Ë¡¢÷Èπ 65 ‡¡µ√, §à“ MMRC ®“°‡¥‘¡ 3.25 §–·ππ ≈¥≈ß‡ªìπ 2.13§–·ππ ≈¥≈ß 1.13 §–·ππ, §à“ FEV1 ‡æ‘Ë¡¢÷Èπ 2.74 %, §à“ SGQ ®“°‡¥‘¡ 45.75 §–·ππ ≈¥≈ß‡ªìπ 38.63 §–·ππ ≈¥≈ß7.13 §–·ππ, §à“ BODE index ®“°‡¥‘¡ 6.25 §–·ππ ≈¥≈ß‡ªìπ 4.25 §–·ππ ≈¥≈ß 2 §–·ππ ‡¡◊ËÕ«‘‡§√“–Àå∑’Ë§«“¡‡™◊ËÕ¡—Ëπ√âÕ¬≈– 95 §à“ 6 MWD, MMRC, SGQ (impact) ·≈– BODE index ¡’π—¬ ”§—≠∑“ß ∂‘µ‘ √ÿª °“√®—¥‚ª√·°√¡ÕÕ°°”≈—ß°“¬∑’Ë∫â“π‚¥¬ª√–¬ÿ°µå„™â‡§√◊ËÕß¡◊Õ∑’ËÀ“‰¥âßà“¬√“§“∂Ÿ° “¡“√∂‡æ‘Ë¡ ¡√√∂¿“æ°“√À“¬„®„πºŸâªÉ«¬ COPD √–¬–√ÿπ·√ß∂÷ß√ÿπ·√ß¡“°„Àâ¥’¢÷Èπ‰¥â

§” ”§—≠: ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ¡√√∂¿“æ°“√À“¬„® °“√ÕÕ°°”≈—ß°“¬

18

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∑’ËµâÕß„™â·√ßß“π‡ªìπª√–®” ‰¡à®”‡ªìπµâÕß∑”°“√Ωñ°ÕÕ°°”≈—ß°“¬°≈â“¡‡π◊ÈÕ ·¡âºŸâªÉ«¬¡’º≈°“√µ√«®«—¥ ‰ª‚√‡¡µ√’¬åÕ¬Ÿà„π¢—Èπ√ÿπ·√ß ‡æ’¬ß§”·π–π” àß‡ √‘¡„Àâ∑”ß“π√à«¡°“√ÕÕ°°”≈—ß°“¬ ¡Ë”‡ ¡ÕÕ¬à“ßµàÕ‡π◊ËÕß´÷Ëß‡ª√’¬∫‡ ¡◊Õπ°“√Ωñ°ÕÕ°°”≈—ß°“¬°≈â“¡‡π◊ÈÕ„π™’«‘µª√–®”«—πÕ¬Ÿà·≈â«ºŸâªÉ«¬∑’Ë¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬‰¡à√ÿπ·√ß ¡’Õ“°“√‡©æ“–‡«≈“ÕÕ°·√ß¡“°º‘¥ª°µ‘ “¡“√∂√—∫°“√Ωñ°ÕÕ°°”≈—ß°“¬∑—Èß·∫∫·Õ‚√∫‘°§≈â“¬°—∫§πª°µ‘‰¥â·µà°”°—∫®—ßÀ«–„Àâ™â“≈ß

”À√—∫ºŸâªÉ«¬∑’Ë¡’Õ“°“√√ÿπ·√ß ‡™àπ ‡Àπ◊ËÕ¬·¡â∑”°‘®°√√¡ª√–®”«—π‡æ’¬ß‡≈Á°πâÕ¬ ¬—ß‰¡à “¡“√∂ÕÕ°°”≈—ß·∫∫·Õ‚√∫‘°∑—Èßµ—«‰¥â‡æ√“–°≈â“¡‡π◊ÈÕÕàÕπ·√ß ‡Àπ◊ËÕ¬≈â“‰¥âÕ¬à“ß√«¥‡√Á«¡“° §«√‡√‘Ë¡Ωñ°‡©æ“–°≈â“¡‡π◊ÈÕ‡ªìπ°≈ÿà¡Ê ‰ª §◊Õ Ωñ°°≈â“¡‡π◊ÈÕ¢Õß¢“ °≈â“¡‡π◊ÈÕ¢Õß·¢π·≈–°≈â“¡‡π◊ÈÕ°“√À“¬„®‡¢â“ ®“°°“√∑∫∑«π√“¬ß“πµà“ßÊ æ∫«à“°“√Ωñ°°≈â“¡‡π◊ÈÕ¥—ß°≈à“«‰¥âº≈¥’™à«¬∑”„Àâ°≈â“¡‡π◊ÈÕ·¢Áß·√ß¢÷Èπ ÕàÕπ≈â“¬“°¢÷Èπ ≈¥ß“π¢Õß°“√À“¬„®≈ß ª√—∫≈—°…≥–°“√À“¬„®‰¥â‡À¡“– ¡¢÷Èπ ·≈–≈¥¿“«– dynamic hyperinflation ≈ß∑”„ÀâºŸâªÉ«¬ “¡“√∂∑”°‘®«—µ√ª√–®”«—π·≈–ÕÕ°·√ß∑”ß“πÀ√◊Õ°‘®°√√¡µà“ßÊ ‰¥â¡“°¢÷Èπ ≈¥§«“¡√Ÿâ ÷°ÀÕ∫‡Àπ◊ËÕ¬¬°√–¥—∫§ÿ≥¿“æ™’«‘µ¢ÕßºŸâªÉ«¬„Àâ¥’¢÷Èπ º≈¥’µà“ßÊ‡À≈à“π’È “¡“√∂§ßÕ¬Ÿà‡ªìπ‡«≈“À≈“¬‡¥◊Õπ∂÷ßªïπ—∫®“° ‘Èπ ÿ¥‚ª√·°√¡°“√Ωñ°8 ·µ°µà“ß®“°°“√„™â¬“¢¬“¬À≈Õ¥≈¡ ‡æ√“–º≈¢Õß¬“®–À¡¥‰ª∑—π∑’‡¡◊ËÕÀ¬ÿ¥„™â¬“„πºŸâªÉ«¬∑’Ë„™â¬“ Ÿ¥¢¬“¬À≈Õ¥≈¡‡ªìπª√–®”Õ¬Ÿà·≈â«·µà¬—ß¡’Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬‡«≈“∑”°‘®°√√¡ª√–®”µà“ßÊ°“√Ωñ°ÕÕ°°”≈—ß°“¬‡æ◊ËÕøóôπøŸ ¡√√∂¿“æ°“√À“¬„®®–™à«¬‡ √‘¡§«“¡ “¡“√∂„π°“√ÕÕ°°”≈—ßÀ√◊Õ∑”°‘®°√√¡ª√–®”«—π9 ´÷Ëßπà“®–‰¥âº≈¥’°«à“·≈– ‘Èπ‡ª≈◊ÕßπâÕ¬°«à“°“√‡æ‘Ë¡™π‘¥¬“¢¬“¬À≈Õ¥≈¡

‚ª√·°√¡°“√Ωñ° ”À√—∫ºŸâªÉ«¬¢—Èπ√ÿπ·√ß¡’°”≈—ß ”√Õß¢Õß°“√À“¬„®®”°—¥Õ¬à“ß¡“° ¡—°‰¡à “¡“√∂∑π°“√ÕÕ°°”≈—ß°“¬·∫∫·Õ‚√∫‘°µàÕ‡π◊ËÕß‰¥âπ“π°“√„™â‚ª√·°√¡·∫∫Ωñ° ≈—∫°—∫æ—°‡ªìπ√–¬–Ê ™à«¬∑”„ÀâºŸâªÉ«¬ ∫“¬·≈–¬Õ¡√à«¡¡◊Õ„π°“√Ωñ°¥’¢÷Èπ ‡æ√“–≈¥°“√‡°‘¥¿“«– dynamic hyperinflation ≈ß10

√Ÿª·∫∫¢Õß‚ª√·°√¡°“√Ωñ° π‘¬¡Ωñ°·∫∫º ¡º “π√–À«à“ß°“√Ωñ°‡æ‘Ë¡§«“¡·¢Áß·√ß ‡™àπ °“√¬°µÿâ¡πÈ”Àπ—°À√◊Õ∂ÿß∑√“¬ √à«¡°—∫°“√Ωñ°§«“¡§ß∑π¢Õß°“√ÕÕ°·√ß ‡™àπ °“√Ωñ°°“√‡¥‘πÀ√◊Õªíòπ®—°√¬“π‡æ√“–™à«¬‡ √‘¡ª√– ‘∑∏‘¿“æ´÷Ëß°—π·≈–°—π11 ‚¥¬„™âÕ—µ√“ß“π∑’ËΩñ°√âÕ¬≈– 60-70 ¢ÕßÕ—µ√“ß“π Ÿß ÿ¥ ‚¥¬Ωñ°Õ¬à“ßµàÕ‡π◊ËÕßÀ√◊ÕÀ“°ºŸâªÉ«¬¡’Õ“°“√‡Àπ◊ËÕ¬ßà“¬„Àâª√—∫°“√Ωñ°‡ªìπ·∫∫™à«ß√–¬–‡«≈“ —ÈπÊ ·≈â«æ—°‡ªìπ√–¬–Ê12 æ—°æÕ∑ÿ‡≈“Õ“°“√‡Àπ◊ËÕ¬·≈â«Ωñ°µàÕ ≈—∫‰ª‡√◊ËÕ¬Ê „Àâ‰¥â√–¬–‡«≈“°“√Ωñ°√«¡·µà≈–§√—Èßπ“πª√–¡“≥ 20-30 π“∑’

À≈—°°“√Ωñ°°“√ÕÕ°°”≈—ß°“¬¢ÕßºŸâªÉ«¬§≈â“¬§≈÷ß°—∫°“√ÕÕ°°”≈—ß°“¬„π§πª°µ‘ °≈à“«§◊ÕÕ¬à“ßπâÕ¬3 §√—ÈßµàÕ —ª¥“Àå §√—Èß≈– 20-30 π“∑’ ‚¥¬Ωñ°Õ¬à“ßµàÕ‡π◊ËÕß À√◊ÕΩñ°‡ªìπ™à«ßÊ ¥â«¬‚ª√·°√¡°“√Ωñ°∑’Ë¡’§«“¡‡¢â¡¢âπ¢Õß°“√„™â°”≈—ßµ—Èß·µà√âÕ¬≈– 40 ®π∂÷ß√âÕ¬≈– 85 ¢Õß oxygen uptake reserve Ωñ°π“πÕ¬à“ßπâÕ¬ 6 —ª¥“Àå ‚ª√·°√¡∑’Ë¡’√–¬–‡«≈“°“√Ωñ°√–¬–π“π¡’º≈¥’Õ¬à“ßµàÕ‡π◊ËÕß„π√–¬–¬“« ¡“°°«à“‚ª√·°√¡∑’Ë¡’√–¬–°“√Ωñ° —Èπ

√–À«à“ß°“√Ωñ°¡’À≈“¬«‘∏’∑’Ë™à«¬∑”„ÀâºŸâªÉ«¬Ωñ°‰¥â∑ππ“π¢÷Èπ ‡™àπ °“√Ωñ°À“¬„®ÕÕ°¬“«Ê ·∫∫ÀàÕª“°(pursed lip breathing) ®π‡§¬™‘π¢≥–Ωñ°13 °“√ Ÿ¥ÕÕ°´‘‡®π‡ √‘¡√–À«à“ß°“√Ωñ°ÕÕ°°”≈—ß‡æ◊ËÕ™à«¬∑”„ÀâÕÕ°°”≈—ß‰¥â¡“°¢÷Èπ14

°“√»÷°…“§√—Èßπ’È¡’«—µ∂ÿª√– ß§å ‡æ◊ËÕ¥Ÿº≈¢Õß°“√ª√–¬ÿ°µå°“√ÕÕ°°”≈—ß°“¬‡æ◊ËÕ‡æ‘Ë¡ ¡√√∂¿“æ°“√À“¬„® ‚¥¬„ÀâºŸâªÉ«¬‰¥âΩñ°°“√ÕÕ°°”≈—ß°“¬°≈â“¡‡π◊ÈÕ·¢π¢“ °≈â“¡‡π◊ÈÕ°“√À“¬„® °“√‡¥‘π ·≈–π”‰ªªØ‘∫—µ‘∑’Ë∫â“π‰¥â‡ÕßÕ¬à“ß∂Ÿ°µâÕß·≈–¡’≠“µ‘™à«¬¥Ÿ·≈·≈–µ‘¥µ“¡°“√ÕÕ°°”≈—ß°“¬ ´÷Ëß‡ªìπ«‘∏’∑’Ë¡’§«“¡‡À¡“– ¡‡ªìπ‰ª‰¥â„π∑“ßªØ‘∫—µ‘ ”À√—∫°“√¥Ÿ·≈ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß (COPD) √–¬–√ÿπ·√ß∂÷ß√ÿπ·√ß¡“°„π√–¥—∫‚√ßæ¬“∫“≈™ÿ¡™π

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“ ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√



«‘π‘®©—¬®“°·æ∑¬å«à“‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß„π√–¬–√ÿπ·√ß∂÷ß √ÿπ·√ß¡“° (FEV1 < 50%) MMRC scoreµ—Èß·µà√–¥—∫ 3 ¢÷Èπ‰ª ¡’Õ“¬ÿ 55-80 ªï ∑’Ë‡ªìπºŸâªÉ«¬ª√–®”§≈‘π‘° COPD ·ºπ°ºŸâªÉ«¬πÕ°¢Õß‚√ßæ¬“∫“≈¬‘π¬Õ¡‡¢â“√à«¡‚§√ß°“√¥â«¬§«“¡ ¡—§√„® ¡’¿“«–∑“ß§≈‘π‘°§ß∑’Ë‰¥â√—∫°“√√—°…“¥â«¬¬“æàπ Ÿ¥Õ¬à“ß ¡Ë”‡ ¡Õ·µàµâÕß‰¡à¡’¿“«– Ischemic heart failure, Cardiacfailure Class 3 ¢÷Èπ‰ª, Musculoskeletal disorder·≈–‚√§∑’Ë®”°—¥„π°“√ÕÕ°°”≈—ß°“¬, ‰¡à¡’ª√–«—µ‘ªÕ¥Õ—°‡ ∫À√◊ÕÀ≈Õ¥≈¡Õ—°‡ ∫À√◊ÕÀÕ∫À◊¥„π 3 ‡¥◊Õπ∑’Ëºà“π¡“ ‰¡à„™â long term oxygen therapy, ‰¡à‰¥â√—∫prednisolone ™π‘¥√—∫ª√–∑“π¡“°°«à“ 10 mg µàÕ«—πÕ¬à“ßµàÕ‡π◊ËÕß·≈–µâÕß “¡“√∂∑”µ“¡‚ª√·°√¡°“√Ωñ°∑’Ë«“ß‰«â‰¥â

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√»÷°…“ ·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫¢âÕ¡Ÿ≈æ◊Èπ∞“π¢ÕßºŸâªÉ«¬ ·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫§ÿ≥¿“æ™’«‘µ (St Gorege Respiratory Questionnaire)·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫√–¥—∫§«“¡ÀÕ∫‡Àπ◊ËÕ¬ (MRCdyspnea score)

‡§√◊ËÕß™—ËßπÈ”Àπ—° ‡§√◊ËÕß«—¥ à«π Ÿß ‡§√◊ËÕß«—¥§«“¡¥—π‚≈À‘µ ‡§√◊ËÕß«—¥ÕäÕ° ‘‡®π„π‡≈◊Õ¥ (Pulseoxymeter) ∂—ßÕÕ°´‘‡®π (Oxygen tank) Õÿª°√≥åÕÕ°°”≈—ß°“¬ ‡™àπ ∂ÿß∑√“¬ ¥√—¡‡∫≈≈å ¬“ß¬◊¥(theraband) „∫∫—π∑÷°°“√∑” 6 MWT ·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫√–¥—∫§«“¡æ¬“¬“¡„π°“√ÕÕ°°”≈—ß°“¬Rating of perceive exertion (RPE À√◊Õ Borgeûsscale) “¬«—¥ π“Ãî°“®—∫‡«≈“ ‚§π®√“®√ ’ â¡ „∫∫—π∑÷°°“√ÕÕ°°”≈—ß°“¬∑’Ë∫â“π ·≈–·∫∫∫—π∑÷°Õ“°“√ÀÕ∫‡Àπ◊ËÕ¬ºŸâªÉ«¬‚√§∂ÿß≈¡‚ªÉßæÕß

°“√¥”‡π‘πß“π §—¥‡≈◊Õ°°≈ÿà¡ÕÕ°°”≈—ß°“¬ 8√“¬ µ“¡‡°≥±å·≈–¬‘π¬Õ¡‡¢â“√à«¡‚§√ß°“√¥â«¬§«“¡ ¡—§√„® π—¥À¡“¬æ√âÕ¡≠“µ‘∑’Ë “¡“√∂¥Ÿ·≈·≈–∫—π∑÷°°“√ÕÕ°°”≈—ß°“¬„π√–¬– 3 ‡¥◊Õπ‰¥â ‡æ◊ËÕ™’È·®ß·≈– Õπ«‘∏’°“√ÕÕ°°”≈—ß°“¬µ“¡‚ª√·°√¡, °“√∫—π∑÷°°“√ÕÕ°°”≈—ß°“¬∑’Ë∫â“π, ¢âÕ§«√√–«—ß¢≥–ÕÕ°°”≈—ß°“¬, “∏‘µ·≈–Ωñ°ªØ‘∫—µ‘°“√ÕÕ°°”≈—ß°“¬æ√âÕ¡°—∫‡®â“Àπâ“∑’Ë‚√ßæ¬“∫“≈ æ√âÕ¡∑—Èß„ÀâÕÿª°√≥å

”À√—∫ÕÕ°°”≈—ß°“¬∑’Ë∫â“π ‰¥â·°à ¥√—¡‡∫≈≈å ¬“ß¬◊¥∂ÿß∑√“¬ ·∫∫∫—π∑÷°°“√ÕÕ°°”≈—ß°“¬

°“√«—¥º≈‚¥¬∑¥ Õ∫«—¥√–¬–∑“ß°“√‡¥‘π¡“µ√∞“π„π‡«≈“ 6 π“∑’ (6 minute - walk distance,6 MWD) √–¥—∫§«“¡√ÿπ·√ß¢ÕßÕ“°“√ÀÕ∫‡Àπ◊ËÕ¬∑’Ë —¡æ—π∏å°—∫°‘®°√√¡µà“ßÊ „™â√–¥—∫§«“¡ÀÕ∫‡Àπ◊ËÕ¬¡“µ√∞“π¢Õß Modified Medical Research Council(MMRC)15 Seale ·∫∫ Õ∫∂“¡§ÿ≥¿“æ™’«‘µ(St Gorege Respiratory Questionnaire) π”µ—«·ª√¡“æ‘®“√≥“°“√æ¬“°√≥å‚√§‡√’¬°«à“ BODE index ∑’Ë0, 1, 2, 3 ‡¥◊Õπ ‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°àÕπ‡¢â“‚ª√·°√¡°“√ÕÕ°°”≈—ß°“¬ ‚¥¬¡’‡°≥±å¡“µ√∞“π°“√°”Àπ¥√–¥—∫°“√‡ª≈’Ë¬π·ª≈ßπâÕ¬∑’Ë ÿ¥∑’Ë “¡“√∂‡ÀÁπº≈∑“ß§≈‘π‘° (minimal clinical important different, MCID)´÷ËßÀ¡“¬∂÷ß°“√‡ª≈’Ë¬π·ª≈ß∑’Ë‡¥‘π‰¥â‡æ‘Ë¡¢÷Èπ¢Õß√–¬–∑“ßÕ¬à“ßπâÕ¬ 54 ‡¡µ√ „π°“√∑¥ Õ∫ 6 π“∑’ §à“MMRC ≈¥≈ß > 1 √–¥—∫§à“ SGQ16 ≈¥≈ß¡“°°«à“ 4§–·ππ §à“ BODE index ≈¥≈ß¡“°°«à“ 2 §–·ππ

°‘®°√√¡π—¥À¡“¬„π™à«ß·√°π’È®–¥”‡π‘π°“√ 3§√—ÈßÊ ≈– 3 ™—Ë«‚¡ß Àà“ß°—π§√—Èß≈– 1 «—π ‡¡◊ËÕ§√∫·≈â«∑”°“√π—¥À¡“¬ºŸâªÉ«¬·≈–≠“µ‘∑ÿ° 1 ‡¥◊Õπ ®”π«π 3§√—Èß ∑ÿ°§√—Èß∑’ËºŸâªÉ«¬¡“æ∫®–∑”°“√µ√«®«—¥µà“ßÊµ√«®∫—π∑÷°°“√ÕÕ°°”≈—ß°“¬ µâÕß‰¡àπâÕ¬°«à“ 3 §√—Èß/ —ª¥“Àå §√—Èß≈–‰¡àπâÕ¬°«à“ 30 π“∑’ ª√—∫§«“¡¬“°¢Õß°“√ÕÕ°·√ßµ“¡§«“¡‡À¡“– ¡·≈–„Àâ°”≈—ß„®µ√«®«—¥ ™—ËßπÈ”Àπ—° ª√–‡¡‘π BMI, ‡ªÕ√å‡™Áπµå‰¢¡—π, 6MWT, St Gorege Respiratory Questionnaire,MMRC dyspnea score Õ∫∂“¡ªí≠À“Õÿª √√§°“√ÕÕ°°”≈—ß°“¬∑’Ë∫â“π

°“√«‘‡§√“–Àå∑“ß ∂‘µ‘ π”¢âÕ¡Ÿ≈ 6 MWT,MMRC dyspnea score, St George RespiratoryQuestionnaire (SGQ), BODE index ¡“«‘‡§√“–Àå§à“‡©≈’Ë¬ºŸâªÉ«¬∑—Èß 8 √“¬ ®—¥∑”¢âÕ¡Ÿ≈‚¥¬„™â‚ª√·°√¡Excel ·≈–„™â‚ª√·°√¡ Stata10 «‘‡§√“–ÀåÀ“§«“¡·µ°µà“ß¢Õß ¡√√∂¿“æ°“√À“¬„® °àÕπ‡¢â“‚ª√·°√¡ÕÕ°°”≈—ß°“¬∑’Ë∫â“π‡ª√’¬∫‡∑’¬∫°—∫ ¡√√∂¿“æ°“√À“¬„®À≈—ß‡¢â“‚ª√·°√¡∑’Ë√–¬– 1 ‡¥◊Õπ 2 ‡¥◊Õπ ·≈– 3

20

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‡¥◊Õπ‚¥¬„™â Mean difference ∑’Ë§à“§«“¡‡™◊ËÕ¡—Ëπ√âÕ¬≈– 95 (95% Confidence Interval) ¥â«¬°“√«‘‡§√“–Àå«‘∏’Paired - T-test ºŸâªÉ«¬∑ÿ°√“¬ “¡“√∂ÕÕ°°”≈—ß°“¬‰¥âµ“¡‚ª√·°√¡ ¡’ºŸâªÉ«¬ 1 √“¬∑’Ë¡’Õ“°“√ª«¥∫√‘‡«≥°≈â“¡‡π◊ÈÕÀ≈—ß·≈–¢“„π‡¥◊Õπ∑’Ë 2 µâÕß√—∫ª√–∑“π¬“‡æ◊ËÕ≈¥Õ“°“√ª«¥ ·π–π”„Àâ≈¥‚ª√·°√¡≈ß 1 —ª¥“ÀåµàÕ¡“Õ“°“√¥’¢÷Èπ “¡“√∂ÕÕ°°”≈—ß°“¬µ“¡‚ª√·°√¡‰¥âµàÕ‰ª®π ‘Èπ ÿ¥‡¥◊Õπ∑’Ë 3

º≈

®“°°“√µ‘¥µ“¡ºŸâªÉ«¬∑—Èß 8 √“¬„π√–¬– 3 ‡¥◊Õπ‰¥â¢âÕ¡Ÿ≈°“√«—¥§à“µà“ßÊ „π·µà≈–‡¥◊Õππ”¢âÕ¡Ÿ≈«‘‡§√“–Àå‡ªìπ§à“‡©≈’Ë¬¢Õß°≈ÿà¡ π”¡“‡ª√’¬∫‡∑’¬∫¥—ß„πµ“√“ß∑’Ë 1 §à“ 6 MWT ‡æ‘Ë¡¢÷Èπµ“¡≈”¥—∫®“°‡¥◊Õπ∑’Ë 0‡¥‘π‰¥â 345.75 ‡¡µ√ ‡ªìπ 410.15 ‡¡µ√ „π‡¥◊Õπ∑’Ë 3,§à“ MMRC ®“° 3.25 „πµÕπ‡√‘Ë¡µâπ‡ªìπ 2.13 „π‡¥◊Õπ∑’Ë 3, §à“ FEV1 ¡’§à“‡ª≈’Ë¬π·ª≈ßπâÕ¬ (+2.74%),§à“ SGQ ¢≥–‡√‘Ë¡µâπ 45.75 ‡ªìπ 38.63 „π‡¥◊Õπ∑’Ë 3≈¥≈ß 7.13 §–·ππ, §à“ BODE index (´÷Ëß‰¥â®“°°“√§”π«≥§à“ 6 MWT MMRC, FEV1, BMI)‡ª≈’Ë¬π·ª≈ß®“° 6.25 ‡ªìπ 4.25 „π‡¥◊Õπ∑’Ë 3

ºŸâªÉ«¬∑—Èß 8 √“¬ “¡“√∂ÕÕ°°”≈—ß°“¬‰¥â¥’ ≠“µ‘¡’§«“¡‡¢â“„®·≈–„Àâ°”≈—ß„® ºŸâªÉ«¬¡’°”≈—ß„®∑’Ë¥’ ¡’

§«“¡µ—Èß„®∑’Ë®–ÕÕ°°”≈—ß°“¬µàÕ‰ªÀ≈—ß ‘Èπ ÿ¥‚ª√·°√¡¢âÕ¡Ÿ≈°“√‡ª≈’Ë¬π·ª≈ß‡√‘Ë¡‡ÀÁπº≈„π∑“ß∑’Ë¥’¢÷Èπµ—Èß·µà‡¥◊Õπ·√° ·≈–¡’·π«‚πâ¡¥’¢÷ÈπÕ¬à“ßµàÕ‡π◊ËÕß„π‡¥◊Õπ∑’Ë2 ·≈–‡¥◊Õπ∑’Ë 3 ¥—ß√Ÿª∑’Ë 1-4

°“√«‘‡§√“–Àåº≈°“√‡ª≈’Ë¬π·ª≈ß¢Õß ¡√√∂¿“æ°“√À“¬„®«à“¥’¢÷ÈπÀ√◊Õ‰¡à Õ’°«‘∏’Àπ÷ËßÕ“®„™â‡°≥±å‡ª√’¬∫‡∑’¬∫°àÕπ·≈–À≈—ß ‘Èπ ÿ¥‚ª√·°√¡„πºŸâªÉ«¬·µà≈–√“¬‚¥¬ §à“ MCID ¢Õß 6 MWT ¡“°°«à“ 54‡¡µ√ „π°≈ÿà¡µ—«Õ¬à“ßºà“π‡°≥±åπ’È 4 √“¬„π 8 √“¬, §à“MMRC ≈¥≈ß¡“°°«à“ 1 √–¥—∫„π°≈ÿà¡µ—«Õ¬à“ßπ’Èºà“π‡°≥±å 7 √“¬„π 8 √“¬, §à“ MCID ¢Õß SGQ ≈¥≈ß¡“°°«à“ 4 §–·ππ„π°≈ÿà¡µ—«Õ¬à“ßπ’Èºà“π‡°≥±å 6 √“¬„π 8 √“¬, §à“ BODE index ≈¥≈ß¡“°°«à“ 2 §–·ππ„π°≈ÿà¡µ—«Õ¬à“ßπ’Èºà“π‡°≥±å 4 √“¬„π 8 √“¬

‡¡◊ËÕπ”¢âÕ¡Ÿ≈¡“«‘‡§√“–Àå∑“ß ∂‘µ‘‚¥¬„™â Meandifference ∑’Ë§à“§«“¡‡™◊ËÕ¡—Ëπ √âÕ¬≈– 95 (95%Confidence interval) ¥â«¬°“√«‘‡§√“–Àå«‘∏’ Paired -T-test ‰¥âº≈¥—ßµ“√“ß∑’Ë 2

®“°µ“√“ßæ∫«à“ §à“‡©≈’Ë¬¢Õß 6 MWD „πºŸâªÉ«¬‚√§∂ÿß≈¡ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß√–¬–√ÿπ·√ß∂÷ß√ÿπ·√ß¡“°„π‡¥◊Õπ∑’Ë 3 À≈—ß‡¢â“‚ª√·°√¡ÕÕ°°”≈—ß°“¬ Ÿß°«à“°àÕπ‡¢â“‚ª√·°√¡Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ‚¥¬¡’§à“ Meandifference = 65 (95%CI = 0.16-129.8) „π¢≥–∑’Ë

µ“√“ß∑’Ë 1 §à“‡©≈’Ë¬∑’Ë‡ª≈’Ë¬π·ª≈ß„π‡¥◊Õπ∑’Ë 1 ∂÷ß‡¥◊Õπ∑’Ë 3 ·≈–º≈‡ª√’¬∫‡∑’¬∫°àÕπÀ≈—ß‡¢â“‚ª√·°√¡

º≈‡ª√’¬∫‡∑’¬∫§à“∑’Ë„™â«—¥/√–¬–‡«≈“ ‡√‘Ë¡µâπ ‡¥◊Õπ∑’Ë 1 ‡¥◊Õπ∑’Ë 2 ‡¥◊Õπ∑’Ë 3

°àÕπÀ≈—ß‡¢â“‚ª√·°√¡

6 MWD (‡¡µ√) 345.75 401.44 406.00 410.75 65.00

MMRC (§–·ππ) 3.25 3.00 2.75 2.13 -1.13

FEV1 (√âÕ¬≈–) 35.60 40.59 38.75 38.34 2.74

SGQ total (§–·ππ) 45.75 43.81 41.94 38.63 -7.13

SGQ symptom (§–·ππ) 13.63 11.25 11.38 10.88 -2.75

SGQ impact (§–·ππ) 13.50 13.50 12.13 9.63 -3.88

SGQ activity (§–·ππ) 20.00 19.06 18.44 18.13 -1.88

BODE index (§–·ππ) 6.25 5 4.75 4.25 -2



50

40

30

20

10

0

Scor

e

‡√‘Ë¡µâπ ‡¥◊Õπ∑’Ë 1 ‡¥◊Õπ∑’Ë 2 ‡¥◊Õπ∑’Ë 3

√–¬–‡«≈“

√Ÿª∑’Ë 3 ‡ª√’¬∫‡∑’¬∫§à“ SGQ „π™à«ß 3 ‡¥◊Õπ

450

400

350

300

Dis

tanc

e

‡√‘Ë¡µâπ ‡¥◊Õπ∑’Ë 1 ‡¥◊Õπ∑’Ë 2 ‡¥◊Õπ∑’Ë 3

√–¬–‡«≈“

√Ÿª∑’Ë 1 ‡ª√’¬∫‡∑’¬∫§à“ 6 MWD „π™à«ß 3 ‡¥◊Õπ

4

3

2

1

0

Scor

e

‡√‘Ë¡µâπ ‡¥◊Õπ∑’Ë 1 ‡¥◊Õπ∑’Ë 2 ‡¥◊Õπ∑’Ë 3

√–¬–‡«≈“

√Ÿª∑’Ë 2 ‡ª√’¬∫‡∑’¬∫§à“ MMRC „π™à«ß 3 ‡¥◊Õπ

7

6

5

4

3

2

1

0

Scor

e

‡√‘Ë¡µâπ ‡¥◊Õπ∑’Ë 1 ‡¥◊Õπ∑’Ë 2 ‡¥◊Õπ∑’Ë 3

√–¬–‡«≈“

√Ÿª∑’Ë 4 ‡ª√’¬∫‡∑’¬∫§à“ BODE „π™à«ß 3 ‡¥◊Õπ

µ“√“ß∑’Ë 2 º≈°“√«‘‡§√“–Àå ¡√√∂¿“æ°“√À“¬„®„π ºŸâªÉ«¬‚√§∂ÿß≈¡ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß√–¬–√ÿπ·√ß ∂÷ß√ÿπ·√ß¡“°°àÕπ

‡¢â“‚ª√·°√¡ÕÕ°°”≈—ß°“¬∑’Ë∫â“π‡ª√’¬∫‡∑’¬∫°—∫ ¡√√∂¿“æ°“√À“¬„®À≈—ß‡¢â“‚ª√·°√¡∑’Ë√–¬– 1 ‡¥◊Õπ

2 ‡¥◊Õπ ·≈– 3 ‡¥◊Õπ

‡¥◊Õπ∑’Ë 1 ‡¥◊Õπ∑’Ë 2 ‡¥◊Õπ∑’Ë 3§à“∑’Ë„™â«—¥

MD* 95%CI MD* 95%CI MD* 95%CI

6 MWD 55.7 -34.6-145.9 60.25 -10.7-131.2 65 0.16-129.8*

MMRC -0.25 -0.6-0.1 -0.5 -0.9-(-0.05)* -1.1 -1.7-(-0.6)*

FEV1 4.9 -0.7-10.6 3.1 -2.9-9.2 2.7 -4.3-9.7

SGQ total -1.9 -7.2-3.3 -3.8 -12.2-4.6 -7.1 -14.7-0.4

SGQ symptom -2.4 -5.5-0.8 -2.2 -6.1-1.6 -2.7 -7.2-1.7

SGQ impact 0 -1.9-1.9 -1.4 -4.1-1.3 -3.9 -5.9-(-1.8)*

SGQ activity -0.9 -5.4-3.5 -1.6 -5.7-2.6 -1.9 -5.2-1.4

BODE index -1.2 -2.3-(-0.2)* -1.5 -2.7-(-0.3)* -2.0 -3.3-(-0.7)*

MD = Mean difference, 6 MWD = 6 minutes walk distance

*À¡“¬∂÷ß p-value < 0.05

22

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

¢Õß°≈ÿà¡≈¥≈ß‰¥â 7.13 §–·ππ ´÷Ëß¡“°°«à“‡°≥±å 4§–·ππ∑’Ëµ—Èß‰«â ‡¡◊ËÕπ”¡“§”π«≥ BODE ‚¥¬„™â‡°≥±å°“√„Àâ§–·ππ®“° §à“ FEV1, 6 MWT, MMRC, BMI°àÕπ·≈–À≈—ß ‘Èπ ÿ¥‚ª√·°√¡¡’§–·ππ≈¥≈ß 2 §–·ππ®“° 6.25 ‡ªìπ 4.25 “¡“√∂„™âæ¬“°√≥åÕ—µ√“°“√‡ ’¬™’«‘µ„π√–¬– 12 ‡¥◊Õπ ∂÷ß 52 ‡¥◊Õπ ´÷Ëßæ‘ Ÿ®πå·≈â««à“¥’°«à“°“√„™â§à“ FEV1 ‡æ’¬ßÕ¬à“ß‡¥’¬«17 “¡“√∂≈¥Õ—µ√“°“√‡ ’¬™’«‘µ ®“°√âÕ¬≈– 2, 14, 40 ‡ªìπ√âÕ¬≈– 2,8, 32 ∑’Ë 12 ‡¥◊Õπ 24 ‡¥◊Õπ ·≈– 52 ‡¥◊Õπ µ“¡≈”¥—∫§à“ FEV1 (% Predict) ‰¡à‡ª≈’Ë¬π·ª≈ß¡“°π—° ‡ªìπ‰ªµ“¡°≈‰°≈¢Õß‚√§´÷Ëß‡ÀÁπº≈‰¥âπâÕ¬·≈–™â“ ºŸâªÉ«¬∑—Èß8 √“¬∑’Ë‡¢â“‚ª√·°√¡„π™à«ß 3 ‡¥◊Õπ ‰¡à¡’√“¬„¥¡’Õ“°“√ÀÕ∫√ÿπ·√ß‡©’¬∫æ≈—π À√◊ÕµâÕßπÕπ‚√ßæ¬“∫“≈°“√‡ª≈’Ë¬π·ª≈ß¢Õß 6 MWT ∑’Ë‡æ‘Ë¡¢÷Èπ¡“°„π‡¥◊Õπ∑’Ë1 πà“®–‡ªìπº≈®“°°“√«—¥§à“ 6 MWT °àÕπ‡¢â“‚§√ß°“√¡’2 √“¬∑’Ë‰¡à “¡“√∂‡¥‘π‰¥â®π§√∫ 6 π“∑’ (220 ‡¡µ√π“∑’∑’Ë 3 ·≈– 151 ‡¡µ√π“∑’∑’Ë 2) ‡π◊ËÕß®“°‡Àπ◊ËÕ¬ÀÕ∫¡“°µâÕßÀ¬ÿ¥æ—°

°“√Ωñ°ÕÕ°°”≈— ß°“¬∑’Ë∫â “π “¡“√∂øóôπøŸ ¡√√∂¿“æ°“√À“¬„® “¡“√∂π”¡“ª√—∫„™â°—∫ºŸâªÉ«¬„π√–¥—∫Õ”‡¿Õ‰¥â ‚¥¬„™â¥—¡‡∫≈, ∂ÿß∑√“¬ ·≈–¬“ß¬◊¥ ‡π◊ËÕß®“°‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ë¡’√“§“∂Ÿ° À“‰¥âßà“¬°«à“‡§√◊ËÕß¡◊Õ∑’Ë„™â„π‚√ßæ¬“∫“≈¡À“√“™π§√‡™’¬ß„À¡à ´÷Ëß‰¥â·°à ®—°√¬“π¡◊Õ ®—°√¬“π‡∑â“ ‡¥‘π¢÷Èπ “¬æ“π(Suandok Exercise training)18 ºŸâªÉ«¬ “¡“√∂ª√—∫µ—«‡¢â“°—∫‡§√◊ËÕß¡◊Õ‰¥â‰¡à¬“° Ωñ°‰¥â∑ÿ°«—π ‰¡àµâÕß‡¥‘π∑“ß¡“‚√ßæ¬“∫“≈ ·≈– “¡“√∂π”‰ªΩñ°µàÕ‡π◊ËÕß∑’Ë∫â“πÀ≈—ß ‘Èπ ÿ¥‚ª√·°√¡‰¥âÕ’°¥â«¬ §à“ 6 MWT,MMRC, SGQ ¥’¢÷Èπµ“¡≈”¥—∫„π‡¥◊Õπ∑’Ë 1, 2, 3· ¥ß∂÷ß·π«‚πâ¡∑’Ë¥’¢÷ÈπÕ¬à“ßµàÕ‡π◊ËÕßÕ“®®–∑”°“√»÷°…“µ‘¥µ“¡„π√–¬–‡«≈“∑’Ëπ“π¢÷Èππà“®–‰¥âº≈∑’Ë™—¥‡®π¬‘Ëß¢÷Èπ°“√øóôπøŸ ¡√√∂¿“æ°“√À“¬„®¥â«¬°“√ÕÕ°°”≈—ß°“¬¡’ª√–‚¬™πå„πºŸâªÉ«¬ COPD °≈ÿà¡ÕàÕπ·≈–ª“π°≈“ß·≈– “¡“√∂°√–µÿâπ„ÀâÕÕ°°”≈—ß°“¬·∫∫ Aerobic∑—Èßµ—«‰¥â ‚¥¬‰¡àµâÕßΩñ°°≈â“¡‡π◊ÈÕ‡©æ“– à«π °“√°√–µÿâπ„ÀâºŸâªÉ«¬‰¥â‡¢â“„®·≈–π”‰ªΩñ°ªØ‘∫—µ‘‡ªìπ ‘Ëß∑’Ë®–‡°‘¥ª√–‚¬™πå°—∫ºŸâªÉ«¬ ·µà∫ÿ§≈“°√∑“ß°“√·æ∑¬å¬—ß

§à“‡©≈’Ë¬¢Õß MMRC, SGQ impact, BODE index„πºŸâªÉ«¬‚√§∂ÿß≈¡ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß√–¬–√ÿπ·√ß∂÷ß√ÿπ·√ß¡“°„π‡¥◊Õπ∑’Ë 3 À≈—ß‡¢â“‚ª√·°√¡ÕÕ°°”≈—ß°“¬µË”°«à“°àÕπ‡¢â“‚ª√·°√¡Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘‚¥¬¡’§à“ Mean difference= -1.1 [95%CI = -1.7-(-0.6)], -3.9 [95%CI = -5.9-(-1.8)] ·≈– -2.0[95%CI = -3.3-(-0.7)] µ“¡≈”¥—∫

·≈–¬—ßæ∫«à“§à“‡©≈’Ë¬¢Õß MMRC „π‡¥◊Õπ∑’Ë 2À≈—ß‡¢â“‚ª√·°√¡ÕÕ°°”≈—ß°“¬µË”°«à“°àÕπ‡¢â“‚ª√·°√¡Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ‚¥¬¡’§à“ Mean difference= -0.5 [95%CI =-0.9-(-0.05)] à«π§à“‡©≈’Ë¬¢ÕßBODE index „π‡¥◊Õπ∑’Ë 1 ·≈– 2 À≈—ß‡¢â“‚ª√·°√¡ÕÕ°°”≈—ß°“¬µË”°«à“°àÕπ‡¢â“‚ª√·°√¡Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘‡™àπ°—π ‚¥¬¡’§à“ Mean difference = -1.2[95%CI = -2.3-(-0.2)] ·≈– -1.5 [95%CI = -2.7-(-0.3)] µ“¡≈”¥—∫

«‘®“√≥å

°“√øóôπøŸ ¿“æ„πºŸâªÉ«¬ COPD ¢—Èπ√ÿπ·√ß¡—°¡’¢âÕ®”°—¥¢Õß°“√À“¬„®·≈–°≈â“¡‡π◊ÈÕ∑’ËÕàÕπ·√ß ·≈–‡Àπ◊ËÕ¬≈â“‰¥âÕ¬à“ß√«¥‡√Á«¡“° °“√‡√‘Ë¡ÕÕ°°”≈—ß°“¬®–‡√‘Ë¡¥â«¬°“√Ωñ°°≈â“¡‡π◊ÈÕ‡ªìπ°≈ÿà¡Ê ‰ª §◊Õ Ωñ°°≈â“¡‡π◊ÈÕ¢Õß¢“ °≈â“¡‡π◊ÈÕ·¢π ·≈–°≈â“¡‡π◊ÈÕ°“√À“¬„®‡¢â“ °“√Ωñ°„π™à«ß·√°æ√âÕ¡°—∫≠“µ‘ ‡æ◊ËÕ∑’Ë®–ª√—∫À√◊Õ‡æ‘Ë¡√–¥—∫Õ—µ√“ß“πΩñ°∑’Ë‡À¡“– ¡„πºŸâªÉ«¬·µà≈–√“¬ À“°‡Àπ◊ËÕ¬ßà“¬®–ª√—∫°“√Ωñ°‡ªìπ√–¬–‡«≈“ —ÈπÊ æ—°‡ªìπ√–¬–Ê æÕ∑ÿ‡≈“Õ“°“√‡Àπ◊ËÕ¬·≈â«Ωñ°µàÕ ≈—∫‰ª‡√◊ËÕ¬Ê „Àâ‰¥â√–¬–‡«≈“Ωñ°π“πª√–¡“≥30 π“∑’ —ª¥“Àå≈–‰¡àπâÕ¬°«à“ 3 «—π ≠“µ‘®–°√–µÿâπ„Àâ°”≈—ß„®À√◊ÕÕ“®®–∑”°“√Ωñ°√à«¡¥â«¬·≈–∫—π∑÷°º≈°“√Ωñ° ºŸâªÉ«¬∑’Ë “¡“√∂‡¥‘π‰¥â¥’¢÷Èπ·≈â«®–·π–π”„ÀâΩñ°‡¥‘π„Àâ‰¥â‡«≈“π“π¢÷Èπ

º≈¢Õß°“√µ‘¥µ“¡ 3 ‡¥◊ÕπÀ≈—ßΩñ° §à“‡©≈’Ë¬6 MWT ¢Õß°≈ÿà¡‡æ‘Ë¡¢÷Èπ 65 ‡¡µ√ ¡“°°«à“‡°≥±å∑’Ëµ—Èß‰«â∑’Ë 54 ‡¡µ√, §à“ MMRC ´÷Ëß®–„™â°“√ Õ∫∂“¡ºŸâªÉ«¬∂÷ß¿“«–À“¬„®≈”∫“° §à“‡©≈’Ë¬¢Õß°≈ÿà¡≈¥≈ß‰¥â1.13 √–¥—∫, §à“ SGQ À√◊Õ°“√«—¥√–¥—∫§ÿ≥¿“æ™’«‘µ



‰¡à‰¥â∑”Õ¬à“ß®√‘ß®—ß

√ÿª

°“√®—¥‚ª√·°√¡ÕÕ°°”≈—ß°“¬„πºŸâªÉ«¬ COPD ¢—Èπ√ÿπ·√ß∂÷ß√ÿπ·√ß¡“°‚¥¬°“√ª√–¬ÿ°µå„™â‡§√◊ËÕß¡◊Õ∑’ËÀ“‰¥âßà“¬‰¥â·°à∂ÿß∑√“¬, Dumbbell, ¬“ß¬◊¥ ‚¥¬„Àâ°“√Ωñ°„π™à«ß·√°∑’Ë‚√ßæ¬“∫“≈ 3 §√—Èß ·≈â«π”°≈—∫‰ªÕÕ°°”≈—ß°“¬∑’Ë∫â“π √à«¡°—∫°“√‡¥‘π ‚¥¬¡’≠“µ‘§Õ¬¥Ÿ·≈„Àâ°”≈—ß„® ª√–‡¡‘πºŸâªÉ«¬®π§√∫ 3 ‡¥◊Õπ §à“‡©≈’Ë¬ 6MWT, MMRC, SGQ, BODE index ¥’¢÷Èπ ‰¡à¡’ºŸâªÉ«¬∑’Ë¡’Õ“°“√°”‡√‘∫„π¢≥–‡¢â“‚ª√·°√¡ ºŸâªÉ«¬·≈–≠“µ‘¡’§«“¡æ÷ßæÕ„®„π‚ª√·°√¡°“√Ωñ° πà“®–‡ªìπ√Ÿª·∫∫∑’Ë‡À¡“– ¡∑’Ë®–™à«¬øóôπøŸ ¿“æºŸâªÉ«¬ COPD ¢—Èπ√ÿπ·√ß∂÷ß√ÿπ·√ß¡“°‰¥â

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥π“¬·æ∑¬å™Ÿæß»å · ß «à“ß∑’Ë™à«¬«‘‡§√“–Àå¢âÕ¡Ÿ≈ ∂‘µ‘ ‡®â“Àπâ“∑’Ë§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‚√ßæ¬“∫“≈‡™’¬ß¥“« ‡®â“Àπâ“∑’Ë·ºπ°°“¬¿“æ∫”∫—¥‚√ßæ¬“∫“≈‡™’¬ß¥“«∑’Ë™à«¬‡À≈◊Õ®π∑”„Àâß“π«‘®—¬§√—Èßπ’È ”‡√Á®¥â«¬¥’

5. Pothirat C, Petchsuk N, Pisanthanaphan S,

Chedsadaphan N, Innchai J. Prevalence, smoking risk

factor, and severity of COPD in community: a

comparative study between an urban and a rural in

Chiang Mai. (∫∑§—¥¬àÕ) Àπ—ß ◊Õª√–°Õ∫°“√ª√–™ÿ¡ “¡—≠·≈–°“√ª√–™ÿ¡«‘™“°“√ª√–®”ªï ¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬; 2549.

6. Nici L, Donner C, Wouters E, Zuwallack R, Ambrosini

N, Bourbeau J, et al. American Thoracic Society/

European Respiratory Society statement on pulmonary

rehabilitation. Am J Respir Crit Care Med 2006;

173:1390-413.

7. Global Initiative Obstructive Lung Disease. Global

strategy for the diagnosis, management, and prevention

of chronic obstructive lung disease (executive

summary). Updated2005.http://www.goldcopd.com/

Guidelineitem.asp?-/1=2&/2=18&intld=996. Accessed

August 14, 2006.

8. Troostes T, Casaburi R, Gosselink R, Decramer M.

Pulmonary rehabilitation in chronic obstructive

pulmonary disease. Am J Respir Crit Care Med 2005;

172:19-38.

9. Casaburi R, Kakafka D, Cooper C, Wang S Kesten S.

Improvement in exercise tolerance with the combination

of tiotropium and pulmonary rehabilitation exercise

training in COPD patients. Chest 2005; 127:809-17.

10. Vogiatzis I, Nanas S, Roussos C. Interval training as an

alternative modality to continuous exercise in patients

with COPD. Eur Respir J 2002; 20:12-9

11. Bernard SF Whittom P, LeBlance J, Jobin J, Belleau R,

Berube C, et al. Aerobic and strength training in

patients with chronic obstructive pulmonary disease.

Am J Respir Crit Care Med 1999; 159:896-901.

12. Horowitz MB, Littenberg B, Mahler DA. Dyspnea

ratings for prescribing exercise intensity in patients

with COPD Chest 1996; 109:1169-75.

13. Bianchi R, Gigliotti F, Romagnoli I, Lanini B, Castellani

C, Grazzini M, et al. Chest wall kinetics and

breathlessness during pursed-lip breathing in patients

with COPD. Chest 2004; 125:459-65.

14. Emtner M, Porszasz J, Burns M,Somfay A, Casaburi R.

Bebefits of supplemental oxygen in exercise training in

non-hypoxemic COPD patients. Am J Respir Crit Care

Med 2003; 168:1034-42.

15. Fletcher CM, Elmes PC, Wood CH. The significance

of respiratory symptoms and the diagnosis of chronic

bronchitis in a working population. BrMed J 1959;

1:257-66.


1. World Health Organization/World Bank. Global Burden

of Disease Study. Acessed online August 14,2006,

athttp://www.who.int/respiratory/copd/burden/en/

print.html

2. Lacasse Y, Brosseau L, Milne S. Pulmonary

rehabilitation for chronic obstructive pulmonary disease.

Cochrane Database Syst Rrv 2002; CD003793.

3. Griffiths TL, Burr ML, Cambell La, Lewis-Jenkins V,

Mullins J, Shiels K. Result at 1 year of multidisciplinary

pulmonary rehabilitation: a randomized comtrolled

trial. Lancet 2000; 355:362-8.

4. Puhan MA, Scharplatz M, troosters T, Steurer J.

Respiratory rehabilitation after acute exacerbation of

COPD may reduce risk of readmission and mortality: a

systemic review. Respir Res 2005; 6:54-64.

24

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

16. Jones PW, Quirk FH, Baveystock CM, LittleJohn T. A

self complete measure of health status for chronic

airflow limitation. Am Rev Respir Dis 1992; 145:1321-

7.

17. Celli B, Cote CG, Marin JM, Casanova C, Montes de

Oca M, Mendez RA, et al. The Body - mass index,

Airflow Obstruction, Dyspnea, and exercise capacity

index in chronic obstructive pulmonary disease. N

Engl J Med 2004; 350:1005-12.

18. Pothirat C, Somrit K, Petchsuke N, Pisanthanaphun S.

Suandok intensive exercise training program for COPD

patients: a short and long term efficacy analysis.

(∫∑§—¥¬àÕ) Àπ—ß ◊Õª√–°Õ∫°“√ª√–™ÿ¡ “¡—≠ª√–®”ªï·≈–°“√ª√–™ÿ¡«‘™“°“√ª√–®”ªï ¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬; 2548. p. 104.




°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬‡∑§π‘§°“√‡ªî¥·º≈¢π“¥‡≈Á°„π‚√ßæ¬“∫“≈™ÿ¡™π∏’√æ≈ ™≈‡¥™ æ.∫.‚√ßæ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬ ®—ßÀ«—¥¡À“ “√§“¡

Abstract Minilaparotomy Cholecystectomy in District HospitalChonladej T.

Phayakabhumpisai Hospital, Mahasarakam, Thailand


Since 1987, laparoscopic cholecystectomy has become the standard treatment of gall bladderdisease. Its benefits over conventional open cholecystectomy have been well documented. There is not manydistrict hospital that have laparoscope in Thailand. The instrument and disposable materials are expensiveand need operative team’s skill. The conventional open cholecystectomy seem to be necessary for patients whoavvided sequalae of large operative wound. These patients have to admit in the hospital for many days. Inthis report we have 5 years experience from October 1, 2003 to September 30, 2007. There were 136 patientsin Phayakkhaphumpisai hospital that was treated cholecystectomy by open a small surgical wound(Minilaparotomy) . We compared the effectiveness and safety of this tecnique to other studies,and found thatminilaparotomy cholecystectomy is safe and effective less invasive procedure as well as laparoscopiccholecystectomy.

Key words: minilaparotomy cholecystectomy, laparoscopic cholecystectomy

‡√◊ËÕß¬àÕ ªí®®ÿ∫—π°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬°≈âÕß«’¥‘∑—»πå (Laparoscopic cholecystectomy) ‡ªìπ¡“µ√∞“π°“√√—°…“·≈–‡ªìπ∑’Ë¬Õ¡√—∫°—π„π∑“ß»—≈¬°√√¡ Õ¬à“ß‰√°Áµ“¡¬—ß¡’¢âÕ®”°—¥¥â«¬‡√◊ËÕß«— ¥ÿÕÿª°√≥å∑’Ë¡’√“§“·æß´÷Ëß‚√ßæ¬“∫“≈™ÿ¡™π à«π„À≠à¬—ß‰¡à “¡“√∂®—¥À“‰¥â µâÕß„™â§«“¡™”π“≠®“°·æ∑¬åºŸâºà“µ—¥ ∑”„Àâ°“√ºà“µ—¥¥â«¬«‘∏’¥—Èß‡¥‘¡ (Conventional open cholecystectomy)¬—ß¡’§«“¡®”‡ªìπ‡æ◊ËÕµÕ∫ πÕßµàÕºŸâªÉ«¬∑’Ë¡“„™â∫√‘°“√®”π«π¡“°´÷ËßºŸâªÉ«¬®–¡’·º≈ºà“µ—¥¢π“¥„À≠à ¡’§«“¡‡®Á∫ª«¥¡“° µâÕßÕ¬Ÿà‚√ßæ¬“∫“≈π“π´÷Ëß®– àßº≈µàÕ°“√°≈—∫‰ª∑”ß“πª√–®” ºŸâ√“¬ß“π®÷ß‰¥âª√–¬ÿ°µå°“√ºà“µ—¥¥â«¬‡∑§π‘§°“√‡ªî¥·º≈¢π“¥‡≈Á°‚¥¬‰¡àµâÕß„™â‡§√◊ËÕß¡◊Õæ‘‡»… ‡ªî¥·º≈∫√‘‡«≥ upper midline ‰¡àµâÕßµ—¥°≈â“¡‡π◊ÈÕ ·º≈¢π“¥‡≈Á° 3-5 ‡´Áπµ‘‡¡µ√ µ“¡§«“¡Àπ“¢Õßºπ—ßÀπâ“∑âÕß “¡“√∂§«∫§ÿ¡®ÿ¥ ”§—≠¢ÕßÕ«—¬«–∑’Ëºà“µ—¥‰¥âßà“¬ „™â‡«≈“„π°“√ºà“µ—¥‰¡à‡°‘π 1 ™—Ë«‚¡ß ‚¥¬∑”°“√ºà“µ—¥∂ÿßπÈ”¥’∑’Ë‰¡à¡’¿“«–°“√Õ—°‡ ∫ µ—Èß·µà«—π∑’Ë 1 µÿ≈“§¡ æ.». 2545 ∂÷ß«—π∑’Ë 30 °—π¬“¬π æ.». 2550 ®”π«π 136 √“¬ ‡ª√’¬∫‡∑’¬∫º≈°—∫ ∂“∫—πÕ◊ËπÊ ∑’Ë√«∫√«¡‰«â º≈°“√ºà“µ—¥‰¥âº≈¥’„°≈â‡§’¬ß°—∫°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå „π·ßà¢Õß√–¬–‡«≈“°“√ºà“µ—¥√–¬–‡«≈“Õ¬Ÿà ‚√ßæ¬“∫“≈ §«“¡µâÕß°“√¬“√–ß—∫ª«¥ √–¬–‡«≈“°“√°≈—∫‰ª∑”ß“πª√–®” ·≈–¿“«–·∑√°´âÕπ ®÷ß‡ªìπ«‘∏’ºà“µ—¥∑’Ëπà“®–·π–π”„π°“√ºà“µ—¥∂ÿßπÈ”¥’∑ÿ°√“¬∑’Ë‰¥â√—∫°“√√—°…“„π‚√ßæ¬“∫“≈™ÿ¡™π∑’Ë¬—ß‰¡à¡’∫√‘°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå

§” ”§—≠: °“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬·º≈‡ªî¥¢π“¥‡≈Á° °“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬°≈âÕß«’¥‘∑—»πå

26

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

„πªï æ.». 2530 øî≈‘ª ¡Õ√å‡√∑ (Phillippe Mouret)»—≈¬·æ∑¬å™“«Ω√—Ëß‡» ‰¥âæ—≤π“«‘∏’°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬°≈âÕß«’¥‘∑—»πå®π‡ªìπ∑’Ë·æ√àÀ≈“¬·≈–π‘¬¡¢Õß»—≈¬·æ∑¬å1,2 ´÷Ëß¡’¢âÕ¥’§◊Õ ºŸâªÉ«¬¡’·º≈¢π“¥‡≈Á° øóôπµ—«‡√Á« ·≈–≈¥§«“¡‡®Á∫ª«¥¢Õß∫“¥·º≈ √–¬–‡«≈“°“√πÕπ‚√ßæ¬“∫“≈ —Èπ3-6 ¢≥–‡¥’¬«°—π°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬°≈âÕß«’¥‘∑—»πåÕ“®‡°‘¥¿“«–·∑√° âÕπ∑’Ë‡ªìπÕ—πµ√“¬µàÕºŸâªÉ«¬‰¥â7-10 „π√–¬–‡«≈“¬’Ë ‘∫°«à“ªï¡“π’È»—≈¬·æ∑¬å¡’§«“¡™”π“≠·≈–æ—≤π“‡∑§π‘§°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå®π¡’¿“«–·∑√°´âÕπµË”¡“° ¢≥–π’È°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬°≈âÕß«’¥‘∑—»πå®÷ß‡ªìπ∑’Ëπ‘¬¡·≈–¬Õ¡√—∫®π‡ªìπ¡“µ√∞“π¢Õß°“√ºà“µ—¥∂ÿßπÈ”¥’„ ∂“∫—π°“√·æ∑¬å™—Èππ”¢Õßª√–‡∑»‰∑¬·≈–µà“ßª√–‡∑»2-6,11

Õ¬à“ß‰√°Áµ“¡„π‚√ßæ¬“∫“≈™ÿ¡™π¢Õßª√–‡∑»‰∑¬¬—ß¡’πâÕ¬∑’Ë®–¡’°≈âÕß«’¥’∑—»πå ÷Ëß¡’√“§“·æß·≈–«— ¥ÿ ‘Èπ‡ª≈◊Õß´÷Ëß„™â·≈â«µâÕß∑‘Èß‰ª (disposable materials)µâÕß¡’»—≈¬·æ∑¬å·≈–∑’¡ß“π∑’Ë¡’§«“¡™”π“≠„π°“√ºà“µ—¥ ´÷Ëß‚√ßæ¬“∫“≈™ÿ¡™π®–µâÕßª√–‡¡‘π§«“¡§ÿâ¡∑ÿπ·≈–°“√°√–®“¬∫√‘°“√¥â“πµà“ßÊ „Àâ∑—Ë«∂÷ß ®÷ß‡ªìπ°“√¬“°∑’ËºŸâ∫√‘À“√‚√ßæ¬“∫“≈™ÿ¡™π®–µ—¥ ‘π„®®—¥∫√‘°“√°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå

‚√ßæ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬‡ªìπ‚√ßæ¬“∫“≈™ÿ¡™π¢π“¥ 90 ‡µ’¬ß∑’ËÕ¬ŸàÀà“ß‰°≈®“°‚√ßæ¬“∫“≈®—ßÀ«—¥ 84 °‘‚≈‡¡µ√ ¬—ß‰¡à¡’∫√‘°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå·µàºŸâªÉ«¬¡’§«“¡æÕ„®„π∫√‘°“√°“√ºà“µ—¥ ÷Ëß„Àâ∫√‘°“√∑—Èß„πÕ”‡¿Õ‡Õß·≈–Õ”‡¿Õ¢â“ß‡§’¬ß ºŸâªÉ«¬∑’Ë®”‡ªìπµâÕßºà“µ—¥∂ÿßπÈ”¥’¡’®”π«π¡“°À“°®–µâÕß∑”ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πåµâÕß‰ª√Õ‡¢â“§‘«ºà“µ—¥„π‚√ßæ¬“∫“≈∑—Ë«‰ª´÷Ëß®–„™â‡«≈“ π“πÀ≈“¬‡¥◊Õπ

‚√ßæ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬‚¥¬ß“π∫√‘°“√»—≈¬-°√√¡‰¥â√«∫√«¡º≈°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬‡∑§π‘§°“√‡ªî¥·º≈¢π“¥‡≈Á°‡æ◊ËÕ√“¬ß“πª√– ‘∑∏‘º≈·≈–§«“¡ª≈Õ¥¿—¬¢ÕßºŸâªÉ«¬®”π«π 136 √“¬„π√–¬–‡«≈“ 5 ªï

«—µ∂ÿ·≈–«‘∏’°“√

‰¥â‡≈◊Õ°ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìππ‘Ë«·≈–

‡π◊ÈÕßÕ° (Polyp) „π∂ÿßπÈ”¥’®“°°“√µ√«®¥â«¬Õÿ≈µ√“´“«¥å‚¥¬‰¡à¡’¿“«–°“√Õ—°‡ ∫¢Õß∂ÿßπÈ”¥’∑—ÈßÀ¡¥ 136√“¬ ∑”ºà“µ—¥‚¥¬»—≈¬·æ∑¬å§π‡¥’¬«°—π µ—Èß·µà«—π∑’Ë 1°—π¬“¬π æ.». 2545 ∂÷ß«—π∑’Ë 30 µÿ≈“§¡ æ.». 2550Õ“¬ÿ√–À«à“ß 20-81 ªï ‡æ»™“¬ 56 ‡æ»À≠‘ß 80 ‡ªìππ‘Ë«∑’Ë‰¡à¡’Õ“°“√ 108 √“¬ ¡’Õ“°“√ dyspepsia 26 √“¬‡ªìπ‡π◊ÈÕßÕ° (polyp) 2 √“¬ „π√“¬∑’Ë¡’Õ“°“√®–‰¥â√—∫°“√µ√«®°“√∑”ß“π¢Õßµ—∫„π‡≈◊Õ¥ ‚¥¬¥Ÿ®“°º≈‡≈◊Õ¥Bilirubin ·≈– Alkaline phosphatase º‘¥ª°µ‘®–‰¡à∑”°“√ºà“µ—¥«‘∏’π’È ºŸâªÉ«¬∑ÿ°√“¬‰¡à¡’¿“«–‡ ’Ë¬ßµàÕ°“√‰¥â√—∫°“√¥¡¬“ ≈∫ (General anesthesia) ·≈–‰¡à‡§¬ºà“µ—¥™àÕß∑âÕß à«π∫π¡“°àÕπ ºŸâªÉ«¬®–‰¥â√—∫°“√Õ∏‘∫“¬«à“°“√ºà“µ—¥¡’ 2 «‘∏’§◊Õ°“√ àÕß°≈âÕß·≈–°“√ºà“µ—¥·∫∫‡ªî¥™àÕß∑âÕß „Àâ∑√“∫¢âÕ¥’¢âÕ‡ ’¬·≈â«„ÀâºŸâªÉ«¬‡≈◊Õ°‡Õß·≈–≈ßπ“¡¬‘π¬Õ¡√—∫°“√ºà“µ—¥

ºŸâªÉ«¬®–∂Ÿ°√—∫µ—«‰«â„π‚√ßæ¬“∫“≈°àÕπ«—πºà“µ—¥1 «—π‡æ◊ËÕª√–‡¡‘π ÿ¢¿“æ∑—Ë«‰ª ·≈– routine lab ®–∑”°“√∫—π∑÷° √–¬–‡«≈“ºà“µ—¥ °“√‰¥â√—∫Õ“À“√À≈—ßºà“µ—¥¿“«–·∑√°´âÕπÀ≈—ßºà“µ—¥ √–¬–‡«≈“°“√πÕπ‚√ßæ¬“∫“≈ ”À√—∫¬“·°âª«¥À≈—ßºà“µ—¥®–¡’§” —Ëß„ÀâParacetamol 500 ¡‘≈≈‘°√—¡ 1 ‡¡Á¥ 3 ‡«≈“À≈—ßÕ“À“√Indomethacin 25 ¡‘≈≈‘°√—¡ 1 ‡¡Á¥ 3 ‡«≈“À≈—ßÕ“À“√·≈– Pethidine 50 ¡‘≈≈‘°√—¡ ∂â“ª«¥·º≈¡“°

‡∑§π‘§°“√ºà“µ—¥

°“√‡µ√’¬¡ºŸâªÉ«¬°àÕπºà“µ—¥∑”µ“¡ª°µ‘ À≈—ß®“°∑’ËºŸâªÉ«¬‰¥â√—∫°“√«“ß¬“ ≈∫·≈â«®—¥∑à“ºŸâªÉ«¬πÕπÀß“¬„™âÀ¡Õπ∑√“¬ÀπÿπÀ≈—ß∫√‘‡«≥∑’Ëµ√ß°—∫ Epigastrium

µ“√“ß∑’Ë 1 ®”π«π·≈–≈—°…≥–ºŸâªÉ«¬∑’Ë‡≈◊Õ°¡“ºà“µ—¥

Disease ™“¬ À≠‘ß √«¡

Asymptomatic gall stone 47 61 108

Symptomatic gall stone 9 17 26

Gall bladder polyp 0 2 2

√«¡ 56 80 136



¢Õß¥â“πÀπâ“ °“√ºà“µ—¥„™âºŸâ™à«¬ºà“µ—¥ 1 §π ºŸâ™à«¬®–¡Õß‰¡à‡ÀÁπ„π Field ºà“µ—¥‡æ√“–·º≈®–‡≈Á°·≈–Õ¬Ÿà≈÷°

µ”·Àπàß∑’Ë≈ß·º≈ºà“µ—¥∑’Ë Upper midline „π∫√‘‡«≥ Subxiphoid ´÷Ëß®–‡√’¬°«à“ Minimal stresstriangle (MST) ¡’¢Õ∫‡¢µ√–À«à“ß costochondralcartilage ∑’Ë 6-8 ∫√‘‡«≥¬Õ¥§◊Õ√Õ¬µàÕ√–À«à“ßcostochondral cartilage ∑’Ë 6 °—∫ Sternum ∫√‘‡«≥∞“π§◊Õ‡ âπ∑’Ë≈“°√–À«à“ß Costochondral cartilage ∑’Ë8 ∑—Èß Õß¢â“ß ´÷Ëß®–µ√ß°—∫µ”·Àπàß¢Õß°√–¥Ÿ° —πÀ≈—ß à«πÕ°∑’Ë 12 Calotûs triangle ´÷Ëß‡ªìπµ”·Àπàß∑“ß°“¬«‘¿“§∑’Ë ”§—≠ „π°“√ºà“µ—¥∂ÿßπÈ”¥’®–Õ¬Ÿà„π¢Õ∫‡¢µ¢Õß MST10 (√Ÿª∑’Ë 1)

°“√≈ß¡’¥ºà“µ—¥®“°ª≈“¬¢Õß°√–¥Ÿ°ÕàÕπXiphoid ≈ß≈à“ßª√–¡“≥ 3-5 ‡´πµ‘‡¡µ√ ·≈â«·µà§«“¡Àπ“¢Õßºπ—ßÀπâ“∑âÕßºŸâªÉ«¬ °“√‡¢â“™àÕß∑âÕß®–‡¢â“∑“ß¥â“π¢«“¢Õß Falciform ligament ‡æ◊ËÕ„Àâµ√ß·≈–ßà“¬µàÕ°“√∑”ºà“µ—¥·≈–ºŸ° Cystic ductjunction ·≈– Cystic artery ™à«¬„Àâ “¡“√∂µ√«®¥Ÿ¢π“¥¢Õß Common bile duct ‰¥â ‡¡◊ËÕ‡¢â“™àÕß∑âÕß®–„™â Deaver ¢π“¥‡≈Á°¥—π Posterior surface ¢Õßµ—∫¢÷Èπ¥â“π∫π ·≈– Falciform ligament ‰ª∑“ß¥â“π´â“¬ µ√«®¥Ÿµ”·Àπàß·≈–æ¬“∏‘ ¿“æ¢Õß∂ÿßπÈ”¥’°àÕπ

·≈â« Approach Calotûs triangle §âπÀ“·≈–ºŸ° µ—¥Cystic artery ”À√—∫ Cystic duct ºŸâ√“¬ß“ππ‘¬¡ºŸ°µ—¥∑’À≈—ß‚¥¬®–„™â Sponge forcep ®—∫∑’Ë∫√‘‡«≥ Fundus¢Õß∂ÿßπÈ”¥’·≈–¥÷ß Fundus ‡¢â“¡“À“∫√‘‡«≥·º≈·≈â«®÷ßµ—¥‡≈“–∂ÿßπÈ”¥’ÕÕ°®“°µ—∫®π¡“∂÷ß∫√‘‡«≥ Cysticduct junction ·≈â«®÷ßºŸ° µ—¥ Cystic duct ÿ¥∑â“¬‡æ◊ËÕªÑÕß°—π°“√‡°‘¥ injury µàÕ Common bile ductæ√âÕ¡°—∫ ”√«®¥Ÿ¢π“¥¢Õß Common bile duct À“°¡’‡≈◊Õ¥´÷¡∫√‘‡«≥„µâµ—∫‡≈Á°πâÕ¬®–„ à Vacuum drain‰«â

º≈

ºŸâªÉ«¬∑—Èß 136 √“¬∑”ºà“µ—¥ ”‡√Á®‚¥¬‰¡àµâÕß‡ª≈’Ë¬π°“√ºà“µ—¥‰ª‡ªìπ°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬«‘∏’¥—È ß ‡¥‘¡(Conventional open cholecystectomy) √–¬–‡«≈“ºà“µ—¥‡©≈’Ë¬ 32 π“∑’ (19-52 π“∑’) æ¬“∏‘ ¿“æ∑’Ëæ∫‡ªìπ normal gall bladder 113 √“¬ ºπ—ßÀπ“ 23 √“¬¡’ Adhesion 11 √“¬ ¡’ bleeding ®“° Hepatic sur-face 9 √“¬ µâÕß„ à Vaccum drain 5 √“¬ Commonbile duct “¡“√∂¡Õß‡ÀÁπ·≈–µ√«®¥Ÿæ¬“∏‘ ¿“æ·≈–¢π“¥‰¥â∑ÿ°√“¬ ‰¡à¡’§«“¡º‘¥ª°µ‘∑—Èß¢π“¥·≈–æ¬“∏‘ ¿“æ (¢π“¥‰¡à‡°‘π 1 ‡´πµ‘‡¡µ√ ºπ—ß∫“ß¡Õß‡ÀÁππÈ”¥’ ’‡¢’¬«Õ¬Ÿà¢â“ß„π)

ºŸâªÉ«¬ “¡“√∂°‘πÕ“À“√‰¥â„π«—π∑’Ëºà“µ—¥ À“°ºà“µ—¥°àÕπ‡«≈“ 12.00 π. µÕπ‡¬Áπ®– “¡“√∂°‘πÕ“À“√ÕàÕπ‰¥â À“°ºà“µ—¥„π™à«ß∫à“¬®–„Àâ°‘πÕ“À“√‡À≈«„πµÕπ‡¬Áπ°àÕπ ∑ÿ°√“¬ “¡“√∂°‘πÕ“À“√ª°µ‘‰¥â„π«—π√ÿàß¢÷Èπ ”À√—∫¬“·°âª«¥ºŸâªÉ«¬‰¥â√—∫ Pethidine 1 dose®”π«π 58 √“¬ ‰¥â√—∫ Pethidine 2 dose ®”π«π 7 √“¬‰¡àµâÕß©’¥‡≈¬ ®”π«π 71 √“¬

¿“«–·∑√°´âÕπÀ≈—ßºà“µ—¥æ∫«à“¡’ woundhematoma 3 √“¬ (√âÕ¬≈– 2.2) ‰¡à¡’ bile ductinjuries °“√®”Àπà“¬®“°‚√ßæ¬“∫“≈ 127 √“¬®”Àπà“¬„π«—π∑’Ë 2 À≈—ßºà“µ—¥ 7 √“¬®”Àπà“¬‰¥â„π«—π∑’Ë3 À≈—ßºà“µ—¥ 2 √“¬ ®”Àπà“¬‰¥â„π«—π∑’Ë 4 À≈—ßºà“µ—¥

®“°°“√´—°ª√–«—µ‘‡¡◊ËÕºŸâªÉ«¬°≈—∫¡“µ‘¥µ“¡º≈°“√√—°…“ 2 —ª¥“ÀåÀ≈—ßºà“µ—¥ ºŸâªÉ«¬°≈—∫¡“µ√«®√Ÿª∑’Ë 1 ¢Õ∫‡¢µ¢Õß Minimal stress triangle (MST)

28

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ‘¥µ“¡º≈°“√√—°…“ 133 √“¬ ‰¡à¡“µ√«® 3 √“¬ ºŸâªÉ«¬57 √“¬¡’Õ“°“√µ÷ß∫√‘‡«≥·º≈‡æ’¬ß‡≈Á°πâÕ¬ ºŸâªÉ«¬∑ÿ°√“¬ “¡“√∂∑”ß“π‰¥âµ“¡ª°µ‘¿“¬„π 1 —ª¥“Àå ·≈–¡’§«“¡æ÷ßæÕ„®º≈°“√ºà“µ—¥«‘∏’π’È ‚¥¬‡©æ“–√“¬∑’Ë‡§¬‡ÀÁπ·º≈ºŸâªÉ«¬∑’Ë‡§¬ºà“µ—¥¥â«¬«‘∏’¥—Èß‡¥‘¡ (µ“√“ß∑’Ë 2)

«‘®“√≥å

°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬·º≈‡ªî¥¢π“¥‡≈Á°¡’À≈“¬‡∑§π‘§´÷Ëß»—≈¬·æ∑¬å∑—ÈßÀ≈“¬‰¥â∑”ºà“µ—¥¥â«¬§«“¡™”π“≠·≈–§«“¡∂π—¥∑’Ë·µ°µà“ß°—π °“√∑’ËºŸâ»÷°…“‡≈◊Õ°µ”·Àπàß midline ·≈–‡¢â“™àÕß∑âÕß∑“ß¥â“π¢«“¢Õß Falciform ligament ‡π◊ËÕß®“°‡ªìπµ”·Àπàß¢ÕßCalotû triangle ´÷Ëß‡ªìπ®ÿ¥ ”§—≠∑’Ë®–¡Õß‡ÀÁπ¢π“¥·≈–æ¬“∏‘ ¿“æ¢Õß Common bile duct, cystic artery·≈– hepatic artery ‰¥âßà“¬ “¡“√∂ control ‰¥â –¥«°À“°‡°‘¥ injury √–À«à“ßºà“µ—¥ Õ’°∑—Èß‡ªìπ®ÿ¥∑’Ë¡’§«“¡µ÷ßµ—«πâÕ¬∑’Ë ÿ¥¢Õßºπ—ßÀπâ“∑âÕß‡¡◊ËÕ¡’°“√‡§≈◊ËÕπ‰À«¢Õß≈”µ—« ‰¡à¡’°“√µ—¥ºà“π°≈â“¡‡π◊ÈÕ „™â‡«≈“°“√‡ªî¥·º≈‡¢â“ Ÿà™àÕß∑âÕß‰¥â‡√Á« ®÷ß§‘¥«à“πà“®–‡ªìπµ”·Àπàß∑’Ë‡À¡“– ¡∑’Ë ÿ¥„π°“√≈ß¡’¥ºà“µ—¥

°àÕπÀπâ“π’ÈºŸâ»÷°…“‰¥âºà“µ—¥∂ÿßπÈ”¥’·µà‡ªî¥·º≈·∫∫tranverse ∑’Ëº‘«Àπ—ß¿“¬„π¢Õ∫‡¢µ¢Õß MST ·≈–‡ªî¥·º≈∑’Ë anterior ·≈– posterior rectus sheath‡ªìπ·∫∫ right paramedean 1 ‡´Áπµ‘‡¡µ√ ¥â“π¢«“¢Õßmidline ‚¥¬ retract °≈â“¡‡π◊ÈÕ rectus abdominisÕÕ°‰ª∑“ß lateral ‚¥¬‰¡à¡’°“√µ—¥°≈â“¡‡π◊ÈÕ ´÷Ëß®–‡ ’¬‡«≈“„π°“√‡¢â“ Ÿà™àÕß∑âÕßπ“π·≈–¢≥–∑”ºà“µ—¥®–¡’æ∫°≈â“¡‡π◊ÈÕ rectus abdominis ™Õ°™È”·≈–©’°¢“¥®÷ß‰¥â‡ª≈’Ë¬π·ª≈ß°“√≈ß¡’¥∑’Ëº‘«Àπ—ß‡ªìπ midline

°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬°≈âÕß«’¥‘∑—»πå¡’º≈¥’°«à“°“√ºà“µ—¥¥â«¬«‘∏’¥—Èß‡¥‘¡Õ¬à“ß™—¥‡®π5,6 ¥—ßπ—Èπ®“°√“¬ß“ππ’È®÷ß‡ª√’¬∫‡∑’¬∫º≈°—∫°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå®“°

√Ÿª∑’Ë 2 ºŸâªÉ«¬∑’Ë°≈—∫¡“µ—¥‰À¡ 7 «—πÀ≈—ßºà“µ—¥

µ“√“ß∑’Ë 2 º≈°“√ºà“µ—¥·∫∫‡ªî¥·º≈¢π“¥‡≈Á°„π‚√ß

æ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬

√–¬–‡«≈“ºà“µ—¥‡©≈’Ë¬ (π“∑’) 32

Õ—µ√“°“√‡ª≈’Ë¬π·ª≈ß°“√ºà“µ—¥‡ªìπ·∫∫‡ªî¥

¥â«¬«‘∏’¥—Èß‡¥‘¡ 0

°“√√—∫ª√–∑“πÕ“À“√À≈—ßºà“µ—¥

- „π«—πºà“µ—¥ 62

- „π«—π∑’Ë 1 À≈—ßºà“µ—¥ 74

°“√‰¥â√—∫¬“·°âª«¥™π‘¥ narcotic

- ‰¡àµâÕß„™â¬“·°âª«¥ 71

- „™â 1 §√—Èß 58

- „™â 2 §√—Èß 7

- „™â 3 §√—Èß 0

Õ—µ√“°“√‡°‘¥¿“«–·∑√° âÕπ

- ¿¬—πµ√“¬µàÕ∑àÕπÈ”¥’ 0

- Õ◊ËπÊ 2.2

√–¬–‡«≈“πÕπ‚√ßæ¬“∫“≈‡©≈’Ë¬ («—π) 2.3

√–¬–‡«≈“°“√°≈—∫‰ª∑”ß“πµ“¡ª°µ‘ («—π) 7.0



√“¬ß“π¢Õß ∂“∫—πµà“ßÊ ∑’Ë‰¥â√«∫√«¡‰«â„π·ßà¢Õß√–¬–‡«≈“°“√ºà“µ—¥°“√ºà“µ—¥¥â«¬‡∑§π‘§

‡ªî¥·º≈¢π“¥‡≈Á°„™â√–¬–‡«≈“‡©≈’Ë¬ 32 π“∑’´÷Ëß —Èπ°«à“°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå ®“°√“¬ß“πµà“ßÊ‚¥¬¡’§à“‡©≈’Ë¬ 10511, 8612, 10213, 9914, 13815 π“∑’

ºŸâªÉ«¬∑’Ëºπ—ßÀπâ“∑âÕß∫“ß´÷Ëß à«π„À≠à®–‡ªìπ‡æ»™“¬ °“√ºà“µ—¥®–∑”‰¥âßà“¬·≈–√«¥‡√Á«¡“°Õ’°∑—Èß»—≈¬·æ∑¬å°Á¡’§«“¡§ÿâπ‡§¬°—∫°“√ºà“µ—¥¡“°¢÷Èπ‡√◊ËÕ¬Ê®÷ß∑”„Àâ°“√ºà“µ—¥„π√“¬À≈—ßÊ „™â‡«≈“πâÕ¬≈ß¡“°

„π°“√ºà“µ—¥ 136 √“¬ √–¬–‡«≈“ 5 ªï ‰¡à¡’°“√‡ª≈’Ë¬π°“√ºà“µ—¥‡ªìπ«‘∏’¥—Èß‡¥‘¡„π√–À«à“ßºà“µ—¥´÷Ëß®“° ∂“∫—πµà“ßÊ ®–¡’‡≈Á°πâÕ¬ (√âÕ¬≈– 3.6-6.5)4

”À√—∫°“√„™â¬“·°âª«¥™π‘¥ narcotic √“¬ß“ππ’ÈºŸâªÉ«¬‰¡à‰¥â„™â¬“ 71 √“¬ (√âÕ¬≈– 52.2) „°≈â‡§’¬ß°—∫√“¬ß“π¢Õß‚√ßæ¬“∫“≈ ¡ÿ∑√ª√“°“√ (√âÕ¬≈– 50)

¿“«–·∑√° âÕπ®“°°“√∫“¥‡®Á∫µàÕ∑“ß‡¥‘ππÈ”¥’„π√“¬ß“ππ’È‰¡àæ∫‡≈¬ Õ“®‡°‘¥®“°°“√‡≈◊Õ°‡©æ“–ºŸâªÉ«¬∑’Ë‰¡à¡’°“√Õ—°‡ ∫¢Õß∂ÿßπÈ”¥’À√◊Õªí®®—¬∑“ß°“¬«‘¿“§¢ÕßºŸâªÉ«¬‡Õß „π√“¬∑’Ë‡°‘¥ wound hematoma‰¥â·π–π”„ÀâºŸâªÉ«¬πÕπ‚√ßæ¬“∫“≈‡æ◊ËÕ√—°…“·º≈ ∑—Èß3 √“¬ “¡“√∂‡¬Á∫·º≈·≈–„Àâ°≈—∫∫â“π‰¥â¿“¬„π 1 —ª¥“Àå·≈–À≈—ßµ—¥‰À¡°Á‰¡àæ∫ªí≠À“·µàÕ¬à“ß„¥

√–¬–‡«≈“°“√πÕπ‚√ßæ¬“∫“≈¢ÕßºŸâªÉ«¬¡’√–¬–‡«≈“‡©≈’Ë¬ —Èπ 2.3 «—π ´÷Ëß¡“°°«à“°“√πÕπ‚√ßæ¬“∫“≈®“°°“√∑”ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå„πµà“ßª√–‡∑» (1.0-1.6 «—π) ·µàπâÕ¬°«à“®“°√“¬ß“π¢Õß‚√ßæ¬“∫“≈ ¡ÿ∑√ª√“°“√ §à“‡©≈’Ë¬∑’Ë 4.5 «—π „π‚√ßæ¬“∫“≈™ÿ¡™πÕ“®¡’º≈πâÕ¬µàÕºŸâ√—∫∫√‘°“√„πæ◊Èπ∑’Ë‡π◊ËÕß®“°ª√–°Õ∫Õ“™’æ‡°…µ√°√√¡·≈–‰¡à‰¥â‡√àß√’∫„π°“√ª√–°Õ∫Õ“™’æ ®”π«π‡µ’¬ß„π‚√ßæ¬“∫“≈™ÿ¡™π¬—ß¡’„Àâ∫√‘°“√Õ¬à“ßæÕ‡æ’¬ß µâπ∑ÿπ§à“„™à®à“¬¢Õß‚√ßæ¬“∫“≈‰¡à¡“° °“√®”Àπà“¬®“°‚√ßæ¬“∫“≈™â“‰ª‡æ’¬ß«—π Õß«—π®÷ß‰¡à‡°‘¥º≈°√–∑∫¡“°µàÕºŸâªÉ«¬·≈–‚√ßæ¬“∫“≈

µ“√“ß∑’Ë 3 ‡ª√’¬∫‡∑’¬∫°“√‰¥â√—∫¬“©’¥·°âª«¥™π‘¥

Narcotic √–À«à“ß°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå

¢Õß‚√ßæ¬“∫“≈ ¡ÿ∑√ª√“°“√·≈–°“√ºà“µ—¥

·∫∫‡ªî¥·º≈¢π“¥‡≈Á°¢Õß‚√ßæ¬“∫“≈

æ¬—§¶¿Ÿ¡‘æ‘ —¬

‚√ßæ¬“∫“≈ ‚√ßæ¬“∫“≈

®”π«π§√—Èß ¡ÿ∑√ª√“°“√ æ¬—§¶¿Ÿ¡‘æ‘ —¬

®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–)

0 22 (50) 71 (52.2)

1 13 (29.5) 58 (42.6)

2 7 (15.9) 7 (5.1)

3 2 (4.5) 0

√«¡ 44 (100) 136 (100)

µ“√“ß∑’Ë 4 √–¬–‡«≈“°“√ºà“µ—¥·≈–¿“«–·∑√° âÕπ¢Õß°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå®“° ∂“∫—πµà“ßÊ ·≈–°“√ºà“µ—¥¥â«¬

‡∑§π‘§°“√‡ªî¥·º≈¢π“¥‡≈Á°¢Õß‚√ßæ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬

√–¬–‡«≈“ºà“µ—¥ √–¬–‡«≈“πÕπ ¿“«– °“√°≈—∫‰ª∑”ß“π ∂“∫—πµà“ßÊ

‡©≈’Ë¬ (π“∑’) ‚√ßæ¬“∫“≈ («—π) ·∑√°´âÕπ µ“¡ª°µ‘ («—π)

∫“‡Õ‘∑ ·≈–§≥– (⁄Baird et al)12 86 1.2 3.1 8.4

‰∫‡≈ ·≈–§≥– (Bailey et al)13 102 1.3 3.5 7.0

‚´‡ªÕ√å ·≈–§≥– (Soper et al)14 99 1.0 2.0 8.0

´‘¡‡∫Õ√å ·≈–§≥– (Schirmer et al)15 138 1.28 11.2 7.0

√.æ. ¡ÿ∑√ª√“°“√11 105 4.5 4.5 ‰¡à¡’º≈

√.æ.æ¬—§¶¿Ÿ¡‘æ‘ —¬ 32 2.3 2.2 7.0

30

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

”À√—∫°“√°≈—∫‰ª∑”ß“πµ“¡°‘®«—µ√ª°µ‘®“°√“¬ß“πµà“ßÊ °«à“√âÕ¬≈– 50 √“¬ß“π«à“ª√–‡¡‘π¬“°‡æ√“–¡’√“¬≈–‡Õ’¬¥¢Õß°‘®«—µ√ª√–®”«—π¡“°·≈–°“√ª√–‡¡‘π¡’§«“¡‰¡à·πàπÕπ ®“°√“¬ß“π∑’Ë√«∫√«¡‰¥â°“√ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå®– “¡“√∂‰ª∑”ß“πµ“¡ª°µ‘‰¥âª√–¡“≥ 7-10 «—π√“¬ß“ππ’È„™â«‘∏’ —¡¿“…≥åºŸâªÉ«¬∑’Ë¡“µ‘¥µ“¡º≈°“√√—°…“°Áæ∫«à“‰ª∑”ß“π‰¥âª√–¡“≥ 1 —ª¥“Àå‡™àπ°—π

¢âÕ¥âÕ¬¢Õß°“√ºà“µ—¥·∫∫‡ªî¥·º≈¢π“¥‡≈Á°§◊Õ‡√“‰¡à “¡“√∂¡Õß‡ÀÁπæ¬“∏‘ ¿“æÕ◊Ëπ¿“¬„π™àÕß∑âÕß‰¥â‡À¡◊Õπ Laparoscopic cholecystectomy À√◊Õ„™â¡◊Õ‰ª§≈” ”√«®Õ«—¬«–Õ◊ËπÊ ‰¥â‚¥¬‡©æ“–µ—∫‡À¡◊Õπ°“√∑” Conventional open cholecystectomy‡æ√“–·¡â®–¡’º≈µ√«®®“°Õÿ≈µ√“´“«¥åÀ√◊Õ CT scanÕ“®¡’∫“ß à«π∑’Ëæ∫«à“ºŸâªÉ«¬¡’ Intraabdominalcarcinoma √à«¡¥â«¬ ‚¥¬‡©æ“–¡–‡√Áßµ—∫

¬—ß¡’ºŸâªÉ«¬∫“ß à«π∑’ËµâÕß°“√∑”ºà“µ—¥¥â«¬°≈âÕß«’¥‘∑—»πå ‚¥¬‡©æ“–°≈ÿà¡∑’Ë‡ªìπ¢â“√“™°“√°Á‰¥â·π–„ÀâºŸâªÉ«¬‰ª√—∫°“√√—°…“∑’Ë‚√ßæ¬“∫“≈∑—Ë«‰ªÀ√◊Õ‚√ßæ¬“∫“≈»Ÿπ¬å∑’Ë¡’‡§√◊ËÕß¡◊Õ (µ“√“ß∑’Ë 4)

√ÿª

°“√ºà“µ—¥∂ÿßπÈ”¥’¥â«¬·º≈‡ªî¥¢π“¥‡≈Á°∫√‘‡«≥upper midline ¡’º≈¥’À≈“¬ª√–°“√‰¥â·°à ¡’°“√∫“¥‡®Á∫µàÕºŸâªÉ«¬πâÕ¬ µâÕß°“√¬“·°âª«¥„πª√‘¡“≥‰¡à¡“°ºŸâªÉ«¬øóôπµ—«À≈—ßºà“µ—¥‡√Á« ¿“«–·∑√°´âÕπµË” °≈—∫‰ª∑”ß“πÀ√◊Õ°‘®«—µ√‰¥â„π√–¬–‡«≈“Õ—π —Èπ ¡’·º≈¢π“¥‡≈Á°ºŸâªÉ«¬¡’§«“¡æ÷ßæÕ„® À—µ∂°“√π’È “¡“√∂π”‰ª„™âºà“µ—¥ºŸâªÉ«¬®“°‚√§∂ÿßπÈ”¥’‰¥â‡°◊Õ∫∑ÿ°™π‘¥ ®÷ß‡ªìπ«‘∏’Àπ÷Ëß∑’Ë§«√‡≈◊Õ°„™â‡¡◊ËÕ‰¡à “¡“√∂®–ºà“µ—¥‰¥â¥â«¬«’∏’ºà“π°≈âÕß«’¥‘∑—»πå

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥‡®â“Àπâ“∑’Ë·≈–ºŸâªÉ«¬‚√ßæ¬“∫“≈æ¬—§¶¿Ÿ¡‘æ‘ —¬∑ÿ°∑à“π ∑’Ë„Àâ§«“¡√à«¡¡◊Õ„π°“√»÷°…“‡ªìπÕ¬à“ß¥’


1. Dobis F, Berterlot G, Levard H. Laparoscopic chole-

cystectomy: historical perspective and personal

experience. Surg Laparosc Endosc 1991; 1:52-7.

2. Gadacz TR, Tolamini MA, Lillemoe KD, Yeo CJ.

Laparoscopic cholecystectomy. Surg Clin North Am

1990; 70:1249-62.

3. Berci G, Sackier JM. The Los Angeles experience with

laparoscospic cholecystectomy. Am J Surg 161:302-4.

4. Cuschieri A, Dobois F, Mouiel J. The European

experience with laparoscopic cholecystectomy. Am J

Surg 1991; 161:385-7.

5. Jeffrey S, Alan N, Jonathan L. Laparoscopic Versus

Open cholecystectomy: the Canadian experience. Am

J Surg 1993; 165:455-8.

6. Soper NJ,Barteau JA ,Clayman RV. Comparision of

early postoperative result for laparoscopic versus

standard open cholecystectomy. Surg Gynecol Obst

1992; 174:114-8.

7. Ponski JL. Complication of laparoscopic cholecys-

tectomy. Am J Surg 1990;161:393-5

8. Moosa AR, Easter DW, VanSonnenberg E.

Laparoscopic injury to the bile duct. Am J Surg 1992;

215:203-8.

9. Bernard HR. Hartman TW. Complication after laparo-

scopic cholecystectomy. Am J Surg 1993;65:533-5.

10. Tyagi NS, Meridith MC, Lumb JC. A new minimally

invasive technique for cholecystectomy: subxiphoid

“Minimal Stress Triangle” microceliotomy. Ann Surg

1994; 5:617-25.

11. ™≈‘µ ∑Õßª√–¬Ÿ√. ‡ª√’¬∫‡∑’¬∫º≈°“√ºà“µ—¥∂ÿßπÈ”¥’‚¥¬«‘∏’ àÕß°≈âÕß°—∫·∫∫‡ªî¥. «“√ “√°√¡°“√·æ∑¬å 2540; 22:370-4.

12. Baird DR, Wilson JP, Mason EM. A early review of

800 laparoscopic cholecystectomies at a university-

affiliated community teaching hospital. Am Surg 1992;

58:206-10.

13. Bailey RW, Zucker KA, Flowers JL. Laparoscopic

cholecystectomy. Experience with 375 consecutive

patients. Ann Surg 1991; 214:531-41.

14. Soper NJ,Dunnegan DL. Does intraoperative gall-

bladder perforation influence the early outcome of

laparoscopic cholecystectomy? Surg Lap Endosc 1991;

1:156-61.

15. Schirmer BD, Edge SB, Dix J. Laparoscopic

cholecystectomy. Treatment of choice for symptomatic

cholelithiasis. Ann Surg 1991; 213:665-77.




°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡‡À¡“– ¡ ”À√—∫°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°À√◊Õ‰¡à? :°“√»÷°…“§«∫§ÿ¡·∫∫ ÿà¡¥â«¬°“√‡ª√’¬∫‡∑’¬∫„πµ—«Õ¬à“ß‡¥’¬«°—π°ƒ…Æ“ ∂¡¬“∫—µ√ æ.∫.°≈ÿà¡ß“π Ÿµ‘-π√’‡«™»“ µ√å ‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’

Abstract Is Visual Inspection with Acetic Acid (VIA) Appropriate for Cervical Cancer Screening? :Randomized Controlled Trial with Crossover DesignTomyabatra K.

Department of Obstetrics & Gynaecology, Nopparatrajathanee Hospital, Bangkok, Thailand


The accuracy of visual inspection with acetic acid as a cervical screening test is still acontroversial issue. A randomized controlled trial with crossover design was conducted in women aged 30-60 years who attended gynaecological clinic from October 2004 to September 2006 at NopparatrajathaneeHospital, Department of Medical Services, Ministry of Public Health. Subjects (n = 590) were randomlyassigned into 2 groups with different sequence of Pap smear and VIA for counterbalance. Women withatypical squamous cells of undetermined significance (ASCUS) or higher and/or positive VIA were referredto colposcopy. The objective was to compare the accuracy between Pap smear and VIA as cervical cancerscreening tools. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)for the detection of cervical intraepithelial neoplasia grade 2 or higher (CIN2+) were calculated. Differenceof the area under ROC (Receiver-operating characteristic) curves among the screening tests was used tocompare their accuracy. The sensitivities (95%CI) of Pap smear and VIA detecting CIN 2+ were 93.8% (91.8,95.7) and 50.0% (46.0, 54.0), respectively; the corresponding specificities (95%CI) were 92.7% (90.6, 94.8)and 91.3% (89.0, 93.6). The PPV (95%CI) of Pap smear and VIA were 26.3% (22.8, 29.9) and 13.8% (11.0,16.6), respectively; the NPV (95%CI) of Pap smear and VIA were 99.8% (99.5, 100) and 98.5% (97.5, 99.5),respectively. The accuracy of the screening with VIA was lower with 47.5% reduction in the PPV of VIA bycomparing to Pap smear (difference between areas under ROC curves (AUC) = 0.23; 95% CI 0.08, 0.38; p-value = 0.003). The PPV (relative PPV = 0.52; 95%CI = 0.22, 1.21) and the NPV (relative NPV = 0.99; 95%CI= 0.91, 1.08) of VIA were similar to Pap smear. VIA was an inappropriate alternative screening test to Papsmear among 30-60 year-old-women.

Key words: pap smear, VIA

32

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

§«“¡·¡àπ¬”¢Õß°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡ (VIA) ‡æ◊ËÕ°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ° ‡ªìπª√–‡¥Áπ∑’Ë Ÿµ‘-π√’·æ∑¬å¬—ß§ß‚µâ·¬âß°—π ®“°√“¬ß“π°“√»÷°…“À≈“¬©∫—∫· ¥ß„Àâ‡ÀÁπ«à“°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡„™âµâπ∑ÿπ∑’ËµË”°«à“·≈–ßà“¬µàÕ°“√π”¡“„™â´÷Ëß‡À¡“– ¡„π°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°∑¥·∑πPap smear „π ∂“π°“√≥å∑’Ë¢“¥·§≈π∑√—æ¬“°√1-8

„π∫“ß°“√»÷°…“°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡¡’§«“¡‰«µË”°«à“°“√µ√«®¥ŸÀ≈—ßªÑ“¬πÈ”¬“≈Ÿ°Õ≈‰Õ‚Õ¥’π(Visual inspection with Lugolûs iodine À√◊Õ VILI)„π°“√µ√«®æ∫√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«™π‘¥§«“¡√ÿπ·√ß Ÿß(high-grade squamous intraepithelial lesion À√◊ÕHSIL) ·µà∑—Èß Õß«‘∏’¡’§«“¡®”‡æ“–‰¡à·µ°µà“ß°—π3

ª√– ‘∑∏‘¿“æ¢Õß°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡„π°“√≈¥Õÿ∫—µ‘°“√≥å°“√‡ ’¬™’«‘µ®“°¡–‡√Áßª“°¡¥≈Ÿ° ·≈–°“√»÷°…“µâπ∑ÿπ-ª√– ‘∑∏‘º≈°”≈—ßÕ¬Ÿà√–À«à“ß°“√»÷°…“

§«∫§ÿ¡·∫∫ ÿà¡„πª√–‡∑»Õ‘π‡¥’¬9 Õ¬à“ß‰√°Áµ“¡°“√»÷°…“„πª√–‡∑»°≈ÿà¡≈“µ‘πÕ‡¡√‘°—π (Latin AmericanScreening) ‰¡à “¡“√∂· ¥ß„Àâ‡ÀÁπ‰¥â«à“°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡‡æ’¬ßÕ¬à“ß‡¥’¬«¡’ª√– ‘∑∏‘¿“æ„π°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°„π∫“ß√“¬ß“π°“√»÷°…“‚¥¬‡©æ“–„π ∂“π∑’Ë´÷Ëß¡’§«“¡™ÿ°¢Õß¡–‡√Áßª“°¡¥≈Ÿ°§àÕπ¢â“ß Ÿß10 °“√»÷°…“π’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫§«“¡·¡àπ¬”„π°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°√–À«à“ß°“√µ√«® Pap smear ¥â«¬«‘∏’¥—Èß‡¥‘¡·≈–°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡„π µ√’§π‡¥’¬«°—π

«—µ∂ÿ·≈–«‘∏’°“√

°“√»÷°…“π’È ‰¥â√—∫§«“¡‡ÀÁπ™Õ∫„πª√–‡¥Áπ®√‘¬-∏√√¡°“√∑”«‘®—¬„π¡πÿ…¬å®“°§≥–°√√¡°“√æ‘®“√≥“‚§√ß√à“ß°“√«‘®—¬¢Õß‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ ∑”°“√»÷°…“§«∫§ÿ¡·∫∫ ÿà¡¥â«¬°“√‡ª√’¬∫‡∑’¬∫„πµ—«Õ¬à“ß‡¥’¬«°—π ´÷Ëß

‡√◊ËÕß¬àÕ §«“¡·¡àπ¬”„π°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬¥â«¬°√¥πÈ” â¡ (Visual inspection with acetic acid À√◊Õ VIA) ‡æ◊ËÕ§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°¬—ß‡ªìπª√–‡¥Áπ∑’Ë Ÿµ‘-π√’·æ∑¬å¬—ß§ß‚µâ·¬âß°—π ∑”°“√»÷°…“§«∫§ÿ¡·∫∫ ÿà¡¥â«¬°“√µ√«®§—¥°√Õß Õß«‘∏’„π µ√’§π‡¥’¬«°—π (crossover design) ´÷Ëß¡’Õ“¬ÿ√–À«à“ß 30 ∂÷ß 60 ªï ®”π«π 590 √“¬ ∑’Ë¡“√—∫°“√µ√«®∑“ßπ√’‡«™«‘∑¬“√–À«à“ß‡¥◊Õπµÿ≈“§¡ æ.». 2547 ∂÷ß°—π¬“¬π æ.». 2549 ‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢‚¥¬ ÿà¡µ—«Õ¬à“ß·∫àß‡ªìπ 2 °≈ÿà¡Ê ≈– 295 √“¬ ´÷Ëß„π µ√’·µà≈–°≈ÿà¡®–‰¥â√—∫°“√µ√«® Pap smear ·≈– VIA ‡√’¬ß≈”¥—∫ ≈—∫°—π‡æ◊ËÕ„Àâ¡’°“√∂à«ß§«“¡ ¡¥ÿ≈ (counterbalance) ¢Õßº≈°√–∑∫®“°°“√µ√«®°àÕπÀ≈—ß µ√’∑’Ë¡’º≈°“√µ√«® Pap smear ‡ªìπatypical squamous cells of undetermined significance (ASCUS) À√◊Õ√ÿπ·√ß°«à“ ·≈–/À√◊Õº≈°“√µ√«® VIA ‡ªìπº≈∫«°®“°°“√æ∫∫√‘‡«≥ ’¢“«¢Õß°√¥πÈ” â¡„°≈âÀ√◊Õ™‘¥°—∫∫√‘‡«≥√Õ¬µàÕ‡¬◊ËÕ∫ÿª“°¡¥≈Ÿ°®–‰¥â√—∫°“√ àßµàÕ‰ªµ√«® àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ° (colposcopy) «—µ∂ÿª√– ß§å¢Õß°“√»÷°…“‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫§«“¡·¡àπ¬”√–À«à“ß Pap smear ·≈– VIA„π°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ° «‘‡§√“–ÀåÀ“§«“¡‰« §«“¡®”‡æ“– §à“æ¬“°√≥å∫«° (PPV) §à“æ¬“°√≥å≈∫ (NPV) ”À√—∫°“√µ√«®æ∫√Õ¬‚√§¡–‡√Áß™—Èπº‘« (cervical intraepithelial neoplasia À√◊Õ CIN) µ—Èß·µà¢—Èπ∑’Ë 2 ¢÷Èπ‰ª ‡ª√’¬∫‡∑’¬∫§«“¡·¡àπ¬”¢Õß°“√§—¥°√Õß¥â«¬§«“¡·µ°µà“ß√–À«à“ßæ◊Èπ∑’Ë„µâ ROC (receiver-operating characteristic) curve º≈°“√»÷°…“æ∫«à“§«“¡‰« (95% CI) ¢Õß Pap smear ·≈– VIA „π°“√µ√«®À“√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«µ—Èß·µà¢—Èπ∑’Ë 2 ¢÷Èπ‰ª‡∑à“°—∫ √âÕ¬≈– 93.8(91.8, 95.7) ·≈–√âÕ¬≈– 50.0 (46.0, 54.0) µ“¡≈”¥—∫; §«“¡®”‡æ“– (95% CI) ‡∑à“°—∫ √âÕ¬≈– 92.7 (90.6, 94.8) ·≈–√âÕ¬≈–91.3 (89.0, 93.6) µ“¡≈”¥—∫ §à“æ¬“°√≥å∫«° (95% CI) ¢Õß Pap smear ·≈– VIA ‡∑à“°—∫√âÕ¬≈– 26.3 (22.8, 29.9) ·≈–√âÕ¬≈– 13.8 (11.0, 16.6) µ“¡≈”¥—∫; §à“æ¬“°√≥å≈∫ (95% CI) ¢Õß Pap smear ·≈– VIA ‡∑à“°—∫√âÕ¬≈– 99.8 (99.5, 100)·≈–√âÕ¬≈– 98.5 (97.5, 99.5) µ“¡≈”¥—∫ °“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°¥â«¬ VIA ¡’§«“¡·¡àπ¬”∑’ËµË”°«à“ √à«¡°—∫¡’§à“æ¬“°√≥å∫«°≈¥≈ß√âÕ¬≈– 47.5 ‡¡◊ËÕ‡∑’¬∫°—∫ Pap smear (§«“¡·µ°µà“ß¿“¬„µâæ◊Èπ∑’Ë ROC curves = 0.23; 95% CI 0.08,0.38; p-value = 0.003) §à“æ¬“°√≥å∫«° (§à“æ¬“°√≥å∫«° —¡æ—∑∏å = 0.52; 95% CI = 0.22, 1.21) ·≈–§à“æ¬“°√≥å≈∫(§à“æ¬“°√≥å≈∫ —¡æ—∑∏å = 0.99; 95% CI = 0.91, 1.08) ¢Õß VIA ‰¡à·µ°µà“ß∑“ß ∂‘µ‘°—∫ Pap smear √ÿª‰¥â«à“ VIA‰¡à‡À¡“– ¡„π°“√π”¡“‡ªìπ‡§√◊ËÕß¡◊Õ§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°∑¥·∑π Pap smear „π µ√’Õ“¬ÿ 30-60 ªï

§” ”§—≠: Pap smear °“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡



µ—«·ª√¢Õßµ—«Õ¬à“ß‡°’Ë¬«°—∫‡™◊ÈÕ™“µ‘ Õ“¬ÿ ·≈–§«“¡√ÿπ·√ß¢Õß‚√§∂Ÿ°§«∫§ÿ¡‚¥¬°“√µ√«® È”„πµ—«Õ¬à“ß‡¥’¬«°—π‡æ◊ËÕ≈¥Õ§µ‘„π°“√§—¥‡≈◊Õ° (selection bias) µ√’®”π«π 590 √“¬ ∑’Ë¡’Õ“¬ÿ 36.6 ± 6.5 ªï (30-60 ªï)·≈–¡“√—∫°“√µ√«®∑“ßπ√’‡«™√–À«à“ß‡¥◊Õπµÿ≈“§¡ æ.».2547 ∂÷ß°—π¬“¬π æ.». 2549 ∑’Ë‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’ ‰¥â√—∫°“√ ÿà¡‡ªìπ 2 °≈ÿà¡

‚¥¬‡ªìπ°“√»÷°…“·∫∫ crossover design °≈à“«§◊Õ °≈ÿà¡·√°®”π«π 295 √“¬ ‰¥â√—∫°“√µ√«®§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°¥â«¬ Pap smear °àÕπ ·≈â«µ“¡¥â«¬°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡ „π°≈ÿà¡∑’Ë 2 ®”π«π295 √“¬ ®—¥≈”¥—∫°“√µ√«®§—¥°√Õß ≈—∫°—∫°≈ÿà¡·√°¥â«¬°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡°àÕπ ·≈â«µ“¡¥â«¬°“√µ√«® Pap smear µ“¡≈”¥—∫ ´÷Ëß‡ªìπ«‘∏’∂à«ß§«“¡ ¡¥ÿ≈√–À«à“ßº≈°√–∑∫®“°°“√µ√«®§√—Èß·√°(carryover effect) µàÕ°“√µ√«® §√—Èß∑’Ë 2 „π µ√’§π‡¥’¬«°—π

‡°Á∫µ—«Õ¬à“ß‡´≈≈åª“°¡¥≈Ÿ° ¥â«¬‰¡â Ayreûsspatula °“√µ√«®¥Ÿª“°¡¥≈Ÿ°¥â«¬µ“‡ª≈à“À≈—ß°“√ªÑ“¬°√¥πÈ” â¡§«“¡‡¢â¡¢âπ√âÕ¬≈– 3 ·ª√º≈°“√µ√«®Pap smear µ“¡À≈—°°“√«‘π‘®©—¬¢Õß The Bethesdasystem 2001 µ√’®–‰¥â√—∫°“√ àßµ√«® àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ° (colposcopy) ‡¡◊ËÕº≈°“√µ√«®Pap smear ‡ªìπ atypical squamous cells ofundetermined significance (ASCUS) À√◊Õ√ÿπ·√ß°«à“ ·≈– àßµàÕ„π√“¬∑’Ë‰¥â√—∫°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡‰¥âº≈∫«°®“°°“√µ√«®æ∫∫√‘‡«≥∑’Ëµ‘¥ ’¢“«¢Õß°√¥πÈ” â¡„°≈âÀ√◊Õ™‘¥°—∫√Õ¬µàÕ‡¬◊ËÕ∫ÿº‘«ª“°¡¥≈Ÿ°(squamocolumnar junction) √âÕ¬≈– 10 (59/590)¢Õß µ√’∑’Ë¡’º≈°“√µ√«®∑—Èß Õß«‘∏’‡ªìπ≈∫‰¥â√—∫°“√ àÕß°≈âÕßµ√«®¢¬“¬¿“æª“°¡¥≈Ÿ°‡æ◊ËÕ≈¥Õ§µ‘„π°“√æ‘ Ÿ®πå (verification bias)

∑”°“√µ—¥™‘Èπ‡π◊ÈÕª“°¡¥≈Ÿ°ºà“π°≈âÕßµ“¡¢âÕ∫àß™’È«‘‡§√“–ÀåÀ“§«“¡‰« §«“¡®”‡æ“– §à“æ¬“°√≥å∫«°§à“æ¬“°√≥å≈∫ ”À√—∫°“√µ√«®À“√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«¢Õßª“°¡¥≈Ÿ°µ—Èß·µà¢—Èπ∑’Ë 2 ‡ªìπµâπ‰ª (CIN2+)‡ª√’¬∫‡∑’¬∫§«“¡·¡àπ¬”¢Õß°“√§—¥°√Õß∑—Èß Õß«‘∏’´÷Ëß

∑”„π µ√’§π‡¥’¬«°—π¥â«¬§«“¡·µ°µà“ß√–À«à“ßæ◊Èπ∑’Ë„µâROC curve

º≈

µ√’„π°“√»÷°…“π’È¡’Õ“¬ÿ‡©≈’Ë¬‡∑à“°—∫ 36.6 ± 6.5ªï (30-60 ªï) Õ“¬ÿ‡©≈’Ë¬¢Õß°“√¡’‡æ» —¡æ—π∏å§√—Èß·√°‡∑à“°—∫ 21.5 ± 4.3 ªï (13-37) ·≈– ¡’∞“ππ‘¬¡¢Õß®”π«π°“√§≈Õ¥‡∑à“°—∫ 2 §√—Èß (0-7) µ√«®æ∫ µ√’∑’Ë¡’º≈ Pap smear º‘¥ª°µ‘µ—Èß·µà ASCUS ¢÷Èπ‰ª √âÕ¬≈–10.3 (61/590) Õ—µ√“¢Õßº≈°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡‡ªìπ∫«°‡∑à“°—∫√âÕ¬≈– 9.8 (58/590) (µ“√“ß∑’Ë1).

§«“¡‰« (95% CI) ¢Õß Pap smear ·≈– VIA „π°“√µ√«®À“√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«µ—Èß·µà¢—Èπ∑’Ë 2 ¢÷Èπ‰ª‡∑à“°—∫√âÕ¬≈– 93.8 (91.8, 95.7) ·≈–√âÕ¬≈– 50.0 (46.0,54.0) µ“¡≈”¥—∫; §«“¡®”‡æ“– (95% CI) ‡∑à“°—∫√âÕ¬≈– 92.7 (90.6, 94.8) ·≈–√âÕ¬≈– 91.3 (89.0,93.6) µ“¡≈”¥—∫ §à“æ¬“°√≥å∫«° (95% CI) ¢Õß Papsmear ·≈– VIA ‡∑à“°—∫√âÕ¬≈– 26.3 (22.8, 29.9) ·≈–√âÕ¬≈– 13.8 (11.0, 16.6) µ“¡≈”¥—∫; §à“æ¬“°√≥å≈∫(95% CI) ¢Õß°“√§—¥°√Õß∑—Èß Õß«‘∏’ ‡∑à“°—∫√âÕ¬≈–99.8 (99.5, 100) ·≈–√âÕ¬≈– 98.5 (97.5, 99.5)µ“¡≈”¥—∫ æ∫«à“ VIA ¡’§à“æ¬“°√≥å∫«°≈¥≈ß√âÕ¬≈–47.5 ‡¡◊ËÕ‡∑’¬∫°—∫ Pap smear ∑—Èß§à“æ¬“°√≥å∫«°(§à“æ¬“°√≥å∫«° —¡æ—∑∏å = 0.52; 95% CI = 0.22,1.21) ·≈–§à“æ¬“°√≥å≈∫ (§à“æ¬“°√≥å ≈∫ —¡æ—∑∏å =0.99; 95% CI = 0.91, 1.08) ¢Õß VIA ‰¡à·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘°—∫ Pap smear (µ“√“ß∑’Ë 2)

æ◊Èπ∑’Ë„µâ ROC curve (95%CI) ¢Õß Pap smear·≈– VIA ‡∑à“°—∫ 0.93 (0.91, 0.95) ·≈– 0.75 (0.67,0.74) µ“¡≈”¥—∫ (µ“√“ß∑’Ë 3).

OR ¢Õß«‘∏’§—¥°√Õß¥â«¬ Pap smear ‡∑à“°—∫ 153.46∫Õ°∂÷ß¢π“¥¢Õß§«“¡ ”§—≠∑’Ë¡“°°«à“«‘∏’§—¥°√Õß¥â«¬VIA ´÷Ëß¡’ OR ‡∑à“°—∫ 10.48

§«“¡·µ°µà“ß¢Õßæ◊Èπ∑’Ë„µâ ROC curve (95%CI)√–À«à“ß Pap smear-VIA ‡∑à“°—∫ 0.23 (0.08, 0.38),p-value = 0.003 (µ“√“ß∑’Ë 4).

34

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ“√“ß∑’Ë 1 Pap smear °“√µ√«®¥ŸÀ≈—°°“√ªÑ“¬°√¥πÈ” â¡ (VIA) ·≈– º≈°“√µ√«®∑“ßæ¬“∏‘«‘∑¬“¢Õß‡π◊ÈÕ‡¬◊ËÕª“°

¡¥≈Ÿ°

º≈∑“ßæ¬“∏‘«‘∑¬“¢Õß‡π◊ÈÕ‡¬◊ËÕª“°¡¥≈Ÿ°

«‘∏’°“√§—¥°√Õß ‰¡à‰¥â√—∫°“√ ‰¡àæ∫√Õ¬‚√§

àÕß°≈âÕß¢¬“¬ ‡¬◊ËÕ∫ÿº‘« CIN1 CIN2 CIN3 √«¡

¿“æª“°¡¥≈Ÿ° ª“°¡¥≈Ÿ°*

Pap smear

ª°µ‘/¡’°“√Õ—°‡ ∫ 454 71 3 1 0 529

ASCUS/AGUS 0 28 2 0 0 30

LSIL 0 7 2 8 0 17

HSIL 0 4 3 3 4 14

√«¡ 454 110 10 12 4 590

VIA

º≈≈∫ 452 67 5 7 1 532

º≈∫«° 0 45 5 5 3 58

√«¡ 452 112 10 12 4 590

ASCUS/AGUS = Atypical squamous cells of undetermined significance/atypical glandular cells of undetermined significanceLSIL = Low-grade squamous intraepithelial lesionHSIL = High-grade squamous intraepithelial lesionCIN = Cervical intraepithelial neoplasia*√«¡ µ√’∑’Ë‰¥â√—∫°“√ àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ°º≈ª°µ‘·≈–‰¡à‰¥âµ—¥™‘Èπ‡π◊ÈÕ

µ“√“ß∑’Ë 2 §«“¡‰« §«“¡®”‡æ“– §à“æ¬“°√≥å∫«° (PPV) ·≈–§à“æ¬“°√≥å≈∫ (NPV) ”À√—∫°“√«‘π‘®©—¬√Õ¬‚√§‡¬◊ËÕ

∫ÿº‘«ª“°¡¥≈Ÿ°µ—Èß·µà¢—Èπ∑’Ë 2 ¢Õß Pap smear ·≈– VIA

§«“¡‰« §«“¡®”‡æ“– §à“æ¬“°√≥å∫«° §à“æ¬“°√≥å∫«° §à“æ¬“°√≥å≈∫ §à“æ¬“°√≥å≈∫«‘∏’°“√

(√âÕ¬≈–) (√âÕ¬≈–) (√âÕ¬≈–) —¡æ—∑∏å (√âÕ¬≈–) —¡æ—∑∏å§—¥°√Õß

(95%CI) (95%CI) (95%CI) (95%CI) (95%CI) (95%CI)

Pap smear 93.8 92.7 26.3 1.00 99.8 1.00

(91.8, 95.7) (90.6, 94.8) (22.8, 29.9) (§à“Õâ“ßÕ‘ß) (99.5, 100) (§à“Õâ“ßÕ‘ß)

VIA 50.0 91.3 13.8 0.52 98.5 0.99

(46.0, 54.0) (89.0, 93.6) (11.0, 16.6) (0.22, 1.21) (97.5, 99.5) (0.91, 1.08)



∫«°·≈–≈∫¢Õß VIA ‰¡à·µ°µà“ß®“°¢Õß Pap smear·µà§à“æ¬“°√≥å∫«°¢Õß VIA µË”°«à“ Pap smear ∂÷ß√âÕ¬≈– 47.5 · ¥ß«à“ VIA ∑”„Àâ¡’°“√‡æ‘Ë¡º≈∫«°≈«ßÕ¬à“ß¡“° º≈°√–∑∫∑’ËÕ“®‡ªìπ‰ª‰¥â„π µ√’∑’Ë‰¥â√—∫º≈°“√µ√«®‡ªìπº≈∫«°≈«ß‰¥â·°à°“√√—°…“∑’Ë‰¡à®”‡ªìπ„π°“√µ√«®æ∫‚√§∑’Ë‰¡à ”§—≠ ‡™àπ √Õ¬‚√§‡¬◊ËÕ∫ÿº‘«ª“°¡¥≈Ÿ°™π‘¥√ÿπ·√ßµË” (LSIL) ´÷ËßÕ“®‰¡à¡’Õ“°“√„¥Ê À√◊Õ‰¡à‡ª≈’Ë¬π·ª≈ß‰ª‡ªìπ™π‘¥√ÿπ·√ß Ÿß (HSIL)µ≈Õ¥™’«‘µ¢Õß µ√’∑’Ë¡“µ√«®§—¥°√Õß °“√µ√«®«‘π‘®©—¬µàÕ‚¥¬‰¡à®”‡ªìπ §«“¡«‘µ°°—ß«≈ §à“„™â®à“¬·≈–§«“¡‰¡à –¥«°¢Õß µ√’∑’Ë‰¥â√—∫°“√«‘π‘®©—¬ §à“æ¬“°√≥å≈∫∑’Ë

µ“√“ß∑’Ë 4 °“√‡ª√’¬∫‡∑’¬∫æ◊Èπ∑’Ë„µâ ROC curve ”À√—∫

°“√«‘π‘®©—¬√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«ª“°¡¥≈Ÿ°µ—Èß·µà

¢—Èπ∑’Ë 2 ¢Õß Pap smear ·≈– VIA

°“√‡ª√’¬∫‡∑’¬∫ §«“¡·µ°µà“ß¢Õßæ◊Èπ∑’Ë„µâp-value

«‘∏’°“√§—¥°√Õß ROC curve (95%CI)

Pap smear-VIA 0.23 (0.08, 0.38) 0.003*

*¡’§«“¡·µ°µà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (p-value < 0.05)

µ“√“ß∑’Ë 3 æ◊Èπ∑’Ë„µâ ROC curve ”À√—∫°“√«‘π‘®©—¬√Õ¬

‚√§‡¬◊ËÕ∫ÿº‘«ª“°¡¥≈Ÿ°µ—Èß·µà¢—Èπ∑’Ë 2 ¢Õß Pap

smear ·≈– VIA

Odds Ratio æ◊Èπ∑’Ë„µâ ROC curve«‘∏’°“√§—¥°√Õß

(OR) (95%CI)

Pap smear 153.46 0.93 (0.91, 0.95)

VIA 10.48 0.75 (0.67, 0.74)

√Ÿª∑’Ë 1 °“√‡ª√’¬∫‡∑’¬∫ ROC curve ¢Õß Pap smear ·≈– VIA

«‘®“√≥å

√“¬ß“π°“√»÷°…“π’È· ¥ß„Àâ‡ÀÁπº≈¢Õß°“√‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°¥â«¬Pap smear ·≈–°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡(VIA) ´÷Ëß‡ªìπ°“√»÷°…“§«∫§ÿ¡·∫∫ ÿà¡„π µ√’§π‡¥’¬«°—π §«“¡·¡àπ¬”¢Õß VIA µË”°«à“ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫Õâ“ßÕ‘ß°—∫ Pap smear (§«“¡·µ°µà“ß¢Õßæ◊Èπ∑’Ë„µâROC curve (95%CI) √–À«à“ß Pap smear-VIA‡∑à“°—∫ 0.23 (0.08, 0.38), p-value = 0.003) ‚¥¬æ∫«à“§«“¡‰«¢Õß Pap smear ‡∑à“°—∫√âÕ¬≈– 93.8 à«π¢Õß VIA ‡∑à“°—∫√âÕ¬≈– 50.0 ∑—ÈßÊ ∑’Ë§à“æ¬“°√≥å

36

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

§àÕπ¢â“ß Ÿß¡“°¢Õß∑—Èß Õß«‘∏’∑’Ë„™â„π°“√§—¥°√Õßπà“®–‡ªìπº≈¡“®“°º≈≈∫≈«ß∑’ËµË”Õ¬à“ß¡“°´÷Ëß§«√æ‘®“√≥“‡æ◊ËÕ≈¥Õ§µ‘„π°“√æ‘ Ÿ®πå (verification bias) „ÀâπâÕ¬°«à“‡¥‘¡ ‚¥¬°“√ àßµàÕ µ√’∑ÿ°√“¬∑’Ë¡’º≈°“√µ√«®§—¥°√Õß‡ªìπº≈≈∫∑—Èß Õß«‘∏’‰ª√—∫°“√ àÕßµ√«®¢¬“¬¿“æª“°¡¥≈Ÿ°À“√Õ¬‚√§

®“°√“¬ß“π°“√»÷°…“∑’Ëºà“π¡“· ¥ß„Àâ‡ÀÁπ«à“°“√µ√«®¥Ÿª“°¡¥≈Ÿ°À≈—ß°“√ªÑ“¬°√¥πÈ” â¡¡’§ÿ≥§à“„π°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°√à«¡°—∫°“√µ√«® Papsmear ¥â«¬«‘∏’¥—ß‡¥‘¡ ·≈–Õ“®®–π”‰ª„™â„π ∂“π°“√≥å∑’Ë¢“¥·§≈π∑√—æ¬“°√ Õ¬à“ß‰√°Áµ“¡‡ªìπ°“√¬“°∑’Ë®–∑”°“√»÷°…“«‘‡§√“–Àå∞“π¢âÕ¡Ÿ≈ (meta-analysis)‡π◊ËÕß®“°§«“¡·µ°µà“ß¢Õß√Ÿª·∫∫°“√«‘®—¬·≈–«‘∏’°“√«‘‡§√“–Àå ‚¥¬‡©æ“–Õ§µ‘„π°“√§—¥‡≈◊Õ°µ—«Õ¬à“ß (sam-pling bias) Õ§µ‘„π°“√æ‘ Ÿ®πå (verification bias)®ÿ¥µ—¥√–À«à“ß√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«√–¥—∫§«“¡√ÿπ·√ßµË”(LSIL) ·≈–§«“¡√ÿπ·√ß Ÿß (HSIL) °“√·ª√º≈∫«°¢Õß°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡ °“√Õ∫√¡·≈–ª√– ∫°“√≥å¢ÕßºŸâµ√«®§—¥°√Õß §«“¡™ÿ°¢Õß‚√§Õ“¬ÿ¢Õßµ—«Õ¬à“ß ·≈–¢π“¥µ—«Õ¬à“ß

°“√»÷°…“ à«π¡“°„π‡√◊ËÕß°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“ „π°“√»÷°…“π’È‡ªìπ°“√»÷°…“§«∫§ÿ¡·∫∫ ÿà¡„π µ√’§π‡¥’¬«°—π°“√§—¥°√Õß∑—Èß∑’Ë‡ªìπ°“√§«∫§ÿ¡·≈–°“√∑¥≈Õß„π µ√’§π‡¥’¬«°—π¡’º≈∑”„Àâ “¡“√∂≈¥Õ§µ‘„π°“√§—¥‡≈◊Õ°µ—«Õ¬à“ß‰¥â ‚¥¬‡©æ“–Õ“¬ÿ·≈–§«“¡√ÿπ·√ß¢Õß‚√§ ”À√—∫°“√ ÿà¡µ—«Õ¬à“ß ·≈–·∫àßÕÕ°‡ªìπ Õß°≈ÿà¡´÷Ëß¡’≈”¥—∫°“√µ√«®§—¥°√Õß∑’Ë·µ°µà“ß°—ππ—Èπ “¡“√∂∑”„Àâ¡’°“√∂à«ß§«“¡ ¡¥ÿ≈¢Õßº≈°√–∑∫„π°“√∑¥ Õ∫·√°∑’Ë¡’µàÕ°“√∑¥ Õ∫§√—Èß∑’Ë 2 (carry over effect) ‰¥â„π°“√»÷°…“π’È„™âæ◊Èπ∑’Ë„µâ ROC curve ‡ªìπ¥√√™π’„π°“√·¬°‚√§´÷Ëß√«¡§«“¡‰«·≈–§«“¡®”‡æ“–¢Õß°“√∑¥ Õ∫«‘π‘®©—¬‰«â¥â«¬°—π πÕ°®“°π—Èπ¬—ß‰¡à¢÷Èπ°—∫§«“¡™ÿ°¢Õß‚√§ ∑—ÈßÊ ∑’Ë¡’°“√‡ πÕ«‘∏’°“√«‘‡§√“–Àå·∫∫„À¡à ‰¥â·°à conditional relative odds ratio(CROR), based on McNemarûs odds ratio bydisease status ´÷Ëß‡ªìπ¥√√™π’∑’Ë¡’Õ§µ‘πâÕ¬°«à“‡æ◊ËÕ¥Ÿ

§«“¡·µ°µà“ß¢Õß°“√∑¥ Õ∫ Õß«‘∏’∑’Ë∑”„πµ—«Õ¬à“ß‡¥’¬«°—π

Õ¬à“ß‰√°Áµ“¡¬—ß¡’¢âÕ®”°—¥„π°“√·ª√º≈11 ¢âÕ®”°—¥∑’Ë¡’‚Õ°“ ‡°‘¥¢÷Èπ‰¥â¢Õß°“√»÷°…“π’È§◊Õ §«“¡™”π“≠∑’Ë‡æ‘Ë¡¡“°¢÷Èπ¢ÕßºŸâ§—¥°√Õß„π°“√·ª√º≈‡ªìπ∫«° àßº≈°√–∑∫µàÕ°“√º≈°“√»÷°…“‰¥â ”À√—∫°“√≈¥Õ§µ‘„π°“√æ‘ Ÿ®πå¥â«¬°“√ àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ°‡©æ“–„π√“¬∑’Ëº≈°“√§—¥°√Õß‡ªìπº≈∫«°π—Èπ ‰¥â∑”°“√ ÿà¡µ√«® µ√’√âÕ¬≈– 10 (59/590) ∑’Ë¡’º≈°“√§—¥°√Õß∑—Èß Õß«‘∏’‡ªìπº≈≈∫¡“ àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ°‡æ◊ËÕ°“√«‘π‘®©—¬ æ∫«à“º≈°“√µ√«®∑—ÈßÀ¡¥‰¡àæ∫§«“¡º‘¥ª°µ‘ ·¡â«à“π—°‡´≈≈å«‘∑¬“‰¡à∑√“∫º≈°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡°Áµ“¡ ·µà·æ∑¬å∑’Ë àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ°¬—ß§ß∑√“∫º≈°“√µ√«®§—¥°√Õß«à“‡ªìπ∫«°À√◊Õ≈∫ ´÷ËßÕ“®‡ªìπ “‡Àµÿ„Àâ¡’§«“¡µ—Èß„®„π°“√ àÕß°≈âÕß∑’Ë·µ°µà“ß°—π‚¥¬‰¡à√Ÿâµ—«

®“°√“¬ß“π°“√»÷°…“π’È Õ—µ√“°“√µ√«®§—¥°√Õß∑’Ë‡ªìπº≈∫«°¢Õß VIA ‡∑à“°—∫√âÕ¬≈– 9.8 ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√»÷°…“Õ◊Ëπ´÷Ëßæ∫„πÕ—µ√“√âÕ¬≈– 16.1§«“¡·µ°µà“ß¢ÕßÕ—µ√“°“√§—¥°√Õß‡ªìπº≈∫«°¢÷Èπ°—∫‡°≥±å„π°“√«‘π‘®©—¬·≈–ª√– ∫°“√≥å„π°”Àπ¥º≈∫«°¢ÕßºŸâ§—¥°√Õß §«“¡‰« §«“¡®”‡æ“– §à“æ¬“°√≥å∫«°·≈–§à“æ¬“°√≥å≈∫¢Õß VIA ‡∑à“°—∫√âÕ¬≈– 50.0,√âÕ¬≈– 91.3, √âÕ¬≈– 13.8 ·≈–√âÕ¬≈– 98.5 µ“¡≈”¥—∫‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫æ‘ —¬¢Õß§«“¡‰«·≈–§«“¡®”‡æ“–¢ÕßVIA „π°“√»÷°…“Õ◊Ëπ‡∑à“°—∫√âÕ¬≈– 55.5-100 ·≈–√âÕ¬≈– 53.0-85.1 µ“¡≈”¥—∫1,2,4,9,12 §«“¡‰«·≈–§«“¡®”‡æ“–¢Õß Pap smear „π°“√µ√«®æ∫√Õ¬‚√§‡¬◊ËÕ∫ÿº‘«ª“°¡¥≈Ÿ°µ—Èß·µà¢—Èπ∑’Ë 2 ¢÷Èπ‰ª„π°“√»÷°…“π’È‡∑à“°—∫√âÕ¬≈– 93.8 ·≈–√âÕ¬≈– 92.7 µ“¡≈”¥—∫ º≈°“√»÷°…“π’È Ÿß°«à“§«“¡‰«‡©≈’Ë¬¢Õß Pap smear „π°“√»÷°…“«‘‡§√“–Àå·ª√∞“π¢âÕ¡Ÿ≈∑’Ëºà“π¡“´÷Ëß¡’º≈‡©≈’Ë¬√âÕ¬≈– 59.0 (47.0-62.0) ‚¥¬¢÷Èπ°—∫®ÿ¥µ—¥¢Õß§«“¡º‘¥ª°µ‘∑’Ë„™â„π°“√π‘¬“¡º≈∫«°¢Õß°“√§—¥°√Õß·≈–¡’§«“¡®”‡æ“–‡©≈’Ë¬‡∑à“°—∫√âÕ¬≈– 75.0 (60.0-95.0)13-15

§«“¡·¡àπ¬”¢Õß VIA µË”°«à“¢Õß Pap smear



Õ¬à“ß¡“°„π°“√§—¥°√Õß√Õ¬‚√§‡¬◊ËÕ∫ÿª“°¡¥≈Ÿ°√–¥—∫√ÿπ·√ß Ÿß (HSIL) (§«“¡·µ°µà“ß√–À«à“ßæ◊Èπ∑’Ë„µâ ROCcurve = 0.23; 95% CI 0.08, 0.38; p-value = 0.003)§à“æ¬“°√≥å∫«°∑’ËµË”°«à“Õ¬à“ß¡“°¢Õß VIA ¡’º≈∑”„Àâº≈∫«°≈«ß§àÕπ¢â“ß Ÿß´÷ËßÕ“®¡’º≈‡ ’¬¡“°°«à“ª√–‚¬™πå„π°“√µ√«®§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ° ·¡â«à“§à“æ¬“°√≥å≈∫¢Õß VIA ¥Ÿ‡À¡◊Õπ®– Ÿß‡∑à“°—∫ Papsmear ·µàº≈≈∫≈«ß∑’ËµË”¡“°Õ“®‡ªìπº≈¡“°®“°Õ§µ‘„π°“√æ‘ Ÿ®πå (verification bias) ¥—ßπ—Èπ°“√»÷°…“„πÕπ“§µ§«√ÕÕ°·∫∫„Àâ¡’°“√·°â‰¢Õ§µ‘¥—ß°≈à“«‡æ◊ËÕ„Àâº≈≈∫≈«ß∑’Ë‰¥â„°≈â‡§’¬ß§«“¡‡ªìπ®√‘ß·≈–§«√·π–π”„Àâ µ√’∑’Ë¡“√—∫°“√§—¥°√Õß∑ÿ°√“¬‰¥â√—∫°“√ àÕß°≈âÕß¢¬“¬¿“æª“°¡¥≈Ÿ°‚¥¬·æ∑¬åºŸâ àÕß°≈âÕß«‘π‘®©—¬‰¡à∑√“∫º≈°“√§—¥°√Õß∑ÿ°™π‘¥¡“°àÕπ

√ÿª

°“√»÷°…“π’È· ¥ß„Àâ‡ÀÁπ«à“°“√µ√«®¥ŸÀ≈—ß°“√ªÑ“¬°√¥πÈ” â¡ (VIA) ‰¡à‡À¡“– ¡∑’Ë®–π”¡“„™â„π°“√§—¥°√Õß¡–‡√Áßª“°¡¥≈Ÿ°∑¥·∑π Pap smear ‰¥â „π µ√’Õ“¬ÿ√–À«à“ß 30-60 ªï

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ √Õß»“ µ√“®“√¬åπ“¬·æ∑¬å™¬—πµ√å∏√ª∑ÿ¡“ππ∑å “¢“√–∫“¥«‘∑¬“·≈– ∂‘µ‘ ¿“§«‘™“‡«™»“ µ√å™ÿ¡™π §≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à ∑’Ë°√ÿ≥“„Àâ§”ª√÷°…“·≈–«‘®“√≥å°“√»÷°…“©∫—∫π’È‚¥¬‡©æ“–°“√«‘‡§√“–Àå∑“ß ∂‘µ‘ √«¡∑—Èß¢Õ¢Õ∫§ÿ≥π“¬·æ∑¬åÕÿ∑—¬ µ—≥»≈“√—°…å·≈–·æ∑¬åÀ≠‘ßºÿ ¥’ ∏√√¡“π«—µ√å ‚√ßæ¬“æ¬“∫“≈πæ√—µπ√“™∏“π’‡ªìπÕ¬à“ß¬‘Ëß∑’Ë„Àâ°“√ π—∫ πÿπ·≈–„Àâ§”ª√÷°…“·π–π”

2. Shastri SS, Dinshaw K, Amin G, Goswami S, Patil S,

Chinoy R, et al. Concurrent evaluation of visual,

cytological and HPV testing as screening methods for

the early detection of cervical neoplasia in Mumbai,

India. Bull World Health Organ 2005; 83:186-94.

3. Sankaranarayanan R, Basu P, Wesley RS, Mahe C,

Keita N, Mbalawa CC, et al. Accuracy of visual

screening for cervical neoplasia: results from an IARC

multicentre study in India and Africa. Int J Cancer

2004; 110:907-13.

4. Sankaranarayanan R, Wesley R, Thara S, Dhakad N,

Chandralekha B, Sebastian P, et al. Test characteristics

of visual inspection with 4% acetic acid (VIA) and

Lugol’s iodine (VILI) in cervical cancer screening in

Kerala, India. Int J Cancer 2003; 106:404-8.

5. Singh V, Sehgal A, Parashari A, Sodhani P,

Satyanarayana L. Early detection of cervical cancer

through acetic acid application-and aided visual

inspection. Singapore Med J 2001; 42:351-4.

6. University of Zimbabwe/JHPIEGO Cervical Cancer

Project. Visual inspection with acetic acid for cervical-

cancer screening: test qualities in a primary-care setting.

Lancet 1999; 353:869-73.

7. Sankaranarayanan R, Shyamalakumary B, Wesley R,

Sredevi Amma N, Parkin DM, Nair MK. Visual

inspection with acetic acid in the early detection of

cervical cancer and precursors. Int J Cancer 1999;

80:161-3.

8. Londhe M, George SS, Seshadri L. Detection of CIN

by naked eye visualization after application of acetic

acid. Indian J Cancer 1997; 34:88-91.

9. Sankaranarayanan R, Nene BM, Dinshaw K, Rajkumar

R, Shastri S, Wesley R, et al. Early detection of cervical

cancer with visual inspection methods: a summary of

completed and on-going studies in India. Salud Publica

Mex 2003; 45 (Suppl 3):S399-407.

10. Sarian LO, Derchain SF, Naud P, Roteli-Martins C,

Longatto-Filho A, Tatti S, et al. Evaluation of visual

inspection with acetic acid (VIA), Lugol’s iodine (VILI),

cervical cytology and HPV testing as cervical screening

tools in Latin America. This report refers to partial

results from the LAMS (Latin AMerican Screening)

study. J Med Screen 2005; 12:142-9.

11. Suzuki S. Conditional Relative Odds Ratio and

Comparison of Accuracy of Diagnostic Tests Based on

2x2 Tables. J Epidemiol 2006; 16:145-53.

12. Bhatla N, Mukhopadhyay A, Joshi S, Kumar A, Kriplani

A, Pandey RM, et al. Visual inspection for cervical


1. Sangwa-Lugoma G, Mahmud S, Nasr SH, Liaras J,

Kayembe PK, Tozin RR, et al. Visual inspection as a

cervical cancer screening method in a primary health

care setting in Africa. Int J Cancer 2006; 119:1389-95.

38

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

screening evaluation by doctor versus paramedical

worker. Indian J Cancer 2004; 41:32-6.

13. Fahey MT, Irwig L, Macaskill P. Metaanalysis of Pap

test accuracy. Am J Epidemiol 1995; 141:680-9.

14. Mitchell MF, Cantor SB, Brookner C, Utzinger U,

Schottenfeld D, Richards-Kortum R. Screening for

squamous intraepithelial lesions with fluorescence

spectroscopy. Obstet Gynecol 1999; 94:889-96.

15. Nanda K, McCrory DC, Myers ER, Bastian LA,

Hasselblad V, Hickey JD, Matchar DB. Accuracy of

the Papanicolaou test in screening for and follow-up of

cervical cytologic abnormalities: a systematic review.

Ann Intern Med 2000; 132:810-9.




°“√„™â Heparin-Free Saline Drip Technique¢≥–øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰µ‡∑’¬¡„πºŸâªÉ«¬∑’Ë¡’¿“«–‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ°∫ÿ≠√—°…“ ‡À≈à“π¿“æ√ æ¬.∫.*π—π∑π“ ™ªî≈‡≈ æ¬.¡.*®‘µ√¥“ ¥â«ß§ß æ¬.∫.* ÿ¡π°“≠®πå ≈“¿°‘µµ‘‡®√‘≠™—¬ æ¬.∫.* ÿ‰≈æ√ ≈—ß∫ÿªº“ æ¬.∫.*‰æ‚√®πå ¬‘Ëß«—≤π‡¥™ æ.∫.**™¬—πµ√å∏√ ª∑ÿ¡“ππ∑å D.Sc.****Àπà«¬‰µ‡∑’¬¡ ‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’**°≈ÿà¡ß“πÕ“¬ÿ√°√√¡ ‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’***§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à

Abstract Heparin Free-Saline Drip Technique in Hemodialytic Patients with High Risk ofBleedingLaonapaporn B.*, Spilles N.*, Duangkhong J.*, Lapkittichareonchai S.*, Lungbuppha S.*,Yingwatanadej P.**, Patumanond J.****Hemodialysis Unit, Nopparat Rajathanee Hospital, **Department of Medicine, Nopparat RajathaneeHospital, ***Faculty of Medicine, Chiang Mai UniversityBull Dept Med Serv 2007; 32:39-46.

Heparin-free dialyses reduce the risk of bleeding in hemodialysis patients with active bleedingor at risk of hemorrhage. The technique, however, is associated with clotting complications in theextracorporeal circuit. Many studies indicated that early signs of coagulation frequently appeared in thevenous trap chamber rather than in the dialyzer. The study was conducted at Nopparat Rajathanee Hospital,in 14 patients, 31 hemodialyses to compare the effectiveness of the heparin free-saline drip (HSD) to theheparin free-saline flush (HSF) technique, in reducing hemodialysis system coagulation. Patients with highrisk of hemorrhage were randomly assigned in advance to undergo hemodialysis with the HSD or the HSFtechnique. All dialyses were performed under the blood flow rate of 150 to 250 ml/min. Coagulation occurredin 2 of 15 dialyses (13.3%) in the HSD group compared to 5 of 16 dialyses (31.3%) in the HSF (p = 0.394). Theaverage time when the system started to clot in the HSD group was 190 min (± 10) and in the HSF, 150 min(± 26.8) (p = 0.417). The risk of coagulation in the HSD was 0.33 times of the HSF group (95%CI = 0.04 to 02.97,p = 0.324). It was concluded that the HSD technique reduces hemodialysis system coagulation, but the studysize was too small to have sufficient statistical power to show statistical significance. The study should becontinued in order to achieve a more valid conclusion.

Key words: hemodialysis, anticoagulant, heparin, blood coagulation, renal lailure

40

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

°“√øÕ°‡≈◊Õ¥ºŸâªÉ«¬‰µ«“¬¥â«¬‡§√◊ËÕß‰µ‡∑’¬¡®”‡ªìπµâÕß„™â “√µâ“π°“√·¢Áßµ—«¢Õß‡≈◊Õ¥√–À«à“ß°“√øÕ°‡≈◊Õ¥‡æ◊ËÕªÑÕß°—π°“√Õÿ¥µ—π¢Õß “¬ àß‡≈◊Õ¥À√◊Õµ—«°√Õß‡≈◊Õ¥1-4 °“√Õÿ¥µ—π¥—ß°≈à“«®–∑”„ÀâºŸâªÉ«¬‡ ’¬‡≈◊Õ¥∑’Ë§â“ßÕ¬Ÿà„π√–∫∫‰ª®”π«πÀπ÷Ëß ·≈–µâÕßÀ¬ÿ¥°“√øÕ°‡≈◊Õ¥‡æ◊ËÕ‡ª≈’Ë¬π “¬ àß‡≈◊Õ¥À√◊Õµ—«°√Õß‡≈◊Õ¥∑”„Àâ°“√øÕ°‡≈◊Õ¥‰¡àµàÕ‡π◊ËÕß·≈– ‘Èπ‡ª≈◊Õß§à“„™â®à“¬µà“ßÊ ‡æ‘Ë¡¢÷Èπ

ºŸâªÉ«¬∑’Ë¡’ªí®®—¬‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ° ®”‡ªìπµâÕßÀ≈’°‡≈’Ë¬ß°“√„™â¬“ªÑÕß°—π°“√·¢Áßµ—«¢Õß‡≈◊Õ¥„π¢≥–øÕ°‡≈◊Õ¥ (no anticoagulant hemodialysis)‡æ◊ËÕªÑÕß°—π§«“¡‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ°‡æ‘Ë¡¢÷Èπ

ªí®®ÿ∫—π «‘∏’°“√øÕ°‡≈◊Õ¥ ”À√—∫ºŸâªÉ«¬∑’Ë‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ° Ÿß ‰¥â·°à °“√„™â regional heparin,low-dose heparin, low-molecular weight heparin·≈–«‘∏’ no anticoagulant (heparin free-saline flush)´÷Ëß¬—ßæ∫«à“¡’°“√Õÿ¥µ—π¢Õß “¬ àß‡≈◊Õ¥À√◊Õµ—«°√Õß‡≈◊Õ¥„π¢≥–øÕ°‡≈◊Õ¥Õ¬Ÿà1,3,5 ®“°ª√– ∫°“√≥å„πÀπà«¬‰µ‡∑’¬¡¢Õß‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’·≈–°“√»÷°…“∑’Ëºà“π¡“æ∫«à“∫√‘‡«≥ venous trap chamber‡ªìπ à«π∑’ËÕÿ¥µ—π∫àÕ¬∑’Ë ÿ¥2,6 “‡Àµÿ¥—ß°≈à“«‡°‘¥®“°°“√≈¥≈ß¢Õß·√ß¥—π‡≈◊Õ¥À≈—ßºà“πµ—«°√Õß‡≈◊Õ¥ ·≈–

°“√¥÷ßπÈ”¢≥–øÕ°‡≈◊Õ¥∑’Ë∑”„Àâ§«“¡‡¢â¡¢âπ‡≈◊Õ¥ Ÿß¢÷Èπ¢≥–‰À≈ºà“πµ—«°√Õß‡≈◊Õ¥¡“∑’Ë venous trapchamber πÕ°®“°π—Èπ °“√„™â«‘∏’ heparin free-salineflush ·∫∫‡¥‘¡ µâÕß flush µ—«°√Õß¥â«¬ saline ®”π«π100-200 ¡‘≈≈‘≈‘µ√µàÕπ“∑’ ∑ÿ° 15-30 π“∑’ ´÷ËßÕ“®∑”„Àâ¡’ª√‘¡“≥πÈ” à«π‡°‘π 1,000-1,400 ¡‘≈≈‘≈‘µ√‡¢â“‰ª„π√à“ß°“¬ √«¡∑—Èß°“√‡ªî¥Õ—µ√“°“√¥÷ßπÈ”„Àâ Ÿß¢÷Èπ‡æ◊ËÕ¢®—¥πÈ” à«π∑’Ë‡°‘ππ’ÈÕÕ° Õ“®‡ √‘¡„Àâ‡°‘¥¿“«–§«“¡¥—π‚≈À‘µµË”‰¥âßà“¬ ·≈–À“°‰¡à¥÷ßπÈ”„Àâ‡æ’¬ßæÕºŸâªÉ«¬Õ“®‡°‘¥¿“«–πÈ”‡°‘π‰¥â7,8 πÕ°®“°π—Èπ°“√„™â«‘∏’heparin free ¬—ßµâÕß‡ªî¥ blood flow rate ª√–¡“≥250-300 ¡‘≈≈‘≈‘µ√/π“∑’ ÷ËßÕ“®‡ √‘¡„Àâ‡°‘¥¿“«–§«“¡¥—π‚≈À‘µµË”·≈– dialysis dis-equilibriumsyndrome ‰¥âßà“¬8

°“√„™â«‘∏’ heparin-free saline drip technique·∫∫„À¡à‚¥¬„™â normal saline drip ∑“ß venous trapchamber „πÕ—µ√“ 100 ¡‘≈≈‘≈‘µ√/π“∑’ ™–≈â“ß·≈–‡®◊Õ®“ß§«“¡‡¢â¡¢âπ¢Õß‡≈◊Õ¥À≈—ßºà“πµ—«°√Õß‡≈◊Õ¥‡ªìπ°“√≈¥°“√Õÿ¥µ—π∑’Ë∫√‘‡«≥ venous trap chamberÕ¬à“ßµàÕ‡π◊ËÕß √à«¡°—∫°“√„™â normal saline flush “¬ àß‡≈◊Õ¥·≈–µ—«°√Õß‡≈◊Õ¥§√—Èß≈– 100 ¡‘≈≈‘≈‘µ√∑ÿ°1 ™—Ë«‚¡ß ®–∑”„ÀâπÈ” à«π‡°‘π∑’ËºŸâªÉ«¬‰¥â√—∫¡’ª√‘¡“≥πâÕ¬°«à“«‘∏’ heparin free-saline flush §◊Õª√–¡“≥

‡√◊ËÕß¬àÕ °“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ heparin-free ‡ªìπ°“√≈¥§«“¡‡ ’Ë¬ßµàÕ¿“«–‡≈◊Õ¥ÕÕ°„πºŸâªÉ«¬øÕ°‡≈◊Õ¥∑’Ë¡’‚Õ°“ ‡≈◊Õ¥ÕÕ° Ÿß ·µàÕ“®‡æ‘Ë¡ªí≠À“∑’Ë‡°‘¥®“°°“√Õÿ¥µ—π¢Õßµ—«°√Õß‡≈◊Õ¥·≈– “¬ àß‡≈◊Õ¥ °“√»÷°…“∑’Ëºà“π¡“æ∫«à“°“√Õÿ¥µ—π¡—°‡√‘Ë¡‡°‘¥∑’Ë∫√‘‡«≥ venous trap chamber °àÕπ°“√Õÿ¥µ—π„πµ—«°√Õß‡≈◊Õ¥ °“√»÷°…“§√—Èßπ’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕª√–‡¡‘πª√– ‘∑∏‘¿“æ°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ heparin free-saline drip technique (HSD) ·∫∫„À¡à ‡ª√’¬∫‡∑’¬∫°—∫«‘∏’ heparin free-saline flushtechnique (HSF) ·∫∫‡¥‘¡ ‚¥¬»÷°…“ºŸâªÉ«¬øÕ°‡≈◊Õ¥¢Õß‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’ ∑’Ë¡’§«“¡‡ ’Ë¬ßµàÕ¿“«–‡≈◊Õ¥ÕÕ° Ÿß ®”π«π14 §π „π°“√øÕ°‡≈◊Õ¥∑—ÈßÀ¡¥ 31 §√—Èß ÿà¡ºŸâªÉ«¬‡¢â“°≈ÿà¡»÷°…“∑’Ë„™â«‘∏’ HSD ·≈–°≈ÿà¡‡ª√’¬∫‡∑’¬∫´÷Ëß„™â«‘∏’ HSF ¥â«¬°“√®—∫©≈“°≈à«ßÀπâ“ „™âÕ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥ (blood flow rate) 150-250 ¡‘≈≈‘≈‘µ√µàÕπ“∑’µ≈Õ¥°“√øÕ°‡≈◊Õ¥ æ∫«à“°≈ÿà¡∑’ËøÕ°‡≈◊Õ¥¥â«¬«‘∏’ HSD ‡°‘¥°“√Õÿ¥µ—π 2 §√—Èß (13.3%) ‡ªìπ —¥ à«π∑’ËπâÕ¬°«à“°≈ÿà¡ HSF ÷ËßÕÿ¥µ—π 5 §√—Èß (31.3%) (p = 0.394)·≈–„π√“¬∑’Ë¡’°“√Õÿ¥µ—π √–¬–‡«≈“‡©≈’Ë¬°àÕπ°“√Õÿ¥µ—π„π°≈ÿà¡ HSD π“π°«à“„π°≈ÿà¡ HSF §◊Õ‡∑à“°—∫ 190 π“∑’ (± 10.0 π“∑’)·≈– 150 π“∑’ (± 26.8 π“∑’) (p = 0.417) §«“¡‡ ’Ë¬ß¢Õß°“√Õÿ¥µ—π„π°≈ÿà¡ HSD πâÕ¬°«à“°≈ÿà¡ HSF 0.33 ‡∑à“ (risk ratio= 0.33, 95%CI = 0.04 ∂÷ß 2.97 ‡∑à“, p = 0.324) º≈°“√»÷°…“· ¥ß„Àâ‡ÀÁπ«à“°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ HSD ≈¥°“√Õÿ¥µ—π¢Õßµ—«°√Õß‡≈◊Õ¥·≈– “¬ àß‡≈◊Õ¥‰¥â ·µà‡π◊ËÕß®“°°≈ÿà¡µ—«Õ¬à“ß¡’®”π«ππâÕ¬ ®÷ß‰¡à¡’Õ”π“®∑“ß ∂‘µ‘‡æ’¬ßæÕ∑’Ë®–∑”„Àâ‡ÀÁππ—¬ ”§—≠∑“ß ∂‘µ‘‰¥â ´÷Ëß‡ªìπ¢âÕ∫àß™’È«à“§«√ π—∫ πÿπ„Àâ∑”°“√»÷°…“π’ÈµàÕ‰ª®π°«à“®–‰¥â¢âÕ √ÿª∑’Ë™—¥‡®π

§” ”§—≠: øÕ°‡≈◊Õ¥ “√°—π°“√·¢Áßµ—«¢Õß‡≈◊Õ¥ ‡Œæ“√‘π °“√·¢Áßµ—«¢Õß‡≈◊Õ¥ ‰µ«“¬



700 ¡‘≈≈‘≈‘µ√ „π°“√øÕ°‡≈◊Õ¥·µà≈–§√—Èß ·≈–™à«¬≈¥Õ—µ√“°“√¥÷ßπÈ”‰¡à„Àâ Ÿß¡“°

°“√»÷°…“§√—Èßπ’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫ª√– ‘∑∏‘º≈¢Õß°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ heparin-freesaline flush technique ·∫∫‡¥‘¡ °—∫«‘∏’ heparin-freesaline drip technique ·∫∫„À¡à ‡æ◊ËÕπ”º≈°“√»÷°…“∑’Ë‰¥â‰ª„™â„π∑“ßªØ‘∫—µ‘∑“ß§≈‘π‘°µàÕ‰ª

«—µ∂ÿ·≈–«‘∏’°“√

°“√»÷°…“§√—Èßπ’È‡ªìπ°“√»÷°…“‡™‘ß∑¥≈Õß∑“ß§≈‘π‘°(clinical trial) ª√–™“°√∑’Ë»÷°…“‡ªìπºŸâªÉ«¬∑’ËµâÕß‰¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰µ‡∑’¬¡¢Õß‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’´÷Ëß·æ∑¬åÀâ“¡„™â heparin ‡π◊ËÕß®“°¡’§«“¡‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ° Ÿß ‚¥¬®—¥ºŸâªÉ«¬‡ªìπ 4°≈ÿà¡µ“¡‡°≥±å¢Õß «Õµ´å (Swartz) ·≈–æÕµå∑ (Port)3

„π·µà≈–°≈ÿà¡‡ ’Ë¬ß ∑”°“√ ÿà¡ (randomize) ºŸâªÉ«¬‡¢â“°≈ÿà¡»÷°…“´÷Ëß„™â heparin free-saline drip technique(HSD) À√◊Õ°≈ÿà¡‡ª√’¬∫‡∑’¬∫´÷Ëß„™â heparin free-saline flush technique (HSF) ¥â«¬°“√®—∫©≈“°≈à«ßÀπâ“ µ—«Õ¬à“ß‡≈◊Õ¥¢ÕßºŸâªÉ«¬®–‰¥â√—∫°“√µ√«®hematocrit, platelet count, prothrombin time (PT),partial throm-boplastin time (PTT) ·≈– serumsodium °àÕπ°“√øÕ°‡≈◊Õ¥ ºŸâªÉ«¬∑ÿ°√“¬‰¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰µ‡∑’¬¡™π‘¥ Fresenius 4008 E„™â§«“¡‡¢â¡¢âπ¢Õß dialysate sodium ∑’Ë 138 mEq/L·≈– bicarbonate ∑’Ë 32 mEq/L „™âµ—«°√Õß‡≈◊Õ¥™π‘¥cellulose tri-acetate hollow fiber (Nipro SF 110E) ≈â“ßµ—«°√Õß·≈– “¬ àß‡≈◊Õ¥°àÕπ°“√øÕ°‡≈◊Õ¥¢Õß∑—Èß 2 «‘∏’‚¥¬ª√—∫«‘∏’¡“®“°·´π‡¥Õ√å (Sander)·≈–§≥–1 §◊Õ„™â normal saline 1 ≈‘µ√≈â“ßµ—«°√Õß·≈– “¬ àß‡≈◊Õ¥ ·≈–∑” recirculation ∑’ËÕ—µ√“°“√¥÷ßπÈ” 3,000 ¡‘≈≈‘≈‘µ√/™—Ë«‚¡ß ‡ªìπ‡«≈“ 10 π“∑’ ≈â“ßµ—«°√Õß·≈– “¬ àß‡≈◊Õ¥¥â«¬ normal saline 1 ≈‘µ√∑’Ë¡’ heparin 3,000 ¬Ÿπ‘µ „πÕ—µ√“°“√‰À≈ 100¡‘≈≈‘≈‘µ√/π“∑’ ·≈–≈â“ßµàÕ¥â«¬ normal saline ∑’Ë‰¡à¡’heparin „πµÕπ ÿ¥∑â“¬Õ’° 1 ≈‘µ√ „πÕ—µ√“°“√‰À≈100 ¡‘≈≈‘≈‘µ√/π“∑’

°≈ÿà¡‡ª√’¬∫‡∑’¬∫∑’Ë∑” heparin-free saline flushtechnique (HSF) „™â normal saline flush “¬ àß‡≈◊Õ¥·≈–µ—«°√Õß‡≈◊Õ¥§√—Èß≈– 200 ¡‘≈≈‘≈‘µ√ ∑ÿ° 30π“∑’ ¢≥–∑” hemodialysis à«π°≈ÿà¡»÷°…“∑’Ë∑” heparinfree-saline drip technique (HSD) „™â normal salinedrip ∑“ß venous trap chamber ‚¥¬„™â infusionpump (Volumed m VP 5005) „πÕ—µ√“ 100 ¡‘≈≈‘≈‘µ√/π“∑’ √à«¡°—∫ normal saline flush “¬ àß‡≈◊Õ¥·≈–µ—«°√Õß‡≈◊Õ¥§√—Èß≈– 100 ¡‘≈≈‘≈‘µ√ ∑ÿ° 60 π“∑’§«∫§ÿ¡Õ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥ (blood flow rate) ∑’Ë150-250 ¡‘≈≈‘≈‘µ√/π“∑’ ·≈–§«∫§ÿ¡Õ—µ√“°“√¥÷ßπÈ”‰¡à‡°‘π 1.5 ≈‘µ√/™—Ë«‚¡ß (√«¡®”π«π normal saline à«π‡°‘π∑’Ë„™â ”À√—∫ flush) ‡«≈“∑’Ë„™â„π°“√øÕ°‡≈◊Õ¥3-4 ™—Ë«‚¡ß ‡ΩÑ“ —ß‡°µ·≈–∫—π∑÷°°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥·≈–°“√Õÿ¥µ—π¢Õßµ—«°√Õß‡≈◊Õ¥·≈– “¬ àß‡≈◊Õ¥ À≈—ß°“√øÕ°‡≈◊Õ¥ àßµ—«Õ¬à“ß‡≈◊Õ¥µ√«® hematocrit ·≈–sodium ≈â“ßµ—«°√Õß¥â«¬‡§√◊ËÕß≈â“ßµ—«°√Õß‰µ‡∑’¬¡·∫∫Õ—µ‚π¡—µ‘ Kidney kleen Model KK II ·≈–«—¥ª√‘¡“µ√¢Õßµ—«°√Õß‡≈◊Õ¥ (total cell volume : TCV)∑’Ë‡À≈◊ÕÕ¬Ÿà

«‘‡§√“–Àå¢âÕ¡Ÿ≈∫ÿ§§≈·≈–¢âÕ¡Ÿ≈æ◊Èπ∞“π∑—Ë«‰ª¢ÕßºŸâªÉ«¬ · ¥ß‡ªìπ®”π«π √âÕ¬≈– §à“‡©≈’Ë¬ à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π ‡ª√’¬∫‡∑’¬∫√âÕ¬≈–·≈–§à“‡©≈’Ë¬¥â«¬exact probability test À√◊Õ t-test µ“¡§«“¡‡À¡“– ¡¢Õß¢âÕ¡Ÿ≈ §”π«≥Õ—µ√“°“√Õÿ¥µ—π„π√Ÿª incidencerate (§√—ÈßµàÕ patient-minute) ·≈–· ¥ß‡ªìπ√Ÿª∑’Ë§”π«≥¥â«¬«‘∏’¢Õß Kaplan ·≈– Meier «‘‡§√“–Àå· ¥ßª√– ‘∑∏‘º≈¢Õß«‘∏’°“√øÕ°‡≈◊Õ¥¢Õß°≈ÿà¡»÷°…“¥â«¬§à“§«“¡‡ ’Ë¬ß —¡æ—∑∏å (risk ratio) ·≈–ª√—∫§«“¡·µ°µà“ß∑“ß≈—°…≥–æ◊Èπ∞“π¢Õß∑—Èß 2 °≈ÿà¡¥â«¬°“√«‘‡§√“–Àå°“√∂¥∂Õ¬æÀÿ·∫∫√‘ °å‡√‚™ (multiple riskratio regression analysis)

º≈

ºŸâªÉ«¬∑’Ë‡ ’Ë¬ßµàÕ°“√¡’‡≈◊Õ¥ÕÕ°„π°“√»÷°…“∑—ÈßÀ¡¥ 14 √“¬ ‡ªìπ™“¬ 10 √“¬ À≠‘ß 4 √“¬ ‰¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬‡§√◊ËÕß‰µ‡∑’¬¡√«¡∑—Èß ‘Èπ 31 §√—Èß

42

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

Õ“¬ÿ¢≥–‰¥â√—∫°“√øÕ°‡≈◊Õ¥µ—Èß·µà 13 ∂÷ß 80 ªï (‡©≈’Ë¬44.4 ªï) ¡’ºŸâªÉ«¬ 10 √“¬∑’Ë‰¥â√—∫°“√øÕ°‡≈◊Õ¥¡“°°«à“1 §√—Èß„π√–¬– 12 ‡¥◊Õπ∑’Ëºà“π¡“ ®—¥‡ªìπ°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ HSD √«¡ 15 §√—Èß ·≈–«‘∏’ HSF √«¡ 16§√—Èß °“√»÷°…“§√—Èßπ’È„™â®”π«π§√—Èß¢Õß°“√øÕ°‡≈◊Õ¥‡ªìπÀπà«¬ (unit) „π°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈‡™‘ß‡ª√’¬∫‡∑’¬∫æ∫«à“‡æ» Õ“¬ÿ‡©≈’Ë¬ ·≈–°“√°√–®“¬Õ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß ŸßµàÕ°“√¡’‡≈◊Õ¥ÕÕ°µ“¡‡°≥±å¢Õß Swartz ·≈– Port3,platelet count, prothrombin time ·≈– partial

thromboplastin time ®”π«π§√—Èß¢Õß°“√„™â dialyzer´È” Õ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥ §◊Õ blood flow rate ·≈–ultrainfiltration rate ¢Õß°“√øÕ°‡≈◊Õ¥∑—Èß 2 °≈ÿà¡„°≈â‡§’¬ß°—π (µ“√“ß∑’Ë 1)

°≈ÿà¡∑’Ë‰¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ HSD ‡°‘¥°“√Õÿ¥µ—π 2 §√—Èß (√âÕ¬≈– 13.3) ‡ªìπ —¥ à«π∑’ËπâÕ¬°«à“°≈ÿà¡ HSF ÷ËßÕÿ¥µ—π 5 §√—Èß (√âÕ¬≈– 31.3) (p = 0.394)·≈–„π√“¬∑’Ë¡’°“√Õÿ¥µ—π √–¬–‡«≈“‡©≈’Ë¬°àÕπ°“√Õÿ¥µ—π„π°≈ÿà¡ HSD π“π°«à“„π°≈ÿà¡ HSF §◊Õ‡∑à“°—∫

µ“√“ß∑’Ë 1 ≈—°…≥–æ◊Èπ∞“π¢ÕßºŸâªÉ«¬ ®”·π°µ“¡«‘∏’°“√øÕ°‡≈◊Õ¥

HSD (n = 15) HSF (n = 16) p-value

‡æ»

™“¬ 10 8 0.473

À≠‘ß 5 8

Õ“¬ÿ (ªï)

µË”°«à“ 15 1 1

15-60 10 6

¡“°°«à“ 60 4 9

‡©≈’Ë¬ (_ SE) 43.9 (± 5.4) 52.6 (± 6.4) 0.305

§«“¡‡ ’Ë¬ßµàÕ¿“«–°“√¡’‡≈◊Õ¥ÕÕ° Ÿß*

Very high 7 9 0.940

High 4 3

Moderate 1 1

Low 3 3

Platelet count (10,000/ul) : ‡©≈’Ë¬ (± SE) 16.2 (± 3.0) 15.9 (± 3.0) 0.994

Prothrombin time (π“∑’) : ‡©≈’Ë¬ (± SE) 12.8 (± 0.2) 12.6 (± 0.2) 0.397

Partial thromboplastin time (π“∑’) : ‡©≈’Ë¬ (± SE) 37.1 (± 0.7) 34.4 (± 1.9) 0.212

Dialyzer

„À¡à 9 10 1.000

Reused 6 6

Blood flow rate (ml/min) : ‡©≈’Ë¬ (± SE) 214.7 (± 10.5) 211.9 (± 8.8) 0.839

Ultrainfiltration rate (ml/hr): ‡©≈’Ë¬ (± SE) 0.9 (± 0.2) 0.8 (± 0.2) 0.646

*®”·π°µ“¡‡°≥±å¢Õß Swartz and Port, 1979.



190 π“∑’ (± 10.0 π“∑’) ·≈– 150 π“∑’ (± 26.8 π“∑’)(p = 0.417) à«πª√‘¡“µ√µ—«°√Õß‰µ‡∑’¬¡À≈—ß°“√øÕ°‡≈◊Õ¥¢Õß°≈ÿà¡ HSD ¡“°°«à“¢Õß°≈ÿà¡ HSF §◊Õ‡∑à“°—∫ 56.3 ml (± 2.9 ¡‘≈≈‘≈‘µ√) ·≈– 55.2 ¡‘≈≈‘≈‘µ√(± 2.3 ¡‘≈≈‘≈‘µ√) µ“¡≈”¥—∫ (p = 0.760) (µ“√“ß∑’Ë 2)

„π°≈ÿà¡∑’Ë‰¥â√—∫°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ HSD Õ—µ√“§«“¡‡√Á«¢Õß°“√Õÿ¥µ—π‡©≈’Ë¬ 0.00065 À√◊Õ√âÕ¬≈– 6.5§√—Èß„π°“√øÕ°‡≈◊Õ¥∑ÿ°Ê 100 π“∑’ „π¢≥–∑’ËÕ—µ√“

°“√Õÿ¥µ—π„π°≈ÿà¡ HSF ‡©≈’Ë¬ 0.00156 À√◊Õ√âÕ¬≈–15.6 §√—Èß„π°“√øÕ°‡≈◊Õ¥∑ÿ°Ê 100 π“∑’ ´÷Ëß‡ªìπÕ—µ√“°“√ clot ∑’Ë™â“°«à“ (p = 0.290) (µ“√“ß∑’Ë 2) (√Ÿª∑’Ë1)

√âÕ¬≈–¢Õß°“√Õÿ¥µ—π„π°≈ÿà¡ HSD (√âÕ¬≈– 13.3)πâÕ¬°«à“„π°≈ÿà¡ HDF (√âÕ¬≈– 31.3) √âÕ¬≈– 18.0À√◊Õ‡ªìπ§«“¡‡ ’Ë¬ß∑’Ë≈¥≈ß‡À≈◊Õ 0.43 ‡∑à“ ·≈–‡¡◊ËÕª√—∫§«“¡·µ°µà“ß¢Õß≈—°…≥–∑’ËÕ“®¡’º≈µàÕ°“√Õÿ¥µ—π

√Ÿª∑’Ë 1 Õ—µ√“ (rate) °“√Õÿ¥µ—π¢Õß√–∫∫øÕ°‡≈◊Õ¥«‘∏’ heparin free-saline flush technique (HSF) (‡ âπª√–) ·≈–«‘∏’

heparin free-saline drip technique (HSD) (‡ âπ∑÷∫) §”π«≥¥â«¬«‘∏’¢Õß Kaplan ·≈– Meier

µ“√“ß∑’Ë 2 °“√Õÿ¥µ—π¢Õß√–∫∫øÕ°‡≈◊Õ¥ Õ—µ√“°“√Õÿ¥µ—π √–¬–‡«≈“°àÕπ°“√Õÿ¥µ—π ·≈–ª√‘¡“µ√µ—«°√Õß‰µ‡∑’¬¡

(total cell volume : TCV) ¿“¬À≈—ß°“√øÕ°‡≈◊Õ¥ ®”·π°µ“¡«‘∏’°“√øÕ°‡≈◊Õ¥


°“√Õÿ¥µ—π (clot) ¢Õßµ—«°√ÕßÀ√◊Õ “¬ àß‡≈◊Õ¥

Õÿ¥µ—π 2 (√âÕ¬≈– 13.3) 5 (√âÕ¬≈– 31.3) 0.394

‰¡àÕÿ¥µ—π 13 11

Õ—µ√“°“√Õÿ¥µ—π (§√—ÈßµàÕ 100 π“∑’) : √âÕ¬≈– 6.5 15.6 0.290

√–¬–‡«≈“°àÕπ°“√Õÿ¥µ—π (π“∑’) : ‡©≈’Ë¬ (± SE) 190 (± 10.0) 150 (± 26.8) 0.417

TCV * (ml.) : ‡©≈’Ë¬ (± SE) 56.3 (± 2.9) 55.2 (± 2.3) 0.760

*TCV ¢Õßµ—«°√Õß‡≈◊Õ¥ Dialyzer SF110 Ÿß ÿ¥ = 65 ¡‘≈≈‘≈‘µ√

.5

.4

.3

.2

.1

0

0 60 120 180 240

Dialysis Time (Minute)

HSD

HSF

Probability of clot

44

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

°≈ÿà¡ HSD ≈¥≈ß‡À≈◊Õ 0.33 ‡∑à“ (95%CI = 0.04 ∂÷ß2.97 ‡∑à“, p = 0.324) (√Ÿª∑’Ë 2)

√–¥—∫ sodium °àÕπ·≈–À≈—ß°“√øÕ°‡≈◊Õ¥„π°≈ÿà¡«‘∏’ HSD Ÿß°«à“„π°≈ÿà¡ HSF·≈–‡æ‘Ë¡¢÷Èπ„πª√‘¡“≥∑’ËπâÕ¬°«à“°≈ÿà¡ HSF (p = 0.807) à«π

¢Õß√–∫∫øÕ°‡≈◊Õ¥√–À«à“ß 2 °≈ÿà¡ ‰¥â·°à °“√®”·π°µ“¡°≈ÿà¡‡ ’Ë¬ß hematocrit, platelet count, prothrombintime, partial thromboplastin time °àÕπøÕ°‡≈◊Õ¥blood infiltration rate ·≈– ultrainfiltration rate¥â«¬«‘∏’°“√∑“ß ∂‘µ‘·≈â« æ∫«à“ ‚Õ°“ °“√Õÿ¥µ—π„π

µ“√“ß∑’Ë 3 √–¥—∫‚´‡¥’¬¡ ·≈–§«“¡‡¢â¡¢âπ¢Õß‡≈◊Õ¥ (°àÕπøÕ°‡≈◊Õ¥ À≈—ßøÕ°‡≈◊Õ¥ ·≈–§«“¡‡ª≈’Ë¬π·ª≈ß) ®”·π°

µ“¡«‘∏’°“√øÕ°‡≈◊Õ¥


√–¥—∫‚´‡¥’¬¡ (mEq/L)

°àÕπ 134.5 (± 1.8) 133.9 (± 1.3) 0.794

À≈—ß 138.1 (± 0.7) 137.9 (± 1.0) 0.915

‡æ‘Ë¡¢÷Èπ 3.6 (± 1.7) 4.0 (± 0.7) 0.807

§«“¡‡¢â¡¢âπ¢Õß‡≈◊Õ¥ (Hematocrit) (√âÕ¬≈–)

°àÕπ 26.6 (± 1.5) 24.9 (± 0.8) 0.350

À≈—ß 30.7 (± 1.3) 29.4 (± 1.0) 0.439

‡æ‘Ë¡¢÷Èπ 4.2 (± 0.7) 4.5 (± 0.8) 0.760

√Ÿª∑’Ë 2 §«“¡πà“®–‡ªìπ (probability) ¢Õß§«“¡‡ ’Ë¬ß —¡æ—∑∏å (risk ratio) ∑’Ë°“√øÕ°‡≈◊Õ¥·∫∫ HSD ®–≈¥§«“¡‡ ’Ë¬ßµàÕ

°“√Õÿ¥µ—π ‡ª√’¬∫‡∑’¬∫°—∫°“√øÕ°‡≈◊Õ¥·∫∫ HSF (‡ âπª√–·π«µ—Èß§◊Õ risk ratio = 1 À¡“¬∂÷ß°“√øÕ°‡≈◊Õ¥

¥â«¬«‘∏’ HSD ‰¡à¡’º≈„π°“√ªÑÕß°—π°“√Õÿ¥µ—π ‡ âπª√–·π«πÕπ§◊Õ p-value = 0.05 À¡“¬∂÷ß√–¥—∫π—¬ ”§—≠∑“ß

∂‘µ‘)

.10

.8

.6

.4

.2

0

.01 .1 1 10

Risk Ratio

Protective effect Harmful effect

Probability of clot



hematocrit °àÕπ·≈–À≈—ß°“√øÕ°‡≈◊Õ¥„π°≈ÿà¡«‘∏’ HSD Ÿß°«à“„π°≈ÿà¡ HDF ·≈–‡æ‘Ë¡¢÷Èπ„πª√‘¡“≥∑’ËπâÕ¬°«à“(p = 0.760) (µ“√“ß∑’Ë 3)

‡¡◊ËÕπ”§«“¡·µ°µà“ß¢Õß —¥ à«π (proportion)°“√Õÿ¥µ—π¢Õß∑—Èß 2 °≈ÿà¡¡“§”π«≥À“ number neededto prevent ®“° ¡°“√ 1/absolute difference ‰¥â®”π«πºŸâªÉ«¬∑’ËµâÕß‰¥â√—∫°“√øÕ°‡≈◊Õ¥‡æ◊ËÕªÑÕß°—π°“√Õÿ¥µ—π 1 §√—Èß ‡∑à“°—∫ 5.58 √“¬ à«π§«“¡·µ°µà“ß¢ÕßÕ—µ√“ (rate) °“√Õÿ¥µ—π §”π«≥√“¬-π“∑’ (patient-minute) ∑’ËµâÕßøÕ°‡≈◊Õ¥‡æ◊ËÕªÑÕß°—π°“√Õÿ¥µ—π 1 §√—Èß‡∑à“°—∫ 1,000.96 √“¬-π“∑’ ∂â“ª√–¡“≥«à“°“√øÕ°‡≈◊Õ¥·µà≈–§√—Èß (cycle) „™â‡«≈“ 3-4 ™—Ë«‚¡ß (‡©≈’Ë¬ 3.5™—Ë«‚¡ß À√◊Õ 210 π“∑’) µàÕ√“¬ ®–ª√–¡“≥®”π«π§√—Èß¢Õß°“√øÕ°‡≈◊Õ¥‡æ◊ËÕªÑÕß°—π°“√Õÿ¥µ—π 1 §√—Èß‡∑à“°—∫ 5.24 cycle ´÷Ëß Õ¥§≈âÕß°—π ·≈–À¡“¬§«“¡«à“∑ÿ°Ê 5-6 cycle ¢Õß°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’„À¡à ®–ªÑÕß°—π°“√Õÿ¥µ—π‰¥â 1 §√—Èß

«‘®“√≥å

«‘∏’ heparin free-saline drip technique (HSD)‚¥¬„™â saline drip ∑“ß venous trap chamber ≈¥‚Õ°“ °“√Õÿ¥µ—π√–À«à“ßøÕ°‡≈◊Õ¥‰¥â‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫«‘∏’ heparin free-saline flush technique (HSF)(µ“√“ß∑’Ë 2) (√Ÿª∑’Ë 1,2) ·≈–¬—ß™à«¬≈¥®”π«ππÈ”‡°≈◊Õ∑’Ë‡¢â“‰ª„π√à“ß°“¬¥â«¬ °“√∑” heparin free dialysis‚¥¬∑—Ë«‰ª„™âµ—«°√Õß∑’Ë¡’ bio-compatibility ¥â«¬Õ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥ (blood flow rate) ‡√Á«°«à“250-300 ¡‘≈≈‘≈‘µ√/π“∑’ √à«¡°—∫°“√„™âπÈ”‡°≈◊Õ≈â“ß “¬∫àÕ¬Ê ·≈–°“√‡ΩÑ“√–«—ßÕ¬à“ß„°≈â™‘¥9 ºŸâªÉ«¬∫“ß√“¬∑’Ë‰¡à “¡“√∂„™âÕ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥¥—ß°≈à“«‰¥â®”‡ªìπµâÕßª√—∫Õ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥„Àâ™â“°«à“ 250¡‘≈≈‘≈‘µ√/π“∑’ Õ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥™â“∑”„Àâµ—«°√Õß·≈– “¬ àß‡≈◊Õ¥Õÿ¥µ—πßà“¬¢÷Èπ2,7,9,10 „π¢≥–‡¥’¬«°—π°“√„™âπÈ”‡°≈◊Õ≈â“ß “¬∫àÕ¬Ê ∑”„ÀâºŸâªÉ«¬‰¥â√—∫πÈ” à«π‡°‘π®”π«πÀπ÷Ëß ´÷ËßÀ“°‰¡à‰¥â§”π«≥ ultrafiltrationrate „Àâ‡æ’¬ßæÕ·≈â« ºŸâªÉ«¬Õ“®‡°‘¥¿“«–πÈ”‡°‘π‰¥â11

°“√»÷°…“§√—Èßπ’È‡ªìπ§«“¡æ¬“¬“¡„π°“√À“«‘∏’

≈¥°“√Õÿ¥µ—π„πºŸâªÉ«¬øÕ°‡≈◊Õ¥∑’Ë„™âÕ—µ√“°“√‰À≈¢Õß‡≈◊Õ¥ (blood flow rate) ™â“°«à“ 250 ¡‘≈≈‘≈‘µ√/π“∑’µ—«°√Õß‡≈◊Õ¥∑’Ë„™â„π°“√»÷°…“π’È‡ªìπ™π‘¥ cellulosetriacetate (CTA) ‡ªìπ synthetically modifiedmembrane ´÷Ëß¡’ bio-compatibility Ÿß12 «‘∏’ HSD·∫∫„À¡à„™âπÈ”‡°≈◊Õ≈â“ß “¬πâÕ¬°«à“«‘∏’ HSF ‡¥‘¡‡æ√“– drip saline ‡¢â“∑“ß venous trap chamberÕ¬à“ßµàÕ‡π◊ËÕß‡æ◊ËÕ™à«¬≈¥°“√ clot ∑’Ë¡—°‡°‘¥¢÷Èπ∫√‘‡«≥π’È°àÕπ √à«¡°—∫°“√ flush πÈ”‡°≈◊Õª√‘¡“≥πâÕ¬°«à“·≈–‡«âπ√–¬–‡«≈“π“π¢÷Èπ‡ªìπ∑ÿ° 1 ™—Ë«‚¡ß ·≈–®“°°“√ —ß‡°µ°“√Õÿ¥µ—π¢Õß«‘∏’ HSF·∫∫‡¥‘¡ 4 „π 5 §√—Èßæ∫«à“∫√‘‡«≥∑’Ë‡√‘Ë¡Õÿ¥µ—π°àÕπ§◊Õ venous trap chamber´÷Ëß Õ¥§≈âÕß°—∫°“√»÷°…“∑’Ëºà“π¡“2,6 ‡«≈“∑’Ë‡°‘¥°“√Õÿ¥µ—π„π°≈ÿà¡ HSD ‡√‘Ë¡∑’Ëπ“∑’∑’Ë 180 à«π°“√Õÿ¥µ—π„π°≈ÿà¡ HSF ‡°‘¥¢÷Èπ‡√Á«°«à“ §◊Õµ—Èß·µàπ“∑’∑’Ë 60 ¢Õß°“√øÕ°‡≈◊Õ¥

À≈—ß°“√øÕ°‡≈◊Õ¥‰¡àæ∫§«“¡·µ°µà“ß¢Õß‚´‡¥’¬¡À√◊Õ hematocrit ®“°°“√øÕ°‡≈◊Õ¥∑—Èß 2 «‘∏’ (µ“√“ß∑’Ë3) ·¡â®–„™â saline ª√‘¡“≥µà“ß°—π°Áµ“¡ ª√‘¡“µ√¢Õßµ—«°√Õß‡≈◊Õ¥ (total cell volume : TCV) À≈—ß°“√øÕ°‡≈◊Õ¥„°≈â‡§’¬ß°—π (µ“√“ß∑’Ë 2) ‡π◊ËÕß®“°°“√Õÿ¥µ—π à«π„À≠à‡°‘¥¢÷Èπ∑’Ë venous trap chamber ®÷ß¬—ß§ß¡’ª√‘¡“≥ TCV ∑’Ë‰¡à‡ª≈’Ë¬π·ª≈ß¡“°π—°

°“√»÷°…“§√—Èßπ’È®÷ß· ¥ß„Àâ‡ÀÁπ«à“°“√„™â«‘∏’ HSD·∫∫„À¡à ™à«¬„Àâ°“√Õÿ¥µ—π„π√–∫∫øÕ°‡≈◊Õ¥¢ÕßºŸâªÉ«¬∑’Ë„™â blood flow ™â“°«à“ 250 ¡‘≈≈‘≈‘µ√/π“∑’ ‡°‘¥¢÷ÈππâÕ¬·≈–™â“°«à“«‘∏’ HSF ·∫∫‡¥‘¡ ´÷Ëß®–≈¥§«“¡‡ ’Ë¬ßµàÕ°“√‡ ’¬‡≈◊Õ¥ À¬ÿ¥øÕ°‡≈◊Õ¥ ‡ª≈’Ë¬πµ—«°√Õß‡≈◊Õ¥·≈– “¬ àß‡≈◊Õ¥¢≥–øÕ°‡≈◊Õ¥‰¥â √«¡∑—Èß™à«¬≈¥§à“„™â®à“¬„π°“√øÕ°‡≈◊Õ¥‰¥â∫“ß à«π ·≈–¬—ß™à«¬≈¥¿“√–ß“π¢Õßæ¬“∫“≈ª√–®”Àπà«¬‰µ‡∑’¬¡∑’ËµâÕß‡¢â“‰ª¥Ÿ·≈‡æ◊ËÕ≈â“ß “¬ àß‡≈◊Õ¥∑ÿ° 15-30 π“∑’

Õ¬à“ß‰√°Á¥’ ‡π◊ËÕß®“°®”π«πºŸâªÉ«¬„π°“√»÷°…“§√—Èßπ’È¡’πâÕ¬ ∑”„Àâ°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈‰¡à “¡“√∂ √ÿª„Àâ‡ÀÁππ—¬ ”§—≠∑“ß ∂‘µ‘‰¥â ®÷ß§”π«≥¢π“¥µ—«Õ¬à“ß¬âÕπ°≈—∫ ‰¥â¢π“¥µ—«Õ¬à“ß∑’Ë®–∑”„Àâ°“√»÷°…“§√—Èßπ’È¡’π—¬ ”§—≠∑“ß ∂‘µ‘‡∑à“°—∫ 90.10 √“¬ ´÷ËßÀ¡“¬§«“¡«à“

46

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∂â“µâÕß°“√„Àâæ∫π—¬ ”§—≠∑“ß ∂‘µ‘ (p < 0.05) ®–µâÕß„™â°≈ÿà¡µ—«Õ¬à“ß„π°“√øÕ°‡≈◊Õ¥°≈ÿà¡≈–‰¡àµË”°«à“ 91 √“¬°“√»÷°…“§√—Èßπ’È¡’®”π«πºŸâªÉ«¬‡æ’¬ß°≈ÿà¡≈– 15-16 √“¬®÷ß‰¡à¡’Õ”π“®∑“ß ∂‘µ‘ (statistical power) ‡æ’¬ßæÕ∑’Ë®–∑”„Àâ‡ÀÁππ—¬ ”§—≠∑“ß ∂‘µ‘‰¥â ´÷Ëß‡ªìπ¢âÕ∫àß™’È°«à“§«√ π—∫ πÿπ„Àâ∑”°“√»÷°…“π’ÈµàÕ‰ª ®π°«à“®–‰¥â¢âÕ √ÿª∑’Ë™—¥‡®π

√ÿª

°“√øÕ°‡≈◊Õ¥¥â«¬«‘∏’ Heparin free-saline drip„πºŸâªÉ«¬∑’ËµâÕß„™â blood flow ™â“°«à“ 250 ¡‘≈≈‘≈‘µ√/π“∑’ ¬◊¥√–¬–‡«≈“°“√Õÿ¥µ—π·≈–≈¥®”π«π§√—Èß°“√Õÿ¥µ—π¢Õßµ—«°√Õß‡≈◊Õ¥·≈– “¬ àß‡≈◊Õ¥„π√–∫∫øÕ°‡≈◊Õ¥‰¥â §«√ π—∫ πÿπ„Àâ∑”°“√»÷°…“π’ÈµàÕ‰ª ®π°«à“®–‰¥â¢âÕ √ÿª∑’Ë™—¥‡®π∑“ß ∂‘µ‘¬‘Ëß¢÷Èπ

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫æ√–§ÿ≥ √».¥√.√Õ.πæ.™¬—πµ√å∏√ ª∑ÿ¡¡“ππ∑å ¿“§«‘™“‡«™»“ µ√å™ÿ¡™π §≥–·æ∑¬-»“ µ√å¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à ∑’Ë°√ÿ≥“„Àâ§”ª√÷°…“·≈–µ√«®∑“πµâπ©∫—∫ ¢Õ¢Õ∫§ÿ≥ π“¬·æ∑¬å‰æ‚√®πå ¬‘Ëß«—≤π‡¥™ Õ“¬ÿ√·æ∑¬å‚√§‰µ∑’Ë„Àâª√÷°…“„π°“√∑”«‘®—¬ √«¡∑—Èß¢Õ¢Õ∫§ÿ≥ ºŸâªÉ«¬ ‡®â“Àπâ“∑’Ë∑’Ë‡°’Ë¬«¢âÕß·≈–°≈ÿà¡ß“π π—∫ πÿπ«‘™“°“√‚√ßæ¬“∫“≈πæ√—µπ√“™∏“π’ ∑’Ë„Àâ§«“¡√à«¡¡◊Õ·≈– π—∫ πÿπ„π°“√∑”«‘®—¬§√—Èßπ’È

2. Keller F, Seemann J, Preuschof L, Offermann G. Risk

factors of system clotting in heparin-free hemodialysis.

Nephrol Dial Transplant 1990; 5:802-7.

3. Swartz RD, Port FK. Preventing hemorrhage in high-

risk hemodialysis: regional versus low-dose heparin.

Kidney Int 1979; 16:513-8.

4. Sepulveda S, Davis L, Schwab SJ. Blood transfusion

during heparin-free hemodialysis. Kidney Int 1997;

51:2018-21.

5. Glaser P, Guesder R, Rouby JJ , Eurin B. Hemodialysis

without heparin is possible. Lancet 1979; 2:579-80.

6. Casati S, Moia M, Graziani G, Cantaluppi A, Citterio

A, Manucci PM, Ponticelli C. Hemodialysis without

anticoagulation: efficiency and hemostatic aspects. Clin

Nephrol 1984; 21:102-5.

7. Caruana RJ, Raja RM, Bush TV, Kramer MS, Goldstein

SJ. Heparin free dialysis: comparative data and results

in high risk patients. Kidney Int 1987; 31:1351-5.

8. Õÿ¥¡ ‰°√ƒ∑∏‘™—¬. Anticoagulation for hemodialysis.„π: ¡™“¬ ‡Õ’Ë¬¡ÕàÕß, ‡°√’¬ß µ—Èß ßà“, ‡°◊ÈÕ‡°’¬√µ‘ª√–¥‘…∞åæ√»‘≈ªá, ∫√√≥“∏‘°“√. Practical dialysis.°√ÿß‡∑æ¡À“π§√: Text and Journal Publication; 2545.Àπâ“ 253-82.

9. Schwab SJ, Onorato JJ, Sharar LR, Dennis PA.

Hemodialysis without anticoagulation. One-year

prospective trial in hospitalized patients at risk for

bleeding. Am J Med 1987; 83:405-10.

10. Raja R, Kramer M, Rosenbaum JL, Bolisay C, Krug M.

Hemodialysis without heparin infusion using Cordis

Dow 3500 hollow fiber. Proc Clin Dial Transplant

Forum 1980; 10:39-42.

11. ª√–‡ √‘∞ ∏π°‘®®“√ÿ. Anticoagulation. „π: ‡°√’¬ß µ—Èß ßà“, ¡™“¬ ‡Õ’Ë¬¡ÕàÕß, ∫√√≥“∏‘°“√. Hemodialysis.°√ÿß‡∑æ¡À“π§√: Text and Journal Publication; 2542.Àπâ“ 213-37.

12. [no author given] The world of dialysis membranes. In:

Gunther C. editor. Membrane letter (news for nephro-

logists) 2004; [no issue or volume].


1. Sanders PW, Taylor H, Curtis JJ. Hemodialysis without

anticoagulation. Am J Kidney Dis 1985; 5:32-5.




°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥‡æ◊ËÕ„™â„π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬·≈–∑“√°·√°‡°‘¥πÈ”Àπ—°¡“°¢®√»‘≈ªá ºàÕß «— ¥‘Ï°ÿ≈ æ.∫.°≈ÿà¡ß“π Ÿµ‘-π√’‡«™°√√¡ ‚√ßæ¬“∫“≈æ–‡¬“

Abstract Intrapartum Symphysis - Fundal Height Measurement in Prediction of both LowBirthweight and Big BabyPongsawatkul K.Department of Obstetrics and Gynecology Phayao Hospital, Phayao Province, ThailandBull Dept Med Serv 2006; 31:47-54.

This is a descriptive study carried out in 1,000 normal pregnant women attened antenatal careand delivered at Phayao Hospital during November 2000 to August 2005. The objective of this study is theability to find the sensitivity, specificity and predictive value of symphysis - fundal (S-F) height measurementmade in low risk, having spontaneous labor pain, pregnant women with relationship to low and large bodyweight in the newborns. Moreover, the author intended to discover the best fitted cut-off S-F heightmeasurement value in prediction of the low and large fetal body weight. The results of this study was shownas followed : 1. The value of low birth weight is 5.4% (< 2,500 gm), 2. The value of large birth weight is 1.8% (≥≥≥≥≥ 4,000 gm), 3. The best predictive S-F value for the low birth weight infant is 34 cm with the sensitivityof 95.4%, specificity of 38.0%, positive predictive value of 6.47% and negative predictive value of 99.5%,4. The best predictive S-F value for the large birth weight infant is 40 cm with the sensitivity of 98.5%,specificity of 25.0%, positive predictive value of 98.2% and negative predictive value of 28.6%. This method(S-F measurement) was simple, widely available, non-invasive, precise and low cost obstetric skill which wasalso appropriate for screening at PCU (primary care unit) or rural obstetric units, helping in the referralsystem throughout the country, having good benefit in MCH health care.

Key words: Symphysis - fundal height (S-F), Prediction, Fetal body weight

‡√◊ËÕß¬àÕ ‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“„π¡“√¥“µ—Èß§√√¿åª°µ‘ ®”π«π 1,000 √“¬ ∑’Ë¡“Ω“°§√√¿å·≈–§≈Õ¥∑’Ë‚√ßæ¬“∫“≈æ–‡¬“√–À«à“ß‡¥◊Õπæƒ»®‘°“¬π æ.». 2543 ∂÷ß‡¥◊Õπ ‘ßÀ“§¡ æ.». 2548 ‚¥¬¡’«—µ∂ÿª√– ß§å‡æ◊ËÕÀ“§à“§«“¡‰« §«“¡®”‡æ“– §à“°“√∑”π“¬¢Õß√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°´÷Ëß«—¥‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥ µàÕ°“√‡°‘¥∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬·≈–¡“° µ≈Õ¥®πÀ“§à“√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ° ∑’Ë¡’§à“§«“¡‰« ·≈–§«“¡®”‡æ“–„π°“√∑”π“¬πÈ”Àπ—°∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬·≈–¡“° ∑’Ë¥’∑’Ë ÿ¥ ®“°°“√»÷°…“π’Èæ∫«à“¡’∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ √âÕ¬≈– 5.4 √–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ° ∑’Ë√–¥—∫πâÕ¬°«à“À√◊Õ‡∑à“°—∫ 34 ‡´πµ‘‡¡µ√ ¡’§à“§«“¡‰«·≈–§à“§«“¡®”‡æ“–¡“°∑’Ë ÿ¥ ‚¥¬§à“§«“¡‰«√âÕ¬≈– 95.4 §à“§«“¡®”‡æ“–√âÕ¬≈– 38.0 §à“°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ √âÕ¬≈– 6.5 §à“°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°ª°µ‘√âÕ¬≈– 99.5 ·≈–„π∑”πÕß‡¥’¬«°—πæ∫«à“¡’∑“√°·√°‡°‘¥πÈ”Àπ—°¡“°√âÕ¬≈– 1.8 √–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°∑’Ë√–¥—∫¡“°°«à“À√◊Õ‡∑à“°—∫ 40 ‡´πµ‘‡¡µ√ ¡’§à“§«“¡‰«·≈–§à“§«“¡®”‡æ“–¡“°∑’Ë ÿ¥ ‚¥¬§à“§«“¡‰«√âÕ¬≈– 98.5 §à“§«“¡®”‡æ“–√âÕ¬≈– 25.0 §à“°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°¡“°√âÕ¬≈– 98.2 §à“°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°ª°µ‘√âÕ¬≈– 28.6 ®“°º≈∑’Ë‰¥âæ∫«à“ °“√«—¥√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ° ‡ªìπ«‘∏’°“√µ√«®°√Õß∑’Ëßà“¬ –¥«° ¡’§«“¡·¡àπ¬” “¡“√∂ª√–¬ÿ°µå„™â‰¥â∑—Èß„π‚√ßæ¬“∫“≈™ÿ¡™π ·≈– ∂“π’Õπ“¡—¬¢π“¥„À≠à‚¥¬∫ÿ§≈“°√∑’Ë¡‘„™à·æ∑¬å ´÷Ëß‡ªìπ‡§√◊ËÕß¡◊ÕÕ—πÀπ÷Ëß„π°“√ àßµàÕºŸâ§≈Õ¥ ¡“¬—ß‚√ßæ¬“∫“≈∑—Ë«‰ª∑’Ë¡’ Ÿµ‘·æ∑¬åª√–®”Õ¬Ÿà ∑—Èßπ’È‡æ◊ËÕ‡°‘¥ª√–‚¬™πå Ÿß ÿ¥·°à¡“√¥“∑’Ë‡®Á∫§√√¿å§≈Õ¥·≈–∑“√°„π§√√¿å

§” ”§—≠: §«“¡ Ÿß¢Õß¡¥≈Ÿ° °“√∑”π“¬ πÈ”Àπ—°∑“√°„π§√√¿å

48

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

°“√„Àâ∫√‘°“√„πß“πÕπ“¡—¬·¡à·≈–‡¥Á°¢Õßª√–‡∑»‰∑¬ ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß∑“ß¿“§‡Àπ◊Õ¢Õßª√–‡∑» µ√’µ—Èß§√√¿å‡¡◊ËÕ∑√“∫«à“µ—Èß§√√¿å à«π„À≠àπ‘¬¡‰ªΩ“°§√√¿å∑’Ë ∂“π’Õπ“¡—¬¢π“¥„À≠à„°≈â∫â“π(PCU) ´÷Ëß‡®â“Àπâ“∑’Ëª√–®” ∂“π’Õπ“¡—¬¡—°„Àâ∫√‘°“√‡©æ“–°“√Ω“°§√√¿å‡æ’¬ßÕ¬à“ß‡¥’¬« ‡¡◊ËÕ§√∫°”Àπ¥§≈Õ¥°Á·π–π”„Àâ µ√’µ—Èß§√√¿å¡“§≈Õ¥∑’Ë‚√ßæ¬“∫“≈™ÿ¡™π„πÕ”‡¿Õ∑’ËµπÕ¬Ÿà‡ªìπ à«π„À≠à ªí≠À“∑’Ë·æ∑¬å·≈–æ¬“∫“≈ª√–®”‚√ßæ¬“∫“≈™ÿ¡™π¡—°®–æ∫‡ªìπª√–®”°Á§◊Õ Õ“¬ÿ§√√¿å∑’Ë‰¡à·πàπÕπÕ“®‡π◊ËÕß®“° °“√π—∫Õ“¬ÿ§√√¿å®“°ª√–®”‡¥◊Õπ§√—Èß ÿ¥∑â“¬ (LMP)Õ“®¡’§«“¡§≈“¥‡§≈◊ËÕπ ∂â“¡‘‰¥â√—∫°“√¬◊π¬—πÕ“¬ÿ§√√¿å®“°·æ∑¬åª√–®”‚√ßæ¬“∫“≈™ÿ¡™π¡“°àÕπÕ“¬ÿ§√√¿å 20 —ª¥“Àå À√◊Õ∫“ß·ÀàßÕ“®¬◊π¬—πÕ“¬ÿ§√√¿å‚¥¬°“√µ√«®¥â«¬‡§√◊ËÕß§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß (ultra-sonography) ∑’ËµâÕß∑”°“√µ√«®°àÕπÕ“¬ÿ§√√¿å 20 —ª¥“Àå®÷ß∂◊Õ«à“¡’§«“¡‡™◊ËÕ∂◊Õ‰¥â ·µà‚√ßæ¬“∫“≈™ÿ¡™π°Á¡‘‰¥â°√–∑”‡ªìπ°‘®«—µ√ (routine examination)∑ÿ°·Ààß

ª√–°Õ∫°—∫¡’°“√µ—Èß§√√¿å∑’Ë¡‘æ÷ßª√– ß§å„π‡¥Á°«—¬√ÿàπ∑’ËÕ“®¬—ßÕ¬Ÿà„π«—¬‡√’¬π ∑’Ë¬—ß‰¡àæ√âÕ¡ ‚¥¬∑’Ë°≈ÿà¡ µ√’µ—Èß§√√¿å‡À≈à“π’È¡—°‰¡à¬Õ¡Ω“°§√√¿å‡π◊ËÕß®“°°≈—«°“√‡ªî¥‡º¬µ—«‡Õß ‡¡◊ËÕ∂÷ß‡«≈“‡®Á∫§√√¿å§≈Õ¥®÷ß¡“§≈Õ¥∑’Ë‚√ßæ¬“∫“≈™ÿ¡™π ¥â«¬ “‡Àµÿ¥—ß°≈à“«¡“π’È∫ÿ§≈“°√∑“ß “∏“√≥ ÿ¢∑’ËµâÕß¥Ÿ·≈°≈ÿà¡ µ√’¥—ß°≈à“«®÷ßª√– ∫ªí≠À“„π°“√§—¥°√Õß«à“ °√≥’„¥ ¡§«√„Àâ§≈Õ¥∑’Ë‚√ßæ¬“∫“≈™ÿ¡™πÕ¬à“ßª≈Õ¥¿—¬ °√≥’„¥µâÕß∑”°“√ àß¡“∑’Ë‚√ßæ¬“∫“≈∑—Ë«‰ªª√–®”®—ßÀ«—¥ ¥—ßπ—ÈπºŸâ√“¬ß“π®÷ß‰¥â»÷°…“‡°’Ë¬«°—∫°“√«—¥ à«π Ÿß¢Õß¡¥≈Ÿ°(height of fundal measurement) ´÷Ëß‡ªìπ∫√‘°“√∑’Ë∑“ß‚√ßæ¬“∫“≈™ÿ¡™πÀ√◊Õ‚√ßæ¬“∫“≈∑—Ë«‰ª ‰¥â„Àâ∫√‘°“√·°à µ√’µ—Èß§√√¿å∑’Ë‡®Á∫§√√¿å§≈Õ¥Õ¬Ÿà·≈â« ¡“„™âª√–‚¬™πå„π·ßà¢Õß°“√§—¥°√Õß·≈–∑”π“¬∂÷ß‚Õ°“ ∑’Ë∑“√°„π§√√¿åÕ“®¡’πÈ”Àπ—°µ—«πâÕ¬1 (πÈ”Àπ—°πâÕ¬°«à“2,500 °√—¡ ‡¡◊ËÕ·√°§≈Õ¥) À√◊Õ¡’πÈ”Àπ—°¡“°(πÈ”Àπ—°¡“°°«à“ 4,000 °√—¡ ‡¡◊ËÕ·√°§≈Õ¥) ∑—Èßπ’È

‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√ àßµàÕ µ√’µ—Èß§√√¿å‰¥âÕ¬à“ß‡À¡“– ¡

ªí≠À“·∑√°´âÕπ¢Õß∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬‰¡à«à“‡π◊ËÕß¡“®“° “‡Àµÿ¢Õß°“√§≈Õ¥°àÕπ°”Àπ¥À√◊Õ¿“«–‡®√‘≠‡µ‘∫‚µ™â“„π§√√¿å æ∫«à“Õ—µ√“°“√µ“¬À≈—ß§≈Õ¥ ¿“¬„π 28 «—π Ÿß°«à“∑“√°·√°‡°‘¥πÈ”Àπ—°ª°µ‘∂÷ß 40 ‡∑à“2 ‚¥¬‡©æ“–∂â“πÈ”Àπ—° 1,500 °√—¡À√◊ÕπâÕ¬°«à“ ‚Õ°“ µ“¬‡æ‘Ë¡¢÷Èπ‡ªìπ 200 ‡∑à“¢Õß∑“√°·√°‡°‘¥πÈ”Àπ—°ª°µ‘ à«πªí≠À“¥â“πÕ◊Ëπ∑’Ëæ∫‰¥â∫àÕ¬§◊Õ ¿“«– birth asphyxia, respiratory distresssyndrome, hypoglycemia, intraventricularhemorrhage ‡ªìπµâπ ·≈–„π°“√¥Ÿ·≈√—°…“ ∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ Õ“®¡’º≈·∑√°´âÕπµ“¡¡“‰¥â ‡™àπretinopathy of prematurity, respiratory sequelae®“° respiratory intervention ”À√—∫ªí≠À“·∑√°´âÕπ¢Õß∑“√°·√°‡°‘¥πÈ”Àπ—°¡“° (≥ 4,000 °√—¡‡¡◊ËÕ§≈Õ¥) §◊Õ¿“«–§≈Õ¥¬“°µâÕß„™âÀ—µ∂°“√„π°“√™à«¬§≈Õ¥ (forceps / vacuum extraction) ∑”„Àâ¡’‚Õ°“ ‡°‘¥ birth trauma ·°à‡¥Á°, ¿“«–°“√§≈Õ¥µ‘¥‰À≈à (shoulder dystocia) ´÷Ëß∂◊Õ‡ªìπ¿“«–©ÿ°‡©‘π∑“ß Ÿµ‘°√√¡Õ¬à“ßÀπ÷Ëß, ¿“«– undiagnosed twins ∑”„Àâ¢“¥°“√‡µ√’¬¡™à«¬‡À≈◊Õ°“√§≈Õ¥≈à«ßÀπâ“ ‡°‘¥¿“«–·∑√°´âÕπ„π∑“√°·√°‡°‘¥‚¥¬‰¡à®”‡ªìπ ´÷Ëß¿“«–À≈—ß ÿ¥π’È °“√«—¥ à«π Ÿß¢Õß¡¥≈Ÿ°®– Ÿß°«à“ª°µ‘

„πªï §.». 1954 ®ÕÀåπ —π (Johnson) ·≈–§≥–3 ‰¥â§‘¥§âπ Ÿµ√¢Õß°“√À“πÈ”Àπ—°‡¥Á°∑“√°„π§√√¿å ´÷Ëß§”π«≥‰¥â®“°°“√«—¥ à«π Ÿß¢Õß¡¥≈Ÿ° √à«¡°—∫ station ¢Õß»’√…–‡¥Á°·≈–πÈ”Àπ—°¢Õß¡“√¥“ æ∫«à“¡’ accuracy √âÕ¬≈– 68, ≈Õø‡≈Õ√å (Loeffler)4

‰¥â∑”°“√§“¥§–‡ππÈ”Àπ—°∑“√°„π§√√¿å „π™à«ß‡®Á∫§√√¿å§≈Õ¥„π µ√’µ—Èß§√√¿å 585 √“¬ ‚¥¬«‘∏’°“√§≈”Àπâ“∑âÕß·≈â«‡ª√’¬∫‡∑’¬∫°—∫πÈ”Àπ—°·∑â®√‘ß¢Õß∑“√°·√°‡°‘¥ æ∫«à“ °“√§“¥§–‡π¡’§«“¡·¡àπ¬” Ÿß ∂â“πÈ”Àπ—°∑“√°·√°‡°‘¥Õ¬Ÿà„π™à«ß„°≈â 3,000 °√—¡ ·µà§«“¡§≈“¥‡§≈◊ËÕπ ®“°°“√§“¥§–‡π¡’§à“ Ÿß¡“° ∂â“πÈ”Àπ—°∑“√°·√°‡°‘¥πâÕ¬°«à“ 2,300 °√—¡ ·≈–¡’§à“µ—Èß·µà 4,000 °√—¡¢÷Èπ‰ª µàÕ¡“ «Õ√å´Õø (Warsof)



·≈–§≥–5 ‰¥â∑” ultrasonography «—¥ fetal bodyparameters (BPD, AC) ¡“‡¢â“ Ÿµ√∑”π“¬πÈ”Àπ—°∑“√°„π§√√¿å‰¥â∂Ÿ°µâÕß‚¥¬¡’§à“‡∫’Ë¬ß‡∫π¡“µ√∞“π(SD) 106 °√—¡µàÕ°‘‚≈°√—¡ body weight, Linasmita·≈–§≥–6 ‰¥â √â“ß normal uterine growth curve‚¥¬°“√«—¥ symphysial-fundal height „π µ√’µ—Èß§√√¿å415 √“¬ ∑’Ë¡“Ω“°§√√¿å∑’Ë§≥–·æ∑¬»“ µ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ ‚¥¬¡’Õ“¬ÿ§√√¿åµ—Èß·µà 16-41 —ª¥“Àå ·≈–æ∫«à“§à“‡©≈’Ë¬¢Õß fundal height at term §◊Õ 34.1‡´πµ‘‡¡µ√, π’≈ —π (Neilson) ·≈–§≥–7 ‰¥â„™â°“√«—¥symphysis-fundal height ¡“™à«¬„π°“√§âπÀ“¿“«–twin pregnancy ‡æ◊ËÕªÑÕß°—π¿“«–‡®Á∫§√√¿å°àÕπ°”Àπ¥·≈–‡æ◊ËÕ≈¥¿“«– SGA (small for gestational age)¢Õß§√√¿å·Ω¥‡π◊ËÕß®“° “¡“√∂«‘π‘®©—¬‰¥â°àÕπ‡®Á∫§√√¿å§≈Õ¥·≈–„Àâ°“√¥Ÿ·≈Õ¬à“ß„°≈â™‘¥, «“≈å√“‡«π(Walraven) ·≈–§≥–8 ‰¥â„™â°“√«—¥ à«π Ÿß¢Õß¡¥≈Ÿ°¢Õß µ√’µ—Èß§√√¿å∑’Ë‡®Á∫§√√¿å¡“§≈Õ¥ ®”π«π 1,582√“¬ æ∫«à“§à“ à«π Ÿß¢Õß¡¥≈Ÿ°∑’Ë 30 ‡´πµ‘‡¡µ√≈ß¡“ “¡“√∂§âπæ∫∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ ‰¥â√âÕ¬≈–66 à«π§à“ à«π Ÿß¢Õß¡¥≈Ÿ°∑’Ë 38 ‡´πµ‘‡¡µ√¢÷Èπ‰ª “¡“√∂§âπæ∫∑“√°·√°‡°‘¥πÈ”Àπ—°¡“° √à«¡°—∫¿“«–µ—Èß§√√¿å·Ω¥‰¥â√âÕ¬≈– 76

‡ÀÁπ‰¥â«à“¡’°“√»÷°…“≈à“ ÿ¥∑’Ë∑”„πª√–‡∑»·∑π´“‡π’¬ ´÷Ëß¡’√Ÿª·∫∫°“√«‘®—¬„°≈â‡§’¬ß°—π ¬—ß‰¡àæ∫°“√»÷°…“≈—°…≥–π’È„πª√–‡∑»‰∑¬ ºŸâ√“¬ß“π®÷ß¡’§«“¡ π„®∑’Ë®–∑”°“√»÷°…“‡π◊ËÕß®“°‡ªìπ«‘∏’°“√∑’Ë –¥«° ßà“¬ ª√–À¬—¥ ·≈–¡’§«“¡·¡àπ¬”®÷ßÕ“®π”¡“„™â‡ªìπ‡§√◊ËÕß¡◊Õµ√«®°√Õß „π µ√’µ—Èß§√√¿å∑’Ë‡¢â“ Ÿà√–¬–°“√§≈Õ¥‰¥â

«—µ∂ÿ·≈–«‘∏’°“√

§”π«≥À“®”π«π¢Õß µ√’µ—Èß§√√¿å®“° Ÿµ√9

Z2 PQN =

D2

‚¥¬§à“§«“¡πà“®–‡ªìπ (P) ‡∑à“°—∫√âÕ¬≈– 66®“°°“√»÷°…“¢Õß«“≈å√“‡«π (Walraven) ·≈–®“° ∂‘µ‘Õ—µ√“∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬¢Õß‚√ßæ¬“∫“≈

æ–‡¬“ ‡∑à“°—∫√âÕ¬≈– 10 ¥—ßπ—Èπ®÷ßµâÕß«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ°„π µ√’µ—Èß§√√¿å∑—ÈßÀ¡¥ 862 √“¬ ·µà∑—Èßπ’ÈºŸâ√“¬ß“π‰¥â«—¥‡æ‘Ë¡¢÷Èπ‡ªìπ 1,000 √“¬ ‡π◊ËÕß®“°∫“ß√“¬Õ“®‰¡à§≈Õ¥¿“¬„π 24 ™—Ë«‚¡ß µ—Èß·µà·√°√—∫∑’ËÀâÕß§≈Õ¥‡π◊ËÕß®“°‡ªìπ¿“«– false labor pain ºŸâ√“¬ß“π®”‡ªìπµâÕßµ—¥∑‘ÈßÕÕ°‰ª À√◊Õ∫“ß√“¬¢âÕ¡Ÿ≈Õ“®‰¡à ¡∫Ÿ√≥åÀ√◊Õ Ÿ≠À“¬ ¥—ßπ—Èπ®”π«π∑’Ë«—¥‰¥â·≈–¢âÕ¡Ÿ≈§√∫∂â«πµ“¡ inclusion criteria ∑—ÈßÀ¡¥ 1,000 √“¬πà“®–¡’§«“¡‡À¡“– ¡‡æ’¬ßæÕ„π°“√»÷°…“§√—Èßπ’È

§—¥‡≈◊Õ° µ√’µ—Èß§√√¿å∑’Ë¡“§≈Õ¥∑’Ë‚√ßæ¬“∫“≈æ–‡¬“ √–À«à“ß‡¥◊Õπæƒ»®‘°“¬π æ.». 2543 ∂÷ß‡¥◊Õπ ‘ßÀ“§¡ æ.». 2548 ®”π«π 1,000 √“¬ ‚¥¬¡’§ÿ≥ ¡∫—µ‘¥—ßπ’È

1. µ—Èß§√√¿å‡¥’Ë¬«‰¡à¡’¿“«–·∑√°´âÕπ„¥Ê (lowrisk case) ¡“¥â«¬Õ“°“√‡®Á∫§√√¿å®√‘ß (true laborpain)

2. ∑“√°„π§√√¿å‡ªìπ∑à“»’√…–‡ªìπ à«ππ” (vertexpresentation)

3. µ√«®¿“¬„πª√–‡¡‘π°“√‡ªî¥¢Õßª“°¡¥≈Ÿ°∑ÿ°√“¬ ‚¥¬∑’Ë∂ÿßπÈ”¬—ß‰¡à·µ° (intact fetal membranes)

4. ∂â“ µ√’µ—Èß§√√¿å√“¬„¥‰¡à§≈Õ¥¿“¬„π 24™—Ë«‚¡ßµ—Èß·µà·√°√—∫®–§—¥ÕÕ°®“°°“√»÷°…“

‡§√◊ËÕß¡◊Õ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ à«πµ—« §◊Õ ™◊ËÕ π“¡ °ÿ≈ Õ“¬ÿ

≈”¥—∫§√√¿å (gravida) ≈”¥—∫°“√§≈Õ¥ (parity) πÈ”Àπ—° à«π Ÿß °“√µ√«®¿“¬„π (cervical dilatation,effacement, station) √–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°‡ªìπ‡´πµ‘‡¡µ√ Õ“¬ÿ§√√¿å (∂â“∑√“∫)

“¬‡∑ª«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° 1 ™ÿ¥«‘∏’°“√«—¥·≈–∫—π∑÷°¢âÕ¡Ÿ≈ºŸâ√“¬ß“π·≈–§≥– (æ¬“∫“≈«‘™“™’æª√–®”ÀâÕß

§≈Õ¥ ´÷Ëß‰¥âºà“π°“√Ωñ°°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°¥—ß«‘∏’°“√„π¢âÕ 2 ∑”°“√«—¥·≈–‡°Á∫¢âÕ¡Ÿ≈∑ÿ°«—π ‡«≈“08.00-16.00 π.

À≈—ß®“°„Àâ µ√’µ—Èß§√√¿å∂à“¬ªí “«–‡√’¬∫√âÕ¬·≈â««—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ°¢≥–¡¥≈Ÿ°§≈“¬µ—« ‚¥¬„™âª“°°“¢’¥∫πº‘«Àπ—ß∫√‘‡«≥¢Õ∫ pubic bone ¥â“π∫π ·≈â«

50

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

π” “¬‡∑ª‡ âπ‡¥’¬«°—π„™â«—¥ µ√’µ—Èß§√√¿å∑ÿ°√“¬ ‚¥¬„Àâ¥â“π∑’Ë¡“µ√“«—¥‡ªìππ‘È«‰«â¥â“π∫π ¥â“π‡ªìπ‡´πµ‘‡¡µ√‰«â¥â“π≈à“ß·π∫®“°¢Õ∫∫π¢Õß pubic bone ∑“∫‰ªµ“¡¡¥≈Ÿ°ºà“π –¥◊Õ‰ª®π∂÷ß¬Õ¥¡¥≈Ÿ° (fundal part)®“°π—Èπ®÷ßæ≈‘° “¬‡∑ªπ”¥â“π∑’Ë‡ªìπ¡“µ√“‡´πµ‘‡¡µ√¢÷Èπ¡“Õà“πº≈ ·≈â«∫—π∑÷°≈ß„π·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ ÷Ëß°“√«—¥π’È°√–∑”¿“¬„π 60 π“∑’ µ—Èß·µà√—∫‰«â„π‚√ßæ¬“∫“≈ ‚¥¬∑’ËºŸâ«—¥‰¡à∑√“∫Õ“¬ÿ§√√¿å¡“°àÕπ

´—°ª√–«—µ‘‡æ◊ËÕ∫—π∑÷°¢âÕ¡Ÿ≈∑’Ë‡À≈◊ÕÕ¬Ÿàæ√âÕ¡°—∫ª√–‡¡‘πÕ“¬ÿ§√√¿å

„Àâ°“√¥Ÿ·≈°“√§≈Õ¥µ“¡¡“µ√∞“π¢ÕßÀâÕß§≈Õ¥‚√ßæ¬“∫“≈æ–‡¬“ ®π°√–∑—Ëß§≈Õ¥∫ÿµ√ ‰¡à«à“‡ªìπ°“√§≈Õ¥∑“ß™àÕß§≈Õ¥ À√◊Õºà“µ—¥§≈Õ¥∑“ßÀπâ“∑âÕß

°“√™—ËßπÈ”Àπ—°∑“√°·√°§≈Õ¥ (actual birthweight) ¥”‡π‘π°“√™—ËßπÈ”Àπ—°¿“¬„π 30 π“∑’À≈—ß§≈Õ¥∑ÿ°√“¬ ‚¥¬„™â‡§√◊ËÕß™—ËßÕ—π‡¥’¬«°—π

∂‘µ‘∑’Ë„™â„π°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈¡’¥—ßπ’È1. §à“ ∂‘µ‘æ◊Èπ∞“π„™â§à“√âÕ¬≈– §à“‡©≈’Ë¬·≈–

à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π2. §à“ ∂‘µ‘∑’Ë„™â„π°“√§”π«≥§à“§«“¡‰«·≈–

§«“¡®”‡æ“–„™â Ÿµ√¢Õß diagnostic test

º≈

µ√’µ—Èß§√√¿å®”π«π 1,000 √“¬ ∑’Ë¡“ÀâÕß§≈Õ¥‚√ßæ¬“∫“≈æ–‡¬“ ¥â«¬Õ“°“√‡®Á∫§√√¿å§≈Õ¥ ·≈–¡’§ÿ≥ ¡∫—µ‘µ“¡∑’Ë°”Àπ¥‰«â ‰¥â√—∫°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° æ∫«à“¡’∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬‡∑à“°—∫ 54 √“¬§‘¥‡ªìπ√âÕ¬≈– 5.4 ·≈–∑“√°·√°‡°‘¥πÈ”Àπ—°¡“°‡∑à“°—∫18 √“¬ §‘¥‡ªìπ√âÕ¬≈– 1.8 ‚¥¬¡’§à“‡©≈’Ë¬¢ÕßπÈ”Àπ—°∑“√°·√°‡°‘¥∑—ÈßÀ¡¥‡∑à“°—∫ 3,125.18 °√—¡ ‚¥¬æ∫«à“°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° (HF) ¢Õß µ√’µ—Èß§√√¿å à«π„À≠à¡’§à“√–À«à“ß 31-35 ‡´πµ‘‡¡µ√ §‘¥‡ªìπ√âÕ¬≈– 66.9 ‚¥¬¡’§à“‡©≈’Ë¬‡∑à“°—∫ 33.74 ‡´πµ‘‡¡µ√(µ“√“ß∑’Ë 1) §ÿ≥≈—°…≥–∑“ß™’«¿“æ¢Õß µ√’µ—Èß§√√¿å∑—ÈßÀ¡¥¡’¥—ßπ’È Õ“¬ÿ‡©≈’Ë¬ 26.48 ªï πÈ”Àπ—°‡©≈’Ë¬ 63.80°‘‚≈°√—¡ ‚¥¬¡’πÈ”Àπ—°µ—Èß·µà 81 °‘‚≈°√—¡¢÷Èπ‰ª 45 √“¬§‘¥‡ªìπ√âÕ¬≈– 4.5 (µ“√“ß∑’Ë 2) à«π Ÿß‡©≈’Ë¬ 154.75

‡´πµ‘‡¡µ√ Õ“¬ÿ§√√¿å‡©≈’Ë¬ 38.6 —ª¥“Àå æ∫«à“ à«π„À≠à‡ªìπ°“√µ—Èß§√√¿å§√—Èß·√° ·≈–‰¡à‡§¬ºà“π°“√§≈Õ¥¡“°àÕπ (µ“√“ß∑’Ë 3) à«π§à“§«“¡‰« (sensitivity)·≈–§«“¡®”‡æ“– (specificity) ¢Õß°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°¢Õß µ√’µ—Èß§√√¿å‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥„π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ ∑’Ë√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°µà“ßÊ · ¥ß„πµ“√“ß∑’Ë 4 ·≈–®“° ROCcurve æ∫«à“®ÿ¥∑’Ë¡’§«“¡‰« (sensitivity) ·≈–§«“¡®”‡æ“– (specificity) ¥’∑’Ë ÿ¥§◊Õ ®ÿ¥∑’Ë√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°∑’Ë ≤ 34 ‡´πµ‘‡¡µ√ ‚¥¬¡’§«“¡‰« (sensitivity)·≈–§«“¡®”‡æ“– (specificity) ‡∑à“°—∫√âÕ¬≈– 95.4·≈–√âÕ¬≈– 38.0 µ“¡≈”¥—∫ (√Ÿª∑’Ë 1) „π∑”πÕß‡¥’¬«°—π§à“§«“¡‰« (sensitivity) ·≈–§«“¡®”‡æ“–(specificity) ¢Õß°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°„π

µ“√“ß∑’Ë 1 §«“¡ Ÿß¢Õß¡¥≈Ÿ°„π µ√’µ—Èß§√√¿å (HF)

§«“¡ Ÿß¢Õß¡¥≈Ÿ° ®”π«π√âÕ¬≈–

(‡´πµ‘‡¡µ√) (√“¬)

µË” ÿ¥ - 25 2 0.2

26 - 30 104 10.4

31 - 35 669 66.9

36 - 40 214 21.4

41 - 45 10 1.0

46 - Ÿß ÿ¥ 1 0.1

√«¡ 1,000 100

µ“√“ß∑’Ë 2 πÈ”Àπ—°¢Õß µ√’µ—Èß§√√¿å

πÈ”Àπ—° (°‘‚≈°√—¡) ®”π«π (√“¬) √âÕ¬≈–

µË” ÿ¥ - 50 40 4.0

51 - 60 329 32.9

61 - 70 433 43.3

71 - 80 153 15.3

81 - 90 36 3.6

91 - Ÿß ÿ¥ 9 0.9

√«¡ 1,000 100



µ“√“ß∑’Ë 3 §à“‡©≈’Ë¬·≈– à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π

µ—«·ª√ xxxxx SD

Õ“¬ÿ¡“√¥“ (ªï) 26.48 6.073

πÈ”Àπ—°¡“√¥“ (°‘‚≈°√—¡) 63.801 8.710

à«π Ÿß¡“√¥“ (‡´πµ‘‡¡µ√) 154.75 5.426

§«“¡ Ÿß¢Õß¡¥≈Ÿ° (HF) 33.74 2.673

(‡´πµ‘‡¡µ√)

πÈ”Àπ—°∑“√°·√°§≈Õ¥(°√—¡) 3,125.18 396.789

Õ“¬ÿ§√√¿å ( —ª¥“Àå) 38.6 1.319

µ“√“ß∑’Ë 4 §à“§«“¡‰« (sensitivity) ·≈–§à“§«“¡®”‡æ“–

(specificity) ¢Õß°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß

¡¥≈Ÿ° ¢Õß µ√’µ—Èß§√√¿å‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥

„π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ ∑’Ë

√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°µà“ßÊ

√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ° §à“§«“¡‰« §«“¡®”‡æ“–

(‡´πµ‘‡¡µ√) (Sensitivity) (Specificity)

≥ 29 25.6 95.5

≥ 30 37.2 90.6

≥ 31 51.2 83.9

≥ 32 65.1 71.1

≥ 33 88.4 54.2

≥ 34 95.4 38.0

≥ 35 95.4 23.3

√Ÿª∑’Ë 1 ROC curve æ∫«à“®ÿ¥∑’Ë¡’§«“¡‰« (sensitivity)

·≈–§«“¡®”‡æ“– (specificity) ¥’∑’Ë ÿ¥ §◊Õ ®ÿ¥∑’Ë

√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°∑’Ë ≥ 34 ¡. ‚¥¬¡’§«“¡

‰«‡∑à“°—∫√âÕ¬≈– 95.4 ·≈–§«“¡®”‡æ“–‡∑à“°—∫

√âÕ¬≈– 38.0

°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°¡“°∑’Ë√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°µà“ßÊ · ¥ß„πµ“√“ß∑’Ë 5 ·≈–®“° ROCcurve æ∫«à“®ÿ¥∑’Ë¡’§à“§«“¡‰«·≈–§«“¡®”‡æ“–¥’∑’Ë ÿ¥§◊Õ ®ÿ¥∑’Ë√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ° ≥ 40 ‡´πµ‘‡¡µ√ ‚¥¬¡’§à“§«“¡‰«·≈–§«“¡®”‡æ“– ‡∑à“°—∫√âÕ¬≈– 98.5·≈–√âÕ¬≈– 25.0 µ“¡≈”¥—∫ (√Ÿª∑’Ë 2)

«‘®“√≥å

®“°º≈°“√»÷°…“ (µ“√“ß∑’Ë 3) æ∫«à“Õ“¬ÿ‡©≈’Ë¬¢Õß

µ“√“ß∑’Ë 5 §à“§«“¡‰« (sensitivity) ·≈–§à“§«“¡®”‡æ“–

(specificity) ¢Õß°“√«—¥√–¥—∫§«“¡ Ÿß¢Õß

¡¥≈Ÿ°„π µ√’µ—Èß§√√¿å‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥

„π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°¡“° ∑’Ë

√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°µà“ßÊ

√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°§à“§«“¡‰« §«“¡®”‡æ“–

(‡´πµ‘‡¡µ√)

≥ 34 48.6 91.7≥ 35 65.6 83.3≥ 36 78.9 79.2≥ 37 87.8 66.7≥ 38 93.9 54.2≥ 39 97.3 45.8≥ 40 98.5 25.0≥ 41 99.3 16.7≥ 42 99.5 16.7

µ√’µ—Èß§√√¿å¡’§à“ 26.5 ªï πÈ”Àπ—°‡©≈’Ë¬ 63.8 °‘‚≈°√—¡ à«π Ÿß‡©≈’Ë¬ 154.8 ‡´πµ‘‡¡µ√ ·≈–Õ“¬ÿ§√√¿å‡©≈’Ë¬38.6 —ª¥“Àå ´÷ËßÕ¬Ÿà„π‡°≥±å¢Õß µ√’µ—Èß§√√¿å¢Õß§π‰∑¬∑—Ë«‰ª ∂◊Õ‰¥â«à“πà“®–‡ªìπµ—«·∑π¢Õß µ√’µ—Èß§√√¿å

100

80

60

40

20

0

Sensitivty

20 40 60 80 1001-Specificity

52

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∑—Ë«ª√–‡∑»„π‡¢µ™π∫∑ ∑’Ë¡‘„™à°√ÿß‡∑æœ ´÷Ëß ∂“π∫√‘°“√ “∏“√≥ ÿ¢ (√æ.»Ÿπ¬å, √æ.∑—Ë«‰ª À√◊Õ√æ.™ÿ¡™π)µâÕß„Àâ∫√‘°“√·°à µ√’µ—Èß§√√¿å∑’Ë¡’§ÿ≥≈—°…≥–·∫∫π’ÈÕ¬Ÿà·≈â« ºŸâ√“¬ß“π®÷ßæ‘®“√≥“µ“¡‡°≥±å·≈–‡Àµÿº≈¥—ß°≈à“«·≈â««à“°“√«—¥ à«π Ÿß¢Õß¡¥≈Ÿ°„π§√—Èßπ’È πà“®–¡’ª√–‚¬™πåπ”‰ª„™â„π ∂“π∫√‘°“√∑“ß “∏“√≥ ÿ¢∑—Ë«ª√–‡∑»‰¥â

„π°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° ºŸâ√“¬ß“π·≈–§≥–‰¥â´—°´âÕ¡«‘∏’·≈–¢—ÈπµÕπ°“√«—¥„Àâ‰¥â¡“µ√∞“π„°≈â‡§’¬ß°—π ‚¥¬‰¥â∑¥≈Õß«—¥°àÕπ‡°Á∫¢âÕ¡Ÿ≈®√‘ß ®π°√–∑—Ëß·πà„®„π§«“¡·¡àπ¬” ®÷ß‡√‘Ë¡‡°Á∫¢âÕ¡Ÿ≈ °“√‡µ√’¬¡°“√¢ÕßºŸâ√“¬ß“π®÷ß‡ªìπ°“√¢®—¥§«“¡¡’Õ§µ‘®“°°“√«—¥∑’ËÕ“®‡°‘¥®“°·µà≈–∫ÿ§§≈πà“®–‡°‘¥πâÕ¬∑’Ë ÿ¥¢âÕ¡Ÿ≈®÷ß¡’§«“¡πà“®–‡™◊ËÕ∂◊Õ‰¥â¡“° “¡“√∂π”¡“·ª≈º≈‰¥â

”À√—∫ªí®®—¬∑“ß™’«¿“æ¢Õß µ√’µ—Èß§√√¿å∑’Ëæ‘®“√≥“®“°¢âÕ¡Ÿ≈·≈â«æ∫«à“πà“®–¡’º≈µàÕ§«“¡º‘¥æ≈“¥®“°°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° §◊ÕπÈ”Àπ—°¢Õß¡“√¥“ °√≥’∑’ËπÈ”Àπ—°¢Õß¡“√¥“¡“°°«à“ 81 °‘‚≈°√—¡

¢÷Èπ‰ª (´÷Ëß¡’Õ¬Ÿà√âÕ¬≈– 4.5) ‚¥¬∑—Ë«‰ª¡—°¡’§«“¡ —¡æ—π∏å‚¥¬µ√ß°—∫§«“¡Àπ“¢ÕßÀπâ“∑âÕß µ√’µ—Èß§√√¿å·≈–Õ’°ªí®®—¬Àπ÷Ëß§◊Õ¿“«–πÈ”§√Ë”¡“° (polyhy-dramnios) °“√»÷°…“§√—Èßπ’È¡‘‰¥âπ”¡“æ‘®“√≥“‡π◊ËÕß®“°¡’§«“¡¬ÿàß¬“°„π°“√π”‰ªªØ‘∫—µ‘‡æ√“–πÕ°®“° Ÿµ‘·æ∑¬å·≈â« ∫ÿ§≈“°√Õ◊Ëπ (·æ∑¬å∑—Ë«‰ªÀ√◊Õæ¬“∫“≈) ‰¡à “¡“√∂„Àâ°“√«‘π‘®©—¬‰¥â‚¥¬∑—Ë«‰ª ÷Ëßµ“¡°“√ªØ‘∫—µ‘ß“π®√‘ßºŸâ„Àâ∫√‘°“√∑“ß “∏“√≥ ÿ¢‚¥¬‡©æ“–„π‚√ßæ¬“∫“≈™ÿ¡™π ‰¡à¡’ ‘∑∏‘ÏªØ‘‡ ∏°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° „π µ√’µ—Èß§√√¿å∑’Ë¡’πÈ”Àπ—°¡“°°«à“81 °‘‚≈°√—¡¢÷Èπ‰ª À√◊Õ¡’¿“«–πÈ”§√Ë”¡“° ‡π◊ËÕß®“°‡ªìπ¡“µ√∞“π°“√„Àâ∫√‘°“√µ“¡ª°µ‘¢ÕßÀâÕß§≈Õ¥∑—Ë«‰ªÕ¬Ÿà·≈â« ºŸâ√“¬ß“π®÷ß¡‘‰¥âπ”ªí®®—¬∑—Èß Õß¡“‡°’Ë¬«¢âÕß¥â«¬

”À√—∫‡Àµÿº≈∑’Ë‡≈◊Õ°®ÿ¥µ—¥∑’Ë ≤ 34 ‡´πµ‘‡¡µ√ „π°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ°„π°“√∑”π“¬∂÷ß¿“«–∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ ‡π◊ËÕß¡“®“°°“√ plot ROC curve(√Ÿª∑’Ë 1) æ∫«à“¡’§«“¡‰«√âÕ¬≈– 95.4 ´÷Ëß¡“°æÕ∑’Ë®–§√Õ∫§≈ÿ¡∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬„Àâ¡“°∑’Ë ÿ¥ ‡æ◊ËÕª√–‚¬™πå·°à ÿ¢¿“æ¢Õß∑“√°·√°‡°‘¥‡Õß ‡æ√“–°“√ àßµàÕ∑“√°πÈ”Àπ—°πâÕ¬„π§√√¿å¡“√¥“πà“®–¥’°«à“ª≈Õ¥¿—¬°«à“ °“√ àßµàÕπÕ°§√√¿å¡“√¥“ ∑’ËÕ“®¡’º≈·∑√° âÕπ°—∫∑“√°·√°‡°‘¥‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß ¿“«–Õÿ≥À¿Ÿ¡‘°“¬µË” (subtemperature in the newborn)‡π◊ËÕß®“°‚√ßæ¬“∫“≈™ÿ¡™π à«π¡“°‰¡à¡’ transportincubator „π°“√π” àß‡¥Á°∑“√°·√°§≈Õ¥πÈ”Àπ—°πâÕ¬‡¡◊ËÕ§≈Õ¥·≈â« ·¡â«à“§à“®ÿ¥µ—¥π’È¡’§à“§«“¡®”‡æ“–(specificity) ‡∑à“°—∫√âÕ¬≈– 38.0 ´÷ËßÀ¡“¬§«“¡«à“„π°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ°∑’Ë√–¥—∫ ≤ 34 ‡´πµ‘‡¡µ√ “¡“√∂∑”π“¬∂÷ß∑“√°πÈ”Àπ—°·√°§≈Õ¥ª°µ‘ ∂Ÿ°µâÕß‡æ’¬ß √âÕ¬≈– 38 à«πÕ’°√âÕ¬≈– 62 ‡¢â“„®«à“πà“®–¡’¿“«–πÈ”Àπ—°πâÕ¬ ´÷Ëß‡¥Á°∑“√°‡À≈à“π’È°Á®–‰¥â√—∫°“√ àßµàÕ‡æ◊ËÕ¡“§≈Õ¥∑’Ë‚√ßæ¬“∫“≈∑—Ë«‰ªÀ√◊Õ‚√ßæ¬“∫“≈»Ÿπ¬å ‚¥¬‰¥â√—∫°“√‡µ√’¬¡§«“¡æ√âÕ¡„π°“√¥Ÿ·≈¿“«–·∑√°´âÕπ®“°πÈ”Àπ—°·√°‡°‘¥πâÕ¬ ·¡â«à“‡¡◊ËÕ§≈Õ¥ÕÕ°¡“·≈â«¡’πÈ”Àπ—°ª°µ‘°Áµ“¡ ´÷Ëß‰¡à¡’¢âÕ‡ ’¬µàÕ ÿ¢¿“æ∑“√°·√°‡°‘¥‡À≈à“π’È „π∑”πÕß‡¥’¬«°—π

√Ÿª∑’Ë 2 ROC curve æ∫«à“®ÿ¥∑’Ë¡’§à“§«“¡‰« (sensitivity)

·≈–§«“¡®”‡æ“– (specificity) ¥’∑’Ë ÿ¥ §◊Õ ®ÿ¥∑’Ë

√–¥—∫§«“¡ Ÿß¢Õß¡¥≈Ÿ°∑’Ë ≥ 40 ´¡. ‚¥¬¡’

§«“¡‰«‡∑à“°—∫√âÕ¬≈– 98.5 ·≈–§«“¡®”‡æ“–

‡∑à“°—∫√âÕ¬≈– 25.0

100

80

60

40

20

0

Sensitivty

20 40 60 80 1001-Specificity



‡Àµÿº≈∑’Ë‡≈◊Õ°®ÿ¥µ—¥∑’Ë ≥ 40 ‡´πµ‘‡¡µ√ „π°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ° „π°“√∑”π“¬∂÷ß¿“«–·√°‡°‘¥πÈ”Àπ—°¡“°‡π◊ËÕß®“° plot ROC curve (√Ÿª∑’Ë 2) æ∫«à“¡’§à“§«“¡‰«(sensitivity) √âÕ¬≈– 98.5 ´÷Ëß¡“°æÕ∑’Ë®–§√Õ∫§≈ÿ¡¿“«–∑“√°µ—«‚µ´÷Ëß®–¡’º≈µàÕ°“√§≈Õ¥¬“° À√◊Õ CPD(cephalo-pelvic disproportion) À√◊Õ °“√§≈Õ¥µ‘¥‰À≈à ≈â«π¡’º≈°√–∑∫Õ¬à“ß¡“°µàÕ ÿ¢¿“æ¢Õß∑“√°·√°§≈Õ¥ ¥—ßπ—Èπ°“√ àßµàÕ„Àâ¡“§≈Õ¥·≈–‰¥â√—∫°“√¥Ÿ·≈®“° Ÿµ‘·æ∑¬å∑’Ë‚√ßæ¬“∫“≈∑—Ë«‰ª/»Ÿπ¬å πà“®–‡À¡“– ¡°«à“ º≈æ≈Õ¬‰¥â®“°°“√«—¥§«“¡ Ÿß¢Õß¡¥≈Ÿ°∑’Ë®ÿ¥µ—¥π’È°Á§◊Õ ¿“«– undiagnosed twin ormultifetal pregnancy ∑’Ë‰¡à “¡“√∂∑√“∫‡≈¬∂â“‰¡à‡§¬ºà“π°“√µ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß¡“°àÕπ„π™à«ßµ—Èß§√√¿å (‚√ßæ¬“∫“≈ à«π„À≠à„πª√–‡∑»‰∑¬¬—ß‰¡à¡’°“√µ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß‡ªìπ°‘®«—µ√‡æ◊ËÕ§âπÀ“°“√µ—Èß§√√¿å·Ω¥) ∑—Èßπ’È‚√ßæ¬“∫“≈ à«π„À≠à¡’‡§√◊ËÕßµ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß À√◊Õ‡Õ°´‡√¬å Õ¬Ÿà·≈â« ∑”„Àâ™à«¬§—¥°√Õß„Àâ°“√«‘π‘®©—¬¿“«–µ—Èß§√√¿å·Ω¥‰¥â°àÕπ°“√§≈Õ¥ “¡“√∂ àßµàÕ¡“§≈Õ¥‰¥â∑—π∑’Ë‚√ßæ¬“∫“≈∑—Ë«‰ª/»Ÿπ¬å ∑’Ë¡’°“√‡µ√’¬¡™à«¬‡À≈◊Õ°“√§≈Õ¥∑—Èß¡“√¥“·≈–∑“√°∑’Ë‡À¡“– ¡°«à“ ∑—Èßπ’È‡æ◊ËÕº≈ª√–‚¬™πå·°à ÿ¢¿“æ‚¥¬√«¡¢Õß∑“√°·√°§≈Õ¥¥â«¬ ·¡â«à“§à“®ÿ¥µ—¥π’È®–¡’§«“¡®”‡æ“– (specificity) √âÕ¬≈– 25´÷ËßÀ¡“¬§«“¡«à“°“√«—¥∑’Ë√–¥—∫π’È®– “¡“√∂∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°ª°µ‘ (< 4,000 °√—¡) ∂Ÿ°µâÕß‡æ’¬ß√âÕ¬≈– 25 à«πÕ’°√âÕ¬≈– 75 ‡ªìπ∑“√°·√°‡°‘¥πÈ”Àπ—°ª°µ‘ ·µà∂Ÿ°∑”π“¬«à“‡ªìπ∑“√°µ—«‚µ ∑—Èßπ’È‡æ◊ËÕ‡ªìπ°“√™à«¬§—¥°√Õß¿“«–µ—Èß§√√¿å·Ω¥À√◊ÕªÑÕß°—π¿“«–§≈Õ¥¬“°À√◊Õ§≈Õ¥µ‘¥‰À≈à ÷Ëß≈â«π¡’º≈ª√–‚¬™πåµàÕ ÿ¢¿“æ∑“√°·√°‡°‘¥∑—Èß ‘Èπ

¥—ßπ—ÈπºŸâ√“¬ß“π¡’§«“¡‡ÀÁπ«à“°“√«—¥§«“¡ Ÿß¢Õß¬Õ¥¡¥≈Ÿ°„π µ√’µ—Èß§√√¿å‡¡◊ËÕ‡®Á∫§√√¿å§≈Õ¥∑ÿ°√“¬‡ªìπ°“√°√–∑”∑’Ë¡’ª√–‚¬™πå “¡“√∂π”‰ª„™â‰¥â∑—Ë«‰ª‡§√◊ËÕß¡◊Õ„π°“√«—¥À“ßà“¬ √“§“∂Ÿ° «‘∏’°“√«—¥‰¡à¬ÿàß¬“° “¡“√∂ªØ‘∫—µ‘‰¥â ‚¥¬·æ∑¬å∑—Ë«‰ªÀ√◊Õæ¬“∫“≈ª√–®”ÀâÕß§≈Õ¥ π”‰ª„™â„π°“√§—¥°√Õß‡∫◊ÈÕßµâπ°àÕπ àßµàÕ‡À¡“– ”À√—∫‚√ßæ¬“∫“≈™ÿ¡™π∑—Ë«‰ª

√ÿª

°“√»÷°…“π’È‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“ ‡æ◊ËÕÀ“§à“®ÿ¥µ—¥∑’Ë‡À¡“– ¡®“°°“√«—¥ à«π Ÿß¢Õß¡¥≈Ÿ°„π µ√’µ—Èß§√√¿å ®”π«π 1,000 √“¬ ∑’Ë¡’Õ“°“√‡®Á∫§√√¿å®√‘ß¡“§≈Õ¥∑’Ë‚√ßæ¬“∫“≈æ–‡¬“ ‚¥¬¡’ inclusion criteria∑’Ë°”Àπ¥ ´÷ËßºŸâ√“¬ß“π∑”°“√«—¥‚¥¬‰¡à∑√“∫Õ“¬ÿ§√√¿å¡“°àÕπ º≈°“√»÷°…“æ∫«à“§à“®ÿ¥µ—¥∑’Ë‡À¡“– ¡®“°§à“§«“¡‰« (sensitivity) ·≈–§«“¡®”‡æ“– (specificity)„π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°πâÕ¬ §◊Õ§à“ ≤ 34‡´πµ‘‡¡µ√ ·≈–§à“ ≥ 40 ‡´πµ‘‡¡µ√ „π°“√∑”π“¬∑“√°·√°‡°‘¥πÈ”Àπ—°¡“° “¡“√∂„™â‡ªìπ‡§√◊ËÕß¡◊Õ¡“µ√∞“π„π°“√ àßµàÕ µ√’µ—Èß§√√¿å®“°‚√ßæ¬“∫“≈™ÿ¡™π¡“¬—ß‚√ßæ¬“∫“≈∑—Ë«‰ª/»Ÿπ¬å

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ π“¬·æ∑¬å»—°¥‘Ï™—¬ Õ—µ∂«‘∫Ÿ≈¬å ºŸâÕ”π«¬°“√‚√ßæ¬“∫“≈æ–‡¬“∑’ËÕπÿ≠“µ„Àâ∑”°“√»÷°…“§√—Èßπ’ÈÕ“®“√¬å ¥√.°π°«√√≥ ‡Õ’Ë¬¡™—¬ À—«Àπâ“ß“π°“√ Õπ«‘∑¬“≈—¬æ¬“∫“≈∫√¡√“™™ππ’ æ–‡¬“ ∑’Ë™à«¬∑¥ Õ∫§à“∑“ß ∂‘µ‘·≈–™à«¬µ√«®∑“πß“π«‘®—¬π’È π“ßπâÕß¢«—≠ ¡ÿ∑√®—°√ æ¬“∫“≈«‘™“™’æ 6 ∑’Ë™à«¬„π°“√·¬°·¬–¢âÕ¡Ÿ≈„π‚ª√·°√¡§Õ¡æ‘«‡µÕ√å


1. Behman RE, Kliegman RM, Arion AM. Nelson textbook

of pediatrics 15th ed. Philadelphia : Saunders; 1996 :

454-62.

2. Shapiro S, Mc Cormik MC, Starfield BH, Krischer JP,

Bross D. Relevance of correlates of infant deaths for

significant morbidity at 1 year of age. Am J Obstet

Gynecol 1980; 136:363-73.

3. Johnson RW, Toshach CE. Estimaton of fetal weight

using longitudinal mensuration. Am J Obstet Gynecol

1954; 68:891-6.

4. Loeffler FE. Clinical fetal weight prediction. J Obstet

Gynaecol Brit Commonw 1967; 74:675-7.

54

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

5. Warsof SL, Gohari P, Berkowitz R, Hobbens JC. The

estimation of fetal weight by computer-assisted analysis.

Am J Obstet Gynecol 1977; 128:881-92.

6. Linasmita V, Sugkraroek P. Normal uterine growth

curve by measurement of symphysial-fundal height in

pregnant women seen at Ramathibodi Hospital. J Med

Assoc Thai 1984; 67:22-6.

7. Neilson JP, Verkuyl DAA, Bannerman C. Tape

measurement of symphysis-fundal height in twin

pregnancies. Br J Obstet Gynaecol 1988; 95:1054-9.

8. Walraven GEL, Mkanje RJB, van Roosmalen J, van

Dongen PWJ, van Asten HAGH, Dolmans WMV.

Single pre-delivery symphysis - fundal height

measurement as a predictor of birthweight and multiple

pregnancy. Br J Obstet Gynaecol 1995; 102:525-9.

9. ∑«‘ª °‘µ¬“¿√≥å. °“√§”π«≥¢π“¥µ—«Õ¬à“ß. „π : ª√–∑—°…å‚Õª√–‡ √‘∞ «— ¥‘Ï , ∫√√≥“∏‘°“√. «‘®—¬∑“ß§≈‘π‘°.°√ÿß‡∑æ¡À“π§√: ”π—°æ‘¡æå‚Œ≈‘ µ‘° æ—∫≈‘™™‘Ëß; 2538.Àπâ“ 65-82.




°“√µ√«®§—¥°√Õß¡–‡√Áß≈”‰ â„À≠à√–¬–‡√‘Ë¡·√°¥â«¬«‘∏’°“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑’Ëªπ°—∫Õÿ®®“√–«ÿ≤‘ ÿ‡¡∏‚™µ‘‡¡∏“ æ∫.*∏’√«ÿ≤‘ §ŸÀ–‡ª√¡– æ∫.* “¬ªÉ“π ¢ÿπ¿—°¥’ æ∫.*√“¡ √—ß ‘π∏ÿå æ∫.***°≈ÿà¡ß“π»—≈¬»“ µ√å ∂“∫—π¡–‡√Áß·Ààß™“µ‘ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢**¿“§«‘™“‡«™»“ µ√å∑À“√·≈–™ÿ¡™π «‘∑¬“≈—¬·æ∑¬»“ µ√åæ√–¡ß°ÿÆ‡°≈â“

Abstract Stool Occult Blood Test for Screening and Early Detection Colorectal CancerSumetchotimaytha W.*, Khuhaprema T.*, Khunpakdee S.*, Rangsin R.**

*National Cancer Institutes, Department of Medical Services MOPH, **


There is growing evidence that annual screening with stool-occult-blood (FOB) tests can lead to

a reduction in mortality from colorectal cancer (CRC) at least 33%. Main aim of this study was to comparethe efficacy of the guaiac-based stool occult-blood tests and immunochemical analysis of stool occult blood indetecting and screening to the colon cancer. The second aim was to determine the risk factors leading to coloncancer and to make model development clinical practice guidelines by means of finding blood in stool andcolonoscopy to early detection colon cancer. Subjects who aged above 40 underwent regular health checkupswere enrolled to receive stool occult-blood tests both guaiac and immunochemical technic examinations.Participants whom results positive for tests were invited for colonoscopy. In negative finding case with do nothave any abnormality in the whole colon, the gastroscopy would be performed to examine the stomachwhether there exist any abnormality responsible for existence of blood in stool or not. In examining 20,377participants, it is seen that there were 332 persons amounting to 1.6 percent having blood in stool with lesionsin their colon. It is found that guaiac Tests give positive results for 2,577 persons or 12.6 % and testing byimmunohistochemcial technic gave positive results for 2,608 persons or 12.8%. One-hundred and fifty(45.2%) of the 332 participants had hyperplastic polyps, 118 persons or 35.5% suffering from hemorrhoid,48 persons or 14.5% had colitis and colon cancer affecting 16 persons or 4.8%. When comparisons have beenmade between guaiac tests and immunochemical technic according to colonoscopic finding, it is seen thatsensitivity of immunochemical technic prove to be higher than guaiac test amounting to 85.8% and 31.3%respectively. In conclusion, testing blood in stool by immunochemical technic is a new system that is reliable,correct and affordable and it has efficiency for testing more than guaiac Test. Based on the results of this study,testing by immunochemical technic method offers reliability of screening people affected by colon cancer upto 85.8% leading to diagnosis of disease from the beginning and this made treatment more effective and saving

more lives.

Key words: stool occult blood test, screening colorectal cancer

56

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

‚√§¡–‡√Áß≈”‰ â„À≠à (Colon cancer) ‡ªìπ‚√§∑’Ëæ∫‰¥â¡“°¢÷Èπ‡√◊ËÕ¬Ê ∑—Èß„πª√–‡∑»·≈–µà“ßª√–‡∑»·≈–π—∫‡ªìπ “‡Àµÿ°“√µ“¬®“°‚√§¡–‡√Áß ‡ªìπÕ—π¥—∫∑’Ë Õß√Õß®“°¡–‡√ÁßªÕ¥ Õ“®‡π◊ËÕß®“°°“√æ—≤π“¢Õß —ß§¡·≈–‡»√…∞°‘®¢Õßª√–‡∑» ∑’Ëª√–™“™π¡’¿“«–°“√¥”√ß™’«‘µ∑’Ë‡√àß√’∫·≈–æƒµ‘°√√¡°“√∫√‘‚¿§Õ“À“√·∫∫ª√–‡∑»µ–«—πµ°

¡–‡√Áß≈”‰ â„À≠à‡°‘¥®“°°“√·∫àßµ—«·≈–‡®√‘≠‡µ‘∫‚µÕ¬à“ßº‘¥ª°µ‘¢Õß‡´≈≈å‡¬◊ËÕ∫ÿº‘« (Epithelial cell)¿“¬„π≈”‰ â„À≠à‡°‘¥‡ªìπ°âÕπ∑’Ë¡’¢π“¥º‘¥ª°µ‘·≈–°≈“¬‡ªìπ‡π◊ÈÕßÕ°√â“¬·√ß µ”·Àπàß∑’Ëæ∫∫àÕ¬ §◊Õ ≈”‰ â„À≠à à«πª≈“¬ (Rectum) √âÕ¬≈– 50 √Õß≈ß¡“§◊Õ∑’Ë∫√‘‡«≥≈”‰ â„À≠à à«πµ√ß (Sigmoid colon) √âÕ¬≈–20-25 ∑’Ë≈”‰ â„À≠à à«πµâπ (Caecum) √âÕ¬≈– 15 ∑’Ë≈”‰ â„À≠à¥â“π¢«“·≈–≈”‰ â„À≠à¥â“π´â“¬ (Ascendingcolon, Descending colon) ª√–¡“≥√âÕ¬≈– 6-8

Õ’°ª√–¡“≥√âÕ¬≈– 1 æ∫∑’Ë Anus ´÷Ëß “‡Àµÿ¢Õß‚√§¡–‡√Áß≈”‰ â„À≠àªí®®ÿ∫—π¬—ß‰¡à∑√“∫·πà™—¥ ·µà¡—°æ∫„πºŸâ∑’Ë¡’ªí®®—¬¥—ßπ’È

ª√–«—µ‘‡ªìπ‚√§¢Õß≈”‰ â∫“ß™π‘¥ ‰¥â·°à µ‘Ëß‡π◊ÈÕßÕ°„πºπ—ß≈”‰ â (Adenomatous Polyps) ‚√§·º≈Õ—°‡ ∫¢Õß≈”‰ â‡√◊ÈÕ√—ß (Chronic ulcerative colitis)π“π 10 ªï À√◊Õ¡“°°«à“®–¡’‚Õ°“ ‡°‘¥‚√§¡–‡√Áß≈”‰ â„À≠à 5-10 ‡∑à“

°√√¡æ—π∏ÿå ¬’π ¡’ª√–«—µ‘¡–‡√Áß≈”‰ â„À≠à„π§√Õ∫§√—« ºŸâÀ≠‘ß∑’Ë¡’ª√–«—µ‘‚√§¡–‡√Áß‡µâ“π¡ √—ß‰¢àÀ√◊Õ¡¥≈Ÿ° ®–¡’‚Õ°“ ‡°‘¥‚√§¡–‡√Áß≈”‰ â„À≠à¡“°¢÷Èπ

Õ“À“√ ª√–‡¿∑‡π◊ÈÕ —µ«å·≈–‰¢¡—π —µ«å ŸßÕ“À“√∑’Ë¡’·§≈Õ≈’Ë Ÿß °“°„¬πâÕ¬ Õ“À“√ªπ‡ªóôÕπ “√æ‘… À√◊Õ°“√ – ¡·∫§∑’‡√’¬„π≈”‰ â °“√§—Ëß§â“ß¢Õß¢Õß‡ ’¬®π‡°‘¥‡ªìπ “√°àÕ¡–‡√Áß ‚¥¬‡©æ“–∑’Ë≈”‰ â„À≠à à«πª≈“¬ ‡ªìπ∫√‘‡«≥∑’Ë —¡º— °“°Õ“À“√∑’Ë¡’ “√°àÕ¡–‡√Áß ‡ªìπ‡«≈“π“π

‡√◊ËÕß¬àÕ °“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑’Ëªπ„πÕÿ®®“√–æ∫«à“ “¡“√∂™à«¬≈¥Õ—µ√“°“√‡ ’¬™’«‘µ®“°¡–‡√Áß≈”‰ â„À≠à‰¥â∂÷ß√âÕ¬≈– 33«—µ∂ÿª√– ß§åÀ≈—°¢Õß°“√»÷°…“§◊Õ ‡ª√’¬∫‡∑’¬∫ª√– ‘∑∏‘¿“æ¢Õß°“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑’Ëªπ„πÕÿ®®“√–¥â«¬«‘∏’ Guaiac test °—∫«‘∏’°“√ Immunochemical technics ‡æ◊ËÕ„™â§—¥°√ÕßÀ“¡–‡√Áß≈”‰ â„À≠à√–¬–‡√‘Ë¡µâπ ·≈–»÷°…“ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥¡–‡√Áß≈”‰ â„À≠à√«¡∑—Èß®—¥∑”·π«∑“ß°“√µ√«®§—¥°√Õß§âπÀ“°≈ÿà¡‡ ’Ë¬ßµàÕ°“√‡°‘¥¡–‡√Áß≈”‰ â„À≠à√–¬–‡√‘Ë¡µâπ °“√¥”‡π‘πß“π ∑”°“√ ÿà¡µ√«®Õÿ®®“√–¥â«¬«‘∏’ Guaiac test ·≈– Immunochemical technics „πª√–™“™π∑’Ë¡’Õ“¬ÿ¡“°°«à“ 40 ªï ∑’Ë‡¢â“¡“√—∫°“√µ√«® ÿ¢¿“æª√–®”ªï „π√“¬∑’Ëæ∫«à“¡’‡≈◊Õ¥ªπ„πÕÿ®®“√–®–¥”‡π‘π°“√ àÕß°≈âÕßµ√«®≈”‰ â„À≠à À“°‰¡àæ∫§«“¡º‘¥ª°µ‘„¥Ê ®–∑”°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√ ‡æ◊ËÕµ√«®‡™Á§§«“¡º‘¥ª°µ‘∑’Ë®–‡ªìπ “‡Àµÿ¢Õß°“√¡’‡≈◊Õ¥ªπ„πÕÿ®®“√– °“√»÷°…“π’È‰¥âµ√«®Õÿ®®“√– „πª√–™“™π®”π«π 20,377 √“¬ æ∫«à“ºŸâ∑’Ë¡’‡≈◊Õ¥ªπÕ¬Ÿà„πÕÿ®®“√–·≈–¡’§«“¡º‘¥ª°µ‘¢Õß≈”‰ â„À≠à®”π«π 332§π (√âÕ¬≈– 1.6) æ∫«à“°“√µ√«®¥â«¬«‘∏’ Guaiac Test ¡’º≈‡ªìπ positive 2,577 √“¬ (√âÕ¬≈– 12.6) ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic ¡’º≈‡ªìπ positive 2,608 √“¬ (√âÕ¬≈– 12.8) „π°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à „πºŸâ∑’Ë¡’‡≈◊Õ¥ªπ„πÕÿ®®“√–æ∫¡’°âÕπ‡π◊ÈÕßÕ°„π≈”‰ â„À≠à (Polyp) 150 √“¬ (√âÕ¬≈– 45.2) √‘¥ ’¥«ß∑«“√Àπ—° (Hemorrhoid) 118 √“¬(√âÕ¬≈– 35.5) ‚√§·º≈Õ—°‡ ∫¢Õß≈”‰ â (Colitis) 48 √“¬ (√âÕ¬≈– 14.5) ·≈–‚√§¡–‡√Áß≈”‰ â„À≠à (Colon cancer) 16 √“¬(√âÕ¬≈– 4.8) ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫√–À«à“ß§«“¡‰« (Sensitivity) ¢Õß°“√µ√«®¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic æ∫«à“„π°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic ¡’§«“¡‰«¢Õß°“√µ√«® Ÿß°«à“«‘∏’ GuaiacTest ´÷Ëß¡’§à“§«“¡‰«√âÕ¬≈– 85.8 ·≈–√âÕ¬≈– 31.3 µ“¡≈”¥—∫ °“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– ¥â«¬«‘∏’ ImmunochemicalTechnic ‡ªìπ«‘∏’°“√µ√«®·∫∫„À¡à∑’Ë¡’§«“¡πà“‡™◊ËÕ∂◊Õ §«“¡∂Ÿ°µâÕß ‡ ’¬§à“„™â®à“¬‰¡à¡“°π—° ·≈–¡’ª√– ‘∑∏‘¿“æ„π°“√µ√«®§—¥°√Õß¡“°°«à“«‘∏’°“√µ√«®·∫∫ Guaiac Test ∑—Èßπ’È °“√µ√«®¥â«¬«‘∏’¥—ß°≈à“«¡’§«“¡πà“‡™◊ËÕ∂◊Õ„π°“√µ√«®§—¥°√ÕßºŸâ∑’Ë‡ªìπ‚√§‡°’Ë¬«°—∫≈”‰ â‰¥â∂÷ß√âÕ¬≈– 94.5 ÷Ëßπ”‰ª Ÿà°“√«‘π‘®©—¬‚√§µ—Èß·µà·√°‡√‘Ë¡‡ªìπ àßº≈„Àâ°“√√—°…“∑’Ë¥’¢÷Èπ °“√Õ¬Ÿà√Õ¥¢ÕßºŸâªÉ«¬¡“°¢÷Èπ

§” ”§—≠: °“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– °“√µ√«®§—¥°√Õß¡–‡√Áß≈”‰ â„À≠à



ªí®®—¬Õ◊ËπÊ ‡™àπ °“√¥◊Ë¡·Õ≈°ÕŒÕ≈å°“√ Ÿ∫∫ÿÀ√’Ë¡“°·≈–π“π°«à“ 35 ªï ®–‡æ‘Ë¡Õ—µ√“°“√‡°‘¥‚√§¡–‡√Áß≈”‰ â„À≠à ·≈–‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à‚¥¬‰¡à∑√“∫ “‡Àµÿ

‡¡◊ËÕ·æ∑¬å‡°‘¥§«“¡ ß —¬«à“ºŸâªÉ«¬®–‡ªìπ‚√§¡–‡√Áß ·æ∑¬å®–´—°ª√–«—µ‘‡°’Ë¬«°—∫ªí®®—¬ àß‡ √‘¡Õ“°“√· ¥ß ª√–«—µ‘°“√‡ªìπ¡–‡√Áß¢Õß§√Õ∫§√—«·≈–∑”°“√µ√«®§—¥°√Õß (screening) ´÷Ëß¡’À≈“¬«‘∏’ ¥—ßπ’È

°“√µ√«®∑“ß∑«“√Àπ—° (Digital RectalExamination : DRE) «‘∏’π’È·æ∑¬å®– «¡∂ÿß¡◊Õ·≈â«∑“πÈ”¡—πÀ≈àÕ≈◊Ëπ ‡™àπ «“ ≈’πÀ√◊Õ‡§«“¬‡®≈≈’ ∑’Ëπ‘È«™’È°àÕ Õ¥π‘È«‡¢â“‰ª∑“ß∑«“√Àπ—°‡∑à“π—Èπ

°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√ °“√µ√«®‡≈◊Õ¥„πÕÿ®®“√– (Stool Occult Blood Test : FOBT) °“√µ√«®À“·Õπµ‘‡®π¢Õß‡´≈≈å¡–‡√Áß (Carcino EmbryonicAntigen : CEA)

°“√ àÕß°≈âÕßµ√«®≈”‰ â„À≠à à«πµ√ß·≈–≈”‰ â„À≠à à«π‚§âß (Flexible Sigmoidoscopy) “¡“√∂ àÕß°≈âÕß¥Ÿ≈”‰ â‰¥âª√–¡“≥ 60 ‡´πµ‘‡¡µ√ ·µà«‘∏’π’È®–‰¡à “¡“√∂µ√«®‰¥âµ≈Õ¥§«“¡¬“«¢Õß≈”‰ â„À≠à∑—ÈßÀ¡¥

°“√µ√«®∑“ß√—ß ’ ‚¥¬°“√„™â “√·∫‡√’¬¡(Double Contrast Barium Enema : DCBE) “¡“√∂‡ÀÁπ‡π◊ÈÕßÕ° ·µà‰¡à “¡“√∂‡ÀÁπ§«“¡º‘¥ª°µ‘„π∫√‘‡«≥≈”‰ â„À≠à à«πµ√ß·≈– à«π°≈“ß

°“√ àÕß°≈âÕßµ√«®¿“¬„π≈”‰ â„À≠à (Colono-scopy) “¡“√∂µ√«®¥Ÿ‰¥âµ≈Õ¥§«“¡¬“«¢Õß colon·≈–‡ÀÁπ°âÕπ¡–‡√Áß∑’ËÕ¬Ÿà à«π∫π¢Õß≈”‰ â„À≠à™—¥‡®π√–À«à“ß àÕß°≈âÕß “¡“√∂µ—¥™‘Èπ‡π◊ÈÕ‡¬◊ËÕ¢Õß≈”‰ â„À≠àµ√«®À“‡´≈≈å¡–‡√Áß

∑—Èßπ’È∂â“ “¡“√∂«‘π‘®©—¬‚√§¡–‡√Áß≈”‰ â‰¥âµ—Èß·µà√–¬–‡√‘Ë¡·√°®– “¡“√∂ªÑÕß°—π √–«—ß°“√≈ÿ°≈“¡¢Õß‚√§‰¥â√âÕ¬≈– 80 ∫“ß§√—Èß “¡“√∂√—°…“„ÀâÀ“¬¢“¥‰¥â‰¡à ‘Èπ‡ª≈◊Õß‡À¡◊Õπ°—∫°“√√—°…“‚√§¡–‡√Áß√–¬–≈ÿ°≈“¡·≈–¬—ß¡’‚Õ°“ √Õ¥™’«‘µ¡“°°«à“ 5 ªï À≈—ß®“°°“√ºà“µ—¥„π√–¬–·√°∂÷ß√âÕ¬≈– 60

‡π◊ËÕß®“°°“√µ√«®«‘π‘®©—¬‚√§¡–‡√Áß≈”‰ â„À≠à„π·µà≈–«‘∏’¡’¢âÕ¥’·≈–¢âÕ‡ ’¬·µ°µà“ß°—π ‡™àπ°“√µ√«®À“

‡≈◊Õ¥„πÕÿ®®“√– ‡ªìπ«‘∏’∑’Ë∑”ßà“¬ √“§“‰¡à·æß ·≈–‰¡à‡®Á∫ ·µà¡’¢âÕ‡ ’¬§◊Õ °“√‡°‘¥‡π◊ÈÕßÕ°·≈–¡–‡√Áß≈”‰ â„À≠à®”π«π¡“°Õ“®®–µ√«®‰¡àæ∫¥â«¬«‘∏’π’È À√◊Õ‰¡àÕ“®„Àâº≈∫«°∑“ß≈«ß§◊Õ ∫Õ°«à“ ¡’‡≈◊Õ¥·µà‡≈◊Õ¥‰¡à‰¥âÕÕ°®√‘ßÊ à«π°“√µ√«®¥â«¬«‘∏’ àÕß°≈âÕßµ√«®¿“¬„π≈”‰ â„À≠à¡’¢âÕ¥’§◊Õ ¡’§«“¡·¡àπ¬” “¡“√∂«‘π‘®©—¬·≈–„πÀ≈“¬°√≥’ “¡“√∂ºà“µ—¥‡π◊ÈÕßÕ° À√◊Õ‡π◊ÈÕ√â“¬ÕÕ°‰¥â‡≈¬ ¢âÕ‡ ’¬§◊Õ ¡’√“§“∑’Ë§àÕπ¢â“ß Ÿß°“√µ√«®√—°…“·µà≈–§√—Èß®–‡ ’¬§à“„™â®à“¬®”π«π¡“°

®“°ªí≠À“¢â“ßµâπ‡ªìπ‡Àµÿ„Àâ‡∑§‚π‚≈¬’«‘∑¬“-»“ µ√å∑“ß°“√·æ∑¬å‰¥âæ—≤π“«‘∏’°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–√–∫∫„À¡à¢÷Èπ§◊Õ °“√µ√«®¥â«¬ Immuno-chemical Technic ´÷Ëß‡™◊ËÕ«à“«‘∏’°“√µ√«®π’È„Àâ§«“¡∂Ÿ°µâÕß¡“°°«à“«‘∏’°“√µ√«®·∫∫‡¥‘¡ Õ’°∑—Èß¬—ß‡ ’¬§à“„™â®à“¬‰¡à¡“°π—° ∑”‰¥âßà“¬ ·≈–·ª≈º≈‰¥â‡√Á« ¥—ßπ—Èπ®÷ß‰¥â àß‡ √‘¡·≈– π—∫ πÿπ°√–µÿâπ„Àâ ∂“π∫√‘°“√∑“ß°“√·æ∑¬åµà“ßÊ·≈–ª√–™“™π‡≈◊Õ°„™â«‘∏’°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–

«—µ∂ÿª√– ß§å¢Õß°“√»÷°…“ ‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫°“√µ√«®§—¥°√Õß‚√§¡–‡√Áß≈”‰ â„À≠à¥â«¬«‘∏’°“√µ√«®·∫∫Guaiac Test °—∫ Immunochemical Technic ‡æ◊ËÕÀ“ªí®®—¬‡ ’Ë¬ß„π°“√‡°‘¥‚√§¡–‡√Áß≈”‰ â„À≠à ·≈–æ—≤π“√Ÿª·∫∫°“√µ√«®§—¥°√Õß°≈ÿà¡‡ ’Ë¬ß¡–‡√Áß≈”‰ â„À≠à‚¥¬«‘∏’°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–·≈–°“√ àÕß°≈âÕßµ√«®≈”‰ â„À≠à (Model development + Clinicalpractice guideline)

÷Ëß “¡“√∂™à«¬≈¥§à“„™â®à“¬·≈–‡æ‘Ë¡§«“¡·¡àπ¬”„π°“√µ√«®æ∫¡–‡√Áß≈”‰ â„À≠à„π√–¬–‡√‘Ë¡µâπ¢ÕßºŸâ∑’ËÕ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß‰¥â ·≈–‡ªìπ°“√‡æ‘Ë¡‚Õ°“ „π°“√√—°…“„ÀâÀ“¬¢“¥

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“ ‚¥¬»÷°…“„πª√–™“™π∑’Ë¡“µ√«® ÿ¢¿“æª√–®”ªï„π ∂“∫—π¡–‡√Áß·Ààß™“µ‘√–À«à“ß‡¥◊Õπµÿ≈“§¡ æ.». 2547 ∂÷ß‡¥◊Õπ°—π¬“¬πæ.». 2549 ®”π«π 20,000 √“¬ ¥”‡π‘π°“√‚¥¬·æ∑¬å´—°ª√–«—µ‘ºŸâªÉ«¬æ∫«à“ ºŸâªÉ«¬Õ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß∑’Ë®–‡ªìπ

58

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‚√§¡–‡√Áß≈”‰ â §◊Õ¡’Õ“¬ÿ¡“°°«à“ 40 ªï ·≈–‰¡à¡’Õ“°“√· ¥ß∑’Ë∫àß∫Õ°«à“‡ªìπ¡–‡√Áß≈”‰ â„À≠à ‰¥â·°à∂à“¬Õÿ®®“√–‡ªìπ‡≈◊Õ¥À√◊Õ¡Ÿ°‡≈◊Õ¥ªπÕÕ°¡“ ¡’Õ“°“√∑âÕßºŸ° ≈—∫°—∫∑âÕß‡ ’¬ πÈ”Àπ—°≈¥≈ß ‡∫◊ËÕÕ“À“√§≈◊Ëπ‰ âÕ“‡®’¬π ®–π”ºŸâªÉ«¬µ√«®µ“¡¢—ÈπµÕπ¥—ßπ’È

°“√µ√«®§—¥°√Õß‚√§¡–‡√Áß≈”‰ â„À≠à√–¬–‡√‘Ë¡·√°¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic ∂â“æ∫«à“ºŸâµ√«®§—¥°√Õß¡’‡≈◊Õ¥ªπ¡“°—∫Õÿ®®“√– ®–∑”°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à‡æ‘Ë¡‡µ‘¡ ´÷Ëß· ¥ß√“¬≈–‡Õ’¬¥¥—ßπ’È

¢âÕ¡Ÿ≈∑—Ë«‰ª¢Õßª√–™“°√∑’ËÕ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß °“√∑¥ Õ∫ Reliability, §«“¡‰« (Sensiti-

vity; Sn) ·≈–§«“¡®”‡æ“– (Specificity; Sp) ¢Õß°“√µ√«®§—¥°√Õß¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic

°“√µ√«® Õ∫§«“¡∂Ÿ°µâÕß¢Õß°“√µ√«®§—¥°√Õß¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic °—∫ °“√µ√«®·∫∫ àÕß°≈âÕß≈”‰ â„À≠à (Colonoscopy) ·≈–°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√ (Gastroscopy)

°“√À“ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à

À≈—°°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– (StoolOccult Blood Test) ¡’ 2 «‘∏’§◊Õ

°“√µ√«®¥â«¬«‘∏’ Guaiac Test ‚¥¬π”µ—«Õ¬à“ßÕÿ®®“√–¡“∑¥ Õ∫°—∫ “√≈–≈“¬ Guaiac ·≈–‰Œ‚¥√‡®π‡ªÕ√åÕÕ°‰´¥å ∂â“„πµ—«Õ¬à“ßÕÿ®®“√–¡’Œ’¡ (Heme)´÷Ëß‡ªìπ à«πª√–°Õ∫ à«πÀπ÷Ëß¢Õß “√Œ’‚¡‚°≈∫‘π „π‡¡Á¥‡≈◊Õ¥ª–ªπÕ¬Ÿà®–‡°‘¥ªÆ‘°‘√‘¬“ÕÕ°´‘‡¥™—π¢÷Èπ ·≈–∑”„Àâ “√≈–≈“¬‡ª≈’Ë¬π‡ªìπ ’øÑ“ („Àâº≈∫«°)

°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic‡ªìπ°“√µ√«®‚¥¬π”µ—«Õ¬à“ßÕÿ®®“√–¡“∑¥ Õ∫¥â«¬ “√anti-human monoclonal antibody ´÷Ëß®–∑”ªØ‘°‘√‘¬“®”‡æ“–‡®“–®ßµàÕ “√Œ’‚¡‚°≈∫‘π„π‡≈◊Õ¥¡πÿ…¬å‡∑à“π—Èπ

°√≥’∑’Ë°“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑—Èß Õß«‘∏’‰¥âº≈‰¡àµ√ß°—π®–∑”°“√µ√«®´È”‡æ◊ËÕ¬◊π¬—πº≈°“√µ√«®

Õ¬à“ß‰√°Áµ“¡°“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑’Ëªπ¡“°—∫Õÿ®®“√–‡ªìπ‡æ’¬ß°“√µ√«®¢—Èπµâπ ®÷ßµâÕßµ√«®·∫∫ àÕß°≈âÕß≈”‰ â„À≠à´È”„πºŸâªÉ«¬∑ÿ°√“¬‡æ◊ËÕ¬◊π¬—πº≈°“√µ√«®„Àâ°—∫°≈ÿà¡µ—«Õ¬à“ß

‡¡◊ËÕµ√«®æ∫«à“ ºŸâªÉ«¬¡’º≈°“√µ√«® StoolOccult Blood Test ‡ªìπº≈∫«° (positive) §◊Õæ∫‡¡Á¥‡≈◊Õ¥ªπ ®–∑”°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à(Colonoscopy)

∂â“æ∫§«“¡º‘¥ª°µ‘¢Õß≈”‰ â„À≠à®–∑”°“√µ—¥™‘Èπ‡π◊ÈÕæ‘ Ÿ®πå (Biopsy) ·µà°√≥’∑’Ë‰¡àæ∫§«“¡º‘¥ª°µ‘¢Õß≈”‰ â„À≠à ®–∑”°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√ (Gastroscopy) ‡æ◊ËÕµ√«®À“§«“¡º‘¥ª°µ‘∑’Ë‡ªìπ “‡Àµÿ¢Õß°“√¡’‡≈◊Õ¥ªπ„πÕÿ®®“√–À√◊Õ‰¡à

∂â“µ√«®·≈â«‰¡àæ∫§«“¡º‘¥ª°µ‘®“°°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à·≈–°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√ ®–∑”°“√π—¥ºŸâªÉ«¬¡“µ√«®Õÿ®®“√–´È”Õ’° 3‡¥◊Õπ∂—¥‰ª

°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈æ◊Èπ∞“π‚¥¬ ∂‘µ‘‡™‘ßæ√√≥π“§à“√âÕ¬≈– §à“‡©≈’Ë¬ §à“ à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π ∑¥ Õ∫§«“¡πà“‡™◊ËÕ∂◊Õ §«“¡‰«·≈–§«“¡®”‡æ“–¢Õß°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– ·≈–§”π«≥À“ªí®®—¬‡ ’Ë¬ß¢Õß‚√§¡–‡√Áß≈”‰ â„À≠à ¥â«¬«‘∏’ Logistic Regression

º≈

ª√–™“°√∑’ËÕ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß∑’Ë¡’‚Õ°“ ‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à „π™à«ß∑’Ë»÷°…“¡’®”π«π∑—ÈßÀ¡¥ 20,377 √“¬

¢âÕ¡Ÿ≈∑—Ë«‰ª¢Õßª√–™“°√∑’ËÕ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß „π°“√µ√«®§—¥°√Õß°≈ÿà¡‡ ’Ë¬ß®”π«π 20,377 √“¬ æ∫«à“‡ªìπºŸâ∑’Ë¡’‡≈◊Õ¥ªπÕ¬Ÿà„πÕÿ®®“√–·≈–¡’§«“¡º‘¥ª°µ‘¢Õß≈”‰ â„À≠à ®”π«π 332 √“¬ (√âÕ¬≈– 1.6) à«πºŸâ∑’Ë¡’ª√–«—µ‘°“√‡ªìπ¡–‡√Áß„π§√Õ∫§√—« ®”π«π 88 √“¬(√âÕ¬≈– 1.7) ∑’Ëæ∫‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– ‰¡à¡’§«“¡·µ°µà“ß∑’Ë√–¥—∫π—¬ ”§—≠°—∫ºŸâ∑’Ë‰¡à¡’ª√–«—µ‘‡ªìπ¡–‡√Áß„π§√Õ∫§√—« ·µà∂â“®”·π°‡ªìπ°≈ÿà¡‡ ’Ë¬ß√–À«à“ßºŸâ∑’Ë¡’ª√–«—µ‘¡–‡√Áß≈”‰ â„À≠à„π§√Õ∫§√—« °—∫ºŸâ∑’Ë‰¡à¡’ª√–«—µ‘¡–‡√Áß≈”‰ â„À≠à„π§√Õ∫§√—« ®–¡’§«“¡·µ°µà“ß°—π„π°“√æ∫‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– (p = 0.034) ‚¥¬æ∫ºŸâ∑’Ë¡’



ª√–«—µ‘°“√‡ªìπ¡–‡√Áß≈”‰ â„À≠à„π§√Õ∫§√—« ®”π«π 19√“¬ (√âÕ¬≈– 2.7)

¥â“πª√–«—µ‘°“√¥◊Ë¡·Õ≈°ÕŒÕ≈åæ∫§«“¡·µ°µà“ß„π°“√µ√«®æ∫‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– (p = 0.001) ºŸâ∑’Ëæ∫‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–·∫àß‡ªìπºŸâ‰¡à¥◊Ë¡·Õ≈°ÕŒÕ≈å®”π«π 197 √“¬ ºŸâ∑’Ë¥◊Ë¡‰¡à‡°‘π —ª¥“Àå≈–§√—Èß®”π«π35 √“¬ ºŸâ∑’Ë¥◊Ë¡‡ªìπª√–®”®”π«π 9 √“¬ ·≈–‡§¬¥◊Ë¡·Õ≈°ÕŒÕ≈å®”π«π 5 √“¬ §‘¥‡ªìπ√âÕ¬≈– 1.5, 2.0, 4.9·≈– 2.0 µ“¡≈”¥—∫

¥â“πª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë æ∫§«“¡·µ°µà“ß„π°“√µ√«®æ∫‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– (p = 0.018) ‚¥¬æ∫«à“°≈ÿà¡∑’Ë¡’º≈ positive ®–‡ªìπºŸâ‰¡à Ÿ∫∫ÿÀ√’Ë®”π«π 215√“¬ (√âÕ¬≈– 1.5) √Õß≈ß¡“§◊Õ ‡§¬ Ÿ∫∫ÿÀ√’Ë®”π«π 17√“¬ (√âÕ¬≈– 2.2)

º≈°“√µ√«®§—¥°√Õß°≈ÿà¡‡ ’Ë¬ß¥â«¬«‘∏’°“√µ√«®·∫∫ Guaiac Test ·≈–«‘∏’ Immunochemical Technicæ∫«à“°“√µ√«®¥â«¬«‘∏’ Guaiac Test ¡’º≈∫«° ®”π«π2,577 √“¬ (√âÕ¬≈– 12.6) ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic ¡’º≈º«° ®”π«π 2,608√“¬ (√âÕ¬≈– 12.8) À≈—ß®“°π—Èπµ√«® È”¥â«¬«‘∏’Colonoscopy æ∫«à“¡’ºŸâ∑’Ëº‘¥ª°µ‘ ®”π«π 329 √“¬(√âÕ¬≈– 22.2) ·≈–°“√µ√«®´È”¥â«¬«‘∏’ Gastroscopy¡’®”π«πºŸâ¡’§«“¡º‘¥ª°µ‘ ®”π«π 136 √“¬ (√âÕ¬≈–36.4) ¥—ßµ“√“ß∑’Ë 1

®“°°“√µ√«®§—¥°√Õß¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic §√—Èß·√°·≈–µ√«®´È”æ∫«à“ «‘∏’ Guaiac Test ¡’§à“§«“¡‰«√âÕ¬≈– 98.5 Ÿß°«à“°“√µ√«®¥â«¬«‘∏’ Immunoche-mical Technic ´÷Ëß¡’§à“√âÕ¬≈– 95.9 „π∑“ß°≈—∫°—π°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic °≈—∫¡’§à“§«“¡®”‡æ“– Ÿß°«à“°“√µ√«®¥â«¬«‘∏’ Guaiac Test´÷Ëß¡’§à“√âÕ¬≈– 99.2% ·≈–√âÕ¬≈– 97.3 µ“¡≈”¥—∫(µ“√“ß∑’Ë 2)

∂â“æ‘®“√≥“®“°§«“¡πà“‡™◊ËÕ∂◊Õ¥â«¬«‘∏’ Kappa¢Õß°“√µ√«®§—¥°√Õß ®–‡ÀÁπ‰¥â«à“«‘∏’°“√µ√«®·∫∫Immunochemical Technic ¡’§à“ Kappa √âÕ¬≈– 94.5¡“°°«à“«‘∏’°“√µ√«®·∫∫ Guaiac Test ´÷Ëß¡’§à“√âÕ¬≈–

89.2 ·µà‡π◊ËÕß¥â«¬∑—Èß§à“ Kappa, §«“¡‰« ·≈–§«“¡®”‡æ“– ∑’Ë‡°‘¥¢÷Èπ®“°°“√µ√«®∑—Èß Õß«‘∏’‰¡à “¡“√∂∑√“∫«à“¡’§«“¡∂Ÿ°µâÕß¡“°πâÕ¬‡æ’¬ß„¥ ∑’¡ºŸâ»÷°…“®÷ß∑”°“√µ√«® È”¥â«¬°“√ àÕß°≈âÕß‡ª√’¬∫‡∑’¬∫°—∫º≈∑’Ë‰¥â®“°°“√µ√«®®“°∑—Èß Õß«‘∏’‡æ◊ËÕ‡ªìπ°“√¬◊π¬—πº≈·≈–µ√«® Õ∫§«“¡∂Ÿ°µâÕß

°“√µ√«® Õ∫§«“¡∂Ÿ°µâÕß¢Õß°“√µ√«®§—¥°√Õß¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic °—∫°“√µ√«®·∫∫ àÕß°≈âÕß≈”‰ â„À≠à (Colonoscopy) ·≈–°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√ (Gastroscopy) „π°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à ª√“°Ø«à“¡’ºŸâ∑’Ë¡’§«“¡º‘¥ª°µ‘ (positive)®”π«π 332 √“¬ (√âÕ¬≈– 1.6) ‚¥¬æ∫≈—°…≥–‡π◊ÈÕßÕ°(Polyp) ®”π«π 150 √“¬ (√âÕ¬≈– 45.2) √‘¥ ’¥«ß∑«“√Àπ—° (Hemorrhoid) ®”π«π 118 √“¬ (√âÕ¬≈–35.5) ‚√§·º≈Õ—°‡ ∫¢Õß≈”‰ â‡√◊ÈÕ√—ß (Chronic colitis)®”π«π 48 √“¬ (√âÕ¬≈– 14.5) ·≈–‚√§¡–‡√Áß≈”‰ â„À≠à(Cancer colon) ®”π«π 16 √“¬ (√âÕ¬≈– 4.8)

‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à°—∫°“√µ√«®¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’Immunochemical Technic æ∫«à“§«“¡‰«„π°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic Ÿß°«à“°“√µ√«®¥â«¬«‘∏’ Guaiac Test ´÷Ëß¡’§à“√âÕ¬≈– 85.8 ·≈–√âÕ¬≈– 31.3 µ“¡≈”¥—∫ °“√µ√«®·∫∫ Immuno-chemical Technic “¡“√∂µ√«®æ∫ºŸâ∑’Ë¡’‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–‰¥â®”π«π 285 √“¬ (√âÕ¬≈– 85.8) ¢ÕßºŸâ∑’Ë¡’º≈°“√µ√«®¥â«¬«‘∏’°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠àº‘¥ª°µ‘·µà°“√µ√«®¥â«¬«‘∏’ Guaiac Test ¡’§à“§«“¡®”‡æ“–„°≈â‡§’¬ß°—∫°“√µ√«®¥â«¬«‘∏’ ImmunochemicalTechnic √âÕ¬≈– 87.6 ·≈–√âÕ¬≈– 88.4 µ“¡≈”¥—∫· ¥ßº≈¥—ßµ“√“ß∑’Ë 3

πÕ°®“°π’È¡’°“√µ√«®¥â«¬«‘∏’°“√ àÕß°≈âÕß°√–‡æ“–Õ“À“√ ®”π«π 374 √“¬ æ∫°≈ÿà¡‡ ’Ë¬ß∑’Ë¡’º≈°“√µ√«®º‘¥ª°µ‘ ®”π«π 138 √“¬ (√âÕ¬≈– 0.7) ¢ÕßºŸâªÉ«¬∑—ÈßÀ¡¥ æ∫≈—°…≥–‡π◊ÈÕßÕ° (Polyp) ®”π«π 6√“¬ (√âÕ¬≈– 4.3) °“√‡ªìπ‚√§·º≈Õ—°‡ ∫¢Õß≈”‰ â‡√◊ÈÕ√—ß(Gastric ulcer) ®”π«π 29 √“¬ (√âÕ¬≈– 21.0) ·≈–

60

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ“√“ß∑’Ë 1 ¢âÕ¡Ÿ≈∑—Ë«‰ª¢Õßª√–™“°√∑’ËÕ¬Ÿà„π°≈ÿà¡‡ ’Ë¬ß

√«¡ Positive Negative¢âÕ¡Ÿ≈∑—Ë«‰ª p-value

®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–)

1. ‡æ»- ™“¬ 4,620 (22.7) 116 (2.5) 4,504 (97.5) <0.001- À≠‘ß 15,757 (77.3) 216 (1.4) 15,541 (98.6)√«¡ 20,377 (100.0) 332 (1.6) 20,045 (98.4)

2. Õ“¬ÿ [Mean (SD)] 51.98 (8.39) 55.12 (8.9) 51.93 (8.37) <0.001

3. ª√–«—µ‘°“√‡ªìπ¡–‡√Áß„π§√Õ∫§√—«- ¡’ 5,254 (25.8) 88 (1.7) 5,166 (98.3) 0.756- ‰¡à¡’ 15,123 (74.2) 244 (1.6) 14,879 (98.4)√«¡ 20,377 (100.0) 332 (1.6) 20,045 (98.4)

4. ª√–«—µ‘°“√‡ªìπ¡–‡√Áß≈”‰ â„À≠à„π§√Õ∫§√—«- ¡’ 710 (4.4) 19 (2.7) 691 (97.3) 0.034- ‰¡à¡’ 15,251 (95.6) 244 (1.6) 15,007 (98.4)√«¡ 15,961 (100.0) 263 (1.6) 15,698 (98.4)

5. ª√–«—µ‘°“√¥◊Ë¡·Õ≈°ÕŒÕ≈å- ‰¡à¥◊Ë¡ 13,532 (86.3) 197 (1.5) 13,335 (98.5) 0.001- ¥◊Ë¡‰¡à‡°‘π —ª¥“Àå≈–§√—Èß 1,720 (11.0) 35 (2.0) 1,685 (98.0)- ¥◊Ë¡‡ªìπª√–®” 182 (1.2) 9 (4.9) 173 (95.1)- ‡§¬¥◊Ë¡ 245 (1.6) 5 (2.0) 240 (98.0)

‡≈‘°¥◊Ë¡¡“π“π (ªï) 8.419.97 3.584.05 8.5210.04√«¡ 15,679 (100.0) 246 (1.6) 15,433 (98.4)

6. ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë 14,423 (92.0) 215 (1.5) 14,208 (98.5) 0.018- ‰¡à Ÿ∫- Ÿ∫ 480 (3.1) 14 (2.9) 466 (97.1)

‡√‘Ë¡ Ÿ∫ (ªï) 21.76 ± 7.09 23.21 ± 7.24 21.71 ± 7.09‡√‘Ë¡ Ÿ∫®π°√–∑—Ëßªí®®ÿ∫—π 29.85 ± 10.41 28.50 ± 9.60 29.89 ± 10.45ª√‘¡“≥°“√ Ÿ∫ (´Õß/ªï)

- ‡§¬ Ÿ∫ 214.04 ± 133.85 213.78 ± 117.49 214.05 ± 134.52‡√‘Ë¡ Ÿ∫‡¡◊ËÕÕ“¬ÿ (ªï) 781 (5.0) 17 (2.2) 764 (97.8)‡≈‘° Ÿ∫‡¡◊ËÕÕ“¬ÿ (ªï) 20.83 ± 5.73 21.12 ± 4.84 20.83 ± 5.75√–¬–‡«≈“„π°“√ Ÿ∫ 38.96 ± 10.86 38.71 ± 8.56 38.96 ± 10.92ª√‘¡“≥°“√ Ÿ∫ (´Õß/ªï) 32.70 ± 10.55 34.88 ± 11.78 32.64 ± 10.52

√«¡ 15,684 (100.0) 246 (1.6) 15,438 (98.4)

7. °“√µ√«®§—¥°√Õß- Immunochemical Technic 20,377 (100.0) 2,608 (12.8) 17,769 (87.2)- Guaiac Test 20,377 (100.0) 2,577 (12.6) 17,800 (87.4)

8. °“√µ√«® àÕß°≈âÕß- µ√«®¿“¬„π≈”‰ â„À≠à (Colonoscopy) 1,487 (7.2) 332 (22.3) 1,155 (77.7)- µ√«®¿“¬„π°√–‡æ“–Õ“À“√ (Gastoscopy) 374 (1.8) 136 (36.4) 238 (63.6)



µ“√“ß∑’Ë 2 §«“¡πà“‡™◊ËÕ∂◊Õ¢Õß°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–¥â«¬«‘∏’°“√µ√«®·∫∫ Guaiac Test ·≈–«‘∏’ Immunochemical

Technic ‚¥¬°“√∑”°“√µ√«®´È” 2 §√—Èß

Guaiac Test IIN = 20,377

Positive Negative p-value Kappa Sn Sp

Guaiac Test I Positive 2,539 (84.0) 482 (16.0) <0.001 89.2% 98.5 97.3Negative 38 (0.2) 17,318 (99.8)

Total 2,577 (12.6) 17,800 (87.4)

Immunohistochemistry

N = 20,377 Technic II

Positive Negative p-value Kappa Sn Sp

Immuno Positive 2,503 (94.4) 148 (5.6) <0.001 94.5% 95.9 99.2histochemistry I Negative 105 (4.0) 17,621 (99.2)

Total 2,608 (12.8) 17,769 (87.2)

Positive = æ∫ ‘Ëßº‘¥ª°µ‘ Sn = §«“¡‰«

Negative = ‰¡àæ∫ ‘Ëßº‘¥ª°µ‘ Sp = §«“¡®”‡æ“–

µ“√“ß∑’Ë 3 º≈‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à °—∫°“√µ√«®¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬

«‘∏’ Immunochemical Technic

Guaiac Test Immunohistochemistry TechnicColonoscopy Total

Positive Negative p-value Positive Negative p-value

Positive 332 (1.6) 104 (31.3) 228 (68.7) <0.001 285 (85.8) 47 (14.2) <0.001

Type- Polyp 150 (45.2) 51 (34.0) 99 (66.0) 132 (88.0) 18 (12.0)- Chronic

Ulcerative colitis 48 (14.5) 14 (29.2) 34 (70.8) 41 (85.4) 7 (14.6)- Hemorrhoid 118 (35.5) 27 (22.9) 91 (77.1) 96 (81.4) 22 (18.6)- Cancer colon 16 (4.8) 12 (75.0) 4 (25.0) 16 (100.0) 0 (0.0)

Total 332 (100.0) 104 (31.3) 228 (68.7) 285 (85.8) 47 (14.2)

Sensitivity (Sn) √âÕ¬≈– 31.3 85.8Specificity (Sp) √âÕ¬≈– 87.6 88.4

‡°‘¥°√–‡æ“–Õ—°‡ ∫ (Gastritis) ®”π«π 103 √“¬(√âÕ¬≈– 74.6)

º≈°“√‡ª√’¬∫‡∑’¬∫«‘∏’ Guaiac Test ·≈–°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic ‰¥âº≈‡™àπ‡¥’¬«°—∫°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à °≈à“«§◊Õ °“√

µ√«®¥â«¬«‘∏’ Immunochemical Technic ¡’§à“§«“¡‰« Ÿß°«à“°“√µ√«®¥â«¬«‘∏’ Guaiac Test (√âÕ¬≈– 73.2·≈–√âÕ¬≈– 48.5 µ“¡≈”¥—∫) ®“°º≈°“√µ√«®¥â«¬«‘∏’°“√ àÕß°≈âÕß°√–‡æ“–Õ“À“√æ∫§«“¡º‘¥ª°µ‘ ®”π«π138 √“¬ °“√µ√«®¥â«¬«‘∏’ Immunochemical Technic

62

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ“√“ß∑’Ë 4 º≈‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√ °—∫°“√µ√«®¥â«¬«‘∏’ Guaiac Test ·≈–°“√µ√«®

¥â«¬«‘∏’ Immunochemical Technic

Guaiac Test Immunohistochemistry TechnicColonoscopy Total

Positive Negative p-value Positive Negative p-value

Positive 138 (0.7) 67 (48.6) 71 (51.4) <0.001 101 (73.2) 37 (26.8) <0.001

Type- Polyp 6 (4.3) 4 (66.7) 2 (33.3) 6 (100.0) 0 (0.0)- Gastric Ulcer 29 (21.0) 16 (55.2) 13 (44.8) 23 (79.3) 6 (20.7)- Gastritis 103 (74.6) 47 (45.6) 56 (54.4) 72 (69.9) 31 (30.1)

Total 138 (0.7) 67 (48.6) 71 (51.4) 101 (73.2) 37 (26.8)

Sensitivity (Sn) √âÕ¬≈– 48.5 73.2Specificity (Sp) √âÕ¬≈– 87.6 87.6

µ“√“ß∑’Ë 5 ™π‘¥¢Õß°“√‡°‘¥‚√§∫√‘‡«≥≈”‰ â„À≠à∑’Ë‡°‘¥®“°°“√µ√«®·∫∫ àÕß°≈âÕß∫√‘‡«≥≈”‰ â„À≠à

ChronicLocation Total Cancer colon Polyp Hemorrhoid

ulcerative colitis

®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–)

Ascending Colon 24 (11.9) 1 (7.1) 22 (15.3) 1 (2.3) 0 (0.0)Caecum 14 (6.9) 1 (7.1) 8 (5.6) 5 (11.6) 0 (0.0)Descending Colon 31(15.3) 1 (7.1) 25 (17.4) 5 (11.6) 0 (0.0)Rectum 40 (19.8) 5 (35.7) 22 (15.3) 12 (27.9) 1 (100.0)Sigmoid Colon 78 (38.7) 4 (28.6) 56 (38.9) 18 (41.9) 0 (0.0)Transverse colon 15 (7.4) 2 (14.4) 11 (7.5) 2 (4.7) 0 (0.0)

Total 202 (100.0) 14 (6.9) 144 (71.3) 43 (21.3) 1 (0.5)

‰¥âº≈µ√ß°—π®”π«π 101 √“¬ (√âÕ¬≈– 73.2) º≈°“√µ√«®§≈“¥‡§≈◊ËÕπ®”π«π 37 √“¬ (√âÕ¬≈– 26.8) ·µà°“√µ√«®¥â«¬«‘∏’ Guaiac Test ¡’§à“§«“¡®”‡æ“–‡∑à“°—∫°“√µ√«®¥â«¬«‘∏’ Immunochemical Technic§◊Õ√âÕ¬≈– 87.6 (µ“√“ß∑’Ë 4)

®“°µ“√“ß∑’Ë 5 æ∫«à“µ”·Àπàß∑’Ëæ∫§«“¡º‘¥ª°µ‘¿“¬„π≈”‰ â„À≠à¡“°∑’Ë ÿ¥§◊Õ µ”·Àπàß≈”‰ â„À≠à à«πµ√ß(Sigmoid Colon) √âÕ¬≈– 38.7 √Õß≈ß¡“§◊Õ∑’Ë≈”‰ â„À≠à à«πª≈“¬ (Rectum) √âÕ¬≈– 19.8 ≈”‰ â„À≠à¥â“π´â“¬ (Descending Colon) √âÕ¬≈– 15.3≈”‰ â„À≠à¥â“π¢«“ (Ascending Colon) √âÕ¬≈– 11.9

≈”‰ â„À≠à à«π¢«“ß (Transverse colon) √âÕ¬≈– 7.4·≈–Õ’°ª√–¡“≥√âÕ¬≈– 6.9 æ∫∑’Ë≈”‰ â„À≠à à«πµâπ

§«“¡º‘¥ª°µ‘¢Õß≈”‰ â„À≠à∑’Ëæ∫Õ—π¥—∫·√°§◊Õ°“√‡°‘¥ polyp ®”π«π 144 √“¬ (√âÕ¬≈– 71.3)Õ—π¥—∫ Õß§◊Õ ‚√§·º≈Õ—°‡ ∫¢Õß≈”‰ â‡√◊ÈÕ√—ß ®”π«π43 √“¬ (√âÕ¬≈– 21.3) ·≈–‡°‘¥¡–‡√Áß≈”‰ â„À≠à ®”π«π14 √“¬ (√âÕ¬≈– 6.9)

°“√À“ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à “‡Àµÿ¢Õßªí®®—¬„π°“√‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠àÕ“®®–‡°‘¥‰¥â®“°À≈“¬ “‡Àµÿ ´÷Ëß„π°“√»÷°…“§√—Èßπ’È∑”°“√À“ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§¡–‡√Áß≈”‰ â ‚¥¬¡’ªí®®—¬„π



µ“√“ß∑’Ë 6 ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à

æ∫§«“¡ Crude RR Adjusted RR√«¡ Negative

¢âÕ¡Ÿ≈∑—Ë«‰ª º‘¥ª°µ‘ p-value p-value√“¬ (√âÕ¬≈–) √“¬ (√âÕ¬≈–)

√“¬ (√âÕ¬≈–) 95% (CI) 95% (CI)

1. ‡æ» <0.001 0.002

- ™“¬ 4,620 (22.7) 116 (2.5) 4,504 (97.5) 1.85 (1.47-2.32) 1.59 (1.18-2.14)

- À≠‘ß 15,757 (77.3) 216 (1.4) 15,541 (98.6) 1 1

2. Õ“¬ÿ <0.001 <0.001

- 50 ªï 11,224 (55.1) 235 (2.1) 10,989 (97.9) 1.99 (1.57-2.53) 1.70 (1.29-2.23)

- < 50 ªï 9,153 (44.9) 97 (1.1) 9,056 (98.9) 1 1

3. ª√–«—µ‘°“√‡ªìπ‚√§¡–‡√Áß„π§√Õ∫§√—« 0.756 0.477

- ¡’ 5,254 (25.8) 88 (1.7) 5,166 (98.3) 1.03 (0.81-1.32) 1.10 (0.84-1.44)

- ‰¡à¡’ 15,123 (74.2) 244 (1.6) 14,879 (98.4) 1 1

4. ª√–«—µ‘°“√¥◊Ë¡·Õ≈°ÕŒÕ≈å 0.009 0.152

- ¥◊Ë¡‡ªìπª√–®”·≈–‡§¬¥◊Ë¡ 427 (2.7) 14 (3.3) 413 (96.7) 2.19 (1.26-3.79) 1.55 (0.85-2.83)

- Õ◊ËπÊ 15,252 (97.3) 232 (1.5) 15,020 (98.5) 1 1

5. ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë 0.008 0.823

- Ÿ∫ 1,429 (9.0) 35 (2.4) 1,394 (97.6) 1.66 (1.15-2.38) 1.05 (0.67-1.65)

- ‰¡à Ÿ∫ 14,423 (91.0) 215 (1.5) 14,208 (98.5) 1 1

«‘®“√≥å

«‘∏’°“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–‡æ◊ËÕ∑”°“√µ√«®§—¥°√Õß¡–‡√Áß≈”‰ â„À≠à „πª√–™“°√°≈ÿà¡‡ ’Ë¬ß√–¬–‡√‘Ë¡µâπ ¥â«¬«‘∏’°“√µ√«®·∫∫«‘∏’ ImmunochemicalTechnic ‡ª√’¬∫‡∑’¬∫°—∫°“√µ√«®¥â«¬«‘∏’ Guaiac Test®“°°“√»÷°…“π’È “¡“√∂ √ÿª‰¥â«à“«‘∏’ ImmunochemicalTechnic ∑’Ëæ—≤π“¢÷Èπ¡“„À¡àπ—Èπ ¡’ª√– ‘∑∏‘¿“æ„π°“√µ√«®§—¥°√Õß°≈ÿà¡‡ ’Ë¬ß‰¥âÕ¬à“ß∂Ÿ°µâÕß ·ª≈º≈‰¥âÕ¬à“ß√«¥‡√Á«°«à“°“√µ√«®¥â«¬ Guaiac Test ‚¥¬°“√»÷°…“π’È‰¥â¡’°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à·≈–°“√µ√«® àÕß°≈âÕß°√–‡æ“–Õ“À“√‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ‡ªìπ°“√µ√«®À“§«“¡º‘¥ª°µ‘°—∫ºŸâ∑’Ë‡°‘¥º≈°“√µ√«®Õÿ®®“√–«à“¡’‡≈◊Õ¥ªπ∑ÿ°√“¬ ´÷Ëß‰¥âº≈ √ÿª‡ªìπ¢âÕÊ¥—ßπ’È

1. °“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√– ¥â«¬«‘∏’°“√µ√«®·∫∫ Immunochemical Technic ‡ªìπ«‘∏’°“√

°“√»÷°…“ §◊Õ ªí®®—¬¥â“π‡æ» Õ“¬ÿ ª√–«—µ‘ °“√‡ªìπ‚√§¡–‡√Áß„π§√Õ∫§√—« ª√–«—µ‘°“√¥◊Ë¡·Õ≈°ÕŒÕ≈å·≈–ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë ‰¥âº≈¥—ßµ“√“ß∑’Ë 6

®“°µ“√“ß∑’Ë 6 ®–‡ÀÁπ‰¥â«à“ªí®®—¬¥â“π‡æ» Õ“¬ÿª√–«—µ‘°“√‡ªìπ‚√§¡–‡√Áß„π§√Õ∫§√—« ª√–«—µ‘°“√¥◊Ë¡·Õ≈°ÕŒÕ≈å ·≈–ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë ∑—Èß 5 ªí®®—¬ æ∫«à“¡’‡æ’¬ßªí®®—¬ 2 ªí®®—¬ ∑’Ë¡’§«“¡‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§¡–‡√Áß≈”‰ â„À≠à®“°°“√»÷°…“§√—Èßπ’È ∑’Ë√–¥—∫π—¬ ”§—≠0.05 ‰¥â·°à

1. ªí®®—¬¥â“π‡æ» ®–æ∫«à“‡æ»™“¬¡’‚Õ°“ ‡ ’Ë¬ß∑’Ë®–‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à¡“°°«à“‡æ»À≠‘ß 1.59‡∑à“ ‚¥¬‡æ»™“¬√âÕ¬≈– 2.5 ¡’º≈‡ªìπ positive

2. ªí®®—¬¥â“πÕ“¬ÿ ºŸâ∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï‚Õ°“ ‡ ’Ë¬ß¡“°°«à“§π∑’ËÕ“¬ÿπâÕ¬°«à“ 50 ªï 1.70 ‡∑à“‚¥¬ºŸâ∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï √âÕ¬≈– 2.1 ¡’º≈‡ªìπ positive

64

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ√«®·∫∫„À¡à∑’Ë¡’§«“¡πà“‡™◊ËÕ∂◊Õ §«“¡∂Ÿ°µâÕß ‡ ’¬§à“„™â®à“¬‰¡à¡“°π—° ·≈–¡’ª√– ‘∑∏‘¿“æ„π°“√µ√«®§—¥°√Õß¡“°°«à“«‘∏’°“√µ√«®·∫∫ Guaiac Test ∑—Èßπ’È°“√µ√«®¥â«¬«‘∏’¥—ß°≈à“«¡’§«“¡πà“‡™◊ËÕ∂◊Õ„π°“√µ√«®§—¥°√ÕßºŸâ∑’Ë‡ªìπ‚√§‡°’Ë¬«°—∫≈”‰ â‰¥â∂÷ß√âÕ¬≈– 94.5 ´÷Ëßπ”‰ª Ÿà°“√«‘π‘®©—¬‚√§µ—Èß·µà·√°‡√‘Ë¡‡ªìπ àßº≈„Àâ°“√√—°…“∑’Ë¥’¢÷Èπ °“√Õ¬Ÿà√Õ¥¢ÕßºŸâªÉ«¬¡“°¢÷Èπ

πÕ°®“°§«“¡πà“‡™◊ËÕ∂◊Õ¢Õß°“√µ√«®¥â«¬«‘∏’Immunochemical Technic ·≈â« ‡¡◊ËÕπ”‰ªµ√«® Õ∫§«“¡∂Ÿ°µâÕß¢Õß°“√µ√«®°—∫°“√µ√«®¥â«¬°“√ àÕß°≈âÕß≈”‰ â„À≠à·≈–°√–‡æ“–Õ“À“√ ®–‡ÀÁπ«à“«‘∏’°“√µ√«®·∫∫«‘∏’ Immunochemical Technic ¡’§«“¡‰« Ÿß„π°“√µ√«®§—¥°√Õß¢—Èπµâπ‡∑à“°—∫√âÕ¬≈–85.8 ·≈–√âÕ¬≈– 73.2 µ“¡≈”¥—∫ ´÷Ëßπ—ËπÀ¡“¬§«“¡«à“∂â“‡√“µ√«®¥â«¬«‘∏’¥—ß°≈à“«®”π«π 100 √“¬ º≈°“√µ√«®®–§≈“¥‡§≈◊ËÕπ®“°°“√µ√«®¥â«¬°“√ àÕß°≈âÕß≈”‰ â„À≠à¡’ª√–¡“≥ 15 √“¬ ∂÷ß·¡â«à“°“√µ√«®¥â«¬°“√ àÕß°≈âÕß≈”‰ â„À≠à·≈–°√–‡æ“–Õ“À“√®–¡’ª√– ‘∑∏‘¿“æ ¡’§«“¡·¡àπ¬”„π°“√µ√«®¡“°·µà¢âÕ‡ ’¬°Á§◊Õ °“√∑’Ë°“√µ√«®„π≈—°…≥–∑—Èß Õß®–∑”ºŸâªÉ«¬√Ÿâ ÷°Õ÷¥Õ—¥ ·≈–§à“„™â®à“¬„π°“√µ√«® Ÿß

¥—ßπ—Èπ «‘∏’°“√µ√«®·∫∫ ImmunochemicalTechnic ¡’§«“¡§ÿâ¡§à“„π°“√µ√«®§—¥°√Õß‚√§¡–‡√Áß≈”‰ â„À≠à¡“°°«à“«‘∏’°“√µ√«®·∫∫ Guaiac Test

2. °“√æ‘®“√≥“ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡ªìπ‚√§¡–‡√Áß≈”‰ â„À≠à ®“°°“√»÷°…“§√—Èßπ’È “¡“√∂æ‘®“√≥“‰¥â®“°ªí®®—¬‡ ’Ë¬ßπ’È

ªí®®—¬¥â“π‡æ» ‡π◊ËÕß®“°‡æ»™“¬¡’æƒµ‘°√√¡°“√ Ÿ∫∫ÿÀ√’Ë·≈–¥◊Ë¡ ÿ√“¡“°°«à“‡æ»À≠‘ß ·≈–°“√∫√‘‚¿§·µà≈–§√—Èß¡’ª√‘¡“≥¡“°®÷ß‡ªìπ‡Àµÿ‡°’Ë¬«‡π◊ËÕß„Àâ‡æ»™“¬¡’‚Õ°“ ‡ªìπ‚√§¡–‡√Áß≈”‰ â¡“°°«à“‡æ»À≠‘ß

ªí®®—¬¥â“πÕ“¬ÿ ºŸâ∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï ®–¡’‚Õ°“ ‡ ’Ë¬ß¡“°°«à“§π∑’Ë¡’Õ“¬ÿπâÕ¬°«à“ 50 ªï ºŸâ∑’Ë¡’Õ“¬ÿ¡“°π—Èπ√–∫∫∑“ß‡¥‘πÕ“À“√Õ“®¡’°“√∑”ß“π‰¡à Ÿâ¥’π—° ®÷ß∑”„Àâ‡°‘¥§«“¡‡ ’Ë¬ß∑’Ë®–‡ªìπ‚√§¡“°°«à“ºŸâ∑’Ë¡’Õ“¬ÿπâÕ¬´÷Ëß√–∫∫°“√∑”ß“πµà“ßÊ„π√à“ß°“¬¬—ß¡’ª√– ‘∑∏‘¿“æ¥’Õ¬Ÿà

3. „π°“√µ√«®§√—Èßπ’È∫√‘‡«≥¢Õß≈”‰ â∑’Ëæ∫≈—°…≥–¢Õß‚√§∑’Ë‡°’Ë¬«°—∫≈”‰ â¡“°∑’Ë ÿ¥µ”·Àπàß≈”‰ â „À≠à à«πµ√ß (Sigmoid Colon) §‘¥‡ªìπ√âÕ¬≈– 38.7 ´÷Ëß‡ªìπ°“√‡°‘¥‡π◊ÈÕßÕ° Polyp ®”π«π 56 §π (√âÕ¬≈–38.9) ·≈–¡’‚Õ°“ °≈“¬‡ªìπ‡π◊ÈÕ√â“¬ §«“¡‡ ’Ë¬ß„π°“√‡°‘¥‚√§¡–‡√Áß≈”‰ â„À≠à‡æ‘Ë¡¢÷Èπ

¢âÕ‡ πÕ·π–

„πªí®®ÿ∫—π¬—ß§ß‰¡à “¡“√∂ √ÿª‰¥â«à“«‘∏’°“√„¥‡ªìπ«‘∏’°“√∑’Ë„™âµ√«®§—¥°√Õß¡–‡√Áß≈”‰ â„À≠à‰¥â¥’∑’Ë ÿ¥ ·≈–°“√µ√«®À“‡¡Á¥‡≈◊Õ¥∑’Ëªπ¡“„πÕÿ®®“√–∂◊Õ«à“‡ªìπ«‘∏’∑’Ë –¥«°√«¥‡√Á« ‡ ’¬§à“„™â®à“¬πâÕ¬ “¡“√∂µ√«®‰¥âµ“¡ ∂“πæ¬“∫“≈∑—Ë«‰ª ‰¡àµâÕß„™â‡§√◊ËÕß¡◊Õ∑’Ë¡’√“§“·æß√«¡∑—Èß®“°°“√»÷°…“«‘®—¬„πµà“ßª√–‡∑»°Áæ∫«à“ °“√µ√«®À“‡¡Á¥‡≈◊Õ¥„πÕÿ®®“√–π’È¬—ß “¡“√∂≈¥Õ—µ√“°“√‡°‘¥·≈–Õ—µ√“°“√‡ ’¬™’«‘µ®“°¡–‡√Áß≈”‰ â„À≠à≈ß‰¥â°“√µ√«®¥â«¬«‘∏’ guaiac test ¡’¢âÕ®”°—¥§◊Õ §«“¡‰«¢Õß°“√µ√«®§àÕπ¢â“ßµË”Õ¬Ÿà∑’Ë§à“‡©≈’Ë¬ª√–¡“≥√âÕ¬≈–25-30 √«¡∂÷ß°“√¡’º≈∫«°≈«ß§àÕπ¢â“ß¡“° ‡™àπ °“√√—∫ª√–∑“π‡π◊ÈÕ —µ«å À√◊Õº—°º≈‰¡â∫“ß™π‘¥°Á®–∑”„Àâ‡°‘¥ªØ‘°√‘¬“ ÕÕ°´‘‡¥™—π °—∫ “√ guaiac ‰¥â ¥—ßπ—Èπ°àÕπ°“√∑”°“√µ√«®®–µâÕß¡’°“√·π–π”„ÀâºŸâªÉ«¬ªØ‘∫—µ‘µ—«§àÕπ¢â“ß®–¬ÿàß¬“° ”À√—∫°“√µ√«®¥â«¬«‘∏’Immunochemical technics ®–‡ªìπ°“√µ√«®‚¥¬„™â “√·Õπµ’∫Õ¥’ ∑’Ë®”‡æ“–‡®“–®ß°—∫ Œ’‚¡‚°≈∫‘π¢Õß§π‚¥¬µ√ß´÷Ëß®–‰¥âº≈°“√µ√«®∑’Ë¡’§«“¡‰«·≈–®”‡æ“–‡®“–®ß¡“°°«à“ ·≈–º≈¢Õß°“√µ√«®®–‰¡à∂Ÿ°√∫°«π®“° “√ Heme À√◊Õ “√æ«° anti-oxidases „πÕ“À“√πÕ°®“°π’È°“√µ√«®¥â«¬«‘∏’ Immunochemical technics¬—ß‡ªìπ°“√µ√«®À“‡©æ“–‡≈◊Õ¥∑’ËÕÕ°®“°∑“ß‡¥‘πÕ“À“√ à«πª≈“¬‡∑à“π—Èπ ‡æ√“– “√Œ’‚¡‚°≈∫‘π∑’Ë‡°‘¥®“°°“√¡’‡≈◊Õ¥ÕÕ°„π∑“ß‡¥‘πÕ“À“√ à«πµâπ®–∂Ÿ°¬àÕ¬ ≈“¬‡ª≈’Ë¬π ¿“æ‰ªÀ¡¥°àÕπ∑’Ë®–∂÷ß≈”‰ â„À≠à·≈–∂Ÿ°¢—∫∂à“¬ÕÕ°¡“„πÕÿ®®“√– à«π¢âÕ¥’¥â“πÕ◊Ëπ¢Õß°“√µ√«® Immunochemical technics §◊Õ°“√‡µ√’¬¡µ—«¢Õß§π‰¢â –¥«°°«à“ Õ’°∑—Èß¬—ß™à«¬≈¥®”π«π¢Õß°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à≈ß‰¥â ”À√—∫¢âÕ®”°—¥



¢Õß°“√µ√«®¥â«¬«‘∏’ Immunochemical technics π’È§ß®–¡’·µà‡√◊ËÕß§à“µ√«®∑’Ë¡’√“§“§àÕπ¢â“ß Ÿß‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√µ√«®¥â«¬«‘∏’ Guaiac test ·µà∂â“π”§à“„™â®à“¬„π°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à„π√“¬∑’Ë¡’º≈∫«°≈«ß®“°°“√µ√«®¥â«¬«‘∏’ Guaiac test ¡“§”≥«π·≈â«®–æ∫«à“ °“√µ√«®¥â«¬«‘∏’ Immunochemical technic¡’§à“„™â®à“¬√«¡πâÕ¬°«à“

„πÕπ“§µ ”À√—∫ª√–‡∑»‰∑¬°“√µ√«®Õÿ®®“√–À“°≈ÿà¡‡ ’Ë¬ß¡–‡√Áß≈”‰ â„À≠à§«√®–¡’°“√æ‘®“√≥“π”«‘∏’Immunochemical technics ¡“„™â √à«¡°—∫°“√®—¥‚ª√·°√¡µ“√“ß°“√µ√«® àÕß°≈âÕß≈”‰ â„À≠à À√◊Õ‡Õ°´å‡√¬å «π·ªÑß·∫‡√’¬¡ ‡æ◊ËÕ‡ªìπ°“√µ√«®§âπÀ“√Õ¬‚√§À√◊Õ§«“¡º‘¥ª°µ‘¢Õß≈”‰ â„À≠à∑’Ë®–¡’‚Õ°“ æ—≤π“°≈“¬‡ªìπ¡–‡√Áß‰¥â ÷Ëß®–™à«¬„ÀâÕ—µ√“°“√‡°‘¥·≈–Õ—µ√“°“√‡ ’¬™’«‘µ®“°¡–‡√Á ß≈”‰ â „À≠à¢Õßª√–™“™π‰∑¬≈¥≈ß ·≈–¬—ß™à«¬≈¥¿“√–§à“„™â®à“¬∑“ß¥â“πß∫ª√–¡“≥¢Õßª√–‡∑»∑’Ë®–µâÕß¡“√—∫¿“√–„π°“√¥Ÿ·≈ºŸâªÉ«¬¡–‡√Áß≈”‰ â„À≠à≈ß

6. Eisen GM, Weinberg DS. Narrative review: screening

for colorectal cancer in patients with a first-degree

relative with colonic neoplasia. Ann Intern Med 2005;

143:190-8.

7. Hamilton W, Sharp D. Diagnosis of colorectal cancer

in primary care: the evidence base for guidelines. Fam

Pract 2004; 21:99-106.

8. Hardcastle JD, Chamberlain JD, Robinson MHE.

Randomised controlled trial of Stool-occult-blood

screening for colorectal cancer. Lancet 1996; 348:1472-

7.

9. Heitman SJ, Manns BJ, Hilsden RJ, Fong A, Dean S,

Romagnuolo J. Cost-effectiveness of computerized

tomographic colonography versus colonoscopy for

colorectal cancer screening. CMAJ 2005; 173:877-81.

10. Hoff G, Grotmol T, Thiis-Evensen E, Bretthauer M,

Gondal G, Vatn MH. Testing for stool calprotectin

(PhiCal) in the Norwegian colorectal cancer prevention

trial on flexible sigmoidoscopy screening: comparison

with an immunochemical test for occult blood (FlexSure

OBT). Gut 2004; 53:1329-33.

11. Ilyas M, Straub J, Tomlison IPM. Genetic pathways in

colorectal and other cancers. Eur J Cancer 1999;

35:335-51.

12. Kim Y, Lee S, Park S, Jeon H, Lee W, Kim JK, et al.

Gastrointestinal tract cancer screening using stool

carcinoembryonic antigen. Ann Clin Labor Sci 2003;

33:32-8.

13. Kronborg O, Fenger C, Olsen J, et al. Randomised

study of screening for colorectal cancer with stool-

occult-blood test. Lancet 1996; 348:1467-71.

14. Levin B, Brooks D, Smith RA, Stone A. Emerging

technologies in screening for colorectal cancer: CT

colonography, immunochemical stool occult blood tests,

and stool screening using molecular markers. CA

Cancer J Clin 2003; 53:44-55.

15. Lieberman DA, Prindiville S, Weiss DG, Willett W.

Risk factors for advanced colonic neoplasia and

hyperplastic polyps in asymptomatic individuals.

JAMA 2003; 290:2959-67.

16. Macari M, Bini EJ, Jacobs SL, Naik S, Lui YW, Milano

A, et al. Colorectal polyps and cancers in asympto-

matic average-risk patients: evaluation with CT

colonography. Radiology 2004; 230:629-36.

17. Mandel JS, Church TR, Bond JH, et al. The effect of

stool occult-blood screening on the incidence of

colorectal cancer. N Engl J Med 2000; 343:1603-7.

18. Mandel JS, Church TR, Ederer F, et al. Colorectal


1. Bampton PA, Sandford JJ, Cole SR, Smith A, Morcom

J, Cadd B, et al. Interval stool occult blood testing in a

colonoscopy based screening programme detects

additional pathology. Gut 2005; 54:803-6.

2. Boyle P, Leon ME. Epidemiology of colorectal cancer.

Br Med Bull 2002; 64:1-25.

3. Boyle P, Vainio H, Smith R, Benamouzig R, Lee WC,

Segnan N, et al. Workgroup I: criteria for screening.

UICC International Workshop on Facilitating Screening

for Colorectal Cancer, Oslo, Norway (29 and 30 June

2002). Ann Oncol 2005; 16:25-30.

4. Brenner DE, Rennert G. Stool DNA biomarkers for the

detection of colorectal neoplasia: attractive, but is it

feasible?. J Natl Cancer Inst 2005; 97:1107-9.

5. Collins JF, Lieberman DA, Durbin TE, Weiss DG, and

the Veterans Affairs Cooperative Study #380 Gr.

Accuracy of screening for stool occult blood on a single

stool sample Obtained by digital rectal examination: a

comparison with recommended sampling practice. Ann

Intern Med 2005; 142:81-5.

66

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

services, and epidemiologic research. cancer epidemiol.

Biomarkers Prev 2004; 13:898-905.

24. Walsh JME, Terdiman JP. Colorectal cancer screening:

scientific review. JAMA 2003; 289:1288-96.

25. Whynes DK. The economic case for stool occult blood

screening. Ann Oncol 2002; 13:1953-5.

26. Yabroff KR, Klabunde CN, Myers R, Brown ML.

Physician recommendations for follow-up of positive

stool occult blood tests. Med Care Res Rev 2005;

62:79-110.

27. Yamaji Y, Mitsushima T, Ikuma H, Watabe H, Okamoto

M, Kawabe T, et al. Incidence and recurrence rates of

colorectal adenomas estimated by annually repeated

colonoscopies on asymptomatic Japanese. Gut 2004;

53:568-72.

28. Yeazel MW, Church TR, Jones RM, Kochevar LK,

Watt GD, Cordes JE, et al. (2004). Colorectal cancer

screening adherence in a general population. Cancer

Epidemiol Biomarkers Prev 2004; 13:654-7.

cancer mortality: Effectiveness of Biennial screening

for stool occult blood. J Natl Cancer Inst 1999; 91:434-

7.

19. Mandel JS. Sigmoidoscopy screening probably works,

but how well is still unknown. J Natl Cancer Inst 2003;

95:571-3.

20. Rawl SM, Menon U, Champion VL, May FE, Loehrer

P Sr, Hunter C, et al. (2005). Do benefits and barriers

differ by stage of adoption for colorectal cancer

screening? Health Educ Res 2005; 20:137-48.

21. Robinson MH. Do those with positive stool occult

blood tests need upper gastrointestinal investigations if

no colorectal cancer cause is found?. Gut 2002; 51:466-

7.

22. Scholefield JH. Screening for colorectal cancer. Br

Med Bull 2002; 64:75-80.

23. Vernon SW, Meissner H, Klabunde C, Rimer BK,

Ahnen DJ, Bastani R, et al. Measures for ascertaining

use of colorectal cancer screening in behavioral, health




°“√√—°…“¡–‡√Áß‡µâ“π¡¥â«¬°“√ºà“µ—¥ ß«π‡µâ“π¡·≈–°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥ »Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’æß»∏√ »ÿ¿Õ√√∂°√ æ.∫.°≈ÿà¡ß“π√—ß ’√—°…“ »Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’ °√¡°“√·æ∑¬å

Abstract Breast Cancer Treatment with Breast-conserving Surgery and Post Operative Radiationin Ubonratchathani Cancer CenterPongsatorn S.

Department of Radiation Oncology, Ubonratchathaani Cancer Center


From January 2002-December 2004, 19 breast cancer patients in Ubonratchathani cancercenter had completed treatment with brast-conserving surgery and post operative radiation . The radiationdose was 50 Gy to the whole breast and additional boost to some indicated patients. Median follow up of thesepatients was 41 months (13-63 months). Only one patient had recurrence within the ipsilateral breast. Nodistant metastasis was found. No patient died in the follow up period. Conclusions breast-conserving surgeryplus post operative radiation should be a standard treatment for resectable breast cancer in Ubonratchathanicancer center.

Key words: breast cancer, breast-conserving surgery

‡√◊ËÕß¬àÕ ‰¥â»÷°…“¬âÕπÀ≈—ßºŸâªÉ«¬¡–‡√Áß‡µâ“π¡∑’Ë√—∫°“√√—°…“¥â«¬°“√ºà“µ—¥ ß«π‡µâ“π¡ (breast-conserving surgery) ·≈–©“¬√—ß ’À≈—ßºà“µ—¥µ—Èß·µàªï æ.». 2545-2547 ‡ªìπ®”π«π 19 √“¬ ∑ÿ°√“¬‰¥â√—∫√—ß ’∑’Ë‡µâ“π¡ 50 Gy ‡ªìπÕ¬à“ßπâÕ¬ §à“¡—∏¬∞“π¢Õß√–¬–‡«≈“°“√µ‘¥µ“¡°“√√—°…“‡∑à“°—∫ 41 ‡¥◊Õπ (13-63 ‡¥◊Õπ) æ∫«à“¡’ºŸâªÉ«¬ 1 √“¬ Õ“°“√°”‡√‘∫∑’Ë‡µâ“π¡¢â“ß‡¥‘¡ ‰¡àæ∫°“√°√–®“¬‰ªÕ«—¬«–Õ◊Ëπ Ê ·≈–ºŸâªÉ«¬∑ÿ°√“¬¡’™’«‘µÕ¬Ÿà„π™à«ß‡«≈“∑’Ë “¡“√∂µ‘¥µ“¡º≈°“√√—°…“‰¥â °“√√—°…“¡–‡√Áß‡µâ“π¡¥â«¬«‘∏’ ß«π‡µâ“π¡ ·≈–©“¬√—ßÀ≈—ß°“√ºà“µ—¥‡ªìπ«‘∏’∑’Ë¡’º≈°“√√—°…“‡∑à“‡∑’¬¡°—∫°“√ºà“µ—¥ modified radical mastectomy ¥—ßπ—Èπ§«√‡ªìπ«‘∏’¡“µ√∞“π Õ¬à“ßÀπ÷Ëß„π°“√√—°…“¡–‡√Áß‡µâ“π¡„π»Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’ µàÕ‰ª

§” ”§—≠: ¡–‡√Áß‡µâ“π¡ °“√ºà“µ—¥ ß«π‡µâ“π¡

68

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

¡–‡√Áß‡µâ“π¡‡ªìπ¡–‡√Áß∑’Ëæ∫∫àÕ¬„π µ√’‰∑¬ ®“° ∂‘µ‘‚√§¡–‡√Áß¢Õß»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ ªï æ.». 2545-2547 ¡’ºŸâªÉ«¬¡–‡√Áß‡µâ“π¡ √“¬„À¡à 192-220 √“¬/ªï(√âÕ¬≈– 11-19) ¢ÕßºŸâªÉ«¬„À¡à∑—ÈßÀ¡¥1-4

°“√ºà“µ—¥ modified radical mastectomy ∂◊Õ‡ªìπ°“√ºà“µ—¥∑’Ë„™âÕ¬à“ß·æ√àÀ≈“¬„π°“√√—°…“¡–‡√Áß‡µâ“π¡ ·µà‡π◊ËÕß®“°ºŸâªÉ«¬µâÕß Ÿ≠‡ ’¬ ‡µâ“π¡‰ª®÷ßπ”°“√ºà“µ—¥·∫∫ ß«π‡µâ“π¡ (breast-conservingsurgery) ¡“„™â °“√√—°…“«‘∏’π’ÈºŸâªÉ«¬®”‡ªìπµâÕß‰¥â√—∫°“√‡ √‘¡¥â«¬°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥∑ÿ°√“¬‡æ◊ËÕ≈¥°“√°”‡√‘∫‡©æ“–∑’Ë

®“°°“√»÷°…“¢ÕßÕ—¡‡∫Õ√å‚µ (Umberto) ·≈–§≥–5 ´÷Ëß‰¥â‡ª√’¬∫‡∑’¬∫ºŸâªÉ«¬ ®”π«π 701 √“¬ ‚¥¬·∫àß‡ªìπ°≈ÿà¡ºà“µ—¥ mastectomy ·≈– breast-conserving surgery µ“¡¥â«¬°“√©“¬√—ß ’ À≈—ß°“√ºà“µ—¥ ‚¥¬µ‘¥µ“¡‡ªìπ‡«≈“ 20 ªï ∑—Èß 2 °≈ÿà¡ ¡’‚Õ°“ √Õ¥™’«‘µ‡∑à“‡∑’¬¡°—π

·µà„πª√–‡∑»‰∑¬ ‚¥¬‡©æ“– à«π¿Ÿ¡‘¿“§¬—ß¡’°“√√—°…“¥â«¬«‘∏’ breast-conserving surgery πâÕ¬¡“° „π»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ °“√√—°…“ºŸâªÉ«¬¡–‡√Áß‡µâ“π¡„π√–¬–∑’Ë¬—ßºà“µ—¥‰¥â à«π„À≠à¬—ß‡ªìπ°“√ºà“µ—¥modified radical mastectomy ·≈â«µ“¡¥â«¬ °“√©“¬√—ß ’ , ‡§¡’∫”∫—¥·≈– °“√∫”∫—¥∑“ßŒÕ√å‚¡π ·≈â«·µà¢âÕ∫àß™’È„πºŸâªÉ«¬·µà≈–√“¬

µ—Èß·µàªï æ.». 2545 ∂÷ß ªï æ.». 2547 ¡’ºŸâªÉ«¬®”π«πÀπ÷Ëß´÷Ëß¡’§«“¡ª√– ß§å®–√—∫°“√ºà“µ—¥¥â«¬«‘∏’breast-conserving surgery °“√»÷°…“π’È‰¥âπ”¢âÕ¡Ÿ≈¬âÕπÀ≈—ß°“√√—°…“ºŸâªÉ«¬∑—Èß 19 √“¬ ¡“«‘‡§√“–Àåº≈°“√√—°…“ ‡æ◊ËÕπ”¡“‡ªìπ¢âÕ¡Ÿ≈ ”À√—∫°“√µ—¥ ‘π„®‡≈◊Õ°°“√√—°…“ ”À√—∫·æ∑¬å·≈–ºŸâªÉ«¬µàÕ‰ª

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“¬âÕπÀ≈—ß ºŸâªÉ«¬¡–‡√Áß‡µâ“π¡∑ÿ°√“¬∑’Ë‰¥â√—∫°“√√—°…“¥â«¬°“√ºà“µ—¥ breast-conservingsurgery ‚¥¬«‘∏’ lumpectomy ·≈– axillary nodedissection µ“¡¥â«¬°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥ ≥

»Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’ „π™à«ß√–À«à“ß æ.». 2545 ∂÷ßæ.». 2547

°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥ª√–°Õ∫¥â«¬°“√©“¬√—ß ’∑—Èß‡µâ“π¡ (whole breast radiation) 50 Gy ± °“√©“¬√—ß ’‡æ‘Ë¡ (boots) ∑’Ëµ”·Àπàß‡π◊ÈÕßÕ°∑’Ë‰¥â√—∫°“√ºà“µ—¥ÕÕ°Õ’° 10 Gy ´÷Ëß°“√©“¬√—ß ’‡æ‘Ë¡¢÷Èπ°—∫°“√µ—¥ ‘π„®¢Õß√—ß ’·æ∑¬å∑’Ë√—°…“ ºŸâªÉ«¬∑’Ë¡’°“√°√–®“¬‰ªµàÕ¡πÈ”‡À≈◊Õß√—°·√âµ—Èß·µà 4 µàÕ¡¢÷Èπ‰ª ®–‰¥â√—∫°“√©“¬√—ß ’∑’Ë∫√‘‡«≥‡Àπ◊Õ‰Àª≈“√â“·≈–√—°·√â‡ªìπ ®”π«π50 Gy ∑ÿ°√“¬„™âª√‘¡“≥√—ß ’ 20 Gy/fraction, 5 «—π/ —ª¥“Àå (conventional fractionation) ºŸâªÉ«¬∑’Ë®”‡ªìπµâÕß„Àâ¬“‡§¡’∫”∫—¥®–‰¥â√—∫¬“‡§¡’∫”∫—¥°àÕπ∑”°“√©“¬√—ß ’ à«πŒÕ√å‚¡π∫”∫—¥®–‰¥â√—∫À≈—ß°“√©“¬√—ß ’§√∫

º≈

µ—Èß·µàªï æ.». 2545 ∂÷ß ªïæ.». 2547 ¡’ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√√—°…“¥â«¬«‘∏’ lumpectomy ·≈– axillary nodedissection µ“¡¥â«¬°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥∑’Ë»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ ®”π«π 19 √“¬

≈—°…≥–¢ÕßºŸâªÉ«¬‰¥â· ¥ß„πµ“√“ß∑’Ë 1 “¡“√∂µ‘¥µ“¡°“√√—°…“‰¥â µ—Èß·µà 13-63 ‡¥◊Õπ

‚¥¬π—∫µ—Èß·µà«—π∑’Ë‰¥â√—∫°“√«‘π‘®©—¬ ¡’§à“¡—∏¬∞“π¢Õß√–¬–‡«≈“°“√µ‘¥µ“¡°“√√—°…“ (median follow up)41 ‡¥◊Õπ ºŸâªÉ«¬∑—ÈßÀ¡¥‰¥â√—∫°“√ºà“µ—¥ lumpectomy·≈– axillary node dissection

ºŸâªÉ«¬ 16 √“¬ ‰¥â√—∫‡§¡’∫”∫—¥À≈—ß°“√ºà“µ—¥‚¥¬‰¥â√—∫ Ÿµ√ AC 6 √“¬, CMF 5 √“¬, FEC 2 √“¬,FAC 1 √“¬, EC 1 √“¬, AC T 1 √“¬ (A =Adriamycin, C = Cyclophosphamide, M = MTX,F = 5-FU, E = Epirubicin, T = Paclitaxel)

„π à«π°“√©“¬√—ß ’À≈—ßºà“µ—¥ ºŸâªÉ«¬∑—Èß 19 √“¬‰¥â√—∫°“√©“¬√—ß ’¥â«¬ ‡§√◊ËÕß‚§∫Õ≈∑å-60 ‚¥¬©“¬∑—Èß‡µâ“π¡ (whole breast) ª√‘¡“≥ 50 Gy À≈—ß®“°π—Èπ‰¥â√—∫°“√©“¬‡æ‘Ë¡ª√‘¡“≥√—ß ’√Õ∫·º≈ºà“µ—¥ 10 √“¬‚¥¬‰¥â√—∫ª√‘¡“≥√—ß ’ 10 Gy ®”π«π 9 √“¬, 20 Gy®”π«π 1 √“¬ („π√“¬∑’Ë surgical margin positive)ºŸâªÉ«¬ 9 √“¬ ‰¡à‰¥â√—∫°“√©“¬√—ß ’‡æ‘Ë¡ ºŸâªÉ«¬∑’Ë‰¥â√—∫



‡§¡’∫”∫—¥ ¡’ºŸâªÉ«¬ 1 √“¬ ∑’ËÕ“°“√°”‡√‘∫∑’Ë‡µâ“π¡¢â“ß‡¥‘¡ ·µà‡ªìπ§π≈–µ”·Àπàß°—∫∫√‘‡«≥‡π◊ÈÕßÕ°‡¥‘¡(tumor bed) ‰¡àæ∫ºŸâªÉ«¬∑’Ë¡’°“√°”‡√‘∫∑’Ëµ”·Àπàß‡π◊ÈÕßÕ°‡¥‘¡ (tumor bed) ‰¡àæ∫ºŸâªÉ«¬∑’Ë‡°‘¥°“√°√–®“¬‰ªÕ«—¬«–Õ◊ËπÊ (distant metastasis) „π™à«ß‡«≈“∑’Ëµ‘¥µ“¡°“√√—°…“‡≈¬

«‘®“√≥å

„π√–¬–‡«≈“∑’Ëºà“π¡“°“√√—°…“¡–‡√Áß‡µâ“π¡¥â«¬«‘∏’ ß«π‡µâ“π¡¬—ß‰¡à·æ√àÀ≈“¬π—°„π à«π¿Ÿ¡‘¿“§·¡â·µà„π»Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’‡Õß´÷Ëß¡’§«“¡æ√âÕ¡„π¥â“π°“√„Àâ√—ß ’√—°…“À≈—ß°“√ºà“µ—¥°Á¬—ß¡’°“√√—°…“«‘∏’π’ÈπâÕ¬ Õ“®‡π◊ËÕß®“°ºŸâªÉ«¬¡’§«“¡°—ß«≈„π°“√√—°…“‡µâ“π¡‰«â

®“°°“√µ‘¥µ“¡°“√√—°…“ºŸâªÉ«¬∑—Èß 19 √“¬ ‚¥¬¡’§à“¡—∏¬∞“π¢Õß°“√µ‘¥µ“¡ (median follow-up)45 ‡¥◊Õπ ‰¥âº≈°“√√—°…“‡ªìπ∑’Ëπà“æÕ„® §◊Õ¡’°“√°”‡√‘∫„π‡µâ“π¡¢â“ß‡¥’¬«°—π‡æ’¬ßÀπ÷Ëß√“¬ ·≈–‰¡àæ∫°“√°√–®“¬‰ªÕ«—¬«–Õ◊Ëπ‡≈¬

®“°°“√»÷°…“„πµà“ßª√–‡∑»∑’Ë¡’®”π«πºŸâªÉ«¬‡ªìπ®”π«π¡“° ·≈–¡’°“√µ‘¥µ“¡‡ªìπ√–¬–‡«≈“π“π æ∫«à“°“√√—°…“¡–‡√Áß‡µâ“π¡¥â«¬°“√ºà“µ—¥ breast- conserv-ing surgery ¥â«¬√—ß ’À≈—ß°“√ºà“µ—¥ ‰¥âº≈‡∑à“‡∑’¬¡°—π°—∫°“√ºà“µ—¥ Modified radical mastectomy5,6 ·µà°“√√—°…“«‘∏’π’ÈµâÕßµ“¡¥â«¬°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥‡ ¡Õ ®“°°“√»÷°…“¢Õßøî™‡™Õ√å (Fisher) ·≈–§≥–5

æ∫«à“ ∂â“ºŸâªÉ«¬‰¥â√—∫°“√ºà“µ—¥ lumpectomy Õ¬à“ß‡¥’¬«‚¥¬‰¡à©“¬√—ß ’¡’°“√°”‡√‘∫„π‡µâ“π¡¢â“ß‡¥’¬«°—π∂÷ß√âÕ¬≈– 39.2 ·µà∂â“¡’°“√©“¬√—ß ’√à«¡¥â«¬®–æ∫‚Õ°“ °”‡√‘∫„π‡µâ“π¡¢â“ß‡¥’¬«°—π·§à√âÕ¬≈– 14.3 (p < 0.001)6

°“√√—°…“«‘∏’π’È ¡§«√‰¥â√—∫°“√„™âÕ¬à“ß·æ√à À≈“¬¡“°¬‘Ëß¢÷Èπ ‡æ√“–™à«¬≈¥ª¡¥âÕ¬„π°“√ Ÿ≠‡ ’¬‡µâ“π¡‰ªÕ¬à“ß‰√°Áµ“¡°“√√—°…“¥â«¬«‘∏’π’È®–‡æ‘Ë¡¿“√–ß“π„π°“√©“¬√—ß ’ ®“°ºŸâªÉ«¬„π°“√»÷°…“π’È∑—Èß 19 √“¬ À“°‰¥â√—∫°“√ºà“µ—¥¥â«¬«‘∏’ modified radical mastectomy®–¡’ºŸâªÉ«¬‡æ’¬ß√“¬‡¥’¬«‡∑à“π—Èπ∑’Ë®”‡ªìπµâÕß‰¥â√—∫°“√©“¬√—ß ’À≈—ß°“√ºà“µ—¥

µ“√“ß∑’Ë 1 ≈—°…≥–ºŸâªÉ«¬·≈–‡π◊ÈÕßÕ°

ºŸâªÉ«¬

Õ“¬ÿ

™à«ßÕ“¬ÿ 36-61 ªï

‡©≈’Ë¬Õ“¬ÿ (mean) 44.5 ªï

‡π◊ÈÕßÕ°

¢π“¥¢Õß‡π◊ÈÕßÕ° 1-5 ´¡.

§à“‡©≈’Ë¬¢Õß¢π“¥ (mean) 2.5 ´¡.

√–¬–‚√§

T1 7 √“¬

T2 11 √“¬

T3 1 √“¬

N0 15 √“¬

N1 4 √“¬

º≈æ¬“∏‘

Invasive ductal carcinoma 18 √“¬

Invasive lobular carcinoma 1 √“¬

®”π«πµàÕ¡πÈ”‡À≈◊Õß√—°·√â∑’Ëæ∫

°“√°√–®“¬¢Õß‚√§ (positive nodes)

0 15 √“¬

1 ‡¡Á¥ 1 √“¬

2 ‡¡Á¥ 1 √“¬

5 ‡¡Á¥ 1 √“¬

18 ‡¡Á¥ 1 √“¬

¿“«– Hormone-receptor

Estrogen-receptor positive 10 √“¬

Estrogen-receptor negative 8 √“¬

‰¡à∑√“∫ 1 √“¬

Surgical margin

positive 1 √“¬

negative 18 √“¬

√—ß ’‡æ‘Ë¡ ‰¥â√—∫°“√©“¬√—ß ’‡æ‘Ë¡¥â«¬‡§√◊ËÕß‚§∫Õ≈∑å-60©“¬√—ß ’®“°¥â“πÀπâ“ (anterior field) ¡’ºŸâªÉ«¬ 2 √“¬‰¥â√—∫°“√©“¬√—ß ’∑’Ë∫√‘‡«≥‰Àª≈“√â“·≈–√—°·√âª√‘¡“≥50 Gy

®“°°“√µ‘¥µ“¡ºŸâªÉ«¬À≈—ß°“√√—°…“¥â«¬√—ß ’·≈–

70

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

ªí®®ÿ∫—π¡’‡∑§‚π‚≈¬’„π°“√„Àâ√—ß ’√—°…“„À¡àÊ ¡“√—°…“ºŸâªÉ«¬À≈—ß°“√ºà“µ—¥ breast-conserving surgery‡æ◊ËÕ≈¥°“√‰¥â√—∫√—ß ’¢Õß‡µâ“π¡·≈–≈¥√–¬–‡«≈“„π°“√„Àâ√—ß ’√—°…“„Àâ —Èπ≈ß °“√°”‡√‘∫¢Õß‡π◊ÈÕßÕ°À≈—ß°“√ºà“µ—¥ √âÕ¬≈– 70-80 ®–æ∫„πµ”·Àπàß„°≈â°—∫µ”·Àπàß‡π◊ÈÕßÕ°‡¥‘¡ ¥—ßπ—Èπ®÷ß¡’°“√æ—≤π“°“√„Àâ√—ß ’√—°…“‡©æ“–„πµ”·Àπàß ‡π◊ÈÕßÕ°‡¥‘¡∑’Ë‰¥â√—∫°“√ºà“µ—¥ÕÕ°‰ª·≈â« (accelerated partial breast irradiation)´÷Ëß∑”‰¥âÀ≈“¬«‘∏’ ‡™àπ °“√„ à·√à (brachytheray) ‚¥¬Õÿª°√≥å Mammosite8 À√◊Õ implantation9 °“√©“¬√—ß ’ 3 ¡‘µ‘ À√◊Õ°“√©“¬√—ß ’™π‘¥ª√—∫§«“¡‡¢â¡ (IMRT)´÷Ëß∑—ÈßÀ¡¥π’È®–„Àâ√—ß ’®”°—¥‡©æ“–µ”·Àπàß ‡π◊ÈÕßÕ°‡¥‘¡·≈–‡π◊ÈÕ‡¬◊ËÕ„°≈â‡§’¬ß·≈– “¡“√∂„™â‡«≈“ —Èπ≈ß‰¥â¡“°·µà°“√√—°…“¥â«¬«‘∏’„À¡àÊ π’È ¬—ßµâÕß‰¥â√—∫°“√æ—≤π“»÷°…“°àÕπ®–¡’°“√π”¡“„™â„π»Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’µàÕ‰ª

√ÿª

°“√√—°…“¡–‡√Áß‡µâ“π¡¥â«¬«‘∏’°“√ºà“µ—¥ ß«π‡µâ“π¡ (breast-conserving surgery) ·≈–©“¬√—ß ’À≈—ß°“√ºà“µ—¥ (post operative radiation) ‡ªìπ«‘∏’∑’Ë¡’º≈°“√√—°…“‡∑à“‡∑’¬¡°—∫°“√ºà“µ—¥ modified radicalmastectomy ‡ªìπ«‘∏’∑’Ë§«√„™â‡ªìπ¡“µ√∞“π„π°“√√—°…“¡–‡√Áß‡µâ“π¡Õ¬à“ßÀπ÷Ëß„π»Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’ µàÕ‰ª

2. Àπà«¬∑–‡∫’¬π¡–‡√Áß »Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’. ∂‘µ‘‚√§¡–‡√Áßæ.». 2546 (Hospital base cancer registry). »Ÿπ¬åªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√Áß ®—ßÀ«—¥Õÿ∫≈√“™∏“π’; 2546.


4. Veronesi U, Cascinelli N, Mariani L, Grecom, Saccozzi

R, Luini A. Twenty-year follow-up of a randomized

study comparing breast- conserving surgery with radical

mastectomy for early breast cancer. N Engl J Med 2002;

347:1227-32.

5. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch

M, Fisher ER. Twenty-year follow-up of a randomized

trial comparing total mastectomy, lumpectomy, and

lumpectomy plus irradiation for the treatment of invasive

breast cancer. N Engl J Med 2002; 347:1233-41.

5. Santiago RJ, Wu L, Harris E. Fifteen-year results of

breast-conserving surgery and definitive irradiation for

stage I and I breast carcinoma: the University of

Pennsylvania experience. Int J Radiat Oncol Biol Phys

2004; 58:233.

6. Bartelink H, Horiot JC, Poortmans P. Recurrence rates

after treatment of breast cancer with standard radiotherapy

with or without additional radiation. N Engl J Med 2001;

345:1378.

7. Fisher B. Reanalysis and results after 12 years of follow-

up in a randomized clinical trial comparing total

mastectomy with lumpectomy with or without irradiation

in the treatment of breast cancer. N Engl J Med 1995;

333:1456-61.

8. Astrahan MA, Jozsef G, Streeter OE. Optimization of

mammo site therapy. Int J Radiat Onc Biol Phys 2004;

58:220-32.

9. Vicini FA. Low dose rate brachytherapy as the sole

radiation modality in the management of patients with

Early breast cancer treated with breast-conserving therapy.

Intern J Radiat Oncol, Biol Phys 1997; 38:301-10.






æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áß≥ »Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’∏’√æ≈ ‡®π«‘∑¬“*™≈‘¬“ «“¡–≈ÿπ*Õπÿ™µ√“ «√√≥‡ «°*°ÿ≈∏‘¥“ °ÿ≈ª√–±’ªí≠≠“**‚ ¿‘µ ∑—∫∑‘¡À‘π*æ—™π’ ‡∑æ“Õ¿‘√—°…å**»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ ∂“∫—π¡–‡√Áß·Ààß™“µ‘ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢**«‘∑¬“≈—¬æ¬“∫“≈∫√¡√“™™ππ’ √√æ ‘∑∏‘ª√– ß§å

Abstract Health Promotion Behaviors in Cancer Patient at Ubonratchathani Cancer CenterChenvidhaya D.*, Wamaloon C.*, Wunnasaweqa A.*, Kulprateepanya K**, Tubtimhin S.*,Thepa-apirak P.*Ubonratchathani Cancer Center, National Cancer Institute, Department of Medical Services, Ministryof Public Health


Health promotion behaviors are operationally defined as practice of various activities for theones by themselves, perform in order to have good health and happiness. The purposes of the research wereto study on health promotion behaviors and develop a process of nursing practice that could be geared up tohealth promotion behaviors of cervical carcinoma patients undergoing radiation therapy by means ofparticipatory action research (PAR). The research participants comprised totally 53 in number of patients,care giver, nurses, executives and personnel in Ubonratchathani Cancer Center. The research procedureswere situation analysis and feasibility to conduct health promotion behaviors after that, planning for develophealth promotion behaviors program for the patients who treated by radiation therapy and evaluate patients’self-assessment on health promotion. The research instrument consisted of question guideline for interviewand focusing group, a manual of cervical carcinoma patients being treated by radiotherapy, leaflets, VCD,personnel media (the nurses in charge of giving information and related knowledges), and an evaluation formof health promotion behaviors and quality of life which were completely tried out and worked out by use ofCronbach’s coefficient for reliability of 0.88 and 0.62, respectively. We found that health promotion behaviorand communication are important to quality of life among cancer patients.

Key words: health promotion behaviors, cervical carcinoma

72

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‡√◊ËÕß¬àÕ «—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“°“√ àß‡ √‘¡æƒµ‘°√√¡ ÿ¢¿“æ·≈–æ—≤π“°√–∫«π°“√ªØ‘∫—µ‘°“√æ¬“∫“≈ ∑’Ë®–π”‰ª Ÿàæƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“ ‚¥¬„™â«‘∏’°“√»÷°…“·∫∫¡’ à«π√à«¡ §◊Õ ºŸâªÉ«¬ ≠“µ‘ æ¬“∫“≈ºŸâ∫√‘À“√·≈–∫ÿ§≈“°√∑’Ë‡°’Ë¬«¢âÕß„π»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ ®”π«π∑—Èß ‘Èπ 53 §π °“√«‘‡§√“–Àå ∂“π°“√≥å·≈–§«“¡‡ªìπ‰ª‰¥â„π°“√æ—≤π“°√–∫«π°“√ªØ‘∫—µ‘ß“πæ¬“∫“≈ ∑’Ë®–π”‰ª Ÿàæƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ «“ß·ºπæ—≤π“Õß§å§«“¡√Ÿâ·≈– ◊ËÕ„π°“√π”‡ πÕµàÕºŸâªÉ«¬ √«¡∂÷ß°“√æ—≤π“‚ª√·°√¡æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ ”À√—∫ºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“ ª√–‡¡‘πº≈æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ‚¥¬ºŸâªÉ«¬ª√–‡¡‘πµπ‡Õß ‡§√◊ËÕß¡◊Õ∑’Ë „™â „π°“√«‘®—¬ª√–°Õ∫¥â«¬ ·π«§”∂“¡„π°“√ —¡¿“…≥å ·π«§”∂“¡„π°“√ π∑π“°≈ÿà¡ §Ÿà¡◊Õ§«“¡√Ÿâ‡√◊ËÕß‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“ ·ºàπæ—∫ «’´’¥’ ◊ËÕ∫ÿ§§≈´÷Ëß‡ªìπæ¬“∫“≈∑’Ë„Àâ¢âÕ¡Ÿ≈·≈–Õß§å§«“¡√Ÿâ∑’Ë‡°’Ë¬«¢âÕß ·≈–·∫∫ª√–‡¡‘πæƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ ·∫∫ª√–‡¡‘π§ÿ≥¿“æ™’«‘µ∑’Ëºà“π°“√∑¥≈Õß„™â·≈–À“§à“§«“¡‡™◊ËÕ¡—Ëπ ‚¥¬„™â Ÿµ√ —¡ª√– ‘∑∏‘ÏÕ—≈øÉ“¢Õß§√Õπ∫“§ (Cronbachûs Coefficient) ¡’§à“§«“¡‡™◊ËÕ¡—Ëπ¢Õß·∫∫ª√–‡¡‘π‡∑à“°—∫ 0.88 ·≈– 0.62 µ“¡≈”¥—∫ ®“°°“√»÷°…“ æ∫«à“∫ÿ§≈“°√∑’Ë‡°’Ë¬«¢âÕß‰¥âæ—≤π“Õß§å§«“¡√Ÿâ·≈–«‘‡§√“–Àå‡π◊ÈÕÀ“®—¥∑” ◊ËÕ„Àâ Õ¥§≈âÕß°—∫§«“¡µâÕß°“√¢ÕßºŸâªÉ«¬ ¡’°“√æ—≤π“‚ª√·°√¡·≈–®—¥°√–∫«π°“√ªØ‘∫—µ‘°“√æ¬“∫“≈ ”À√—∫ºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë ‰¥â√—∫√—ß ’√—°…“·≈– “¡“√∂π”‰ª‡ªìπ·π«∑“ß„π°“√ªØ‘∫—µ‘®π‡°‘¥æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¥â«¬µπ‡Õß §«√¡’°“√¥”‡π‘π°“√Õ¬à“ßµàÕ‡π◊ËÕß·≈–¢¬“¬º≈°“√æ—≤π“ ª√—∫ª√ÿß ‡π◊ÈÕÀ“ «‘∏’°“√ ◊ËÕ “√Õß§å§«“¡√Ÿâ„Àâ Õ¥§≈âÕß°—∫ºŸâªÉ«¬¡–‡√Áß°≈ÿà¡Õ◊Ëπ‡æ◊ËÕ„Àâ‡°‘¥æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ·≈–¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’

§” ”§—≠: æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ ¡–‡√Áßª“°¡¥≈Ÿ°

∫∑π”

‚√§¡–‡√Áß‡ªìπªí≠À“ “∏“√≥ ÿ¢¢Õßª√–™“°√‡°◊Õ∫∑ÿ°ª√–‡∑» ‡π◊ËÕß®“°‡ªìπ‚√§∑’Ë¡’Õ—µ√“°“√µ“¬ Ÿß·æ√à°√–®“¬‰ª¬—ßÕ«—¬«–·≈–√–∫∫µà“ßÊ ®÷ß¬“°µàÕ°“√§«∫§ÿ¡À√◊Õ√—°…“„ÀâÀ“¬¢“¥‰¥â‚¥¬°“√√—°…“«‘∏’‡¥’¬«®”‡ªìπµâÕß„™â«‘∏’°“√À≈“¬™π‘¥√à«¡°—π1 ‡¡◊ËÕæ∫«à“‡ªìπ¡–‡√Áß·≈â«®– àßº≈°√–∑∫À≈“¬¥â“π ‰¡à«à“®–‡ªìπµ—«ºŸâªÉ«¬ §√Õ∫§√—« ≠“µ‘ æ’ËπâÕß √«¡∑—Èß¥â“π‡»√…∞°‘®·≈– —ß§¡Õ’°¥â«¬ ‡π◊ËÕß®“°‚√§¡–‡√Áß‡ªìπ‚√§∑’Ë§ÿ°§“¡™’«‘µ¢ÕßºŸâªÉ«¬ ‚¥¬∑”„Àâ‡°‘¥°“√‡ª≈’Ë¬π·ª≈ß·°àºŸâªÉ«¬∑—Èß∑“ß√à“ß°“¬·≈–®‘µ„®2 „πªí®®ÿ∫—π§«“¡‡®√‘≠°â“«Àπâ“∑“ß«‘∑¬“»“ µ√å·≈–‡∑§‚π‚≈¬’ √«¡∑—Èß∑“ß°“√·æ∑¬å®–∑”„Àâ∑√“∫√“¬≈–‡Õ’¬¥¢Õß°√–∫«π°“√‡°‘¥‚√§¥’¢÷ÈπÕß§å°“√Õπ“¡—¬‚≈°‰¥â°”Àπ¥®ÿ¥¡ÿàßÀ¡“¬¢Õß°“√√—°…“‰«â §◊Õ ∑”„ÀâºŸâªÉ«¬À“¬®“°‚√§¡–‡√Áß¡’™’«‘µ∑’Ë¥’·≈–¬◊π¬“« ∑”„Àâ§ÿ≥¿“æ™’«‘µ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áß¥’¢÷Èπ3

®“° ∂‘µ‘ “∏“√≥ ÿ¢ √–À«à“ß æ.». 2542 - æ.».2545 æ∫«à“ “‡Àµÿ°“√µ“¬¢Õßª√–™“°√Õ—π¥—∫Àπ÷Ëß§◊Õ ‚√§¡–‡√Áß4 ·≈–√“¬ß“πÕÿ∫—µ‘°“√≥å°“√‡°‘¥‚√§¡–‡√Áß„π Cancer in Thailand Volume III (æ.». 2538 -æ.». 2540) ´÷Ëßµ’æ‘¡æå„πªï æ.». 2547 æ∫«à“ ¡’ºŸâªÉ«¬¡–‡√Áß√“¬„À¡à ‡∑à“°—∫ 74,006 √“¬ ·¬°‡ªìπ‡æ»™“¬

35,539 √“¬ ·≈–‡æ»À≠‘ß 38,467 √“¬ ‡¡◊ËÕ§”π«≥‚¥¬„™â«‘∏’ª√—∫∞“πÕ“¬ÿ (Age standardized rate) æ∫‡æ»™“¬·≈–‡æ»À≠‘ß§‘¥‡ªìπ 149.2 ·≈– 125.0 §πµàÕª√–™“°√· π§πµ“¡≈”¥—∫5 à«πÕÿ∫—µ‘°“√≥å‡°‘¥‚√§¡–‡√Áß¢Õß µ√’„πª√–‡∑»‰∑¬ æ∫Õ—µ√“‡°‘¥°“√‡°‘¥‚√§¡–‡√Áßª“°¡¥≈Ÿ° ‡ªìπÕ—π¥—∫Àπ÷Ëß §‘¥‡ªìπÕ—µ√“ªÉ«¬19.5 µàÕª√–™“°√· π§π

∂‘µ‘¡–‡√Áßª“°¡¥≈Ÿ°®“°√“¬ß“π ∂‘µ‘‚√§¡–‡√Áßªïæ.». 2545 »Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’ æ∫«à“ ¡’Õÿ∫—µ‘°“√≥å¡“°‡ªìπÕ—π¥—∫Àπ÷Ëß‡°◊Õ∫∑ÿ°ªï ªï æ.». 2545 æ∫√“¬„À¡à 270 √“¬ ÷Ëß‡ªìπÕ—µ√“∑’Ë Ÿß¡“°‡¡◊ËÕ‡∑’¬∫°—∫ªï∑’Ëºà“πÊ ¡“ (ªï æ.». 2541 æ∫‡æ’¬ß 165 √“¬) ·≈–¡’¢âÕ¡Ÿ≈∑’Ëπà“ π„® §◊Õ æ∫¡–‡√Áßª“°¡¥≈Ÿ°√–¬–∑’Ë 1‡æ‘Ë¡¢÷Èπ∑ÿ°ªï‡¡◊ËÕ‡∑’¬∫°—∫√–¬–∑’Ë 2 ¢÷Èπ‰ª6 ·≈– ∂‘µ‘‚√§¡–‡√Áß√–¥—∫‚√ßæ¬“∫“≈ ªï æ.». 2547 æ∫«à“ ¡–‡√Áßª“°¡¥≈Ÿ°¬—ß§ß‡ªìπ¡–‡√Áß∑’Ëæ∫Õ—π¥—∫Àπ÷Ëß¢Õß µ√’‡™àπ‡¥’¬«°—π

ªí≠À“∑’Ë‡°‘¥®“°‚√§¡–‡√Áß¡‘„™à‡ªìπªí≠À“∑“ß¥â“π ÿ¢¿“æ¢ÕßºŸâªÉ«¬‡∑à“π—Èπ ·µà¬—ß‡ªìπªí≠À“∑“ß‡»√…∞°‘® —ß§¡ ¡“°πâÕ¬µ“¡ ∂“π°“√≥å ·≈–§«“¡√ÿπ·√ß·≈–Õÿ∫—µ‘°“√≥å¢Õß‚√§¡–‡√Áß®–‡æ‘Ë¡¢÷Èπ®“°ªí≠À“¢Õß ‘Ëß·«¥≈âÕ¡æƒµ‘°√√¡°“√∫√‘‚¿§¢Õß¡πÿ…¬å æƒµ‘°√√¡



∑“ß‡æ»·≈–°“√¡’™’«‘µ∑’Ë¬“«π“π¢÷Èπ¢Õßª√–™“°√„π‚≈°

‚√§¡–‡√Áß‡ªìπ‚√§∑’ËªÑÕß°—π‰¥â ·≈– “¡“√∂√—°…“„ÀâÀ“¬¢“¥‰¥â ∂â“æ∫„π√–¬–·√°·≈– “¡“√∂¬◊¥√–¬–‡«≈“„Àâ™’«‘µ¬◊π¬“«‰¥â ‚¥¬‡©æ“–„πªí®®ÿ∫—π¡’§«“¡°â“«Àπâ“∑“ß«‘∑¬“°“√∑“ß°“√·æ∑¬å ¡’°“√π”«‘∏’°“√√—°…“·ºπ„À¡à ·≈–º≈°“√«‘π‘®©—¬∑“ß§≈‘π‘°¡“„™â„π°“√√—°…“ ∑”„Àâª√– ‘∑∏‘¿“æ°“√√—°…“ Ÿß¢÷Èπ «‘∑¬“°“√∑“ß°“√·æ∑¬å„πªí®®ÿ∫—π‰¥â®—¥„Àâ¡–‡√Áß‡ªìπ‚√§∑’Ë¡’º≈µàÕ∑ÿ°√–∫∫∑—Ë«√à“ß°“¬ „π°“√¥Ÿ·≈√—°…“®÷ßµâÕß§”π÷ß∂÷ß°“√¥Ÿ·≈∑ÿ°√–∫∫∑’Ë¡–‡√Áß®–·æ√à°√–®“¬‰ª∂÷ß ‡™àπµàÕ¡πÈ”‡À≈◊Õß ªÕ¥ ¡Õß °√–¥Ÿ° ‡ªìπµâπ

πÕ°®“°π’È°“√¥”‡π‘π¢Õß‚√§¡–‡√Áß„™â ‡«≈“¬“«π“π®“°°“√‡°‘¥‚√§ °“√√—°…“ °“√À“¬®“°‚√§°“√‡°‘¥‚√§¢÷Èπ„À¡à ´÷Ëß¡’º≈°√–∑∫µàÕ °“¬ ®‘µ —ß§¡‡»√…∞°‘® ¢Õß∫ÿ§§≈·≈–§√Õ∫§√—« µ≈Õ¥®π —ß§¡®÷ßµâÕß°“√°“√¥Ÿ·≈µàÕ‡π◊ËÕß®“°∑’¡ ÿ¢¿“æ„π°“√√à«¡«“ß·ºπ‡æ◊ËÕªÑÕß°—π §—¥°√Õß «‘π‘®©—¬ ·≈–√—°…“æ¬“∫“≈µ≈Õ¥®π àß‡ √‘¡„ÀâºŸâªÉ«¬·≈–§√Õ∫§√—« “¡“√∂¥Ÿ·≈µπ‡Õß‰¥â∑ÿ°√–¬–¢Õß‚√§ ·≈–°“√√—°…“∑’Ë‰¥â√—∫ ®–‡ÀÁπ‰¥â«à“°“√æ¬“∫“≈ ∑’Ë¡’§ÿ≥¿“æ‰¥â¡“µ√∞“π∂◊Õ‡ªìπ∫∑∫“∑∑’Ë ”§—≠„π°“√‡æ‘Ë¡ª√– ‘∑∏‘¿“æ¢Õß°“√√—°…“

‚¥¬¡’«‘∏’°“√√—°…“∑’Ë‡ªìπ “°≈ §◊Õ °“√ºà“µ—¥°“√„™â “√‡§¡’∫”∫—¥ (√«¡∂÷ß°“√„™âŒÕ√å‚¡π) °“√∫”∫—¥¥â«¬√—ß ’√—°…“À√◊Õ°“√©“¬· ß·≈–™’«∫”∫—¥ ÷Ëß°“√∑’Ë®–„™â«‘∏’°“√„¥„π°“√√—°…“π’È¢÷ÈπÕ¬Ÿà°—∫™π‘¥¢Õß‚√§¡–‡√Áß·≈–√–¬–¢Õß‚√§π—ÈπÊ7 (19 ¡‘∂ÿπ“¬π æ.». 2549)º≈®“°æ¬“∏‘ ¿“æ¢Õß‚√§·≈–°“√√—°…“¡’º≈∑”„ÀâºŸâªÉ«¬‡°‘¥°“√‡ª≈’Ë¬π·ª≈ß∑“ß¥â“π®‘µ —ß§¡ ‡™àπ «‘µ°°—ß«≈‚°√∏ ´÷¡‡»√â“ √Ÿâ ÷°‰¡à·πàπÕπ °≈—«µ“¬ À¡¥Õ“≈—¬ ‘ÈπÀ«—ß √—∫√Ÿâ¿“æ≈—°…≥å„π∑“ß≈∫·≈–§«“¡√Ÿâ ÷°¡’§à“„πµπ‡Õß≈¥≈ß

∫ÿ§≈“°√∑“ß°“√æ¬“∫“≈ “¡“√∂°√–µÿâπ„ÀâºŸâªÉ«¬¡’°“√¥Ÿ·≈ ÿ¢¿“æ¢Õßµπ‡Õß ‚¥¬„™â·π«§‘¥°“√¥Ÿ·≈·≈–æ÷Ëßµπ‡Õß®–∑”„ÀâºŸâªÉ«¬¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’ À√◊ÕÕ“®„ÀâÀ≈—°À√◊Õ·π«§‘¥æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ(Health Promoting Behaviors) ´÷Ëß‡ªìπ°‘®°√√¡∑’Ë

∫ÿ§≈“°√°√–∑”‡æ◊ËÕ¬°√–¥—∫§«“¡‡ªìπÕ¬Ÿà∑’Ë¥’ ·≈–°“√· ¥ßÕÕ°∂÷ß»—°¬¿“æ∑“ß ÿ¢¿“æ¢Õß¡πÿ…¬åÀ√◊Õ°“√· ¥ßÕÕ° ‡æ◊ËÕ∑’Ë®–‡æ‘Ë¡§ÿ≥¿“æ™’«‘µ¢Õß∫ÿ§§≈ ·≈– ‘Ëß·«¥≈âÕ¡∑’Ë —¡æ—π∏å°—π ÷Ëß‡æπ‡¥Õ√å (Pender)8 ‰¥â®—¥æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æÕÕ°‡ªìπ 6 ¥â“π ‰¥â·°à

§«“¡√—∫º‘¥™Õ∫µàÕ¿“«– ÿ¢¿“æ (Healthresponsibility) ‡ªìπæƒµ‘°√√¡∑’ËºŸâªÉ«¬æ¬“¬“¡∑’Ë®–ªØ‘∫—µ‘µ“¡ §”·π–π”¢Õß‡®â“Àπâ“∑’Ë∑’¡ ÿ¢¿“æ·≈–»÷°…“À“§«“¡√Ÿâ‡°’Ë¬«°—∫‚√§

°‘®°√√¡∑“ß¥â“π√à“ß°“¬ (Physical activity)‡ªìπ°‘®°√√¡À√◊Õæƒµ‘°√√¡°“√‡§≈◊ËÕπ‰À«·≈–°“√À≈’°‡≈’Ë¬ß°‘®°√√¡∑’Ë‰¡à‡À¡“– ¡

¿“«–‚¿™π“°“√ (Nutrition) À¡“¬∂÷ß °“√√—∫ª√–∑“πÕ“À“√∑’Ë∂Ÿ°µâÕß‡À¡“– ¡°—∫‚√§

°“√¡’ªØ‘ —¡æ—π∏å√–À«à“ß∫ÿ§§≈ (Interpersonalrelation) ‡æ◊ËÕ‡ªìπÀπ∑“ß ∑’Ë∑”„Àâ¡’°“√‡ª≈’Ë¬π§«“¡§‘¥‡ÀÁπ·≈–‰¥â√—∫¢à“« “√ §«“¡√Ÿâ

°“√æ—≤π“®‘µ«‘≠≠“≥ (Spiritual growth)‡ªìπ ‘Ëß∑’Ë™à«¬‡°◊ÈÕÀπÿπ„ÀâºŸâªÉ«¬¡’°”≈—ß„®„π°“√ªØ‘∫—µ‘°‘®°√√¡µà“ßÊ

°“√®—¥°“√°—∫§«“¡‡§√’¬¥ (Stress management)À¡“¬∂÷ß °“√ºàÕπ§≈“¬§«“¡µ÷ß‡§√’¬¥ °“√·°â‰¢ªí≠À“Õ¬à“ß¡’ µ‘

°“√ªØ‘∫—µ‘æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ∑’Ë‡°‘¥¢÷Èπ°—∫ºŸâªÉ«¬‚√§¡–‡√Áß “¡“√∂ªÑÕß°—π·≈–§«∫§ÿ¡¿“«–·∑√° âÕπÕ—π®–∑”„Àâ ÿ¢¿“æ¢ÕßºŸâªÉ«¬¥’¢÷Èπ ‚¥¬æ¬“∫“≈‡ªìπºŸâ∑’Ë¡’∫∑∫“∑„π°“√™à«¬‡À≈◊Õ∫ÿ§§≈„Àâµ—¥ ‘π„®„π°“√ª√—∫‡ª≈’Ë¬πÀ√◊Õ¬Õ¡√—∫æƒµ‘°√√¡∑’Ë®–¡’º≈µàÕ ÿ¢¿“æ‡æ◊ËÕª√—∫ª√ÿß ÿ¢¿“æ¢Õßµπ‡Õß„Àâ¥’¢÷ÈπÀ√◊Õ„ÀâÀ“¬®“°‚√§À√◊ÕÕ¬Ÿà°—∫‚√§‰¥â ‚¥¬¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’∑’Ë ÿ¥9 „π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§¡–‡√Áßæ¬“∫“≈§«√¡ÿàß‡πâπ‰ª∑’Ë°“√ àß‡ √‘¡ ÿ¢¿“æ ‡æ◊ËÕ™–≈ÕÀ√◊Õ∫√√‡∑“Õ“°“√¢Õß‚√§‰¡à„Àâ√ÿàπ·√ß¡“°¢÷Èπ·≈– “¡“√∂¥”‡π‘π™’«‘µ„π —ß§¡‰¥âµ“¡ª°µ‘

®“°°“√ª√–‡¡‘π ∂“π°“√≥å‡√◊ËÕß°“√¥Ÿ·≈ºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°„π»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ æ∫«à“ºŸâªÉ«¬‰¥â√—∫°“√¥Ÿ·≈Õ¬à“ßµàÕ‡π◊ËÕß·≈–§√Õ∫§≈ÿ¡∑—Èß

74

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

¥â“π√à“ß°“¬ ®‘µ„® Õ“√¡≥å —ß§¡ §«√»÷°…“æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬°≈ÿà¡π’È ‡æ◊ËÕ§âπÀ“§”µÕ∫∑’Ë®–π”‰ª Ÿàß“πæ—≤π“√–∫∫°“√¥Ÿ·≈ ºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°Õ¬à“ß‡ªìπ√Ÿª∏√√¡

¥—ßπ—Èπ∑’¡ºŸâ»÷°…“ ∑—Èß„π∞“π–ºŸâ∫√‘À“√ π—°«‘™“°“√·≈–ºŸâªØ‘∫—µ‘ß“π‡ÀÁπµ√ß°—π«à“§«√„™â°√–∫«π°“√¡’ à«π√à«¡„π°“√∑”ß“π‡ªìπ·π«§‘¥À≈—°„π°“√»÷°…“§√—Èßπ’È‡æ◊ËÕ»÷°…“°“√ àß‡ √‘¡æƒµ‘°√√¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ° ·≈–æ—≤π“ª√—∫ª√ÿß°√–∫«π°“√ªØ‘∫—µ‘°“√æ¬“∫“≈∑’Ë®–π”‰ª Ÿà æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°‰¥âÕ¬à“ß‡À¡“– ¡

«—µ∂ÿ·≈–«‘∏’°“√

°≈ÿà¡ºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“∑’Ë‡¢â“√—∫°“√√—°…“„π»Ÿπ¬å¡–‡√Áß Õÿ∫≈√“™∏“π’ „π√–À«à“ß‡¥◊Õπ°—π¬“¬π æ.». 2547 - °—π¬“¬π æ.». 2548‚¥¬„™â°√–∫«π°“√»÷°…“‡™‘ßªØ‘∫—µ‘°“√·∫∫¡’ à«π√à«¡µ“¡°√Õ∫·π«§‘¥°“√ àß‡ √‘¡ ÿ¢¿“æ¢Õß‡æπ‡¥Õ√å8 ¡“°”Àπ¥∑‘»∑“ß„π°“√æ—≤π“·≈–„™â°√–∫«π°“√«“ß·ºπ·∫∫¡’ à«π√à«¡·≈–‡∑§π‘§ AIC (Appreciationinfluence Control) ™à«¬„π°“√√–¥¡§«“¡§‘¥¢Õß∫ÿ§≈“°√ºŸâ„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬‚√§¡–‡√Áß ‡æ◊ËÕ„Àâ∑ÿ°§π

µ√–Àπ—°∂÷ß∫∑∫“∑Àπâ“∑’Ë¢Õßµπ‡Õß ¡’ªØ‘ —¡æ—π∏å°—π¡’°“√·≈°‡ª≈’Ë¬π§«“¡§‘¥‡ÀÁπ√à«¡°—πÕ—π®–π”‰ª Ÿà°“√æ—≤π“·≈–·°â‰¢ªí≠À“

‚¥¬°“√»÷°…“·∫àß‡ªìπ 3 √–¬– §◊Õ√–¬–∑’Ë 1 °“√«‘‡§√“–Àå ∂“π°“√≥å∑’Ë‡°’Ë¬«¢âÕß

°—∫æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬ ®“°ºŸâ∫√‘À“√ºŸâªØ‘∫—µ‘ ºŸâªÉ«¬·≈–≠“µ‘ ‚¥¬„™â°“√ —¡¿“…≥å‡™‘ß≈÷°·≈–°“√ π∑π“°≈ÿà¡

√–¬–∑’Ë 2 À“·π«∑“ß°“√ àß‡ √‘¡æƒµ‘°√√¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬‚√§¡–‡√Áß ‚¥¬°“√ √â“ß‚ª√·°√¡°“√ àß‡ √‘¡æƒµ‘°√√¡ ÿ¢¿“æ §Ÿà¡◊Õ‡√◊ËÕß‚√§¡–‡√Áßª“°¡¥≈Ÿ°·ºàπæ—∫ «’ ’¥’

√–¬–∑’Ë 3 ª√–‡¡‘πº≈æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ‚¥¬°“√ª√–‡¡‘πæƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ·≈–§ÿ≥¿“æ™’«‘µ

º≈

ºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‡ªìπ°≈ÿà¡µ—«Õ¬à“ß®”π«π 53 √“¬ à«π„À≠à¡’ ∂“π¿“æ ¡√ §Ÿà ®∫°“√»÷°…“√–¥—∫ª√–∂¡»÷°…“§‘¥‡ªìπ√âÕ¬≈– 87.5

¡’æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æÕ¬Ÿà„π√–¥—∫ª“π°≈“ß‡¡◊ËÕæ‘®“√≥“√“¬¥â“π æ∫«à“¥â“π°“√ÕÕ°°”≈—ß°“¬

µ“√“ß∑’Ë 1 §–·ππ‡©≈’Ë¬°“√ àß‡ √‘¡ ÿ¢¿“æ‚¥¬°“√ª√–‡¡‘πµπ‡Õß¢ÕßºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°‰¥â√—∫¢âÕ¡Ÿ≈µ“¡ §Ÿà¡◊Õ·≈–

◊ËÕ„π°“√ àß‡ √‘¡æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ

°“√ àß‡ √‘¡ ÿ¢¿“æ Min Max X S.D. √–¥—∫°“√ àß‡ √‘¡ ÿ¢¿“æ

¥â“π‚¿™π“°“√ 2.19 4.38 3.27 .47 ª“π°≈“ß

¥â“πÕÕ°°”≈—ß°“¬ 1.38 4.38 3.07 .65 πâÕ¬

¥â“π§«“¡√—∫º‘¥™Õ∫µàÕ ÿ¢¿“æ 3.0 4.88 3.91 .35 ª“π°≈“ß

¥â“π§«“¡ —¡æ—π∏å√–À«à“ß∫ÿ§§≈ 2.00 4.5 3.54 .52 ª“π°≈“ß

¥â“π°“√®—¥°“√°—∫§«“¡‡§√’¬¥ 2.33 4.17 3.35 .46 ª“π°≈“ß

°“√ àß‡ √‘¡ ÿ¢¿“æ¥â“π§«“¡ ”‡√Á®„π™’«‘µ 2.25 4.88 3.76 .59 ª“π°≈“ß

¿“æ√«¡æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ 2.63 4.23 3.45 .38 ª“π°≈“ß

Min = §–·ππµË” ÿ¥ X = §à“‡©≈’Ë¬

Max = §–·ππ Ÿß ÿ¥ SD = à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π



ºŸâªÉ«¬¡’æƒµ‘°√√¡πâÕ¬∑’Ë ÿ¥ (µ“√“ß∑’Ë 1) ¡’§ÿ≥¿“æ™’«‘µ‚¥¬√«¡„π√–¥—∫ª“π°≈“ß ‚¥¬¡’§«“¡º“ ÿ°¥â“π —ß§¡/§√Õ∫§√—«¡“°∑’Ë ÿ¥ (§à“‡©≈’Ë¬ = 3.82) ·≈–¡’§«“¡º“ ÿ°¥â“π√à“ß°“¬·≈–Õ“√¡≥å ®‘µ„® πâÕ¬∑’Ë ÿ¥(§à“‡©≈’Ë¬ = 2.69 ·≈– 2.96 µ“¡≈”¥—∫) (µ“√“ß∑’Ë 2)

®“°°“√ —¡¿“…≥åºŸâªÉ«¬·≈–≠“µ‘æ∫«à“ Õß§åª√–°Õ∫∑’Ë¡’ à«π ”§—≠„π°“√ àß‡ √‘¡æƒµ‘°√√¡ ÿ¢¿“æ‰¥â·°à ®‘µ„®¢ÕßºŸâªÉ«¬ ºŸâªÉ«¬µâÕß°“√∑”®‘µ„®„Àâ ∫“¬‰¡à§‘¥¡“° µâÕß°“√°”≈—ß„®®“°§√Õ∫§√—«·≈–≠“µ‘°“√√—∫ª√–∑“πÕ“À“√∑’Ë∂Ÿ°À≈—°Õπ“¡—¬ °“√ÕÕ°°”≈—ß°“¬ °“√πÕπÀ≈—∫æ—°ºàÕπ °“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß∑—Èß√à“ß°“¬·≈–®‘µ„® ·≈–µâÕß°“√§”·π–π”®“°°“√·æ∑¬åæ¬“∫“≈

◊ËÕ·≈–‡π◊ÈÕÀ“∑’ËµâÕß°“√ ‰¥â·°à ∑’«’/«‘∑¬ÿ «’´’¥’/‡∑ª ·ºàπæ—∫ §Ÿà¡◊Õ ‚¥¬¡’‡π◊ÈÕÀ“‡°’Ë¬«°—∫°“√ÕÕ°°”≈—ß°“¬ °“√√—∫ª√–∑“πÕ“À“√ °“√ªØ‘∫—µ‘µπ‡Õß„π°“√¥Ÿ·≈ ÿ¢¿“æ·≈–°“√ªØ‘∫—µ‘¥â“π°“√ àß‡ √‘¡®‘µ„®¢ÕßºŸâªÉ«¬ ‡™àπ °“√„Àâ°”≈—ß„® °“√„Àâ§”ª√÷°…“ ·≈–°“√§≈“¬‡§√’¬¥

«‘®“√≥å

‚¥¬ª°µ‘ºŸâªÉ«¬∑’ËªÉ«¬¥â«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’ËÕ“»—¬„π‡¢µ¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊Õ à«π„À≠à‡ªìπºŸâ∑’Ë®∫°“√»÷°…“¿“§∫—ß§—∫®÷ß∑”„Àâ‡°‘¥§«“¡«‘µ°°—ß«≈

®“°°“√‡®Á∫ªÉ«¬ Ÿß¡“°°«à“ºŸâªÉ«¬∑’ËÕ¬Ÿà„π‡¢µ¿“§Õ◊ËπÊÕ—π àßº≈„Àâ‡°‘¥§«“¡«‘µ°°—ß«≈‡°’Ë¬«°—∫°“√‡®Á∫ªÉ«¬¢Õßµπ‡Õß ‡π◊ËÕß®“°¢“¥§«“¡√Ÿâ‡√◊ËÕß‚√§·≈–°“√ªØ‘∫—µ‘µ—«‡æ◊ËÕ„Àâµπ‡Õß¡’ ÿ¢¿“æ∑’Ë¥’ ¥—ßπ—Èπ §Ÿà¡◊Õ ”À√—∫ºŸâªÉ«¬ 2‡≈à¡∑’ËºŸâ«‘®—¬æ—≤π“¢÷Èπ ‡æ◊ËÕ„Àâ§«“¡√Ÿâ‡√◊ËÕß‚√§¡–‡√Áßª“°¡¥≈Ÿ° ”À√—∫ºŸâªÉ«¬∑’Ë‰¥â√—∫√—ß ’√—°…“∑’Ëª√–°Õ∫¥â«¬§«“¡√Ÿâ‡√◊ËÕß‚√§¡–‡√Áßµ—Èß·µà§«“¡À¡“¬¢Õß‚√§¡–‡√Áß°“¬«‘¿“§·≈– √’√«‘∑¬“¢Õßª“°¡¥≈Ÿ° ∂‘µ‘°“√‡°‘¥‚√§¡–‡√Áßª“°¡¥≈Ÿ° “‡Àµÿ¢Õß°“√‡°‘¥‚√§ Õ“°“√·≈–Õ“°“√· ¥ß °“√µ√«®§âπÀ“¡–‡√Áßª“°¡¥≈Ÿ° °“√ªØ‘∫—µ‘µ—«¢≥–°”≈—ß«‘π‘®©—¬‚√§ √–¬–°“√‡°‘¥¡–‡√Áßª“°¡¥≈Ÿ° ·π«∑“ß°“√√—°…“ °“√¥Ÿ·≈¢≥–∑”°“√√—°…“·≈–§Ÿà¡◊Õ ”À√—∫°“√ªØ‘∫—µ‘µ—«∑—Ë«‰ª¢≥–©“¬√—ß ’ ”À√—∫ºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ° ´÷Ëßª√–°Õ∫¥â«¬°“√ªØ‘∫—µ‘µ—«∑—Ë«‰ª¢≥–©“¬√—ß ’ ‡™àπ Õ“À“√∑’Ë§«√√—∫ª√–∑“π·π«∑“ßªØ‘∫—µ‘‡æ◊ËÕ≈¥Õ“°“√¢â“ß‡§’¬ß °“√ÕÕ°°”≈—ß°“¬°“√§≈“¬‡§√’¬¥ √«¡∑—Èß«’ ’¥’‚ª√·°√¡°“√ π—∫ πÿπæƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æºŸâªÉ«¬‚√§¡–‡√Áß ´÷Ëßª√–°Õ∫¥â«¬ 4 °‘®°√√¡ §◊Õ 1) ‡√’¬π√Ÿâ·≈–√—∫¡◊Õ 2) ·¢Áß·√ß‡√Á«‰«„ à„®‡√◊ËÕß°“√∫√‘‚¿§Õ“À“√ 3) ·¢Áß·√ß‰¥â∂â“ÕÕ°°”≈—ß°“¬‡ªìπª√–®” ·≈– 4) ©“¬√—ß ’„Àâ¡’§«“¡ ÿ¢ ®÷ß‡ªìπ ◊ËÕ∑’Ë Õ¥§≈âÕß°—∫§«“¡µâÕß°“√¢ÕßºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫°“√√—°…“‚¥¬°“√©“¬√—ß ’∑’Ë¡’§«“¡µâÕß°“√∑’ËÀ≈“°À≈“¬·≈–ªìπ ◊ËÕ∑’Ë¡’ ‡π◊ÈÕÀ“

µ“√“ß∑’Ë 2 §–·ππ‡©≈’Ë¬§ÿ≥¿“æ™’«‘µ‚¥¬°“√ª√–‡¡‘πµπ‡Õß¢ÕßºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°À≈—ß‰¥â√—∫¢âÕ¡Ÿ≈µ“¡ §Ÿà¡◊Õ·≈–

◊ËÕ„π°“√ àß‡ √‘¡æƒµ‘°√√¡ àß‡ √‘¡ ÿ¢¿“æ

§ÿ≥¿“æ™’«‘µ Min Max X S.D. √–¥—∫°“√ àß‡ √‘¡ ÿ¢¿“æ

§«“¡ ÿ¢¥â“π√à“ß°“¬ 1.43 4.29 2.69 .65 πâÕ¬

§«“¡ ÿ¢¥â“π —ß§¡/§√Õ∫§√—« 2.86 5.00 3.82 .58 ¡“°

§«“¡ ÿ¢¥â“πÕ“√¡≥å ®‘µ„® 1.67 4.83 2.96 .74 πâÕ¬

§«“¡ ÿ¢¥â“π°“√ªØ‘∫—µ‘°‘®°√√¡ 1.57 5.00 3.54 .70 ª“π°≈“ß

§ÿ≥¿“æ™’«‘µ‚¥¬√«¡ 2.58 3.96 3.28 .32 ª“π°≈“ß

Min = §–·ππµË” ÿ¥ X = §à“‡©≈’Ë¬

Max = §–·ππ Ÿß ÿ¥ SD = à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π

76

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

°‘®°√√¡∑’ËºŸâªÉ«¬·≈–≠“µ‘ “¡“√∂π”‰ªªØ‘∫—µ‘‰¥âÕ¬à“ßµàÕ‡π◊ËÕß∑—Èß¢≥–Õ¬Ÿà‚√ßæ¬“∫“≈ ¢≥–∑”°“√√—°…“·≈–ªØ‘∫—µ‘µàÕ‡π◊ËÕß‡¡◊ËÕÕ¬Ÿà∑’Ë∫â“π Õ’°∑—Èß¬—ß‡ªìπ ◊ËÕ∑’Ë∑”„Àâ§√Õ∫§√—«¢Õß ºŸâªÉ«¬‡¢â“„®·≈– “¡“√∂∑”„Àâ‡°‘¥°“√¡’ à«π√à«¡„π°“√¥Ÿ·≈ºŸâªÉ«¬„Àâ‡°‘¥ ÿ¢¿“æ°“¬·≈– ÿ¢¿“æ®‘µ∑’Ë ¡∫Ÿ√≥å‰¥âÕ’°¥â«¬

√ÿª

ºŸâªÉ«¬∑’Ë‡ªìπ‚√§¡–‡√Áßª“°¡¥≈Ÿ°¡—°®–«‘µ°°—ß«≈·≈–‡°‘¥§«“¡‡§√’¬¥®“°°“√‡ªìπ‚√§·≈–°“√ªØ‘∫—µ‘µ—«¢≥–√—°…“√«¡∑—Èß°“√ªØ‘∫—µ‘µ—«À≈—ß°“√√—°…“ ‘Èπ ÿ¥‡æ◊ËÕ„Àâµπ‡Õß¡’™’«‘µ∑’Ë‡ªìπª°µ‘ ÿ¢ ¥—ßπ—Èπ°“√„Àâ§«“¡√Ÿâ‡√◊ËÕß‚√§·≈–·π«∑“ß°“√ªØ‘∫—µ‘µ—«∑—Èß¢≥–∑”°“√√—°…“·≈–°“√ªØ‘∫—µ‘µ—«‡¡◊ËÕÕ¬Ÿà∑’Ë∫â“π‡æ◊ËÕ √â“ß‡ √‘¡æƒµ‘°√√¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬ ®÷ß‡ªìπ ‘Ëß ”§—≠∑’Ë®–∑”„ÀâºŸâªÉ«¬µàÕ Ÿâ°—∫‚√§‰¥â‡ªìπÕ¬à“ß¥’À√◊Õ„™â™’«‘µÕ¬Ÿà°—∫°“√‡®Á∫ªÉ«¬‰¥âÕ¬à“ß¡’§«“¡ ÿ¢·≈–¡’ µ‘ °“√„™â ◊ËÕÀ≈“°À≈“¬√Ÿª·∫∫®÷ß Õ¥§≈âÕß°—∫§«“¡µâÕß°“√¢ÕßºŸâªÉ«¬ Õ’°∑—Èß¬—ß∑”„Àâ≠“µ‘ºŸâ¥Ÿ·≈‰¥â‡°‘¥§«“¡√Ÿâ ‡æ◊ËÕ„Àâ‡°‘¥°“√¡’ à«π√à«¡„π°“√¥Ÿ·≈ºŸâªÉ«¬Õ—π®–π”‰ª Ÿà°“√¡’ ÿ¢¿“æ®‘µ∑’Ë¥’¢ÕßºŸâªÉ«¬µàÕ‰ª

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ °√¡°“√·æ∑¬å º».æ‘¡æå ÿ√ß§å ‡µ™–∫ÿ≠‡ √‘¡»—°¥‘Ï π“ß®‘√—ß°√Ÿ ≥—∞√—ß ’ ºŸâªÉ«¬∑’Ë‡ªìπ°≈ÿà¡µ—«Õ¬à“ß·≈–∫ÿ§≈“°√¢Õß»Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’∑ÿ°∑à“π


1. ™«πæ‘» π√‡¥™“ππ∑å. ‡§¡’∫”∫—¥ : À≈—°°“√æ¬“∫“≈. ¿“§«‘™“°“√æ¬“∫“≈ Ÿµ‘»“ µ√å-π√’‡«™«‘∑¬“ §≥–æ¬“∫“≈»“ µ√¡À“«‘∑¬“≈—¬¡À‘¥≈, °√ÿß‡∑æœ: ¡ª∑. 2547.

2. ∞‘µ‘æ√ Õ‘ß§∂“«√«ß»å. °“√æ¬“∫“≈¡–‡√ÁßÕ«—¬«– ◊∫æ—π∏ÿå µ√’. ß¢≈“: ∫â“π‡¡◊Õß°“√æ‘¡æå; 2541.

3. Õ“§¡ ‡™’¬√»‘≈ªá. ‚√§¡–‡√Áß·≈–°“√√—°…“ : „π‡¿ —™°√°—∫ºŸâªÉ«¬‚√§¡–‡√Áß. °√ÿß‡∑æœ: π‘«‰∑¬¡‘µ√°“√æ‘¡æå; 2540.Àπâ“ 64-6.

4. ”π—°π‚¬∫“¬·≈–·ºπ “∏“√≥ ÿ¢ °√–∑√«ß “∏“√≥ ÿ¢. ∂‘µ‘ “∏“√≥ ÿ¢. (√–∫∫ÕÕπ‰≈πå). Aviable from URL : http://203.157.19.191/pla22.[2546].[20 æƒ»®‘°“¬π 2548].

5. Sriplung H, Sontipong S, Martin N, et al. Cancer in

Thailand Vol. III 1995-1997, National Cancer institute,

Department of Medical Service. Ministry of Public

Health.

6. Àπà«¬∑–‡∫’¬π¡–‡√Áß »Ÿπ¬å¡–‡√ÁßÕÿ∫≈√“™∏“π’. ∂‘µ‘‚√§¡–‡√Áßªï æ.». 2545. Õÿ∫≈√“™∏“π’ : »‘√‘∏√√¡ÕÕø‡´Á∑°“√æ‘¡æå.2546.

7. ∏’√«ÿ≤‘ §ŸÀ–‡ª√¡–. §≈‘π‘°‡«™ªØ‘∫—µ‘ª√‘∑—»πå. ªí≠À“¡–‡√Áß∑’Ëæ∫∫àÕ¬·≈–°“√¥Ÿ·≈√—°…“ : ”À√—∫·æ∑¬å‡«™ªØ‘∫—µ‘§√Õ∫§√—«. ∂“π°“√≥å‚√§¡–‡√Áß¢Õßª√–‡∑»‰∑¬. (√–∫∫ÕÕπ‰≈πå)Aviable from URL : http://www.nci.go.th/file_download/001_1.pdf (19 ¡‘∂ÿπ“¬π 2549).

8. Pender NJ.Health promotion nursing practice.3rd ed.New

York : Appleton; 1996

9. ¡®‘µ Àπÿ‡®√‘≠°ÿ≈. °“√¥Ÿ·≈µπ‡Õß : »“ µ√å·≈–»‘≈ª–∑“ß°“√æ¬“∫“≈. æ‘¡æå§√—Èß∑’Ë 2. °√ÿß‡∑æœ: «’.‡®.æ√‘πµ‘Èß; 2537.




§«“¡·¡àπ¬”„π°“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡¥â«¬¿“æ∂à“¬√—ß ’ ·≈–§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß≥ »Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’πÈ”∑‘æ¬å À¡—Ëπæ≈»√’ æ.∫.»√’¬“ «‘‡»…π—π∑å «∑.∫.°≈ÿà¡ß“π√—ß ’«‘π‘®©—¬ »Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’ °√¡°“√·æ∑¬å

Abstract Accuracy for Detection Breast Cancer with Mammography and Ultrasound atUdonthani Regional Cancer CenterMulpolsri N., Wisetnan S.

Division of Diagnostic Radiology, Udonthani Regional Cancer Center


Retrospective study was conducted among 1,756 patients who came to Udonthani RegionalCancer Center they had been requested to do performed by mammography and ultrasound from January2004 - December 2006. The mammographic reports were categorized by BIRADS TM classification. andcompared the definite diagnosis with tissue pathology or unchanged 2 years interval follow up mammography.The conclusion of study showed 88.0 percent sensitivity, 98.9 percent specificity and 98.5 percent accuracy.

Key words: mammography, ultrasound, breast cancer

‡√◊ËÕß¬àÕ ‚√§¡–‡√Áß‡µâ“π¡‡ªìπ‚√§∑’Ë¡’Õÿ∫—µ‘°“√≥å°“√‡°‘¥ Ÿß¢÷Èπ∑ÿ°ªï ·≈–ªí®®ÿ∫—π Ÿß‡ªìπÕ—π¥—∫ Õß¢ÕßÀ≠‘ß‰∑¬ ·µà„π¢≥–‡¥’¬«°—π “¡“√∂√—°…“„ÀâÀ“¬¢“¥‰¥âÀ“°«‘π‘®©—¬‰¥âµ—Èß·µà√–¬–·√° ¥—ßπ—Èπ°“√µ√«®«‘π‘®©—¬‡æ◊ËÕ§âπÀ“¡–‡√Áß‡µâ“π¡µ—Èß·µà√–¬–·√° ”§—≠¡“° °≈ÿà¡ß“π√—ß ’«‘π‘®©—¬ »Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’‰¥âµ√–Àπ—°∂÷ß‡√◊ËÕßπ’È ®÷ß‰¥â∑”°“√»÷°…“§«“¡·¡àπ¬”„π°“√·ª≈º≈°“√µ√«®§âπÀ“¡–‡√Áß‡µâ“π¡„πºŸâªÉ«¬À≠‘ß®”π«π 1,756 √“¬ ‚¥¬¿“æ∂à“¬√—ß ’‡µâ“π¡·≈–§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß ª√–°Õ∫°“√·ª≈º≈µ“¡À≈—°¡“µ√∞“π “°≈¢Õß BIRADS TM classification ·≈–¬◊π¬—π§«“¡∂Ÿ°µâÕß„π°“√·ª≈¥â«¬°“√µ√«®™‘Èπ‡π◊ÈÕ À√◊Õµ‘¥µ“¡º≈°“√µ√«®‡Õ°´‡√¬å‡µâ“π¡´È”„π™à«ß‡«≈“ 2 ªï º≈°“√»÷°…“æ∫«à“ °“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡ ∑’Ë»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ ¡’§«“¡·¡àπ¬”·≈–§«“¡πà“‡™◊ËÕ∂◊Õ Ÿß ‚¥¬¡’§«“¡‰«√âÕ¬≈– 88.0 §«“¡®”‡æ“–√âÕ¬≈– 98.9 ·≈–§«“¡·¡àπ¬”„π°“√·ª≈º≈√âÕ¬≈–98.5

§” ”§—≠: ¿“æ∂à“¬√—ß ’‡µâ“π¡ §≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß ¡–‡√Áß‡µâ“π¡

78

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

¡–‡√Áß‡µâ“π¡‡ªìπ‚√§∑’Ëæ∫¡“°‡ªìπÕ—π¥—∫ Õß¢Õß µ√’ ¡’Õÿ∫—µ‘°“√≥åª√–¡“≥ 17.2 µàÕª√–™“°√ 100,000§π ¢Õßª√–‡∑»‰∑¬1 ´÷Ëß‡ªìπ‚√§∑’Ë “√¡“√∂√—°…“„ÀâÀ“¬¢“¥‰¥âÀ“°µ√«®«‘π‘®©—¬‰¥âµ—Èß·µà√–¬–·√° „πªí®®ÿ∫—π¡’‡§√◊ËÕß¡◊Õ∑’Ë¡’ª√– ‘∑∏‘¿“æ ŸßÀ≈“¬™π‘¥„π°“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡ ‡™àπ ‡§√◊ËÕßµ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß Õ—≈µ√â“´“«¥å (Ultrasound) ‡§√◊ËÕß∂à“¬¿“æ√—ß ’‡µâ“π¡·¡¡‚¡·°√¡ (Mammography) ‡§√◊ËÕß‡Õ°´‡√¬å§Õ¡æ‘«‡µÕ√å (CT scan) ‡§√◊ËÕßµ√«®§≈◊Ëπ·¡à‡À≈Á°‰øøÑ“ (MRI) ´÷Ëß‡§√◊ËÕß¡◊Õ·µà≈–™π‘¥¡’ª√– ‘∑∏‘¿“æ„π°“√µ√«®«‘π‘®©—¬µà“ß°—π √«¡∂÷ßµâπ∑ÿπ¢Õß‡§√◊ËÕß¡◊Õ·µà≈–™π‘¥°Áµà“ß°—π¥â«¬

»Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’‡ªìπÀπà«¬ß“π¢Õß√—∞∫“≈ ‡ªìπ ∂“π∫√‘°“√√–¥—∫µµ‘¬¿Ÿ¡‘¥â“π‚√§¡–‡√Áß „π —ß°—¥¢Õß°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢∑’Ë¥Ÿ·≈√—∫º‘¥™Õ∫ª√–™“°√ª√–¡“≥ 9.1 ≈â“π§π „π‡¢µ 9 ®—ßÀ«—¥ ¢Õß¿“§µ–«—πÕÕ°‡©’¬ß‡Àπ◊ÕµÕπ∫π ¡’ºŸâ¡“√—∫∫√‘°“√µ√«®§âπÀ“¡–‡√Áß¥â«¬‡§√◊ËÕß∂à“¬¿“æ√—ß ’‡µâ“π¡·≈–§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß‡©≈’Ë¬ªï≈–ª√–¡“≥ 2,500 §π »Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’¡’Àπâ“∑’ËÀ≈—°∑—Èß„π¥â“πß“π∫√‘°“√ªÑÕß°—π µ√«®√—°…“‚√§¡–‡√Áß ·≈–‡ªìπºŸâπ”∑“ß«‘™“°“√¥â“π‚√§¡–‡√Áß¥—ßπ—Èπ°≈ÿà¡ß“π√—ß ’«‘π‘®©—¬

»Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’‡ªìπ à«πÀπ÷Ëß„π¢Õß°“√√—∫º‘¥™Õ∫„π°“√·ª≈º≈°“√µ√«®¿“æ∂à“¬√—ß ’¢Õß‡µâ“π¡ ‡æ◊ËÕ§âπÀ“¡–‡√Áßµ—Èß·µà√–¬–‡√‘Ë¡·√° ®÷ß‡ÀÁπ§«“¡ ”§—≠¢Õß°“√»÷°…“ª√–‡¡‘π»—°¬¿“æ·≈–ª√– ‘∑∏‘¿“æ§«“¡·¡àπ¬”¢Õß°“√·ª≈º≈°“√µ√«®«‘π‘®©—¬¿“æ∂à“¬√—ß ’‡µâ“π¡ ≥ »Ÿπ¬å¡–‡√ÁßÕÿ¥∏“π’∑—Èßπ’È‡æ◊ËÕ‡ªìπ°“√ π—∫ πÿπ‡°≥±å¡“µ√∞“π¢Õß∫ÿ§≈“°√∑“ß√—ß ’°“√·æ∑¬å∑’Ë ¡§«√‰¥â√—∫°“√√—∫√Õß¡“µ√∞“π„π°“√·ª≈º≈¿“æ∂à“¬√—ß ’‡µâ“π¡2 ·≈–®–‰¥â»÷°…“∂÷ß¢âÕ∫°æ√àÕß¢Õß·π«∑“ßªØ‘∫—µ‘¢Õß»Ÿπ¬å∑’Ë∑”Õ¬Ÿà„πªí®®ÿ∫—π„π°“√§âπÀ“¡–‡√Áß‡µâ“π¡«à“§«√®–ª√—∫ª√ÿß‡ª≈’Ë¬π·ª≈ß‡™àπ‰√ ‡æ◊ËÕ„Àâ°“√µ√«®§âπÀ“¡–‡√Áß‡µâ“π¡‰¥âº≈¡“°∑’Ë ÿ¥

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“¢âÕ¡Ÿ≈¬âÕπÀ≈—ß®“°·øÑ¡ª√–«—µ‘·≈–º≈°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡ ‡æ◊ËÕ¥Ÿ§«“¡º‘¥ª√°µ‘¢Õß‡µâ“π¡ „π µ√’∑’Ë¡“√—∫°“√µ√«®¿“æ¥â«¬√—ß ’‡µâ“π¡∑’Ë»Ÿπ¬å¡–‡√ÁßÕÿ¥√ ∏“π’ „π™à«ß‡¥◊Õπ ¡°√“§¡ æ.». 2547- ∏—π«“§¡ æ.». 2549 ®”π«π 2,000 §π ·≈â«§—¥‡≈◊Õ°ºŸâ∑’Ë¡’§ÿ≥ ¡∫—µ‘‰¡à§√∫∂â«πµ“¡‡°≥±å¢Õß°“√»÷°…“ÕÕ° ‡À≈◊Õ‡æ’¬ß 1,756 √“¬ §‘¥‡ªìπ√âÕ¬≈– 87.8

‡°≥±å ”À√—∫§—¥‡≈◊Õ°ºŸâªÉ«¬„π°“√»÷°…“§√—Èßπ’È

µâÕß‰¥â√—∫°“√µ√«®«‘π‘®©—¬‚√§¥â«¬¿“æ∂à“¬√—ß ’‡µâ“π¡·≈–‡§≈◊ËÕπ‡ ’¬ß§«“¡∂’Ë Ÿß„π™à«ß ¡°√“§¡ æ.».2547 - ∏—π«“§¡ æ.». 2549

µâÕß‰¥â√—∫°“√æ‘ Ÿ®πåº≈º≈§«“¡º‘¥ª°µ‘¢Õß‡µâ“π¡ ‚¥¬«‘∏’

‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕ°√≥’ ß —¬«à“‡ªìπ¡–‡√Áß À√◊Õ

‰¥â√—∫°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡´È”¿“¬„π2 ªï

À≈—°°“√·ª≈º≈°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡3,4

º≈°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡®–·ª≈º≈µ“¡BIRADS Classification ¢Õß American College ofRadiology ¥—ßπ’È

BIRADS 0 : Incomplete study À¡“¬∂÷ß°“√ª√–‡¡‘πº≈‚¥¬ ¿“æ∂à“¬√—ß ’‡µâ“π¡¬—ß‰¡à ¡∫Ÿ√≥å®”‡ªìπµâÕßµ√«®‡æ‘Ë¡‡µ‘¡

BIRADS 1 : Negative study ‰¡àæ∫√àÕß√Õ¬§«“¡º‘¥ª°µ‘¢Õß‡µâ“π¡

BIRADS 2 : Benign study æ∫§«“¡º‘¥ª°µ‘¢Õß‡µâ“π¡ „π¿“æ∂à“¬√—ß ’∑’Ë∫àß∫Õ°«à“‰¡à„™à¡–‡√Áß‡™àπ ∂ÿßπÈ”, °âÕπ‡π◊ÈÕßÕ°∏√√¡¥“, À‘πªŸπ™π‘¥∏√√¡¥“,À√◊ÕµàÕ¡πÈ”‡À≈◊Õß„π‡µâ“π¡

BIRADS 3 : Probably benign study §«“¡º‘¥ª°µ‘∑’Ëæ∫¡’≈—°…≥–Õ¬à“ß∑’Ë∑”„Àâ‰¡à·πà„®«à“®–‡ªìπ¡–‡√ÁßÀ√◊Õ‰¡à ‡™àπ °âÕπ‡π◊ÈÕßÕ° ∑’Ë¡’¢Õ∫‡√’¬∫·µà ¢√ÿ¢√–

BIRADS 4 : Suspicions abnormality ‡™àπ°âÕπ‡π◊ÈÕ¢Õ∫¢√ÿ¢√– (microlobulation) °≈ÿà¡¢Õß



À‘πªŸπ·∫∫≈–‡Õ’¬¥ (cluster of microcalcifications)BIRADS 5 : Highly Suspicions of malig-

nancy ¡’√Õ¬‚√§∑’Ë∫àß™’È«à“ ‡ªìπ¡–‡√Áß‡ªìπ°âÕπ‡π◊ÈÕ¢Õ∫‰¡à‡√’¬∫ ¡’À‘πªŸπ∑’Ë∫àß™’È¡–‡√Áß√–¬–·√°

BIRADS 6 : Known case of canons ‡§¬‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕ¡“·≈â««à“‡ªìπ¡–‡√Áß „π à«π¢ÕßBIRADS 0, 6 ®–∂Ÿ°§—¥ÕÕ°®“°°“√»÷°…“π’È

´÷ËßÀ“°º≈°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡„π√“¬∑’Ë√—ß ’·æ∑¬å ∑à“πÀπ÷Ëß‰¡à·πà„®„π°“√·ª≈º≈°Á®–¡’°“√ª√÷°…“√—ß ’·æ∑¬åÕ’°∑à“π ‡æ◊ËÕ„Àâ·ª≈º≈‰¥â∂Ÿ°µâÕßµ√ß°—π

§”π‘¬“¡

√—ß ’·æ∑¬å (Radiologist) ¡’§ÿ≥ ¡∫—µ‘µ“¡‡°≥±å¡“µ√∞“π∑’Ë°”Àπ¥2

§ÿ≥ ¡∫—µ‘∑—Ë«‰ª ®∫·æ∑¬å»“ µ√å∫—≥±‘µ ·≈–‰¥â√—∫«ÿ≤‘∫—µ√ºŸâ‡™’Ë¬«™“≠¥â“π√—ß ’«‘∑¬“

§ÿ≥ ¡∫—µ‘‡©æ“–‡√‘Ë¡·√°1. ‰¥â√—∫°“√Ωñ°Õ∫√¡°“√«‘π‘®©—¬°“√µ√«®‡µâ“π¡

‚¥¬‡§√◊ËÕß∂à“¬¿“æ√—ß ’‡µâ“π¡„π‚√ß‡√’¬π·æ∑¬åÀ√◊Õ ∂“∫—π∑’Ë‰¥â√—∫°“√√—∫√ÕßÕ¬à“ßπâÕ¬ 1 ‡¥◊Õπ „π¢≥–∑’Ë‡ªìπ·æ∑¬åª√–®”∫â“π

2. °√≥’∑’Ë‰¥â√—∫°“√Ωñ°Õ∫√¡°“√«‘π‘®©—¬°“√µ√«®‡µâ“π¡‚¥¬‡§√◊ËÕß∂à“¬√—ß ’‡µâ“π¡„π¢≥–∑’Ë‡ªìπ·æ∑¬åª√–®”∫â“π À√◊Õ‰¡à‰¥â∑”°“√«‘π‘®©—¬°“√µ√«®¿“æ√—ß ’‡µâ“π¡À≈—ß®∫°“√»÷°…“‡°‘π 3 ªï ®–µâÕßºà“π°“√∫Õ√¡À≈—° Ÿµ√°“√«‘π‘®©—¬°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡„π‚√ß‡√’¬π·æ∑¬åÀ√◊Õ ∂“∫—π∑’Ë‰¥â√—∫°“√√—∫√ÕßÕ¬à“ßπâÕ¬ 120 ™—Ë«‚¡ß ·≈–¡’ª√– ∫°“√≥å°“√Õà“π·ª≈º≈¿“æ∂à“¬√—ß ’‡µâ“π¡Õ¬à“ßπâÕ¬ 240 √“¬

ª√– ∫°“√≥å°“√∑”ß“πµàÕ‡π◊ËÕßÀ√◊ÕΩñ°Õ∫√¡µàÕ‡π◊ËÕß

1. ‡¢â“√à«¡ª√–™ÿ¡«‘™“°“√‡°’Ë¬«°—∫°“√µ√«®·≈–·ª≈º≈¿“æ√—ß ’‡µâ“π¡∑’Ëºà“π°“√√—∫√Õß¢Õß»Ÿπ¬å°“√»÷°…“·æ∑¬åµàÕ‡π◊ËÕßÕ¬à“ßπâÕ¬ 1 §√—Èß/ 3 ªï

2. Õà“π·≈–·ª≈º≈¿“æ∂à“¬√—ß ’‡µâ“π¡Õ¬à“ßπâÕ¬240 √“¬/ªï Õ¬à“ßµàÕ‡π◊ËÕß ∂â“‡«âπ‡°‘π 2 ªï ®–µâÕß‰¥â

√—∫°“√Ωñ°Õ∫√¡„À¡àπ—°√—ß ’‡∑§π‘§ À√◊Õ ‡®â“Àπâ“∑’Ë√—ß ’°“√·æ∑¬å ¡’

§ÿ≥ ¡∫—µ‘µ“¡‡°≥±å¡“µ√∞“π∑’Ë°”Àπ¥2

§ÿ≥ ¡∫—µ‘∑—Ë«‰ª ®∫√—ß ’‡∑§π‘§„πÀ≈—° Ÿµ√Õ¬à“ßπâÕ¬ 2 ªï

§ÿ≥ ¡∫—µ‘‡©æ“–‡√‘Ë¡·√° ®–µâÕß‰¥â√—∫°“√Ωñ°Õ∫√¡„π°“√„™â‡§√◊ËÕß „π¢≥–Ωñ°Õ∫√¡·≈–¡’ª√– ∫°“√≥å„π°“√∑”ß“πÕ¬à“ßπâÕ¬ 25 √“¬

ª√– ∫°“√≥å°“√∑”ß“πµàÕ‡π◊ËÕßÀ√◊ÕΩñ°Õ∫√¡µàÕ‡π◊ËÕß

- ‡¢â“√à«¡ª√–™ÿ¡«‘™“°“√∑’Ë‡°’Ë¬«°—∫°“√µ√«®‡µâ“π¡¥â«¬‡§√◊ËÕß∂à“¬¿“æ√—ß ’‡µâ“π¡Õ¬à“ßπâÕ¬ 1 §√—Èß/3 ªï

- ∑”°“√ªØ‘∫—µ‘ß“πÕ¬à“ßπâÕ¬ 100 √“¬/ªï

‡§√◊ËÕß¡◊Õ·≈–Õÿª°√≥å

‡§√◊ËÕß∂à“¬¿“æ√—ß ’ ‡µâ“π¡ ·¡¡‚¡·°√¡(Mammography) GE √ÿàπ Senograph DMR ¡’2 focal spot §◊Õ ¢π“¥ ‰¡à‡°‘π 0.1-0.3 ¡‘≈≈‘‡¡µ√ ¡’filter 2 ™π‘¥ §◊Õ Molypdinum ·≈– Rhodium “¡“√∂ª√—∫µ—Èß§à“ exposure ‰¥â∑—Èß·∫∫Õ—µ‚π¡—µ‘·≈–·∫∫ª√—∫§à“‡Õß ¢¬“¬¿“æ‰¥â 1.5-1.9 ‡∑à“

‡§√◊ËÕßµ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß- ‡§√◊ËÕßµ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß GE √ÿàπ logic

400 Version 3.1 small part menu, linear probe7.5 MHz

- ‡§√◊ËÕßµ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß Toshiba √ÿàπEccocee, small part menu, linear probe 8 MHz

‡§√◊ËÕß≈â“ßøî≈å¡ Kodak XO 2000 ∑’Ëµ‘¥µ—Èß‰«â ”À√—∫≈â“ßøî≈å¡‡Õ°´‡√¬å‡µâ“π¡‚¥¬‡©æ“–

øî≈å¡¬’ËÀâÕ‚°¥—°√ÿàπ Min R 2000 ¢π“¥ 18 × 24‡´πµ‘‡¡µ√

‡∑§π‘§°“√µ√«®

„™â∑à“¡“µ√∞“πÕ¬à“ßπâÕ¬ 2 ∑à“ ”À√—∫°“√µ√«®ºŸâªÉ«¬·µà≈–√“¬ §◊Õ CC (Cranio-caudal view) (√Ÿª∑’Ë1) ·≈– MLO (mediolateral oblique view) (√Ÿª∑’Ë 2)

80

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

√Ÿª∑’Ë 2 ∑à“¡“µ√∞“π MLO (Mediolateral oblique view)

√Ÿª∑’Ë 1 ∑à“¡“µ√∞“π CC (Cranio-caudal view)

·≈–∫“ß√“¬Õ“®µâÕß°“√µ√«®∑à“Õ◊ËπÊ ‡æ‘Ë¡‡µ‘¡µ“¡§«“¡‡À¡“– ¡ ‡™àπ Magnification view, Conecompression view, Tangential view √«¡∂÷ß°“√µ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß (ultrasound)5,6 ∑—Èßπ’È¢÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß√—ß ’·æ∑¬å

°“√µ√«®™‘Èπ‡π◊ÈÕ„π°√≥’∑’Ëæ∫§«“¡º‘¥ª°µ‘¢Õß¿“æ∂à“¬√—ß ’‡µâ“π¡¡’ 2 «‘∏’ §◊Õ °“√∑” Core NeedleBiopsy Under Ultrasound Guided ·≈–°“√∑” localexcision biopsy

°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈§”π«≥À“§à“§«“¡‰« §«“¡®”‡æ“– §à“§«“¡∂Ÿ°µâÕß

º≈

®”π«πºŸâªÉ«¬∑’Ë¡“√—∫∫√‘°“√∑’Ë¡’§ÿ≥ ¡∫—µ‘§√∫∂â«π®”π«π 1,756 √“¬ ®“°®”π«πºŸâªÉ«¬∑’Ë»÷°…“∑—Èß ‘Èπ

µ“√“ß∑’Ë 1 °≈ÿà¡Õ“¬ÿ¢ÕßºŸâ¡“√—∫∫√‘°“√µ√«®¿“æ∂à“¬√—ß ’

‡µâ“π¡ ∑’Ë»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’

Õ“¬ÿ ®”π«π (√“¬) √âÕ¬≈–

< 30 19 1.1

30-34 49 2.8

35-39 230 13.1

40-44 451 25.7

45-49 458 26.1

50-54 273 15.6

55-59 147 8.4

60-64 71 4.0

65-69 35 2.0

> 70 23 1.3

√«¡ 1,756 100

2,000 √“¬ §‘¥‡ªìπ√âÕ¬≈– 87.8 Õ“¬ÿÕ¬Ÿà„π™à«ß 16-81ªï (‚¥¬ºŸâªÉ«¬∑’ËÕ“¬ÿπâÕ¬ ÿ¥ §◊Õ 16 ªï ‡ªìπºŸâªÉ«¬¡“¥â«¬¡’‡≈◊Õ¥ÕÕ°®“°À—«π¡ ¡“®“° “∏“√≥√—∞ª√–™“∏‘ª‰µ¬ª√–™“™π≈“«) Õ“¬ÿ‡©≈’Ë¬¢ÕßºŸâªÉ«¬ 46.33 ªï à«π¡“°Õ¬Ÿà„π™à«ß 40-49 ªï (µ“√“ß∑’Ë 1 ·≈– √Ÿª∑’Ë 3)

„π®”π«πºŸâªÉ«¬∑’Ë»÷°…“π’È¡’ 1,616 √“¬ ‡ªìπª√–™“°√∑’ËÕ“»—¬Õ¬Ÿà„π‡¢µ§«“¡√—∫º‘¥™Õ∫¢Õß»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ §‘¥‡ªìπ√âÕ¬≈– 92 ∑’Ë‡À≈◊Õ‡ªìπª√–™“°√„π®—ßÀ«—¥Õ◊Ëπ∑’ËÕ¬ŸàπÕ°‡¢µ§«“¡√—∫º‘¥™Õ∫¢Õß»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ √«¡∂÷ß®“° “∏“√≥√—∞ª√–™“∏‘ª‰µ¬ª√–™“π≈“«¥â«¬ (µ“√“ß∑’Ë 2 ·≈–√Ÿª∑’Ë 4)

ºŸâ¡“√—∫∫√‘°“√„π‡¢µ§«“¡√—∫º‘¥™Õ∫‡ªìπª√–™“°√„π®—ßÀ«—¥Õÿ¥√∏“π’ 530 √“¬ §‘¥‡ªìπ√âÕ¬≈– 32.8 ¢Õßª√–™“°√„π‡¢µ§«“¡√—∫º‘¥™Õ∫ (µ“√“ß∑’Ë 3 ·≈–√Ÿª∑’Ë5)

®“°º≈°“√µ√«®«‘π‘®©—¬¥â«¬¿“æ∂à“¬√—ß ’‡µâ“π¡√à«¡°—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß ·ª≈º≈°“√µ√«®«‘π‘®©—¬µ“¡BIRADS classification ‰¥âº≈¥—ßπ’È

ºŸâªÉ«¬„π°≈ÿà¡ BIRADS 1 ®”π«π 847 √“¬ ‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕ 20 √“¬ (√âÕ¬≈– 2.3) º≈‡ªìπFibrocystic change 15 √“¬ Fibrosis 5 √“¬ ·≈–º≈



30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70

Õ“¬ÿ (ªï)

®”π

«π

(√“¬

)

500450400350300250200150100500

ºŸâ¡“√—∫∫√‘°“√µ√«® Mammogram

√Ÿª∑’Ë 3 °≈ÿà¡Õ“¬ÿ¢ÕßºŸâ¡“√—∫∫√‘°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡ ∑’Ë»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’

µ“√“ß∑’Ë 2 ®”π«πºŸâ¡“√—∫∫√‘°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡ ·¬°µ“¡æ◊Èπ∑’Ë√—∫º‘¥™Õ∫»Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’

®—ßÀ«—¥/‡¢µæ◊Èπ∑’Ë ®”π«π (√“¬) √âÕ¬≈–

„π‡¢µæ◊Èπ∑’Ë√—∫º‘¥™Õ∫»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ 1,616 92

πÕ°‡¢µæ◊Èπ∑’Ë√—∫º‘¥™Õ∫»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ 60 3.4

µà“ßª√–‡∑» 80 4.6

1800

1600

1400

1200

1000

800

600

400

200

0

„π‡¢µæ◊Èπ∑’Ë√—∫º‘¥™Õ∫ πÕ°‡¢µæ◊Èπ∑’Ë√—∫º‘¥™Õ∫ µà“ßª√–‡∑»

»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ »Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’

ºŸâ√—∫∫√‘°“√

√Ÿª∑’Ë 4 ®”π«πºŸâ¡“√—∫∫√‘°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡ ·¬°µ“¡æ◊Èπ∑’Ë√—∫º‘¥™Õ∫»Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’

®”π

«π

(√“¬

)

®”π«π (§π)

®”π«π (√“¬)

82

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

°“√µ√«®‡Õ°´‡√¬å‡µâ“π¡‰¡à‡ª≈’Ë¬π·ª≈ß„π™à«ß 2 ªï 827√“¬ (√âÕ¬≈– 97.6)

ºŸâªÉ«¬„π°≈ÿà¡ BIRADS 2 ®”π«π 695 √“¬ ‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕ 38 √“¬ (√âÕ¬≈– 5.5) ‡ªìπFibrocystic change 15 √“¬ Fibroadenoma 18 √“¬Fibroadenosis 3 √“¬ Inflammation 2 √“¬ ·≈–º≈°“√µ√«®‡Õ°´‡√¬å‡µâ“π¡‰¡à‡ª≈’Ë¬π·ª≈ß„π™à«ß 2 ªï 657√“¬ (√âÕ¬≈– 94.5)

ºŸâªÉ«¬„π°≈ÿà¡ BIRADS 3 ®”π«π130√“¬ ‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕ 30 √“¬ (√âÕ¬≈–23.1) ‡ªìπ¡–‡√Áß 9√“¬ Lipoma 1 √“¬ Fibeocystic change 11 √“¬Fibroadenoma 8 √“¬ Benign Phyloides tumor 1√“¬ ·≈–º≈°“√µ√«®‡Õ°´‡√¬å‡µâ“π¡‰¡à‡ª≈’Ë¬π·ª≈ß„π™à«ß 2 ªï 100 √“¬ (√âÕ¬≈– 76.9)

µ“√“ß∑’Ë 3 ºŸâ¡“√—∫∫√‘°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡ „π‡¢µ

æ◊Èπ∑’Ë√—∫º‘¥™Õ∫ 9 ®—ßÀ«—¥

®—ßÀ«—¥ ®”π«π (√“¬) √âÕ¬≈–

Õÿ¥√∏“π’ 530 32.8

°≈π§√ 272 16.8

ÀπÕß§“¬ 257 15.9

‡≈¬ 211 13.1

ÀπÕß∫—«≈”¿Ÿ 121 7.5

°“Ã ‘π∏ÿå 105 6.5

π§√æπ¡ 66 4.1

¡À“ “√§“¡ 22 1.3

¢Õπ·°àπ 32 2.0

√«¡ 1,616 100

600

500

400

300

200

100

0Õÿ¥√∏“π’ °≈π§√ ÀπÕß§“¬ ‡≈¬ ÀπÕß∫—«≈”¿Ÿ °“Ã ‘π∏ÿå π§√æπ¡ ¡À“ “√§“¡ ¢Õπ·°àπ

®—ßÀ«—¥

√Ÿª∑’Ë 5 ºŸâ¡“√—∫∫√‘°“√µ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡„π‡¢µæ◊Èπ∑’Ë√—∫º‘¥™Õ∫ 9 ®—ßÀ«—¥

®”π

«π

(√“¬

)

®”π«π (√“¬)



µ“√“ß∑’Ë 6 Overall PPV and NPV

Mammographic reports PPV (%) NPV (%)

Benign (BIRADS 1, 2, 3) - 99.5

Malignancy (BIRADS 4, 5) 78.6 -

µ“√“ß∑’Ë 5 §à“ PPV 7, 8 ·≈– NPV ·¬°µ“¡ BIRADS

classification

Mammographic reports PPV (%) NPV (%)

BIRADS 1 - 100

BIRADS 2 - 100

BIRADS 3 - 86.4

BIRADS 4 64.6 -

BIRADS 5 97.2 -

(Negative Predictive Value) = TN / Total(Positive Predictive Value) = TP / Total§à“§«“¡‰« (Sensitivity) √âÕ¬≈– 80 §à“§«“¡

®”‡æ“– (Specificity) √âÕ¬≈– 98.9 §à“§«“¡∂Ÿ°µâÕß(Accuracy) √âÕ¬≈– 98.5

„πºŸâªÉ«¬®”π«π 75 √“¬∑’Ë‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ¡–‡√Áß §‘¥‡ªìπ√âÕ¬≈– 4.3 ¢ÕßºŸâªÉ«¬∑’Ë∑”°“√»÷°…“∑—ÈßÀ¡¥ ‚¥¬·∫àßµ“¡™à«ßÕ“¬ÿ‰¥â¥—ßµ“√“ß∑’Ë 7

ºŸâªÉ«¬„π°≈ÿà¡ BIRADS 4 ®”π«π 48 √“¬ ‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕ À¡¥∑—Èß 48 √“¬ (√âÕ¬≈– 100)‡ªìπ¡–‡√Áß 31 √“¬ Intraductal Papilloma 2 √“¬ Fatnecrosis 1 √“¬ Fibrocystic change 3 √“¬Fibroadenoma 10 √“¬ Abscess 1 √“¬

ºŸâªÉ«¬„π°≈ÿà¡ BIRADS 5 ®”π«π 36 √“¬ ‰¥â√—∫°“√µ√«®™‘Èπ‡π◊ÈÕÀ¡¥∑—Èß 36 √“¬ (√âÕ¬≈– 100)‡ªìπ¡–‡√Áß 35 √“¬ ·≈–‡ªìπ Fibroadenoma (Lobulatedcontous) 1 √“¬ (µ“√“ß∑’Ë 4)

®”π«πºŸâªÉ«¬∑—ÈßÀ¡¥∑’Ë∂Ÿ°§—¥‡≈◊Õ°‡¢â“¡“„π°“√»÷°…“π’È®–∂Ÿ°·ª≈º≈·≈–«‘‡§√“–Àå§«“¡πà“‡™◊ËÕ∂◊Õ‚¥¬„™âÀ≈—°∑“ß ∂‘µ‘

True Negative (TN) À¡“¬∂÷ß ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√¬◊π¬—π«à“‰¡à‰¥â‡ªìπ¡–‡√Áß®√‘ß„π°≈ÿà¡ BIRADS I, II,III ®”π«π 1,163 √“¬ (847 + 695 + 121)

True Positive (TP) À¡“¬∂÷ß ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√¬◊π¬—π«à“‡ªìπ¡–‡√Áß®√‘ß„π°≈ÿà¡ BIRADS IV, V®”π«π 66 √“¬ (31 + 35)

False Negative (FN) À¡“¬∂÷ß ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√«‘π‘®©—¬®“°°“√µ√«®™‘Èπ‡π◊ÈÕ«à“‡ªìπ¡–‡√Áß„π°≈ÿà¡BIRADS I, II, III ®”π«π 9 √“¬ (0 + 0 + 9)

False Positive (FP) À¡“¬∂÷ß ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√ ß —¬«à“‡ªìπ¡–‡√Áß®“°‡Õ°´‡√¬å‡µâ“π¡ ·µàº≈°“√µ√«®∑“ßæ¬“∏‘«‘∑¬“¬◊π¬—π«à“‰¡à‡ªìπ¡–‡√Áß ®”π«π 18√“¬ (17 + 1)

µ“√“ß∑’Ë 4 ®”π«πºŸâªÉ«¬∑’Ë‰¥â√—∫°“√µ√«®«‘π‘®©—¬¥â«¬¿“æ∂à“¬√—ß ’‡µâ“π¡ ·≈–º≈°“√µ√«®∑“ßæ¬“∏‘«‘∑¬“

Histopathology or 2 years follow up

mammographyMammographic reports Total

Benign Malignancy

®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈– ®”π«π

BIRADS 1 847 100 0 0 847

BIRADS 2 695 100 0 0 695

BIRADS 3 121 93.1 9 6.9 130

BIRADS 4 17 35.4 31 64.6 48

BIRADS 5 1 2.8 35 97.2 36

84

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

º≈®“°°“√»÷°…“æ∫«à“æ∫ºŸâªÉ«¬∑’Ë‡ªìπ¡–‡√Áß‡µâ“π¡ 76 √“¬ ®“° 1,756 √“¬ §‘¥‡ªìπ√âÕ¬≈– 4.3‚¥¬æ∫‰¥âµ—Èß·µàÕ“¬ÿ 35-76 ªï ·≈– à«π„À≠à®–Õ¬Ÿà„π™à«ßÕ“¬ÿ 40-49 ªï · ¥ß„Àâ‡ÀÁπ«à“°“√µ√«®§âπÀ“¡–‡√Áß‡µâ“π¡¥â«¬‡§√◊ËÕß∂à“¬¿“æ√—ß ’‡µâ“π¡§«√·π–π”„Àâµ√«®„π™à«ßÕ“¬ÿ 40 ªï¢÷Èπ‰ª ¬°‡«âπ„π√“¬∑’Ë¡’Õ“°“√∫àß™’È ß —¬«à“πà“®–‡ªìπ¡–‡√ÁßÀ√◊Õ¡’§«“¡‡ ’Ë¬ßµàÕ°“√‡ªìπ¡–‡√Áß‡µâ“π¡ Ÿß ®÷ß§«√®–·π–π”„Àâµ√«®„π™à«ßÕ“¬ÿπâÕ¬°«à“ 40 ªï

®“°º≈°“√»÷°…“§√—Èßπ’Èæ∫«à“°“√µ√«®§âπÀ“¡–‡√Áß‡µâ“π¡¥â«¬¿“æ∂à“¬√—ß ’‡µâ“π¡√à«¡°—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß™à«¬„Àâ “¡“√∂µ√«®æ∫§«“¡º‘¥ª°µ‘ ‚¥¬‡©æ“–¡–‡√Áß‡µâ“π¡ ‰¥â„π§«“¡‰«√âÕ¬≈– 88.0 §«“¡®”‡æ“–√âÕ¬≈– 98.9 ·≈–§«“¡∂Ÿ°µâÕß·¡àπ¬”√âÕ¬≈– 98.5 ´÷Ëß∂◊Õ«à“‡ªìπº≈°“√»÷°…“∑’Ë¡’§«“¡·¡àπ¬” Ÿß‡ªìπ∑’Ëπà“æÕ„®„°≈â‡§’¬ß°—∫º≈°“√»÷°…“Õ◊ËπÊ ∑’Ë¡’√“¬«“π‰«â9-11

∑”„Àâ»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’‰¥â√—∫§«“¡‰«â«“ß·≈–§«“¡‡™◊ËÕ¡—Ëπ Ÿß„π§«“¡·¡àπ¬”¢Õß°“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡¥â«¬¿“æ∂à“¬∑“ß√—ß ’·≈–§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß®÷ß¡’®”π«πºŸâ¡“√—∫∫√‘°“√‡æ‘Ë¡¢÷Èπ∑ÿ°ªï ¥—ßπ—Èπ·π«∑“ß

√Ÿª∑’Ë 6 ®”π«πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡·¬°µ“¡™à«ßÕ“¬ÿ

0

2

4

6

8

10

12

14

16

18

20

30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70

Õ“¬ÿ (ªï)

®”π

«π

(√“¬

)

CA

®”π«πºŸâªÉ«¬∑’Ë‡ªìπ¡–‡√Áß‡µâ“π¡

µ“√“ß∑’Ë 7 ®”π«πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡·¬°µ“¡™à«ßÕ“¬ÿ

Õ“¬ÿ ®”π«π (√“¬) √âÕ¬≈–

< 30 0 0.0

30-34 0 0.0

35-39 9 12.0

40-44 11 14.7

45-49 19 25.3

50-54 12 16.0

55-59 11 14.7

60-64 4 5.3

65-69 3 4.0

> 69 6 8.0

«‘®“√≥å

®“°“√»÷°…“§√—Èßπ’È¡’®”π«πµàÕ°“√»÷°…“ 1,756√“¬®“°∑—ÈßÀ¡¥ 2,000 √“¬ §‘¥‡ªìπ√âÕ¬≈– 87.8 à«π∑’Ë§—¥ÕÕ°®“°°“√»÷°…“‡æ√“–ºŸâªÉ«¬¢“¥°“√µ‘¥µ“¡º≈°“√√—°…“Õ¬à“ßµàÕ‡π◊ËÕß· ¥ß„Àâ‡ÀÁπ«à“ª√–™“™π à«π„À≠àµ√–Àπ—°∂÷ß§«“¡ ”§—≠¢Õß°“√µ√«®§âπÀ“¡–‡√Áß‡µâ“π¡Õ¬à“ß¡“°



∑’Ë»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’‰¥â«“ß‰«â‡°’Ë¬«°—∫°“√µ√«®§âπÀ“¡–‡√Áß‡µâ“π¡¥â«¬¿“æ∂à“¬√—ß ’√à«¡°—∫§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß∂◊Õ«à“‡ªìπ∑’Ëπà“æÕ„®·≈–§«√®– àß‡ √‘¡√≥√ß§å„Àâ¡’µàÕ‰ª

·π«∑“ß°“√µ√«®§—¥°√Õß¡–‡√Áß‡µâ“π¡¢Õß»Ÿπ¬å

¡–‡√ÁßÕÿ¥√∏“π’ ∑’ËªØ‘∫—µ‘Õ¬Ÿà1. °“√ Õπ«‘∏’°“√µ√«®‡µâ“π¡¥â«¬µπ‡Õß·°à‡®â“

Àπâ“∑’Ë “∏“√≥ ÿ¢·≈–π—°‡√’¬ππ—°»÷°…“∑’ËÕ¬Ÿà„π‡¢µ§«“¡√—∫º‘¥™Õ∫ (breast self examination)

2. °“√ Õπµ√«®‡µâ“π¡¥â«¬µπ‡Õß·°àºŸâ¡“√—∫∫√‘°“√‚¥¬ºà“π ◊ËÕ«‘¥’∑—»πå∑’Ë∫√‘‡«≥µ÷°Õ“§“√ºŸâªÉ«¬πÕ°¢Õß»Ÿπ¬å¡–‡√ÁßÕÿ¥√∏“π’

3. °“√µ√«®§—¥°√Õß‚¥¬·æ∑¬å∑’ËÀâÕßµ√«® ÿ¢¿“æ∑—Ë«‰ª (physical examination) ·≈â«·æ∑¬å®–‡ªìπºŸâæ‘®“√≥“°“√ àßµ√«®¿“æ∂à“¬√—ß ’‡µâ“π¡ À√◊Õ§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß

4. ¡’°“√µ‘¥µ“¡ºŸâªÉ«¬¡“µ√«®´È”µ“¡√–¬–‡«≈“π—¥À¡“¬

·µà∑—Èßπ’È°“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡¥â«¬‡§√◊ËÕß‡Õ°´‡√¬å‡µâ“π¡®–„Àâº≈§«“¡∂Ÿ°µâÕß·¡àπ¬”‰¥â¡“°πâÕ¬‡æ’¬ß‰√ πÕ°®“°®–¢÷Èπ°—∫ª√– ‘∑∏‘¿“æ¢Õß‡§√◊ËÕß∂à“¬¿“æ√—ß ’‡µâ“π¡·≈â« ¬—ß¢÷Èπ°—∫ªí®®—¬Õ◊ËπÊ ¥â«¬‡™àπ ª√– ∫°“√≥å·≈–§«“¡™”π“≠¢Õß√—ß ’·æ∑¬å12

ª√– ∫°“√≥å·≈–§«“¡™”π“≠¢Õßπ—°√—ß ’°“√·æ∑¬åª√– ‘∑∏‘¿“æ¢Õß‡§√◊ËÕßµ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß‡§√◊ËÕß≈â“ßøî≈å¡ °“√»÷°…“À“§«“¡√Ÿâ„À¡àÊ ‡æ‘Ë¡‡µ‘¡‡æ◊ËÕæ—≤π“‡∑§π‘§°“√µ√«®„À¡àÊ ∑’Ë„Àâº≈¥’¡’ª√– ‘∑∏‘¿“æ¡“°¢÷Èπ

°“√»÷°…“§√—Èßπ’ÈÕ“®¡’¢âÕ∫°æ√àÕß„π‡√◊ËÕß¢Õß°“√‡°Á∫¢âÕ¡Ÿ≈‡°’Ë¬«°—∫√“¬≈–‡Õ’¬¥∫“ßÕ¬à“ß¢Õß§π‰¢â‡π◊ËÕß®“°‡ªìπ°“√‡°Á∫¢âÕ¡Ÿ≈¬âÕπÀ≈—ß®“°·øÑ¡ª√–«—µ‘°“√≈ß∫—π∑÷°¢âÕ¡Ÿ≈∑’Ë¡’Õ¬Ÿà¬—ß‰¡à§àÕ¬ ¡∫√Ÿ≥åπ—° ¥—ßπ—Èπ∂â“®–»÷°…“√–∫“¥«‘∑¬“¢Õß¡–‡√Áß‡µâ“π¡§«√®–∑”·∫∫ Õ∫∂“¡·≈–‡ªìπ°“√»÷°…“·∫∫‰ª¢â“ßÀπâ“ À√◊Õ¡’°“√∑∫∑«π°“√≈ß¢âÕ¡Ÿ≈√“¬≈–‡Õ’¬¥„π·øÑ¡ª√–«—µ‘„Àâ≈–‡Õ’¬¥¡“°¢÷Èπ ‡æ◊ËÕ®–‰¥â¢âÕ¡Ÿ≈∑’Ë ¡∫√Ÿ≥å¡“°¢÷Èπ

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ºŸâÕ”π«¬°“√»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’ ·≈–‡®â“Àπâ“∑’Ë»Ÿπ¬å¡–‡√Áß Õÿ¥√∏“π’∑ÿ°∑à“π∑’Ë„Àâ§«“¡ π—∫ πÿπ·≈–§«“¡√à«¡¡◊Õ„π°“√∑”ß“π«‘®—¬§√—Èßπ’È∑”„Àâß“π«‘®—¬§√—Èßπ’È ”‡√Á®‰¥â¥â«¬¥’


1. Cancer in Thailand Vol. III. 1995-1997.2. °“√ª√–‡¡‘π‡∑§‚π‚≈¬’°“√µ√«®«‘π‘®©—¬¡–‡√Áß‡µâ“π¡„π√–¬–

‡√‘Ë¡·√°∑’Ë‡À¡“– ¡ ”À√—∫ª√–‡∑»‰∑¬ °√–∑√«ß “∏“√≥ ÿ¢;2544.

3. American College of Radiology. ACR BI-RADS-Mammography . In: ACR Breast imaging reportingand data system atlas. 4th ed. Reston,VA: AmericanCollege of Radiologt; 2003.

4. Lehman C, Holt S, Peacock S, White E, Urban N. Useof the Americal College of Radiology BI-RADSguidelines by community radiologists: concordance ofassessments and recommendations assigned to screeningmammograms. AJR Am J Roentgenol 2002; 179:15-20.

5. Skaane P. The additional value of US to mammographyin the diagnosis of breast cancer. A prospective study.Acta Radiol 1999; 40:486-90.

6. Feig SA. The role of ultrasound in a breast imagingcenter. Semin Ultrasound CT MR 1989; 10:90-105.

7. Kompas DB. The positive predictive vaule ofmammography. AJR Am J Roentgenol 1992; 158:521-6.

8. Lacquement MA, Mitchell D, Hollingsworth AB.Positive predictive value of the Breast Imaging Reportsand data systems. J Am Coll Surg 1999; 189:34-40.

9. Hirunpat S, Tanomkiat W, Khojarern R, ArpakupakulN. Accuracy of the mammographic report categoryaccording tot BIRADS. J Mead Assoc Thai 2005;88:62-5.

10. Charnvises S. The accuracy of mammography : acomparison with fine needle aspiration cytology. JMed Assoc Thai 1996; 79:27-30.

11. Azzarelli A, Guzzon A, Pilotti S, Quagliuolo V, BonoA, Di Pietro S. Accuracy of breast cancer diagnosis byphysi-cal, radiologic and cytologic combinedexamination. Tumori 1983; 69:137-41.

12. Elmore JG, Wells CK, Howars DH. Dose diagnosticaccuracy in mammography depend on radiologists’sexperiences? J Womens Health 1998; 7:443-9.

86

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å


°“√»÷°…“·∫∫≈Õß°‘®Ÿ¥‘πÕ≈ „π°“√À“§«“¡ —¡æ—π∏å¢ÕßÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ°—∫¿“«–´÷¡‡»√â“º°“«≈’ æÿà¡ ÿ∑—»πå «∑.¡.*®√√¬“ ¿—∑√Õ“™“™—¬ «∑.¥.*¬ß¬ÿ∑∏ »‘√‘ª°“√ æ.∫.*Õÿ¥¡ ≈—°…≥«‘®“√≥å æ.∫.**§≥–·æ∑¬»“ µ√å ¡À“«‘∑¬“≈—¬∏√√¡»“ µ√å

Abstract Longitudinal Study of Chronic Musculoskeletal Pain in Relation to DepressionPoomsu-tat P., Pattaraachachai J., Siripakarn Y., Laksanavicharn U.

Faculty of Medicine, Thammasat University


The study of 1,008 samples in Nakornluang district, Ayutthaya province showed that the pointprevalence of probable depression was 6.6%. Logistic regression showed the significant association of genderand pain intensity to probable depression in 194 chronic musculoskeletal pain subjects (p-value < 0.05).Females had a risk with 10.72 times as high as males. While the subject with a high score of pain intensity hadthe risk about 8.15 times to the one with low score of pain intensity. For the follow-up study of depressionoccurrence in 150 no-pain and 160 chronic musculoskeletal pain subjects, Cochran’s Q test showed significanttrend of high risk depression among 3 periods of times. Relative risks of high risk depression at the 3rd and6th month are 1.06 (95% CI 0.38-2.94) and 2.39 (95% CI 0.50-11.52) respectively.

Key words: musculoskeletal pain, chronic pain, depression

‡√◊ËÕß¬àÕ °“√»÷°…“°≈ÿà¡µ—«Õ¬à“ß®”π«π 1,008 §π „πÕ”‡¿Õπ§√À≈«ß ®—ßÀ«—¥æ√–π§√»√’Õ¬ÿ∏¬“ æ∫§«“¡™ÿ°¢Õß Probabledepression ¡’§à“√âÕ¬≈– 6.6 º≈°“√«‘‡§√“–Àå Logistic regression „π°≈ÿà¡µ—«Õ¬à“ß∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ æ∫«à“ ‡æ»·≈–√–¥—∫Õ“°“√ª«¥‡ªìπªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠µàÕ°“√‡°‘¥ probable depression (p-value < 0.05) ‚¥¬‡æ»À≠‘ß¡’§«“¡‡ ’Ë¬ß¡“°°«à“‡æ»™“¬ 10.72 ‡∑à“ ·≈–ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥ Ÿß¡’§«“¡‡ ’Ë¬ß¡“°°«à“ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥µË” 8.15 ‡∑à“ ®“°°“√µ‘¥µ“¡°“√‡°‘¥¿“«–´÷¡‡»√â“„π°≈ÿà¡µ—«Õ¬à“ß∑’Ë‰¡à¡’Õ“°“√ª«¥®”π«π 150 √“¬ ·≈–°≈ÿà¡µ—«Õ¬à“ß∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ®”π«π 160 √“¬ Cochranûs Q test · ¥ß∂÷ß°“√‡°‘¥ high riskdepression „πµ≈Õ¥ 3 ™à«ß‡«≈“ §à“ Relative risks ¢Õß°“√‡°‘¥ high risk depression ‡¥◊Õπ∑’Ë 3 ·≈–‡¥◊Õπ∑’Ë 6 ¡’§à“‡∑à“°—∫1.06 (95% CI 0.38-2.94) ·≈– 2.39 (95% CI 0.50-11.52) µ“¡≈”¥—∫

§” ”§—≠: ª«¥„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ª«¥‡√◊ÈÕ√—ß ¿“«–´÷¡‡»√â“



∫∑π”

Õ“°“√ª«¥π—∫‡ªìπªí≠À“∑’Ë ”§—≠ªí≠À“Àπ÷Ëß„π°“√π”ºŸâªÉ«¬‡¢â“ Ÿà√–∫∫°“√∫√‘°“√¥â“π ÿ¢¿“æ ‡æ◊ËÕ¡“√—∫°“√∫√√‡∑“·≈–√—°…“Õ“°“√ª«¥ „π∫“ß√“¬ “¡“√∂∑’Ë®–√—°…“„ÀâÀ“¬¢“¥ ·µà∫“ß√“¬Õ“®®–¡’Õ“°“√√ÿπ·√ß¢÷Èπ‡√◊ËÕ¬Ê ®π°≈“¬‡ªìπÕ“°“√ª«¥‡√◊ÈÕ√—ß·≈–∫àÕ¬§√—Èßæ∫√à«¡°—∫ªí≠À“ ÿ¢¿“æ®‘µ ‡™àπ ¿“«–´÷¡‡»√â“1, 2 ´÷Ëß àßº≈°√–∑∫µàÕ»—°¬¿“æ„π°“√¥”√ß™’«‘µ¢ÕßºŸâªÉ«¬„π∑”°‘®«—µ√ª√–®”«—π °“√∑”°‘®°√√¡µà“ßÊ·≈–°“√¥”‡π‘π™’«‘µ„π —ß§¡ √«¡∂÷ß¡’º≈µàÕ°“√∑”ß“π„π™à«ß‡«≈“¢Õß°“√¡’Õ“°“√ª«¥3-5 ‚¥¬∑’ËÕ“°“√ª«¥‡√◊ÈÕ√—ß¡’‚Õ°“ ‡°‘¥√à«¡°—∫ Õ“°“√∑“ß®‘µ‡«™∑’Ë§àÕπ¢â“ß Ÿß2,6 ¥—ß‡™àπ°“√»÷°…“¢Õß·¡°π’ (Magni) ·≈–§≥–7

æ∫«à“ „πª√–™“°√Õ“¬ÿ 25-74 ªï ®”π«π 3,023 §π‡ªìπºŸâ¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ∂÷ß√âÕ¬≈– 14.4 ‚¥¬„π®”π«ππ’È‡ªìπºŸâ¡’¿“«– ÷¡‡»√â“√âÕ¬≈– 23.6 (‡¡◊ËÕ§‘¥ cut off point score ∑’Ë 16)æ∫„π‡æ»À≠‘ß¡“°°«à“‡æ»™“¬ ∂÷ß·¡â«à“„π™à«ß‡«≈“∑’Ëºà“π¡“ ®–¡’°“√»÷°…“Õ¬à“ß°«â“ß¢«“ß‡°’Ë¬«°—∫Õ“°“√ª«¥‡√◊ÈÕ√—ß·≈–¿“«–´÷¡‡»√â“ ·µà¬—ß¡’°“√»÷°…“®”π«ππâÕ¬∑’Ë π„®»÷°…“√–¬–¬“«‡°’Ë¬«°—∫§«“¡ —¡æ—π∏å√–À«à“ßÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ·≈–¿“«–´÷¡‡»√â“8-10

°“√»÷°…“π’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“§«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬‡ ’Ë¬ß·≈–¿“«– ÷¡‡»√â“„πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ·≈–‡ª√’¬∫‡∑’¬∫°“√‡°‘¥¿“«–´÷¡‡»√â“ „π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ

«—µ∂ÿ·≈–«‘∏’°“√

°“√»÷°…“ª√–°Õ∫¥â«¬ ™à«ß∑’Ë 1 »÷°…“§«“¡ —¡æ—π∏å¢Õßªí®®—¬‡ ’Ë¬ß ‡™àπ ªí®®—¬∑“ßª√–™“°√§√Õ∫§√—« —ß§¡ ‡»√…∞°‘® ·≈–Õ“°“√ª«¥ µàÕ¿“«–´÷¡‡»√â“„πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ™à«ß∑’Ë 2 ‡ªìπ√–¬–µ‘¥µ“¡‡æ◊ËÕ»÷°…“°“√‡°‘¥¿“«–´÷¡‡»√â“„π°≈ÿà¡ºŸâ∑’Ë‰¡à¡’Õ“°“√ª«¥·≈–°≈ÿà¡∑’Ë

¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ„π™à«ß∑’Ë 1 °≈ÿà¡µ—«Õ¬à“ß®”π«π 3,000 √“¬

∑’Ë¡’Õ“¬ÿ√–À«à“ß 15-59 ªï “¡“√∂Õà“πÕÕ°‡¢’¬π‰¥â‰¡à¡’ª√–«—µ‘µ‘¥¬“‡ æµ‘¥ ‰¡à¡’ª√–«—µ‘°“√√—°…“∑“ß®‘µ‡«™·≈–‰¡à‡ªìπºŸâæ‘°“√ ∂Ÿ°§—¥‡≈◊Õ°·≈–®—¥ √√µ“¡ —¥ à«π®“°ª√–™“°√‡ªÑ“À¡“¬ 6,995 √“¬ ∑’ËÕ¬Ÿà¿“¬„µâ°“√¥Ÿ·≈¢Õß‡§√◊Õ¢à“¬»Ÿπ¬å ÿ¢¿“æ™ÿ¡™π∑à“™â“ß Õ”‡¿Õπ§√À≈«ß ®—ßÀ«—¥æ√–π§√»√’Õ¬ÿ∏¬“ —¥ à«πµ—«Õ¬à“ß®”·π°µ“¡»Ÿπ¬å ÿ¢¿“æ™ÿ¡™π ‡æ» ·≈–Õ“¬ÿ °≈ÿà¡µ—«Õ¬à“ß∑ÿ°§πµÕ∫·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫ ¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ ªí®®—¬∑“ß‡»√…∞°‘® —ß§¡ ·≈–‰¥â√—∫°“√ª√–‡¡‘πÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ¥â«¬·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ∑’Ë·ª≈®“°·∫∫ Õ∫∂“¡Õ“°“√ª«¥‡√◊ÈÕ√—ß©∫—∫¿“…“Õ—ß°ƒ… (Graded Chronic PainQuestionnaire)11 ·≈–‰¥â√—∫°“√ª√–‡¡‘π¿“«–´÷¡‡»√â“¥â«¬·∫∫«—¥¿“«–´÷¡‡»√â“ (Health-Related SelfReport: HRSR The Diagnostic Screening Test forDepression in Thai Population)12

§à“®ÿ¥µ—¥¢Õß§–·ππ¿“«– ÷¡‡»√â“ (D score) ·∫àß‡ªìπ 2 ·∫∫ §◊Õ ·∫∫∑’Ë 1 D score πâÕ¬°«à“ 20 (Lowrisk depression) ·≈– D score ‡∑à“°—∫À√◊Õ¡“°°«à“ 20(High risk depression) „™â‡æ◊ËÕ»÷°…“‡ª√’¬∫‡∑’¬∫°“√‡°‘¥¿“«–´÷¡‡»√â“„π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥ ·∫∫∑’Ë 2 D score πâÕ¬°«à“ 25 (riskdepression) ·≈– D score ‡∑à“°—∫À√◊Õ¡“°°«à“ 25(probable depression) „™â‡æ◊ËÕ»÷°…“§«“¡ —¡æ—π∏å¢Õßªí®®—¬‡ ’Ë¬ß (ªí®®—¬∑“ßª√–™“°√ §√Õ∫§√—« —ß§¡‡»√…∞°‘® Õ“°“√ª«¥) ·≈–¿“«–´÷¡‡»√â“„πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ

µ—«Õ¬à“ß∑’Ë‰¥â®“°™à«ß∑’Ë 1 °≈ÿà¡∑’Ë¡’Õ“°“√ª«¥¡“°°«à“ 6 ‡¥◊Õπ (ª«¥‡√◊ÈÕ√—ß) ∂Ÿ°·æ∑¬å∑”°“√µ√«®§—¥·¬°·≈–¬◊π¬—πÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ®”π«πµ—«Õ¬à“ß 160 √“¬∂Ÿ°‡≈◊Õ°®“°°≈ÿà¡Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ∑’Ë¡’ Low risk depression ·≈–°≈ÿà¡µ—«Õ¬à“ß®”π«π150 √“¬∂Ÿ°§—¥‡≈◊Õ°·∫∫ ÿà¡®“°°≈ÿà¡‰¡à¡’Õ“°“√ª«¥∑’Ë¡’

88

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

Low risk depression ‡æ◊ËÕ‡¢â“ Ÿà™à«ß∑’Ë 2 ´÷Ëß‡ªìπ™à«ßµ‘¥µ“¡ °≈ÿà¡µ—«Õ¬à“ß∑—Èß 2 °≈ÿà¡ ‰¥â√—∫°“√ª√–‡¡‘πÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ¥â«¬·∫∫ Õ∫∂“¡‡°’Ë¬«°—∫Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ·≈–‰¥â√—∫°“√ª√–‡¡‘π¿“«–´÷¡‡»√â“¥â«¬·∫∫«—¥¿“«–´÷¡‡»√â“ HRSR ∑ÿ° 3 ‡¥◊Õπ ‡ªìπ‡«≈“6 ‡¥◊Õπ

∂‘µ‘∑¥ Õ∫ Chi Square test ·≈– FisherûsExact Test «‘‡§√“–Àå§«“¡ —¡æ—π∏å‡∫◊ÈÕßµâπ¢Õßªí®®—¬‡ ’Ë¬ß·≈–¿“«–´÷¡‡»√â“„π°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ‡æ◊ËÕ§—¥°√Õßªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏åµàÕ¿“«–´÷¡‡»√â“ ªí®®—¬∑’Ë· ¥ß§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ ®–∂Ÿ°π”‰ª«‘‡§√“–ÀåµàÕ¥â«¬ Binary Logistic Regression ‚¥¬°”Àπ¥„Àâµ—«·ª√µ“¡§◊Õ D score πâÕ¬°«à“ 25 (risk depression)and D score ‡∑à“°—∫À√◊Õ¡“°°«à“ 25 (probabledepression) à«πµ—«·ª√µâπ ‰¥â·°à ‡æ» §«“¡‡æ’¬ßæÕ¢Õß√“¬‰¥â §«“¡ —¡æ—π∏å„π§√Õ∫§√—« µ”·ÀπàßÕ“°“√ª«¥ ·≈–√–¥—∫Õ“°“√ª«¥ °“√‡°‘¥ high riskdepression „π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ„πµ≈Õ¥3 ™à«ß‡«≈“ «‘‡§√“–Àå‚¥¬ Cochranûs Q test ‡ª√’¬∫‡∑’¬∫‚Õ°“ ‡ ’Ë¬ß„π°“√‡°‘¥¿“«–´÷¡‡»√â“„π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕµ“¡™à«ß√–¬–‡«≈“∑’Ëµ‘¥µ“¡ ¥â«¬§à“§«“¡‡™◊ËÕ¡—π √âÕ¬≈– 95 (95% confidence interval)´÷Ëß«‘‡§√“–Àå‚¥¬ Taylor Series Technique ‚¥¬°”Àπ¥√–¥—∫§«“¡¡’π—¬ ”§—≠∑’Ë 0.05

º≈

·∫∫ Õ∫∂“¡∑’Ë‰¥â√—∫°≈—∫¡“ ¡’‡æ’¬ß 1,247 ™ÿ¥∑’ËµÕ∫·∫∫«—¥¿“«– ÷¡‡»√â“§√∫∂â«π ÷Ëßæ∫«à“§à“§«“¡™ÿ°≥ ®ÿ¥‡«≈“Àπ÷Ëß¢Õß probable depression „πª√–™“°√∑’ËÕ¬Ÿà¿“¬„µâ°“√¥Ÿ·≈¢Õß»Ÿπ¬å ÿ¢¿“æ™ÿ¡™π‡§√◊Õ¢à“¬∑à“™â“ß ¡’§à“√âÕ¬≈– 6.6 ·∫∫ Õ∫∂“¡®”π«π1,008 ™ÿ¥∑’ËµÕ∫·∫∫ª√–‡¡‘πÕ“°“√ª«¥·≈–·∫∫«—¥¿“«–´÷¡‡»√â“§√∫∂â«π ·∫àß‡ªìπ °≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥

®”π«π 441 √“¬ (√âÕ¬≈– 43.8) °≈ÿà¡∑’Ë¡’Õ“°“√ª«¥πâÕ¬°«à“ 6 ‡¥◊Õπ®”π«π 273 √“¬ (√âÕ¬≈– 27.8)·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß®”π«π 294 √“¬ (√âÕ¬≈–29.2) „π®”π«πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß ·æ∑¬åµ√«®æ∫ºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ®”π«π 194 √“¬ (√âÕ¬≈– 66) ‡¡◊ËÕ»÷°…“µ”·ÀπàßÕ“°“√ª«¥„πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ æ∫«à“ √âÕ¬≈– 55.4 ª«¥À≈“¬µ”·Àπàß√Õß≈ß¡“ª«¥∑’ËÀ≈—ß·≈–°âπ°∫ (√âÕ¬≈– 22.6) ·≈–ª«¥¢“∑àÕπ≈à“ß (√âÕ¬≈– 13.0)

µ“√“ß∑’Ë 1 · ¥ß„Àâ‡ÀÁπ«à“ ®“°°≈ÿà¡µ—«Õ¬à“ß∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ®”π«π194 √“¬ ºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ∑’Ë¡’ Probable depression ®–æ∫¡“°„π‡æ»À≠‘ß ºŸâ∑’Ë¡’√“¬‰¥â‰¡à‡æ’¬ßæÕ ºŸâ∑’Ë¡’§«“¡ —¡æ—π∏å„π§√Õ∫§√—«‰¡à¥’ ºŸâ∑’Ëª«¥√ÿπ·√ß ·≈–ºŸâ∑’Ëª«¥À≈“¬µ”·Àπàß °“√«‘‡§√“–Àå‚¥¬ logistic regression æ∫«à“‡æ»·≈–√–¥—∫Õ“°“√ª«¥‡ªìπªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠µàÕ°“√‡°‘¥ probable depression(p-value < 0.05) ‚¥¬‡æ»À≠‘ß¡’§«“¡‡ ’Ë¬ß¡“°°«à“‡æ»™“¬ 10.72 ‡∑à“ ·≈–ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥ Ÿß¡’§«“¡‡ ’Ë¬ß¡“°°«à“ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥µË” 8.15 ‡∑à“(µ“√“ß∑’Ë 2)

„π™à«ß∑’Ë 2 ‡ªìπ°“√µ‘¥µ“¡°“√‡°‘¥¿“«–´÷¡‡»√â“„π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥ ·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ∑’Ë¡’ Low risk depression‡ªìπ‡«≈“ 6 ‡¥◊Õπ º≈°“√µ‘¥µ“¡¡’°≈ÿà¡µ—«Õ¬à“ß∑’Ë‰¡à¡’Õ“°“√ª«¥®”π«π 82 √“¬ °≈ÿà¡µ—«Õ¬à“ß∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ®”π«π 103√“¬ ∑’ËÕ¬Ÿà§√∫µ≈Õ¥√–¬–‡«≈“°“√µ‘¥µ“¡ 6 ‡¥◊Õπ

µ“√“ß∑’Ë 3 · ¥ß„Àâ‡ÀÁπ«à“ ¡’°“√‡°‘¥ High riskdepression „πµ≈Õ¥ 3 ™à«ß‡«≈“∑—Èß„π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥ ·≈–°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (p < 0.05) Relativerisks ¢Õß°“√‡°‘¥ high risk depression ‡¥◊Õπ∑’Ë 3·≈–‡¥◊Õπ∑’Ë 6 ¡’§à“‡∑à“°—∫ 1.06 (95% CI 0.38-2.94)·≈– 2.39 (95% CI 0.50-11.52) µ“¡≈”¥—∫



µ“√“ß∑’Ë 1 √âÕ¬≈–¢Õß¿“«–´÷¡‡»√â“„π°≈ÿà¡∑’Ëª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ®”·π°µ“¡ªí®®—¬‡ ’Ë¬ß (®”π«π

194 √“¬)

Risk Probableªí®®—¬‡ ’Ë¬ß ®”π«π p-valve

depression depression

‡æ»™“¬ 81 98.8 1.2 0.002*À≠‘ß 108 86.1 13.9

Õ“¬ÿ (ªï)15-29 27 85.2 14.8 0.25330-59 162 92.6 7.4

∂“π¿“æ ¡√ ‚ ¥ 45 88.9 11.1 0.542§Ÿà 142 92.3 7.7

°“√»÷°…“ª√–∂¡»÷°…“À√◊ÕµË”°«à“ 104 89.4 10.6 0.551¡—∏¬¡»÷°…“/ª«™. À√◊Õ Õπÿª√‘≠≠“/ª« . 63 93.7 6.3ª√‘≠≠“µ√’À√◊Õ Ÿß°«à“ 19 94.7 5.3

√“¬‰¥â‡æ’¬ßæÕ 144 95.1 4.9 0.004*‰¡à‡æ’¬ßæÕ 38 78.9 21.1

§«“¡ —¡æ—π∏å„π§√Õ∫§√—«‰¡à¥’‰¡à„™à 112 96.4 3.6 0.003*„™à 75 84 16.0

§«“¡ —¡æ—π∏å„π∑’Ë∑”ß“π‰¡à¥’‰¡à„™à 135 93.3 6.7 0.215„™à 46 87.0 13.0

§«“¡ —¡æ—π∏å„π™ÿ¡™π‰¡à¥’‰¡à„™à 138 91.3 8.7 1.00„™à 48 91.7 8.3

§–·ππ√–¥—∫Õ“°“√ª«¥§–·ππ < 50 100 98.0 2 <0.001*§–·ππ 50 78 83.3 16.7

µ”·ÀπàßÕ“°“√ª«¥Àπ÷Ëßµ”·Àπàß 77 96.1 3.9 0.028*¡“°°«à“Àπ÷Ëßµ”·Àπàß 95 86.3 13.7

√–¬–‡«≈“Õ“°“√ª«¥6 ‡¥◊Õπ ∂÷ß 1 ªï 57 91.2 8.8 0.776¡“°°«à“ 1 ªï 131 92.4 7.6

§–·ππ§«“¡∫°æ√àÕß¢Õß√à“ß°“¬®“°Õ“°“√ª«¥§–·ππ < 3 (‰¡à¡’§«“¡∫°æ√àÕß- §«“¡∫°æ√àÕßµË”) 104 93.3 6.7 0.075§–·ππ 3 (§«“¡∫°æ√àÕß Ÿß) 6 66.7 33.3

90

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

«‘®“√≥å

º≈°“√»÷°…“æ∫«à“ºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ∑’Ë¡’ Probable depression ®–æ∫¡“°„πºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥√ÿπ·√ß ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥ Ÿß¡’§«“¡‡ ’Ë¬ß¡“°°«à“ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥µË” 8.15 ‡∑à“ ÷Ëß Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß«Õπ§Õ≈åø(Von Korff)5 ∑’Ëæ∫«à“ √âÕ¬≈–¢ÕßºŸâ∑’Ë¡’¿“«–´÷¡‡»√â“®–‡æ‘Ë¡¢÷Èπµ“¡§«“¡√ÿπ·√ß¢ÕßÕ“°“√ª«¥ ‚¥¬‡æ‘Ë¡¢÷Èπ®“°√âÕ¬≈– 5 „πºŸâ∑’Ë¡’Õ“°“√ª«¥√–¥—∫ 2 ‡ªìπ√âÕ¬≈–20 „πºŸâ∑’Ë¡’Õ“°“√ª«¥√–¥—∫ 5 ‡™àπ‡¥’¬«°—∫°“√»÷°…“Õ◊ËπÊ ∑’Ëæ∫«à“ √–¥—∫¢Õß¿“«–´÷¡‡»√â“¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠°—∫§«“¡√ÿπ·√ß¢ÕßÕ“°“√ª«¥‡√◊ÈÕ√—ß

‚¥¬æ∫«à“√–¥—∫§«“¡√ÿπ·√ß¢Õß¿“«–´÷¡‡»√â“®–‡æ‘Ë¡¢÷Èπµ“¡°“√‡æ‘Ë¡¢÷Èπ¢Õß√–¥—∫§«“¡√ÿπ·√ß¢ÕßÕ“°“√ª«¥‡√◊ÈÕ√—ß13,14 º≈°“√»÷°…“∑’Ëæ∫«à“ºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ∑’Ë¡’ Probable depression®–æ∫¡“°„π‡æ»À≠‘ß ·≈–ºŸâ∑’Ë¡’√“¬‰¥â‰¡à‡æ’¬ßæÕ Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß·¡°π’ (Magni) ·≈–§≥–7,15 ∑’Ë√“¬ß“π«à“ ºŸâªÉ«¬‡æ»À≠‘ß·≈–¡’√“¬‰¥âπâÕ¬¡’§«“¡ —¡æ—π∏å°—∫§à“ CES-D (the Center forEpidemiologic Studies Depression scale) ‡∑à“°—∫À√◊Õ¡“°°«à“ 16 ·≈– 20 ‚¥¬∫“« (Bao) ·≈–§≥–√“¬ß“π«à“ ºŸâªÉ«¬¿“«–´÷¡‡»√â“∑’Ë¡’Õ“°“√ª«¥√à«¡¥â«¬ à«π„À≠à¡’√“¬‰¥â§√Õ∫§√—«‡©≈’Ë¬ª√–®”ªïµË”¡“°16 à«π

µ“√“ß∑’Ë 2 º≈°“√«‘‡§√“–Àå Logistic regression ¢Õß probable depression ·≈– risk factors „πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß

„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ

95% C.I. for ORªí®®—¬‡ ’Ë¬ß Coefficient S.E. Sig. Odd ratio

Lower Upper

‡æ» 2.37 1.06 0.03 10.72 1.33 86.22

µ”·ÀπàßÕ“°“√ª«¥ 1.19 0.7 0.09 3.27 0.83 12.94

√–¥—∫Õ“°“√ª«¥ 2.10 0.79 0.01 8.15 1.72 38.72

§à“§ß∑’Ë -6.32

(n = 194 √“¬), S.E. = Standard error

µ“√“ß∑’Ë 3 °“√‡°‘¥ High risk depression ¢Õß°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥ ·≈–°≈ÿà¡¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–

°≈â“¡‡π◊ÈÕ „π™à«ß 6 ‡¥◊Õπ

°≈ÿà¡µ—«Õ¬à“ß 95%

‰¡àª«¥ (N = 82) ª«¥‡√◊ÈÕ√—ß (N = 103) Relative Confidence

®”π«π (√âÕ¬≈–) ®”π«π (√âÕ¬≈–) Risk Interval

‡¥◊Õπ∑’Ë 0 0 0 - - -

‡¥◊Õπ∑’Ë 3 6 (7.3) 8 (7.8) 1.06 0.38 2.94

‡¥◊Õπ∑’Ë 6 2 (2.4) 6 (5.8) 2.39 0.50 11.52

p-value 0.033* 0.005*



ª√–‡¥ÁπºŸâ∑’Ë¡’§«“¡ ¡æ—π∏å„π§√Õ∫§√—«‰¡à¥’¡—°®–¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ√à«¡°—∫Probable depression Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß«Õπ§Õ≈åø (Von Korff)17

‡æ»·≈–√–¥—∫Õ“°“√ª«¥‡ªìπªí®®—¬À≈—°∑’Ë¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠µàÕ°“√‡°‘¥ Probabledepression ´÷Ëß§≈â“¬§≈÷ß°—∫°“√»÷°…“∑’Ëæ∫«à“Õ“°“√ª«¥À≈—ß‡√◊ÈÕ√—ß¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠µàÕ°“√‡°‘¥¿“«–´÷¡‡»√â“3 „π∑“ßµ√ß°—π¢â“¡°“√¡’»÷°…“À≈“¬°“√»÷°…“∑’Ëæ∫«à“ ¿“«–´÷¡‡»√â“‡ªìπµ—«∑’Ë¡’§«“¡ ”§—≠„π°“√°√–µÿâπ„Àâ‡°‘¥Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ18,19 ´÷Ëß®“°°“√∑∫∑«π¬—ß‰¡à¡’°“√«‘®—¬„¥ √ÿª«à“ Õ“°“√ª«¥‡√◊ÈÕ√—ßÀ√◊Õ¿“«– ÷¡‡»√â“∑’Ë‡ªìπ “‡ÀµÿÀ√◊Õº≈°—π·πà

„π™à«ß∑’Ë 2 ¢Õß°“√µ‘¥µ“¡æ∫«à“ ‚Õ°“ ‡°‘¥ Highrisk depression „π°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥„°≈â‡§’¬ß°—∫°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ·≈–¡’°“√‡ª≈’Ë¬π·ª≈ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘µ≈Õ¥™à«ß‡«≈“ 6 ‡¥◊Õπ„π∑—Èß 2 °≈ÿà¡ Õ¬à“ß‰√°Áµ“¡ ®“°°“√µ‘¥µ“¡æ∫«à“°≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥„π‡√‘Ë¡·√°¢Õß°“√»÷°…“ ∂÷ß·¡â«à“®–¡’Õ“°“√ª«¥„π™à«ßµ‘¥µ“¡ ·µà°≈ÿà¡µ—«Õ¬à“ß‡À≈à“π’È°Á‰¡à‡°‘¥ High risk depression ´÷ËßÕ“®‡æ√“–‡π◊ËÕß®“°Õ“°“√ª«¥∑’Ë‡°‘¥¢÷Èπ¡‘„™à‡ªìπÕ“°“√ª«¥‡√◊ÈÕ√—ß ‡π◊ËÕß®“°‡°‘¥¢÷ÈππâÕ¬°«à“ 6 ‡¥◊Õπ §à“Relative Risk · ¥ß„Àâ‡ÀÁπ«à“ ‡¡◊ËÕ√–¬–‡«≈“¢ÕßÕ“°“√ª«¥π“π¢÷Èπ §«“¡‡ ’Ë¬ß¢Õß°“√‡°‘¥ High riskdepression ¡’·π«‚πâ¡ Ÿß¢÷Èπ Õ¬à“ß‰√°Áµ“¡º≈· ¥ß„Àâ‡ÀÁπ«à“ §à“ Relative Risk ¡’Õ”π“®µË”„π°“√∫—π∑÷°‡Àµÿ°“√≥å∑’Ë‡°‘¥¢÷Èπ ‡π◊ËÕß®“°°“√µ‘¥µ“¡√–¬– —Èπ ·≈–°≈ÿà¡µ—«Õ¬à“ß¡’®”π«ππâÕ¬°«à“∑’Ë§“¥°“√≥å‰«â √–¬–‡«≈“°“√µ‘¥µ“¡ —Èπ°«à“∑’Ë«“ß·ºπ 6 ‡¥◊Õπ ‡π◊ËÕß®“°‡°‘¥¿“«–πÈ”∑à«¡ à«π°≈ÿà¡µ—«Õ¬à“ß∑’ËπâÕ¬°«à“∑’Ë§“¥°“√≥å‡π◊ËÕß®“°º≈°“√ ”√«®¡’ºŸâµÕ∫·∫∫°≈—∫ ¡∫Ÿ√≥å‡æ’¬ß√âÕ¬≈– 33.6 Õ¬à“ß‰√°Áµ“¡ °“√»÷°…“™’È„Àâ‡ÀÁπ«à“Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ¡‘„™à‡ªìπªí®®—¬‡¥’¬«∑’Ë‡Àπ’Ë¬«π”°“√‡°‘¥¿“«– ÷¡‡»√â“ ‡π◊ËÕß®“°°“√ —¡¿“…≥å‡™‘ß≈÷°„πºŸâ∑’Ë¡’ §à“ High risk depression

„π™à«ßµ‘¥µ“¡ æ∫«à“∫“ß§π¡’ªí≠À“√à«¡„π‡√◊ËÕßÀπ’È ‘π√“¬‰¥â‰¡à‡æ’¬ßæÕ ·≈–ªí≠À“„π§√Õ∫§√—«

∫∑‡√’¬π®“°°“√«‘®—¬æ∫«à“ §«“¡ ”‡√Á®„π°“√»÷°…“«‘®—¬„π™ÿ¡™π®–‡°‘¥¢÷Èπ‰¥â µâÕßÕ“»—¬§π„πæ◊Èπ∑’Ë„π°“√ª√– “πß“π·≈–∑”§«“¡‡¢â“„®°—∫°≈ÿà¡µ—«Õ¬à“ß§àÕπ¢â“ß¡“° °“√‡≈◊Õ°·∫∫ Õ∫∂“¡∑’Ë‡À¡“– ¡°—∫°≈ÿà¡µ—«Õ¬à“ß ∑—Èß„π‡√◊ËÕß√–¥—∫°“√»÷°…“ «—≤π∏√√¡‡ªìπ ‘Ëß∑’Ë ”§—≠∑’Ë®–∑”„Àâ‰¥â¢âÕ¡Ÿ≈§√∫∂â«π ·∫∫ Õ∫∂“¡∑’Ë¡’§”∫√√¬“¬√à«¡°—∫µ—«‡≈¢§–·ππ¡’§«“¡‡À¡– ¡°—∫§π‰∑¬¡“°°«à“·∫∫ Õ∫∂“¡∑’Ë‡ªìπµ—«‡≈¢Õ¬à“ß‡¥’¬«πÕ°®“°π’È°“√»÷°…“ªí≠À“ ÿ¢¿“æ∑’Ë· ¥ßÕ“°“√‰¡à™—¥‡®π‡ªìπ¢âÕ®”°—¥„π°“√»÷°…“·∫∫‡ΩÑ“µ‘¥µ“¡ µ“¡§«“¡§‘¥‡ÀÁπ¢ÕßºŸâ«‘®—¬ ·∫∫ Õ∫∂“¡·∫∫ —¡¿“…≥åÀ√◊Õ°“√ —¡¿“…≥å‡™‘ß≈÷°πà“®–‡À¡“–°—∫°“√»÷°…“ªí≠À“¿“«– ÷¡‡»√â“¡“°°«à“·∫∫ Õ∫∂“¡∑’ËµÕ∫‡Õß·µà®–¡’¢âÕ®”°—¥„π°√≥’∑’Ë°≈ÿà¡µ—«Õ¬à“ß®”π«π¡“°Ê„π°“√»÷°…“§√—ÈßµàÕ‰ª §«√¡’°“√‡æ‘Ë¡®”π«π°≈ÿà¡µ—«Õ¬à“ß·≈–√–¬–‡«≈“¢Õß°“√»÷°…“ ´÷Ëß®–™à«¬‡æ‘Ë¡Õ”π“®„π°“√∫—π∑÷°Õÿ∫—µ‘°“√≥å‡°‘¥¿“«–´÷¡‡»√â“‰¥â¥’¢÷Èπ

√ÿª

°“√»÷°…“π’È· ¥ß∂÷ß§«“¡ —¡æ—π∏å¢Õßªí®®—¬∑“ßª√–™“°√»“ µ√å (Demographic factors), ªí®®—¬∑“ß§√Õ∫§√—« —ß§¡ ‡»√…∞°‘® Õ“°“√ª«¥ ·≈–¿“«–´÷¡‡»√â“°—∫Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ‚¥¬æ∫«à“ ªí®®—¬∑’Ë¡’Õ‘∑∏‘æ≈∑’Ë ÿ¥µàÕ°“√‡°‘¥Probable depression §◊Õ‡æ»·≈–√–¥—∫Õ“°“√ª«¥√ÿπ·√ß ‚¥¬‡æ»À≠‘ß¡’§«“¡‡ ’Ë¬ß¡“°°«à“‡æ»™“¬ 10.72‡∑à“ ·≈–ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥ Ÿß¡’§«“¡‡ ’Ë¬ß¡“°°«à“ºŸâ∑’Ë¡’√–¥—∫Õ“°“√ª«¥µË” 8.15 ‡∑à“ °≈ÿà¡∑’Ë‰¡à¡’Õ“°“√ª«¥¡’‚Õ°“ ‡°‘¥¿“«–´÷¡‡»√â“„°≈â‡§’¬ß°—∫°≈ÿà¡∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ ‚¥¬¡’§à“ Relative risk ¢Õß°“√‡°‘¥ high risk depression„πºŸâ∑’Ë¡’Õ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ‡∑à“°—∫ 1.06 (95% CI 0.38-2.94) ·≈– 2.39 (95% CI0.50-11.52) „π‡¥◊Õπ∑’Ë 3 ·≈–‡¥◊Õπ∑’Ë 6 ¥—ßπ—ÈπÕ“°“√ª«¥‡√◊ÈÕ√—ß„π√–∫∫°√–¥Ÿ°·≈–°≈â“¡‡π◊ÈÕ¡‘„™à

92

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‡ªìπªí®®—¬À≈—°ªí®®—¬‡¥’¬«∑’Ë‡Àπ’Ë¬«π”°“√‡°‘¥¿“«–´÷¡‡»√â“

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥‡®â“Àπâ“∑’Ë·≈–Õ“ “ ¡—§√ “∏“√≥ ÿ¢ª√–®”À¡Ÿà∫â“π¢Õß»Ÿπ¬å ÿ¢¿“æ™ÿ¡™π∑à“™â“ß “¡‰∂·¡à≈“ ·≈–æ√–πÕπ ∑’Ë°√ÿ≥“„Àâ§«“¡Õπÿ‡§√“–Àå„π°“√‡°Á∫¢âÕ¡Ÿ≈·≈–ª√– “πß“π°—∫°≈ÿà¡µ—«Õ¬à“ß ¢Õ¢Õ∫§ÿ≥ ”π—°ß“π°Õß∑ÿπ π—∫ πÿπ°“√ √â“ß‡ √‘¡ ÿ¢¿“æ∑’Ë π—∫ πÿπ∑ÿπ„π°“√∑”«‘®—¬„π§√—Èßπ’È

8. Magni G, Moreschi C, Rigatti-Luchini S, Merskey H.

Prospective study on the relationship between depressive

symptoms and chronic musculoskeletal pain. Pain

1994; 56:289-97.

9. Mossey JM, Gallagher RM. The longitudinal occurrence

and impact of comorbid chronic pain and chronic

depression over two years in continuing care retirement

community residents. Pain Med 2004; 5:335-48.

10. Giesecke T, Gracely RH, Williams DA, Geisser ME,

Petzke FW, Clauw DJ. The relationship between

depression, clinical pain, and experimental pain in a

chronic pain cohort. Arthritis Rheum 2005; 52:1577-

84.

11. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading

the severity of chronic pain. Pain 1992; 50:133-149.

12. Kasantikul D, Karnjanathanalers N, Limsuwan N,

Thongtang O, Vuthiganond S, Khuangsirikul V, et al.

Health-related self-report (HRSR) scale: the diagnostic

screening test for depression in Thai population. J Med

Assoc Thai 1997; 80:647-57.

13. Boersma K, Linton SJ. How does peersistent pain

develop? An analysis of the relationship between

psychological variables, pain and function across stages

of chronicity. Behav Res Ther 2005; 43:1495-507.

14. Tesch RS, Denardin OV, Baptista CA, Dias FL.

Depression levels in chronic orofacial pain patients: a

pilot study. J Oral Rehabil 2004; 31:926-32.

15. Magni G, Marchetti M, Moreschi C, Merskey H, Luchini

S. Chronic musculoskeletal pain and depressive

symtoms in the National Health and Nutrition

Examination: I. Epidemiologic follow-up study. Pain

1993; 53:163-8.

16. Bao Y, Sturm R, Croghan TW. A national study of the

effect of chronic pain on the use of health care by

depressed persons. Psychiatr Serv 2003; 54:693-7.

17. Von Korff M, Dworkin SF, Le Resche L, Kruger A. An

epidemiology comparison of pain complaint. Pain

1988; 32:173-83.

18. Carroll LJ, Cassidy JD, Cote P. Depression as a risk

factor for onset of an episode of troublesoem neck and

low-back pain. Pain 2004; 107:134-9.

19. Leino P, Magni G. Depressive and deistress symptoms

as predictors of low back pain, neck-shoulder pain, and

other musculoskeletal morbidity: a 10-year follow-up-

of metal industry employees. Pain 1993; 53:89-94.


1. Dworkin RH, Gitlin MJ. Clinical aspects of depression

in chronic pain patient. Clin J Pain 1991; 7:79-94.

2. France RD, Krishnan KR, Trainor M, Pelton S. Chronic

pain and depression. IV. DST as a discriminator

between chronic pain and depression. Pain 1987; 28:

39-44.

3. Currie SR, Wang J. Chronic back pain and major

depression in the general Canadian population. Pain

2004; 107:54-60.

4. Munir F, Yarker J, Haslam C, Long H, Leka S, Griffiths

A, et al. Work factors related to psychological and

health-related distress among employees with chronic

illnesses. J Occup Rehabil 2007; 17:259-77.

5. Von Korff M, Dworkin SF, Le Resche L. Graded

chronic pain status: and epidemiologic evaluation. Pain

1990; 40:279-91.

6. Chaturvedi SK. Prevalence of chronic pain in psychiatric

patients. Pain. May 1987; 29:231-7.

7. Magni G, Caldieron C, Rigatti-Luchini S, Merskey H.

Chronic musculoskeletal pain and depressive symtoms

in general population. An analysis of the 1st National

Health and Nutrition Examination Survey Data. Pain

1990; 43:299-307.




º≈¢Õß‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß«‘™≠å ‘√‘‚√®πåæ√ æ.∫.‚√ßæ¬“∫“≈Ω“ß ®—ßÀ«—¥‡™’¬ß„À¡à

Abstract Cost Implication of Dyspnea Management Program on Patients with ChronicObstructive Pulmonary Disease in Fang Hospital, Chiang MaiSirirojporn W.

Fang Hospital, Chaingmai, Thailand


The objectives of the quasi-experimental study were to investigate result from the additionalprogramme to manage dyspnea in the cost of treatment Chronic Obstructive Pulmonary Disease (COPD)patients. Study subjects were 20 persons consisting of helpers and COPD patients in Fang Hospital, ChiangMai. The data were collected during August, 2007 to January, 2008. Instrument for data experiment was theadditional programme to manage dyspnea. Instrument for data collection were questionnaires, cost oftreatment records, past illness records and medication records. Evaluated data before and after usedprogramme. Analysis of data by description and independent sample t-test. The data has been shown thatthe cost of treatment Chronic Obstructive Pulmonary Disease (COPD) patients’s after using this programmewere significantly decrease. (p = 0.05) The result of this study could be considered as the important datareduction in the cost of treatment Chronic Obstructive Pulmonary Disease (COPD) patients.

Key words: additional programme to manage dyspnea, chronic obstructive pulmonary disease,cost

‡√◊ËÕß¬àÕ °“√»÷°…“§√—Èßπ’È‡ªìπ°“√»÷°…“°÷Ëß∑¥≈Õß ¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“º≈¢Õß‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß °≈ÿà¡µ—«Õ¬à“ß §◊Õ ºŸâªÉ«¬ ·≈–ºŸâ¥Ÿ·≈ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë¡“√—∫∫√‘°“√∑’Ë§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚√ßæ¬“∫“≈Ω“ß ®—ßÀ«—¥‡™’¬ß„À¡à ®”π«π 20 √“¬ √–¬–‡«≈“¥”‡π‘π°“√»÷°…“ µ—Èß·µà‡¥◊Õπ ‘ßÀ“§¡ æ.». 2550 ∂÷ß‡¥◊Õπ¡°√“§¡ æ.». 2551 ‚¥¬‡§√◊ËÕß¡◊Õ∑’Ë „™â „π°“√∑¥≈Õß §◊Õ‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“° ·≈–‡§√◊ËÕß¡◊Õ∑’Ë„™â „π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈ ‰¥â·°à ·∫∫ —¡¿“…≥å¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ ·∫∫∫—π∑÷°§à“„™â®à“¬„π°“√√—°…“ ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈°“√‡®Á∫ªÉ«¬ ·≈–°“√√—°…“æ¬“∫“≈¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚¥¬«—¥º≈°àÕπ„Àâ‚ª√·°√¡°—∫À≈—ß„Àâ ‚ª√·°√¡ «‘‡§√“–Àå¢âÕ¡Ÿ≈‚¥¬°“√·®°·®ß§«“¡∂’Ë √âÕ¬≈– ∑¥ Õ∫§«“¡·µ°µà“ß‚¥¬„™â ∂‘µ‘ Independent Sample t-testº≈°“√»÷°…“ æ∫«à“ §à“„™â®à“¬„π°“√√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß À≈—ß®“°‰¥â√—∫‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°≈¥≈ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ 0.05 º≈∑’Ë‰¥â®“°°“√»÷°…“§√—Èßπ’È “¡“√∂„™â‡ªìπ¢âÕ¡Ÿ≈æ◊Èπ∞“π„π°“√≈¥§à“„™â®à“¬„π°“√√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‰¥âÕ¬à“ß¡’§ÿ≥¿“æµàÕ‰ª

§” ”§—≠: ‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“° ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß §à“„™â®à“¬

94

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‡ªìπ°≈ÿà¡‚√§¢ÕßªÕ¥∑’ËÕÿ¥°—Èπ°“√‰À≈¢ÕßÕ“°“»¡’æ¬“∏‘ ¿“æ·∫∫‰¡à§◊π Ÿà ¿“æª°µ‘Õß§å°“√Õπ“¡—¬‚≈°§“¥°“√≥å«à“„πªï §.». 2020 ®–‡ªìπ “‡Àµÿ¢Õß§«“¡∑ÿ°¢å∑√¡“π®“°°“√‡®Á∫ªÉ«¬„πÕ—π¥—∫∑’Ë5 ¢Õß‚≈° √Õß®“°‚√§À—«„®¢“¥‡≈◊Õ¥ ¿“«– ÷¡‡»√â“Õÿ∫—µ‘‡Àµÿ∑“ß®√“®√ ·≈–‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß1 „π À√—∞Õ‡¡√‘°“æ∫ºŸâªÉ«¬‚√§¥—ß°≈à“«‡ ’¬™’«‘µ®”π«π120,000 √“¬µàÕªï2 „πª√–‡∑»‰∑¬¡’®”π«π·≈–Õ—µ√“°“√µ“¬¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß µàÕª√–™“°√ 1 · π§π µ“¡≈”¥—∫¢Õß°≈ÿà¡ “‡Àµÿ°“√µ“¬ 10 Õ—π¥—∫·√°§‘¥‡ªìπÕ—π¥—∫∑’Ë 5 ∂‘µ‘ºŸâ‡ ’¬™’«‘µ‡æ‘Ë¡¢÷Èπ®“° 25,228√“¬ „πªï æ.». 2545 ‡ªìπ 27,010 √“¬ „πªï æ.». 25463

‚√ßæ¬“∫“≈Ω“ßæ∫«à“¡’ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß¡“√—∫∫√‘°“√‡æ‘Ë¡¢÷Èπ®“° 647 √“¬ „πªï æ.». 2548 ‡ªìπ690 √“¬ „πªï æ.». 2549 „πªï æ.». 2550 712 √“¬4

‡¢â“√—∫°“√√—°…“·ºπ°ºŸâªÉ«¬πÕ° Ÿß‡ªìπÕ—π¥—∫ 5 √Õß®“°‚√§§«“¡¥—π‚≈À‘µ Ÿß µ‘¥‡™◊ÈÕ„π√–∫∫∑“ß‡¥‘πÀ“¬„® à«π∫π ‡∫“À«“π °√–‡æ“–Õ“À“√Õ—°‡ ∫ ·≈–ºŸâªÉ«¬¬—ß‡¢â“√—∫°“√√—°…“„πÀÕºŸâªÉ«¬ Ÿß‡ªìπÕ—π¥—∫Àπ÷Ëß√Õß®“°‚√§§«“¡¥—π‚≈À‘µ Ÿß ·≈–‚√§‡∫“À«“π ·≈–¡’§à“„™â®à“¬„π°“√√—°…“·ºπ°ºŸâªÉ«¬πÕ° ‡æ‘Ë¡¢÷Èπ®“°1,575,095 ∫“∑ „πªï æ.». 2549 ‡ªìπ 1,950,452 ∫“∑„πªï æ.». 2550 ´÷Ëß Ÿß‡ªìπÕ—π¥—∫ 8 ¢Õß§à“„™â®à“¬„π°“√√—°…“æ¬“∫“≈·ºπ°ºŸâªÉ«¬πÕ° à«π§à“„™â®à“¬„π°“√√—°…“„π°“√√—°…“æ¬“∫“≈·ºπ°ºŸâªÉ«¬„π ‡æ‘Ë¡¢÷Èπ®“° 2,218,291 ∫“∑ „πªï æ.». 2549 ‡ªìπ 2,266,894∫“∑ „πªï æ.». 2550 ÷Ëß Ÿß‡ªìπÕ—π¥—∫ 5 ¢Õß§à“„™â®à“¬„π°“√√—°…“æ¬“∫“≈ºŸâªÉ«¬„π

∂÷ß·¡â«à“∑“ß‚√ßæ¬“∫“≈ Ω“ß‰¥âæ—≤π“√–∫∫°“√„Àâ∫√‘°“√ ‚¥¬‰¥â‡ªî¥∫√‘°“√§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑ÿ°«—πÕ—ß§“√ ‡«≈“ 08.00-12.00 π.µ—Èß·µà‡¥◊Õπ ‘ßÀ“§¡æ.». 2546 ‡ªìπµâπ¡“ √Ÿª·∫∫°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬„π§≈‘π‘°‡ªìπ°“√¥Ÿ·≈√à«¡°—π ·∫∫∑’¡ À “¢“«‘™“™’æª√–°Õ∫¥â«¬ ·æ∑¬å æ¬“∫“≈ ‡¿ —™°√ π—°°“¬¿“æ∫”∫—¥ ´÷Ëß°‘®°√√¡°“√¥Ÿ·≈ºŸâªÉ«¬„π§≈‘π‘° ‡ªìπ°“√„Àâ§«“¡√Ÿâ·°àºŸâªÉ«¬‡ªìπ°≈ÿà¡ §√—Èß≈– 50-60 √“¬ „π∑ÿ°«—π

Õ—ß§“√«— µ∂ÿª√– ß§å °“√»÷ °…“ ‡æ◊Ë Õ»÷ °…“º≈¢Õß

‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‚√ßæ¬“∫“≈Ω“ß ®—ßÀ«—¥‡™’¬ß„À¡à ´÷Ëß¢âÕ¡Ÿ≈∑’Ë‰¥â®–‡ªìπª√–‚¬™πåµàÕ°“√æ—≤π“√Ÿª·∫∫°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ßµàÕ‰ª

«—µ∂ÿ·≈–«‘∏’°“√

°“√»÷°…“§√—Èßπ’È‡ªìπ°“√»÷°…“°÷Ëß∑¥≈Õß (quasi-experimental study)·∫∫°≈ÿà¡‡¥’¬««—¥°àÕπ·≈–À≈—ß°“√∑¥≈Õß (one groups pre-posttest design)‡æ◊ËÕ»÷°…“º≈¢Õß‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ‚√ßæ¬“∫“≈Ω“ß ®—ßÀ«—¥‡™’¬ß„À¡à

ª√–™“°√∑’Ë»÷°…“ §◊Õ ºŸâ∑’Ë‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë‡¢â“√—∫°“√µ√«®√—°…“∑’Ë§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ·ºπ°ºŸâªÉ«¬πÕ° ‚√ßæ¬“∫“≈Ω“ß ®—ßÀ«—¥‡™’¬ß„À¡à

°≈ÿà¡µ—«Õ¬à“ß §◊Õ ºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë‡¢â“√—∫°“√µ√«®√—°…“„π§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß·ºπ°ºŸâªÉ«¬πÕ°´÷Ëß‰¥â√—∫°“√µ√«®√—°…“¡“·≈â«‰¡àµË”°«à“1 ‡¥◊Õπ‚¥¬‰¡à®”°—¥ ‡æ» Õ“™’æ ∂“π¿“æ ¡√ ∞“π–∑“ß‡»√…∞°‘®√–¬–‡«≈“∑’Ë‡ªìπ‚√§‡≈◊Õ°°≈ÿà¡µ—«Õ¬à“ß®”π«π 20 √“¬ àÿ¡·∫∫‡®“–®ß (purposivesampling)

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√»÷°…“§√—Èßπ’Èª√–°Õ∫¥â«¬2 ª√–‡¿∑ ‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√¥”‡π‘π°“√»÷°…“‡ªìπ‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°∑’Ëæ—≤π“¢÷Èπ5 ‚¥¬ª√–¬ÿ°µå®“°°√Õ∫·π«§‘¥√Ÿª·∫∫°“√®—¥°“√°—∫Õ“°“√¢Õß≈“√å —π·≈–§≥–

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√√«∫√«¡¢âÕ¡Ÿ≈ª√–°Õ∫¥â«¬·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ª√–°Õ∫¥â«¬¢âÕ¡Ÿ≈ ‡æ» Õ“¬ÿ»“ π“ ‡™◊ÈÕ™“µ‘ Õ“™’æ ∂“π¿“æ ¡√ √–¥—∫°“√»÷°…“√“¬‰¥â‡©≈’Ë¬¢Õß§√Õ∫§√—«µàÕ‡¥◊Õπ §«“¡‡æ’¬ßæÕ¢Õß√“¬‰¥â §à“„™â®à“¬„π°“√√—°…“ ªí≠À“‡°’Ë¬«°—∫§à“„™â®à“¬„π°“√√—°…“ ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë



·∫∫∫—π∑÷°¢âÕ¡Ÿ≈°“√‡®Á∫ªÉ«¬ ·≈–°“√√—°…“æ¬“∫“≈

·∫∫∫—π∑÷°§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß´÷Ëß‡ªìπ·∫∫∫—π∑÷°∑’ËºŸâ»÷°…“æ—≤π“¢÷Èπ‡æ◊ËÕ √ÿª§à“„™â®à“¬„π°“√√—°…“„π·µà≈–§√—Èß∑’ËºŸâªÉ«¬¡“√—°…“∑’Ë‚√ßæ¬“∫“≈Ω“ß¥â«¬·æ∑¬å«‘π‘®©—¬«à“‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß

¢—ÈπµÕπ·≈–«‘∏’°“√√«∫√«¡¢âÕ¡Ÿ≈ ™’È·®ß«—µ∂ÿª√– ß§å¢Õß°“√»÷°…“·≈–¢Õ§«“¡√à«¡¡◊Õ„π°“√»÷°…“·≈–¥”‡π‘π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈ ”√«®√“¬™◊ËÕºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë¡“µ√«®„π§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑ÿ°«—πÕ—ß§“√‡«≈“ 08.00-12.00 π. ·ºπ°ºŸâªÉ«¬πÕ°‚√ßæ¬“∫“≈Ω“ß®—ßÀ«—¥‡™’¬ß„À¡àµ“¡‡°≥±å∑’Ë°”Àπ¥§—¥‡≈◊Õ°°≈ÿà¡µ—«Õ¬à“ß »÷°…“ª√–‡¡‘π§à“„™â®à“¬„π°“√√—°…“¢Õß°≈ÿà¡µ—«Õ¬à“ß°àÕπ‡¢â“√à«¡‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°

°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈ ∑“ß ∂‘µ‘‚¥¬„™â‚ª√·°√¡§Õ¡æ‘«‡µÕ√å ”‡√Á®√Ÿª ¥—ßπ’È ¢âÕ¡Ÿ≈ à«π∫ÿ§§≈¢Õß°≈ÿà¡µ—«Õ¬à“ßπ”¡“ ·®°·®ßÀ“§«“¡∂’Ë §”π«≥ À“§à“√âÕ¬≈– ‡ª√’¬∫‡∑’¬∫§à“‡©≈’Ë¬§à“„™â®à“¬„π°“√√—°…“°àÕπ·≈–À≈—ß°“√∑¥≈Õß¥â«¬ ∂‘µ‘ t-test for dependentsample ¿“¬À≈—ß°“√∑¥ Õ∫°“√°√–®“¬¢Õß¢âÕ¡Ÿ≈¥â«¬ ∂‘µ‘ Kolmogorov-Sminov æ∫«à“°“√°√–®“¬¢Õß¢âÕ¡Ÿ≈‡ªìπ‚§âßª°µ‘ ¥”‡π‘π°“√‡°Á∫¢âÕ¡Ÿ≈µ—Èß·µà‡¥◊Õπ ‘ßÀ“§¡ æ.». 2550 ∂÷ß‡¥◊Õπ¡°√“§¡ æ.». 2551

º≈

º≈¢Õß‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§à“„™â®à“¬„π°“√√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß°≈ÿà¡µ—«Õ¬à“ß∑’Ë»÷°…“‡ªìπºŸâªÉ«¬™“¬·≈–À≠‘ß ´÷Ëß‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ·≈–¡“√—∫°“√µ√«®√—°…“∑’Ë·ºπ°ºŸâªÉ«¬πÕ° ‚√ßæ¬“∫“≈Ω“ß ®”π«π 20 √“¬

à«π∑’Ë 1 ¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ ®”·π°µ“¡ ‡æ» Õ“¬ÿ»“ π“ ∂“π¿“æ ¡√ √–¥—∫°“√»÷°…“ Õ“™’æ√“¬‰¥â§√Õ∫§√—«µàÕ‡¥◊Õπ §«“¡‡æ’¬ßæÕ¢Õß√“¬‰¥â «‘∏’°“√®à“¬„π°“√√—°…“ ®”π«π 20 §π °≈ÿà¡µ—«Õ¬à“ß

à«π„À≠à‡ªìπ‡æ»™“¬√âÕ¬≈– 60 ∑ÿ°§ππ—∫∂◊Õ»“ π“æÿ∑∏ ¡’Õ“¬ÿ√–À«à“ß 55-60 ªï ¡“°∑’Ë ÿ¥§◊Õ√âÕ¬≈– 80 ∂“π¿“æ ¡√ §Ÿà √âÕ¬≈– 80 ®∫°“√»÷°…“√–¥—∫ª√–∂¡»÷°…“ √âÕ¬≈– 85 ª√–°Õ∫Õ“™’æ‡°…µ√°√√âÕ¬≈– 45 ¡’√“¬‰¥â§√Õ∫§√—«µàÕ‡¥◊ÕππâÕ¬°«à“ 6,000∫“∑ §«“¡‡æ’¬ßæÕ¢Õß√“¬‰¥âÕ¬Ÿà„π√–¥—∫‡æ’¬ßæÕ§‘¥‡ªìπ√âÕ¬≈– 60 «‘∏’°“√®à“¬„π°“√√—°…“ à«π„À≠à„™â∫—µ√∑Õß √âÕ¬≈– 85 (µ“√“ß∑’Ë 1)

à«π∑’Ë 2 ¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ ®”·π°µ“¡ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë„πÕ¥’µ ®”π«π∫ÿÀ√’Ë∑’Ë‡§¬ Ÿ∫µàÕ«—π√–¬–‡«≈“∑’Ë‡≈‘° Ÿ∫∫ÿÀ√’Ë √–¬–‡«≈“∑’Ë‰¥â√—∫°“√«‘π‘®©—¬¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß √–¥—∫§«“¡√ÿπ·√ß¢Õß‚√§ ·≈–ª√–«—µ‘°“√‡¢â“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈„π√Õ∫ 1 ªï °“√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥ Ÿ¥√à«¡°—∫™π‘¥√—∫ª√–∑“π°≈ÿà¡µ—«Õ¬à“ß∑ÿ°§π‡§¬ Ÿ∫∫ÿÀ√’Ë à«π„À≠à®”π«π∫ÿÀ√’Ë∑’Ë Ÿ∫πâÕ¬°«à“ 5 ¡«πµàÕ«—π √âÕ¬≈– 85 √–¬–‡«≈“∑’Ë‰¥â√—∫°“√«‘π‘®©—¬¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ßπâÕ¬°«à“ 20 ªï√âÕ¬≈– 85 ·≈–¡’§«“¡√ÿπ·√ß¢Õß‚√§Õ¬Ÿà„π√–¥—∫ 2√âÕ¬≈– 80 ∑ÿ°§π‡§¬‡¢â“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈„π™à«ß 1 ªï·≈–¡’°“√„™â¬“¢¬“¬À≈Õ¥≈¡ ™π‘¥ Ÿ¥√à«¡°—∫™π‘¥√—∫ª√–∑“π‡À¡◊Õπ°—π

à«π∑’Ë 3 ‡ª√’¬∫‡∑’¬∫§à“‡©≈’Ë¬§à“„™â®à“¬„π°“√√—°…“°àÕπ·≈–À≈—ß‡¢â“√à«¡‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“° §à“‡©≈’Ë¬ à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π¢Õß§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“¢Õß°≈ÿà¡µ—«Õ¬à“ß°àÕπ·≈–À≈—ß‡¢â“√à«¡‚ª√·°√¡‚¥¬„™â ∂‘µ‘ (t-test fordependent sample) §à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß°àÕπ‡¢â“√à«¡‚ª√·°√¡‡∑à“°—∫29,441.00 ∫“∑ (SD = 1,356.34) ¿“¬À≈—ß‡¢â“√à«¡‚ª√·°√¡‡∑à“°—∫ 18,229.00 ∫“∑ (SD = 744.56)‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§«“¡·µ°µà“ß¢Õß§à“„™â®à“¬‡©≈’Ë¬æ∫«à“¡’§«“¡·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ (p <.05)

«‘®“√≥å

º≈¢Õß°“√≈¥§à“„™â®à“¬„π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‚¥¬„™â‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√

96

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ“√“ß∑’Ë 1 ®”π«π·≈–√âÕ¬≈–¢âÕ¡Ÿ≈ à«π∫ÿ§§≈¢Õß°≈ÿà¡µ—«Õ¬à“ß ®”·π°µ“¡ ‡æ» Õ“¬ÿ »“ π“ ∂“π¿“æ ¡√ √–¥—∫

°“√»÷°…“ Õ“™’æ√“¬‰¥â§√Õ∫§√—«µàÕ‡¥◊Õπ §«“¡‡æ’¬ßæÕ¢Õß√“¬‰¥â «‘∏’°“√®à“¬„π°“√√—°…“ (n = 20)

¢âÕ¡Ÿ≈ ®”π«π (√“¬) √âÕ¬≈–

‡æ»

™“¬ 12 60

À≠‘ß 8 40

Õ“¬ÿ

41-50 ªï 4 20

51-60 ªï 16 80

æ‘ —¬ = 42-59, §à“‡©≈’Ë¬ = 54.60, à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π = 5.19

»“ π“

æÿ∑∏ 20 100

∂“π¿“æ ¡√

§Ÿà 16 60

À¡â“¬ 4 40

√–¥—∫°“√»÷°…“

ª√–∂¡»÷°…“ 17 85

¡—∏¬¡»÷°…“/ª√‘≠≠“µ√’ 3 15

ª√–°“»π’¬∫—µ√

Õ“™’æ

‡°…µ√°√ 9 45

√—∫√“™°“√/§â“¢“¬ 5 25

√—∫®â“ß/‰¡à‰¥âª√–°Õ∫Õ“™’æ 6 30

√“¬‰¥â§√Õ∫§√—«µàÕ‡¥◊Õπ

πâÕ¬°«à“ 6,000 ∫“∑ 13 65

6,000 ∫“∑¢÷Èπ‰ª 7 35

§«“¡‡æ’¬ßæÕ¢Õß√“¬‰¥â

‡æ’¬ßæÕ 12 60

‰¡à‡æ’¬ßæÕ 8 40

«‘∏’°“√®à“¬„π°“√√—°…“

«— ¥‘°“√¢â“√“™°“√ 3 28

∫—µ√∑Õß 17 85



æŸ¥§ÿ¬·≈°‡ª≈’Ë¬πª√– ∫°“√≥å°“√¡’Õ“°“√À“¬„®≈”∫“° ª√–‡¡‘πª√– ∫°“√≥å°“√¡’Õ“°“√À“¬„®≈”∫“°¢Õßµπ‡Õß µ≈Õ¥®π‰¥â√—∫°“√ àß‡ √‘¡„Àâ¡’§«“¡√Ÿâ‡√◊ËÕß‚√§·≈–°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°‚¥¬„™â§Ÿà¡◊Õ°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“° ”À√—∫

À“¬„®≈”∫“°æ∫«à“À≈—ß®“°ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë‡¢â“√à«¡‚ª√·°√¡œ ®”π«π 20 √“¬ ¡’§à“„™â®à“¬≈¥≈ß°«à“°àÕπ‡¢â“√à«¡‚ª√·°√¡ Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ (p < .05) ´÷Ëß‡ªìπ‰ªµ“¡ ¡¡µ‘∞“π∑’Ëµ—Èß‰«â ∑—Èßπ’È‡π◊ËÕß®“°°“√∑’ËºŸâªÉ«¬‰¥â‡¢â“√à«¡‚ª√·°√¡∑”„ÀâºŸâªÉ«¬

µ“√“ß∑’Ë 2 ¢âÕ¡Ÿ≈ à«π∫ÿ§§≈¢Õß°≈ÿà¡µ—«Õ¬à“ß®”·π°µ“¡ ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë„πÕ¥’µ ®”π«π∫ÿÀ√’Ë∑’Ë‡§¬ Ÿ∫µàÕ«—π√–¬–

‡«≈“∑’Ë‡≈‘° Ÿ∫∫ÿÀ√’Ë √–¬–‡«≈“∑’Ë‰¥â√—∫°“√«‘π‘®©—¬¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß √–¥—∫§«“¡√ÿπ·√ß¢Õß‚√§

·≈–ª√–«—µ‘°“√‡¢â“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈„π√Õ∫ 1 ªï °“√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥ Ÿ¥√à«¡°—∫™π‘¥

√—∫ª√–∑“π (n = 20)

¢âÕ¡Ÿ≈ ®”π«π (√“¬) √âÕ¬≈–

ª√–«—µ‘°“√ Ÿ∫∫ÿÀ√’Ë„πÕ¥’µ

‡§¬ Ÿ∫∫ÿÀ√’Ë 20 100

®”π«π∫ÿÀ√’Ë∑’Ë Ÿ∫ (¡«πµàÕ«—π)

πâÕ¬°«à“ 5 ¡«π 17 85

5 ¡«π ¢÷Èπ‰ª 3 15

√–¬–‡«≈“∑’Ë‰¥â√—∫°“√«‘π‘®©—¬¥â«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß

πâÕ¬°«à“ 20 ªï 17 85

20 ªï¢÷Èπ‰ª 3 15

√–¥—∫§«“¡√ÿπ·√ß¢Õß‚√§

2 16 80

3 4 20

ª√–«—µ‘°“√‡¢â“æ—°√—°…“µ—«„π‚√ßæ¬“∫“≈„π™à«ß 1 ªï

‡§¬ 20 100

°“√„™â¬“¢¬“¬À≈Õ¥≈¡™π‘¥ Ÿ¥√à«¡°—∫™π‘¥√—∫ª√–∑“π 20 100

µ“√“ß∑’Ë 3 §à“‡©≈’Ë¬ à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π ¢Õß§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“¢Õß°≈ÿà¡µ—«Õ¬à“ß°àÕπ·≈–À≈—ß‡¢â“√à«¡‚ª√·°√¡

‚¥¬„™â ∂‘µ‘ (t-test for dependent sample)

°≈ÿà¡µ—«Õ¬à“ß º≈√«¡§à“√—°…“ X SD t p

°àÕπ‡¢â“√à«¡‚ª√·°√¡ 29,441.00 1,472.05 1,356.34 1.733 .049

À≈—ß‡¢â“√à«¡‚ª√·°√¡ 18,229.00 911.45 744.56

*p < .05 X = §à“‡©≈’Ë¬ SD = à«π‡∫’Ë¬ß‡∫π¡“µ√∞“π

98

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß2 ª√–°Õ∫ æ√âÕ¡π”§Ÿà¡◊Õ‰ª∑∫∑«π∑’Ë∫â“π ·≈–¬—ß¡’°“√ àß‡ √‘¡„Àâ¡’°“√∫—π∑÷°µ“¡·∫∫∫—π∑÷°«‘∏’°“√®—¥°“√·≈–º≈¢Õß«‘∏’®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°¥â«¬µ—«‡Õß∑’Ë∫â“π∑ÿ°«—πÕ’°∑—Èß¬—ßºŸâªÉ«¬‰¥â√—∫°“√Ωñ°∑—°…–°“√ªØ‘∫—µ‘„π‡√◊ËÕß°“√®—¥∑à“∑’Ë‡À¡“– ¡‡¡◊ËÕ‡°‘¥Õ“°“√À“¬„®≈”∫“° °“√∫√‘À“√°“√À“¬„® °“√‰Õ∑’Ë¡’ª√– ‘∑∏‘¿“æ °“√„™â¬“·≈–°“√ —ß‡°µƒ∑∏‘Ï¢â“ß‡§’¬ß¢Õß¬“ °“√ÕÕ°°”≈—ß°“¬ ‡ªìπ√“¬∫ÿ§§≈·≈–≠“µ‘√à«¡°—∫æ¬“∫“≈‡ªìπ®”π«π 5 §√—Èß§√—Èß≈–ª√–¡“≥ 20-40 π“∑’‡ªìπ√–¬–‡«≈“ 8 —ª¥“À

πÕ°®“°π’Èæ¬“∫“≈¬— ß Õ∫∂“¡∂÷ ßªí≠À“Õÿª √√§„π√–¬–‡«≈“∑’Ëºà“π¡“√–À«à“ß‡¢â“√à«¡‚ª√·°√¡·≈–¬—ßµ‘¥µ“¡º≈¢Õß‚ª√·°√¡®“°·∫∫∫—π∑÷°«‘∏’°“√®—¥°“√·≈–º≈¢Õß«‘∏’®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°®“°ºŸâªÉ«¬ °‘®°√√¡¥—ß°≈à“«∑’Ëºà“π¡“∑”„ÀâºŸâªÉ«¬¡’§«“¡√Ÿâ·≈–‡°‘¥∑—°…–„π°“√®—¥°“√°—∫Õ“°“√À“¬≈”∫“° àßº≈„Àâ¡’°“√‡¢â“¡“√—∫°“√√—°…“„π‚√ßæ¬“∫“≈≈¥≈ß∑”„Àâ§à“„™â®à“¬„π°“√√—°…“≈¥≈ß¥—ßº≈°“√»÷°…“6 æ∫«à“§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“¢ÕßºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë‰¥â√—∫°“√®—¥°“√°—∫Õ“°“√°”‡√‘∫ µ“¡·π«ªØ‘∫—µ‘∑“ß§≈‘π‘°„π°“√®—¥°“√Õ“°“√°”‡√‘∫ ”À√—∫ºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ¡’§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“πâÕ¬°«à“°≈ÿà¡∑’Ë‰¥â√—∫°“√®—¥°“√Õ“°“√°”‡√‘∫µ“¡«‘∏’ª°µ‘· ¥ß„Àâ‡ÀÁπ«à“‚ª√·°√¡œ “¡“√∂π”¡“„™â„π°“√≈¥§à“„™â®à“¬„πºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‰¥â

‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß (Chronic ObstructivePulmonary Disease [COPD]) ‡ªìπ°≈ÿà¡‚√§Õÿ¥°—Èπ„π∑“ß‡¥‘πÀ“¬„® ´÷Ëß‡°‘¥‰¥âµ—Èß·µàÀ≈Õ¥≈¡∂÷ß∂ÿß≈¡„πªÕ¥ ‚¥¬¢∫«π°“√∑’Ë∑”„Àâ‡°‘¥‚√§Õ“®·µ°µà“ß°—π ·µà„π∑“ß§≈‘π‘°®–¡’°“√‡ª≈’Ë¬π·ª≈ß ¡√√∂¿“æ °“√∑”ß“π¢ÕßªÕ¥§≈â“¬§≈÷ß°—π °“√Õÿ¥°—Èπ∑’Ë‡°‘¥„πªÕ¥®–‡ªìπ·∫∫‡√◊ÈÕ√—ß§àÕ¬‡ªìπ§àÕ¬‰ª ·≈–‰¡à°≈—∫§◊π Ÿà ¿“æª°µ‘7,8 “‡Àµÿ∑’Ë ”§—≠∑’Ë ÿ¥§◊Õ °“√ Ÿ∫∫ÿÿÀ√’Ë9 ®“°º≈°“√»÷°…“æ∫«à“ºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß¡’ª√–«—µ‘‡§¬ Ÿ∫∫ÿÀ√’Ë√âÕ¬≈– 100 ·≈–®”π«π∑’Ë Ÿ∫∫ÿÀ√’ËπâÕ¬°«à“5 ¡«πµàÕ«—π√âÕ¬≈– 85, ¡“°°«à“ 5 ¡«π √âÕ¬≈– 15,Õ“¬ÿ 51-60 ªï √âÕ¬≈– 80

§à“„™â®à“¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‡ªìπ‚√§∑’Ë„™â§à“„™â®à“¬®”π«π¡“°„π°“√√—°…“ æ∫«à“„π À√—∞Õ‡¡√‘°“ §à“„™â®à“¬„π°“√√—°…“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß Ÿß∂÷ß ªï≈– 14 æ—π≈â“π‡À√’¬≠ À√—∞1 „πÕÕ ‡µ√‡≈’¬ Ÿß∂÷ß 898≈â“π‡À√’¬≠ À√—∞ ·≈– 25,969 ≈â“π∫“∑ „πª√–‡∑»‰∑¬»÷°…“§à“„™â®à“¬¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß „π‚√ßæ¬“∫“≈√—∞ 8 ·Ààß ∑—Èß 4 ¿“§¢Õßª√–‡∑»‰∑¬·≈–°√ÿß‡∑æ¡À“π§√10 ®”π«π 500 √“¬ ´÷Ëß·∫àß‡ªìπ°≈ÿà¡ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ®”π«π 250 √“¬ ·≈–°≈ÿà¡Õâ“ßÕ‘ß 250 √“¬ „™â«‘∏’ —¡¿“…≥åºŸâªÉ«¬·≈–≠“µ‘‚¥¬·∫∫ Õ∫∂“¡ æ∫«à“ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‡ ’¬§à“„™â®à“¬„π°“√√—°…“‡©≈’Ë¬ 638 ∫“∑µàÕ‡¥◊Õπ à«π°≈ÿà¡Õâ“ßÕ‘ß‡ ’¬§à“„™â®à“¬„π°“√√—°…“ 11 ∫“∑µàÕ‡¥◊Õπ11

Õ¥§≈âÕß°—∫°“√»÷°…“¢Õßπ—¬π“ Õ‘π∑√åª√– ‘∑∏‘Ï (æ.».2544) æ∫«à“ §à“„™â®à“¬„π°“√¡“µ√«®√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß¢Õß‚√ßæ¬“∫“≈æ√–¡ß°ÿÆ‡°≈â“„πªï æ.». 2543 §‘¥‡ªìπ 1,688 ∫“∑µàÕ√“¬ µàÕ 2 ‡¥◊Õπ·≈–§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“¢ÕßºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë‰¥â√—∫°“√®—¥°“√°—∫Õ“°“√°”‡√‘∫ µ“¡·π«ªØ‘∫—µ‘∑“ß§≈‘π‘°„π°“√®—¥°“√Õ“°“√°”‡√‘∫ ”À√—∫ºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ¡’§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“πâÕ¬°«à“°≈ÿà¡∑’Ë‰¥â√—∫°“√®—¥°“√Õ“°“√°”‡√‘∫µ“¡«‘∏’ª°µ‘6

°“√„™â‚ª√·°√¡œ “¡“√∂≈¥§à“„™â®à“¬„π°“√¥Ÿ·≈√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‰¥â ·µà«‘∏’°“√∑’Ë®–≈¥§à“„™â®à“¬ „π°“√√—°…“æ¬“∫“≈‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß12

∑’Ë¥’∑’Ë ÿ¥§◊Õ «‘∏’°“√ªÑÕß°—π°“√‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß‚¥¬°“√·π–π”„Àâ§πÀ¬ÿ¥ Ÿ∫∫ÿÀ√’Ë ·≈–∂â“ºŸâªÉ«¬ Ÿ∫∫ÿÀ√’Ë°Á§«√·π–π”„ÀâÀ¬ÿ¥ Ÿ∫ ∂â“ª√–™“™πÀ¬ÿ¥ Ÿ∫∫ÿÀ√’Ë®”π«πºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß®–≈¥≈ßÕ¬à“ß¡“°´÷Ëß “¡“√∂≈¥§à“„™â®à“¬∑’Ë‡ ’¬‰ª°—∫°“√√—°…“®”π«π¡“°¥â«¬‡™àπ°—π

√ÿª

º≈°“√»÷°…“æ∫«à“ §à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß°àÕπ‡¢â“√à«¡‚ª√·°√¡‡∑à“°—∫ 29,441.00 ∫“∑ (SD = 1,356.34) ¿“¬À≈—ß



‡¢â“√à«¡‚ª√·°√¡‡∑à“°—∫ 18,229.00 ∫“∑ (SD = 744.56)‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§«“¡·µ°µà“ß¢Õß §à“„™â®à“¬‡©≈’Ë¬æ∫«à“¡’§«“¡·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ .05 √ÿª‰¥â«à“¿“¬À≈—ßºŸâªÉ«¬‡¢â“√à«¡‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°§à“„™â®à“¬‡©≈’Ë¬„π°“√√—°…“≈¥≈ß°«à“°àÕπ‡¢â“√à«¡‚ª√·°√¡Õ¬à“ßπ—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ .05

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ π“¬·æ∑¬å∑πß √√§å ÿ∏“∏√√¡ºŸâµ√«®√“™°“√°√–∑√«ß‡¢µ π“¬·æ∑¬å√—∞«ÿ≤‘ ÿ¢¡’ “∏“√≥ ÿ¢π‘‡∑» π“¬·æ∑¬å«—≤π“ °“≠®π°“¡≈ π“¬·æ∑¬å “∏“√≥ ÿ¢®—ßÀ«—¥‡™’¬ß„À¡à∑’Ë°√ÿ≥“„Àâ§”ª√÷°…“·≈–·π–π” ·≈–¢Õ¢Õ∫§ÿ≥ À—«Àπâ“°≈ÿà¡°“√æ¬“∫“≈À—«Àπâ“·ºπ°ºŸâªÉ«¬πÕ° ∑’¡ß“πºŸâ¥Ÿ·≈§≈‘π‘°‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ·ºπ°ÀâÕß¬“ ·ºπ°‡«™√–‡∫’¬π ºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß ∑ÿ°∑à“π ∑’Ë„Àâ§«“¡√à«¡¡◊Õ·≈–™à«¬‡À≈◊Õ„π°“√»÷°…“§√—Èßπ’È ”‡√Á®‰ª¥â«¬¥’

3. ”π—°π‚¬∫“¬·≈–¬ÿ∑∏»“ µ√å. ∂‘µ‘ “∏“√≥ ÿ¢ (µ“¡∫—≠™’µ“√“ßæ◊Èπ∞“π¢Õß∫—≠™’®”·π°‚√§√–À«à“ßª√–‡∑» ©∫—∫·°â‰¢§√—Èß∑’Ë 10) æ.». 2542-2546. Retrieved ∏—π«“§¡ 7,2548, from http//www.moph.go.th/ops/bupp/budg12 .html

4. »Ÿπ¬å¢âÕ¡Ÿ≈¢à“« “√ ß“π‡«™√–‡∫’¬π·≈– ∂‘µ‘. ‚√ßæ¬“∫“≈Ω“ß ®—ßÀ«—¥‡™’¬ß„À¡à; 2549.

5. ’π’π“Ø ªÑÕ¡‡¬Áπ. º≈¢Õß‚ª√·°√¡ àß‡ √‘¡°“√®—¥°“√°—∫Õ“°“√À“¬„®≈”∫“°µàÕ§ÿ≥¿“æ™’«‘µ¢ÕßºŸâ∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß. «‘∑¬“π‘æπ∏åæ¬“∫“≈»“ µ√¡À“∫—≥±‘µ “¢“«‘™“°“√æ¬“∫“≈ºŸâ„À≠à, ∫—≥±‘µ«‘∑¬“≈—¬ ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à; 2547.

6. √’æ—™√å ·°â«¥«ß‡∑’¬π. ª√– ‘∑∏‘º≈¢Õß·π«ªØ‘∫—µ‘∑“ß§≈‘π‘°„π°“√®—¥°“√Õ“°“√°”‡√‘∫ ”À√—∫ºŸâªÉ«¬∑’Ë‡ªìπ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß µàÕ ¿“«–Õ“°“√À“¬„®≈”∫“°®”π«π«—ππÕπ·≈–§à“„™â®à“¬„π°“√√—°…“. «‘∑¬“π‘æπ∏åæ¬“∫“≈»“ µ√¡À“∫—≥±‘µ “¢“«‘™“°“√æ¬“∫“≈ºŸâ„À≠à, ∫—≥±‘µ«‘∑¬“≈—¬¡À“«‘∑¬“≈—¬∫Ÿ√æ“; 2549.

7. ‡æ™√“ ∫ÿ≥¬ß √√§å™—¬. ‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß. „π: ÿ∑∏™“µ‘æ◊™º≈, ∫√√≥“∏‘°“√. ‡«™»“ µ√å©ÿ°‡©‘π. °√ÿß‡∑æœ: π”Õ—°…√°“√æ‘¡æå; 2542.

8. Celli BR, Plata VP. Chronic obstructive lung disease.

In: Parson PE, Heffner JE, editors. Pulmonary therapy

secrets. 2nd ed. Philadelphia: Haley & Belfus; 2002.

9. ¡“§¡Õÿ√‡«™™å·Ààßª√–‡∑»‰∑¬. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß„πª√–‡∑»‰∑¬ (©∫—∫ª√—∫ª√ÿß æ.».2548). °√ÿß‡∑æœ: ¿“ææ‘¡æå; 2548.

10. Õπß§å æŸ„∫. Õ—µ¡‚π∑—»πå¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß∑’Ë√—∫∫√‘°“√„π‚√ßæ¬“∫“≈π“πâÕ¬®—ßÀ«—¥πà“π. «‘∑¬“π‘æπ∏åæ¬“∫“≈»“ µ√¡À“∫—≥±‘µ, ∫—≥±‘µ«‘∑¬“≈—¬¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à; 2547.

11. ÿ√“ß§å√—µπå æâÕßæ“π. §à“„™â®à“¬¢ÕßºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°—Èπ‡√◊ÈÕ√—ß®“°°“√ Ÿ∫∫ÿÀ√’Ë. «‘∑¬“π‘æπ∏åª√‘≠≠“«‘∑¬“»“ µ√¡À“∫—≥±‘µ, “¢“«‘∑¬“°“√√–∫“¥, ∫—≥±‘µ«‘∑¬“≈—¬¡À“«‘∑¬“≈—¬¡À‘¥≈; 2542.

12. «—™√“ ∫ÿ≠ «— ¥‘Ï. ·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬À≈Õ¥≈¡Õÿ¥°—Èπ‡√◊ÈÕ√—ß. „π: ®‘µµ¡“ »‘√‘®’√™—¬, ‡®√‘≠ ™ÿ≥À°“≠®πå, ¿‘√ÿ≠¡ÿµ ‘°æ—π∏å, ∫√√≥“∏‘°“√. Õ“¬ÿ√»“ µ√å§ÿâ¡§à“. ¢Õπ·°àπ:§≈—ßπ“π“«‘∑¬“; 2541.


1. Global Initiative for Chornic Obstructive Lung Disease.

(2005). Fact about chronic obstructive pulmonary

disease.Retrieved Mar, 11, 2006. from http//www.

goldcopd.com/ GOLD_ guideline/facts1.html.

2. Wisniewski A. Chronic bronchitis. Nursing 2003;

33:46-9.

100

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å


§«“¡ —¡æ—π∏åªí®®—¬ à«π∫ÿ§§≈·≈–æƒµ‘°√√¡ ÿ¢¿“æ°—∫‚√§°√–¥Ÿ°æ√ÿπ¢ÕßºŸâπ”™ÿ¡™π∑’ËÕ“¬ÿ 40 ªï¢÷Èπ‰ª„π‡¢µ‡∑»∫“≈‡¡◊Õß ®—ßÀ«—¥∫ÿ√’√—¡¬å ¡™—¬ Õ—»« ÿ¥ “§√ æ.∫.°≈ÿà¡ß“π»—≈¬°√√¡ÕÕ√å‚∏ªî¥‘° å ‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å

Abstract Relationships of Individual Factors and Health Behaviors to Osteoporosis amongCommunity Leader Aged Over Forty Years Old in Municipality Area BuriramProvinceSomchai Auswasudsakorn

Department of Orthopedic service, Buriram Hospital


The objectives of the study were to explore behaviors of Community Leader aged 40 years oldand older in Muang district, Buriram province and to determine the relationships of individual factors andhealth behaviors to bone mineral density (BMD). Data was gathered during April 1 to May 31, 2007 usingquestionaire. Bone mineral density was measured at right forearm by Dual Energy X-ray Absorptiometry(Peripheral Instantaneous X-ray Imager model MDL PIXI # 51245, Lunar Corp.). Two hundred people werevoluntary participants. Individual factors and health behaviors were analyzed using descriptive statisticswith frequency and percentage. Chi-square test was performed to determine the relationships of individualfactors and health behaviors to bone density mass. The results showed that out of 200 people aged 40 yearsold and older, 30% was normal, 43.5% was osteopenia, 23% was osteoporosis and 3.5% was severeosteoporosis, respectively. Age, taking vitamins, calcium supplementary, soy-bean milk were related withbone density mass with statistical significance. Whereas, exercise, active in daily activities, avoiding riskfactors and sex had no relationship with bone density mass. This study demonstrated that osteoporosis is asignificant health problem in Muang municipal people aged 40 years old and older. Promoting of foodconsumption for preventing osteoporosis should be considered and conducted.

Key words: osteoporosis, health behavior, bone mineral density, the relationship, communityleader



∫∑π”

‚√§°√–¥Ÿ°æ√ÿπ‡ªìπ¿“«–∑’Ë¡’°“√‡ª≈’Ë¬π·ª≈ß¢Õß¡«≈°√–¥Ÿ°≈¥≈ß √à«¡°—∫¡’°“√‡ ◊ËÕ¡ ·≈–°“√‡ª≈’Ë¬π·ª≈ß√Ÿª·∫∫¢ÕßÕ≥Ÿ¢Õß‚§√ß √â“ß¿“¬„π¢Õß‡π◊ÈÕ‡¬◊ËÕ°√–¥Ÿ° ∑”„Àâ°√–¥Ÿ°∫“ß≈ß ·≈–‡ ’Ë¬ßµàÕ°“√À—°ßà“¬ ‚¥¬‡©æ“–°√–¥Ÿ°¢âÕ¡◊Õ °√–¥Ÿ° —πÀ≈—ß ·≈–°√–¥Ÿ°¢âÕ –‚æ°1-3 Õß§å°“√Õπ“¡—¬‚≈° (World HealthOrganization [WHO]) ‰¥â„Àâ®”°—¥§«“¡¢Õß‚√§°√–¥Ÿ°æ√ÿπ«à“‡ªìπ¿“«–∑’Ë§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°¡’§à“§–·ππ¡“µ√∞“π∑’ËµË”°«à“À√◊Õ‡∑à“°—∫ -2.5 ´÷Ëß‡ªìπªí≠À“ ÿ¢¿“æ∑’Ë ”§—≠·≈–√ÿπ·√ß¢Õß∑“ß “∏“√≥ ÿ¢„πÀ≈“¬ª√–‡∑»∑—Ë«‚≈° ®“°√“¬ß“π„πª√–‡∑» À√—∞Õ‡¡√‘°“∑’Ë§“¥°“√≥å«à“„πªï §.». 2015 ®–¡’™“«Õ‡¡√‘°—π‡ªìπ‚√§°√–¥Ÿ°æ√ÿπ Ÿß∂÷ß 41 ≈â“π§π´÷Ëß‡æ‘Ë¡®“°®”π«π28 ≈â“π§π„π ªï §.». 20013 ”À√—∫ª√–‡∑»‰∑¬¬—ß‰¡àæ∫√“¬ß“πÕÿ∫—µ‘°“√≥å¢Õß‚√§°√–¥Ÿ°æ√ÿπ„πª√–™“°√ºŸâ ŸßÕ“¬ÿ ·µà¡’‡æ’¬ß√“¬ß“π§«“¡™ÿ°¢Õß‚√§°√–¥Ÿ°æ√ÿπ¡’§«“¡ —¡æ—π∏å∑“ß∫«°°—∫Õ“¬ÿ∑’Ë‡æ‘Ë¡¢÷Èπ ‚¥¬§«“¡™ÿ°¢Õß‚√§°√–¥Ÿ°æ√ÿπ®–¡“°°«à“√âÕ¬≈– 50 ‡¡◊ËÕÕ“¬ÿ¡“°°«à“ 70 ªï4

„πª√–‡∑» À√—∞Õ‡¡√‘°“æ∫‚¥¬æ∫«à“¡’ºŸâªÉ«¬°√–¥Ÿ°À—°®“°‚√§°√–¥Ÿ°æ√ÿπ ∫√‘‡«≥¢âÕ¡◊Õ®”π«π

250,0000 √“¬ ¢âÕ –‚æ° 300,000 √“¬ ·≈–°√–¥Ÿ° —πÀ≈—ß 700,000 √“¬3 à«π„πª√–‡∑»‡∫≈‡¬’Ë¬¡æ∫«à“‡æ‘Ë¡¢÷Èπ∂÷ß√âÕ¬≈– 28 „π√–¬–‡«≈“ 5 ªï „πª√–‡∑» «’‡¥π‡æ‘Ë¡¢÷Èπ∂÷ß√âÕ¬≈– 109 ¿“¬„π√–¬–‡«≈“ 18 ªï5

·≈–§“¥«à“∑—Ë«‚≈°®–‡æ‘Ë¡¢÷Èπ¡“°°«à“ 6 ≈â“π§π„πªï§.». 20506 „πª√–‡∑»‰∑¬°“√‡°‘¥°√–¥Ÿ°¢âÕ –‚æ°À—°¢Õß µ√’‡æ‘Ë¡ Ÿß¢÷Èπ·∫∫°â“«°√–‚¥¥ (exponential)À≈—ß®“°Õ“¬ÿ 60 ªï7 æ∫«à“¿“¬À≈—ß°√–¥Ÿ°¢âÕ –‚æ°À—° 1 ªï √âÕ¬≈– 40 ¢ÕßºŸâªÉ«¬‰¡à “¡“√∂‡¥‘π‰¥â√âÕ¬≈– 60 µâÕß¡’ºŸâ™à«¬„π°“√ªØ‘∫—µ‘°‘®«—µ√ª√–®”«—π´÷Ëß¡’º≈°√–∑∫µàÕ§ÿ≥¿“æ™’«‘µ¢ÕßºŸâªÉ«¬ ‡ªìπ¿“√–·°à§√Õ∫§√—« ·≈– —ß§¡ √«¡∑—Èß∑”„Àâ‡°‘¥ªí≠À“ ÿ¢¿“æ®‘µµ“¡¡“ ·≈–æ∫«à“Õ—µ√“µ“¬¿“¬„πªï·√°¢ÕßºŸâªÉ«¬∑’Ë¡’°√–¥Ÿ°¢âÕ –‚æ°À—° Ÿß∂÷ß√âÕ¬≈– 20 ¡’ºŸâªÉ«¬‡æ’¬ß√âÕ¬≈– 25-50 ‡∑à“π—Èπ∑’Ë°≈—∫‰ª¡’§ÿ≥¿“æ™’«‘µ‡§≈◊ËÕπ‰À«‰¥â¥—ß‡¥‘¡5 „π À√—∞Õ‡¡√‘°“æ∫«à“¡’§à“„™â®à“¬„π°“√√—°…“°√–¥Ÿ°À—°®“°‚√§°√–¥Ÿ°æ√ÿπª√–¡“≥18 æ—π≈â“π‡À√’¬≠ À√—∞ „πªï §.». 2001 ·≈–§“¥«à“®– Ÿß∂÷ß 60 æ—π≈â“π‡À√’¬≠ À√—∞„πªï §.». 20303

√“¬ß“πª√–®”ªï¢Õß‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å„π ªïæ.». 25498 ºŸâªÉ«¬∑’Ë¡“√—∫√—°…“„π·ºπ°»—≈¬°√√¡ÕÕ√å‚∏ªî¥‘° å æ∫«à“¡’°√–¥Ÿ°·µ° °√–¥Ÿ°√â“«·≈–

‡√◊ËÕß¬àÕ °“√»÷°…“§√—Èßπ’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“æƒµ‘°√√¡°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ ¢ÕßºŸâπ”™ÿ¡™π ∑’Ë¡’Õ“¬ÿ 40 ªï¢÷Èπ‰ª„π‡¢µ‡∑»∫“≈‡¡◊Õß Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥∫ÿ√’√—¡¬å ·≈–À“§«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬ à«π∫ÿ§§≈ ·≈–æƒµ‘°√√¡ ÿ¢¿“æªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ°—∫§«“¡Àπ“·πàπ¡«≈°√–¥Ÿ° √–À«à“ß«—π∑’Ë 1 ‡¡…“¬π ∂÷ß 31 æƒ…¿“§¡ æ.». 2550 ‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈‚¥¬„™â·∫∫ Õ∫∂“¡ ·≈–·∫∫®—¥‡°Á∫º≈°“√µ√«®«—¥§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° ®”π«π 200 √“¬ ¢âÕ¡Ÿ≈ à«π∫ÿ§§≈·≈–æƒµ‘°√√¡ ÿ¢¿“æ «‘‡§√“–Àå‚¥¬„™â ∂‘µ‘‡™‘ßæ√√≥π“· ¥ßº≈‡ªìπ®”π«π √âÕ¬≈– «‘‡§√“–Àå§«“¡ —¡æ—π∏å√–À«à“ßªí®®—¬ à«π∫ÿ§§≈ ·≈–æƒµ‘°√√¡ ÿ¢¿“æ°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°‚¥¬„™â ∂‘µ‘‰§ ·§«√å º≈°“√«‘®—¬ æ∫«à“ ºŸâπ”™ÿ¡™π„π‡¢µ‡∑»∫“≈‡¡◊Õß∑’Ë¡’Õ“¬ÿ40 ªï¢÷Èπ‰ª ¡’¡«≈°√–¥Ÿ°ª°µ‘‡æ’¬ß√âÕ¬≈– 30 πÕ°π—Èπæ∫ ¡’¿“«–°√–¥Ÿ°∫“ß√âÕ¬≈– 43.5 ¿“«–°√–¥Ÿ°æ√ÿπ√âÕ¬≈– 23 ·≈–¿“«–°√–¥Ÿ°æ√ÿπÕ¬à“ß√ÿπ·√ß√âÕ¬≈– 3.5 ªí®®—¬∑’Ë¡’º≈µàÕ§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° ‰¥â·°à Õ“¬ÿ °“√√—∫ª√–∑“πÕ“À“√‡ √‘¡«‘µ“¡‘πÀ√◊Õ·§≈‡´’¬¡ °“√√—∫ª√–∑“ππÈ”‡µâ“ÀŸâ¡’§«“¡ —¡æ—π∏åÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° à«π°“√ÕÕ°°”≈—ß°“¬ °“√∑’Ë√à“ß°“¬¡’‡§≈◊ËÕπ‰À« ‡ª≈’Ë¬πÕ‘√‘¬“∫∂Õ¬Ÿà‡ ¡Õ„π·µà≈–«—π °“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ß·≈–‡æ»‰¡à¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° °“√»÷°…“π’È· ¥ß«à“ ªí≠À“‚√§°√–¥Ÿ°æ√ÿπ‡ªìπªí≠À“ ÿ¢¿“æ∑’Ë ”§—≠„πºŸâπ”™ÿ¡™πÕ“¬ÿ 40 ªï¢÷Èπ‰ª ∑’ËÕ“»—¬„π‡¢µ‡∑»∫“≈ Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥∫ÿ√’√—¡¬å §«√¡’°“√ àß‡ √‘¡„Àâª√—∫‡ª≈’Ë¬πæƒµ‘°√√¡°“√√—∫ª√–∑“πÕ“À“√ ‡æ◊ËÕªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ µàÕ‰ª

§” ”§—≠: ‚√§°√–¥Ÿ°æ√ÿπ æƒµ‘°√√¡ ÿ¢¿“æ §«“¡Àπ“·πàπ¡«≈°√–¥Ÿ° §«“¡ —¡æ—π∏å ºŸâπ”™ÿ¡™π

102

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

°√–¥Ÿ°À—°®“°‚√§°√–¥Ÿ°æ√ÿπ µ“¡µ”·ÀπàßµàÕ‰ªπ’È‰¥â·°à °√–¥Ÿ° ¢âÕ –‚æ° °√–¥Ÿ°·¢π·≈–¢âÕ¡◊Õ °√–¥Ÿ° —πÀ≈—ß §‘¥‡ªìπ√âÕ¬≈– 3.75, 6.14, 4.12 µ“¡≈”¥—∫πÕ°®“°π—Èπ¬—ßæ∫«à“ºŸâªÉ«¬∑’Ë¢âÕ –‚æ°À—° ¢âÕ¡◊ÕÀ—° à«π„À≠àÕ¬Ÿà„π°≈ÿà¡Õ“¬ÿ 40 ªï¢÷Èπ‰ª ·≈–‡¡◊ËÕ´—°ª√–«—µ‘µ√«®√à“ß°“¬ ‰¥â¢âÕ¡Ÿ≈«à“‡°‘¥®“°·√ß°√–·∑°∑’Ë‰¡à√ÿπ·√ß ‡™àπ ≈◊Ëπ À°≈â¡ ‡ªìπµâπ ´÷ËßºŸâªÉ«¬∑’Ë‰¥â√—∫°“√√—°…“‚¥¬«‘∏’ºà“µ—¥®–‡ ’¬§à“„™â®à“¬‡©≈’Ë¬ª√–¡“≥√“¬≈–12,055 ∫“∑8 · ¥ß„Àâ‡ÀÁπ«à“ §à“„™â®à“¬„π°“√√—°…“æ¬“∫“≈´÷Ëß àßº≈°√–∑∫µàÕµ—«ºŸâªÉ«¬‡Õßµ≈Õ¥®πß∫ª√–¡“≥¢Õßª√–‡∑»™“µ‘‰¥â ·≈–∂â“ºŸâªÉ«¬¥—ß°≈à“«¡’¿“«–·∑√°´âÕπ §à“„™â®à“¬„π°“√√—°…“æ¬“∫“≈®–¡’®”π«π‡æ‘Ë¡¢÷Èπµ“¡‰ª¥â«¬

¡Ÿ≈π‘∏‘°√–¥Ÿ°æ√ÿπ·Ààßª√–‡∑»‰∑¬9 ”√«®æ∫«à“1 „π 4 ¢Õß§π‰∑¬‰¡à√Ÿâ∂÷ßæ‘…¿—¬¢Õß‚√§°√–¥Ÿ°æ√ÿπ´÷Ëß‡ªìπ¿—¬‡ß’¬∫∑’ËÕ—πµ√“¬ §ÿ°§“¡§ÿ≥¿“æ™’«‘µ ‡π◊ËÕß®“° °√–¥Ÿ°‡ªìπ‚§√ß √â“ß ”§—≠¢Õß√à“ß°“¬ ·≈–‡ªìπ·°π°≈“ß„π°“√∑”ß“π ™à«¬„Àâ√à“ß°“¬¡’°“√∑√ßµ—«‡§≈◊ËÕπ‰À«‰¥âÕ¬à“ßª°µ‘ ¡’ª√– ‘∑∏‘¿“æ √«¡∂÷ß¬—ß‡ªìπ∑’Ë√Õß√—∫πÈ”Àπ—°¢Õß√à“ß°“¬10 ¡πÿ…¬å®÷ß®”‡ªìπ∑’Ë®–µâÕß¡’ ÿ¢¿“æ¢Õß°√–¥Ÿ°∑’Ë¥’ ¡’§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° Ÿß ´÷Ëß§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°¥—ß°≈à“«¬—ß„™â«—¥¿“«–¢Õß°√–¥Ÿ°ª°µ‘ À√◊Õº‘¥ª°µ‘ Õ—π‰¥â·°à°√–¥Ÿ°∫“ß °√–¥Ÿ°æ√ÿπ ¥—ßπ—Èπ®÷ß§«√¡’°“√¥Ÿ·≈ ÿ¢¿“æ¢Õß°√–¥Ÿ° ´÷Ëßª√–°Õ∫¥â«¬°“√√—∫ª√–∑“πÕ“À“√„Àâ¡’§«“¡ ¡¥ÿ≈ °“√ÕÕ°°”≈—ß°“¬ ·≈–°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ß ‡æ◊ËÕ≈¥‚Õ°“ ‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ

¥—ßπ—Èπ°“√»÷°…“§√—Èßπ’È ‡æ◊ËÕ∑√“∫§«“¡™ÿ°¢Õß‚√§°√–¥Ÿ°æ√ÿπ ·≈–‡ªìπ°“√»÷°…“§«“¡ —¡æ—π∏å√–À«à“ßæƒµ‘°√√¡ ÿ¢¿“æ°—∫‚√§°√–¥Ÿ°æ√ÿπ¢ÕßºŸâπ”™ÿ¡™π∑’Ë¡’Õ“¬ÿ 40 ªï¢÷Èπ‰ª ‚¥¬‡≈◊Õ°»÷°…“‡©æ“–ªí®®—¬ à«π∫ÿ§§≈ æƒµ‘°√√¡ ÿ¢¿“æ‡æ◊ËÕªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ‡æ√“–ªí®®—¬‡À≈à“π’È “¡“√∂Õ∏‘∫“¬æƒµ‘°√√¡°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ‰¥â¡“°∑’Ë ÿ¥ ‡æ◊ËÕπ”º≈°“√«‘®—¬¡“„™â‡ªìπ·π«∑“ß°“√„Àâ§«“¡√Ÿâ·≈– àß‡ √‘¡°“√ªØ‘∫—µ‘æƒµ‘°√√¡°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ„πª√–™“°√∑’Ë¡’Õ“¬ÿ

40 ªï¢÷Èπ‰ªµàÕ‰ª

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“‡™‘ß ”√«®·∫∫¿“§µ—¥¢«“ß (Cross-Sectional survey) ª√–™“°√°≈ÿà¡µ—«Õ¬à“ß‡ªìπºŸâπ”™ÿ¡™π∑’ËÕ“¬ÿ 40 ªï¢÷Èπ‰ª „π‡¢µ‡∑»∫“≈‡¡◊Õß Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥∫ÿ√’√—¡¬å ∑’Ë ¡—§√„®‡¢â“√à«¡‚§√ß°“√„π√–À«à“ß«—π∑’Ë 1 ‡¡…“¬π - 31 æƒ…¿“§¡ æ.». 2550√«¡ 200 §π ‚¥¬¥”‡π‘π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈¥â«¬·∫∫ Õ∫∂“¡ ·≈–·∫∫®—¥‡°Á∫º≈°“√µ√«®«—¥§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ°®“°‡§√◊ËÕßµ√«®«—¥§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° (Bone densitometry) ‚¥¬«—¥∑’Ëµ”·ÀπàßForearm ¢â“ß¢«“ (§ÿ≥≈—°…≥–°“√∑”ß“π ‡ªìπ°“√„™âDual Energy X-ray Absorptiometry (DEXA)ª√–‡¿∑ Peripheral Instantaneous X-ray Imager√ÿàπ MDL PIXI # 51245 (Model) º≈‘µ‚¥¬∫√‘…—∑LUNAR Corp.)

°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈∑“ß ∂‘µ‘ ª√–°Õ∫¥â«¬- ¢âÕ¡Ÿ≈ ∂‘µ‘‡™‘ßæ√√≥π“ „™â«‘‡§√“–Àå¢âÕ¡Ÿ≈ à«π

∫ÿ§§≈ ·≈–æƒµ‘°√√¡°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ¢ÕßºŸâπ”™ÿ¡™π∑’Ë¡’Õ“¬ÿ 40 ªï ¢÷Èπ‰ª π”‡ πÕ¢âÕ¡Ÿ≈‚¥¬°“√·®°·®ß§«“¡∂’Ë √âÕ¬≈–

- ∂‘µ‘‡™‘ßÕπÿ¡“π ‡æ◊ËÕÀ“§«“¡ —¡æ—π∏å√–À«à“ßÕ“¬ÿ ‡æ» ·≈–æƒµ‘°√√¡ ÿ¢¿“æ∑’ËªØ‘∫—µ‘µ—«‡æ◊ËÕªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ °—∫§«“¡Àπ“·πàπ¡«≈°√–¥Ÿ°‚¥¬„™â ∂‘µ‘‰§ ·§«√å (chi-square test) ∑’Ë√–¥—∫π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë α = 0.05

- °“√ª√–¡«≈º≈¢âÕ¡Ÿ≈‚¥¬„™â‚ª√·°√¡ ”‡√Á®√ŸªSPSS for window

§”®”°—¥§«“¡

æƒµ‘°√√¡°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ À¡“¬∂÷ß°“√ªØ‘∫—µ‘µ—«‡æ◊ËÕ¡ÿàß√–«—ßÀ√◊ÕÀ≈’°‡≈’Ë¬ßªí®®—¬°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ ∑—Èß„π‡√◊ËÕß°“√√—∫ª√–∑“πÕ“À“√ °“√ÕÕ°°”≈—ß°“¬ ·≈–°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ß µàÕ°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ

°“√√—∫ª√–∑“πÕ“À“√ À¡“¬∂÷ß ≈—°…≥–π‘ —¬·≈–°“√ªØ‘∫—µ‘µ—«„π°“√√—∫ª√–∑“πÕ“À“√ ‰¥â·°à



Õ“À“√∑’Ë¡’·§≈‡´’¬¡ Ÿß ‡™àπ π¡æ√àÕß¡—π‡π¬ ‚¬‡°‘√åµπ¡∂—Ë«‡À≈◊Õß ∂—Ë«‡¡≈Á¥·Àâß ß“¥”ª≈“µ—«‡≈Á° °ÿâßΩÕ¬º—°„∫‡¢’¬«·°à „πª√‘¡“≥∑’Ë‡À¡“– ¡Õ¬à“ß ¡Ë”‡ ¡Õ°“√√—∫ª√–∑“π‰¢à √«¡∂÷ß°“√‰¥â√—∫·§≈‡´’¬¡‡ √‘¡À√◊Õ«‘µ“¡‘π√«¡∑’Ë™à«¬‡ √‘¡ √â“ß¡«≈°√–¥Ÿ°

°“√ÕÕ°°”≈—ß°“¬ À¡“¬∂÷ß °“√„™â·√ß°≈â“¡‡π◊ÈÕ·≈–√à“ß°“¬„Àâ‡§≈◊ËÕπ‰À«‡æ◊ËÕ„Àâ√à“ß°“¬¡’ ÿ¢¿“æ¥’ ‰¥â·°à°“√ÕÕ°°”≈—ß°“¬∑’Ë¡’°“√≈ßπÈ”Àπ—°∑’Ë°√–¥Ÿ°®– àßº≈µàÕ°“√ √â“ß§«“¡·¢Áß·√ß¢Õß°√–¥Ÿ°Õ¬à“ßµàÕ‡π◊ËÕß‡™àπ °“√«‘Ëß‡À¬“– ‡¥‘π‡√Á« ‡µâπ·Õ‚√∫‘° À√◊Õ°’Ã“Õ◊ËπÊ´÷ËßµâÕßªØ‘∫—µ‘Õ¬à“ß ¡Ë”‡ ¡ÕÕ¬à“ßπâÕ¬ —ª¥“Àå≈– 3§√—ÈßÊ ≈– 20-30 π“∑’ °“√∑”ß“πÕ¥‘‡√° ß“π∫â“π ‡™àπ´—°ºâ“ °«“¥∫â“π √¥πÈ”µâπ‰¡â °“√‡ª≈’Ë¬πÕ‘√‘¬“∫∂Õ¬Ÿà‡ ¡Õ ·≈–°“√‰¥â√—∫· ß·¥¥„π™à«ß‡™â“Õ¬à“ßπâÕ¬«—π≈–10-15 π“∑’

°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπÀ¡“¬∂÷ß °“√ªØ‘∫—µ‘‡æ◊ËÕ≈¥ªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ ‰¥â·°à °“√√—∫ª√–∑“πÕ“À“√√ ‡§Á¡À√◊Õ∑’Ë¡’‡°≈◊Õ‚´‡¥’¬¡ Ÿß °“√¥◊Ë¡‡§√◊ËÕß¥◊Ë¡∑’Ë¡’·Õ≈°ÕŒÕ≈å·≈–§“‡øÕ’π °“√ Ÿ∫∫ÿÀ√’Ë

‚√§°√–¥ÿ°æ√ÿπ À¡“¬∂÷ß ¿“«–∑’Ë¡«≈¢Õß°√–¥Ÿ°≈¥≈ßÕ¬à“ß¡“° ®πÕ“®‡°‘¥°“√·µ°À—°¢Õß°√–¥Ÿ°‰¥â («—¥‰¥â®“°§à“ BMD T-Score)

¿“«–°√–¥Ÿ°ª°µ‘ À¡“¬∂÷ß º≈°“√«—¥§à“§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ° ‰¥â¡“°°«à“ -1

¿“«–°√–¥Ÿ°º‘¥ª°µ‘ À¡“¬∂÷ß º≈°“√«—¥§à“§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ°·≈â«æ∫«à“ °√–¥Ÿ°∫“ß À√◊Õ°√–¥Ÿ°æ√ÿπ À√◊Õ°√–¥Ÿ°æ√ÿπÕ¬à“ß√ÿπ·√ß

¿“«–°√–¥Ÿ°∫“ß À¡“¬∂÷ß º≈°“√«—¥§à“§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ° ‰¥âπâÕ¬°«à“ -1 ∂÷ß -2.5

¿“«–°√–¥Ÿ°æ√ÿπ À¡“¬∂÷ß º≈°“√«—¥§à“§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ° ‰¥âπâÕ¬°«à“À√◊Õ‡∑à“°—∫-2.5

¿“«–°√–¥Ÿ°æ√ÿπÕ¬à“ß√ÿπ·√ß À¡“¬∂÷ß º≈°“√«—¥§à“§«“¡Àπ“·πàπ¢Õß°√–¥Ÿ° ‰¥âπâÕ¬°«à“À√◊Õ‡∑à“°—∫-2.5 ·≈–¡’°√–¥Ÿ°À—°√à«¡

º≈

ªí®®—¬ à«π∫ÿ§§≈

º≈°“√»÷°…“ æ∫«à“ ºŸâπ”™ÿ¡™π„π‡¢µ‡∑»∫“≈‡¡◊ÕßÕ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥∫ÿ√’√—¡¬å à«π„À≠à‡ªìπ‡æ»À≠‘ß(√âÕ¬≈– 67.5) Õ“¬ÿ 61 ªï¢÷Èπ‰ª (√âÕ¬≈– 61.5) ¡’§à“¥—™π’¡«≈°“¬Õ¬Ÿà„π√–¥—∫Õâ«π (√âÕ¬≈– 40.1) ∂“π¿“æ§Ÿà(√âÕ¬≈– 74.4) ®∫°“√»÷°…“√–¥—∫ª√–∂¡»÷°…“ (√âÕ¬≈– 34.5) Õ“™’æ¢â“√“™°“√∫”π“≠ ·≈–≈Ÿ°®â“ß¢Õß√—∞(√âÕ¬≈– 29) √“¬‰¥â‡©≈’Ë¬µàÕ§√Õ∫§√—« πâÕ¬°«à“ 10,000∫“∑ (√âÕ¬≈– 41.3)

µ“√“ß∑’Ë 1 ®”π«π ·≈–√âÕ¬≈–¢ÕßºŸâπ”™ÿ¡™πÕ“¬ÿ 40 ªï¢÷Èπ‰ª ®”·π°µ“¡≈—°…≥– à«π∫ÿ§§≈

°≈ÿà¡¡«≈°√–¥Ÿ°ª°µ‘ °≈ÿà¡¡«≈°√–¥Ÿ°º‘¥ª°µ‘

≈—°…≥– à«π∫ÿ§§≈ (N = 60) (N = 140) χ2 df p-value

®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈–

‡æ»

™“¬ 16 24.6 49 75.4 1.33 1 0.249

À≠‘ß 44 32.6 91 67.4

Õ“¬ÿ

40-60 ªï 42 54.5 35 45.5 36.01 1 < 0.001*

> 60 ªï 17 14.3 102 85.7

*Statistical significant p < 0.05

104

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

‡¡◊ËÕæ‘®“√≥“∂÷ßªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° æ∫«à“ ¡’‡æ’¬ß°≈ÿà¡Õ“¬ÿ‡∑à“π—Èπ∑’Ë¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (p <0.001) ‚¥¬ºŸâ∑’ËÕ“¬ÿ¡“°°«à“ 60 ªï ¡’§«“¡º‘¥ª°µ‘¢Õß¡«≈°√–¥Ÿ° Ÿß°«à“°≈ÿà¡Õ“¬ÿ 40-60 ªï à«π§«“¡·µ°µà“ß¢Õß‡æ»‰¡à¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°(µ“√“ß∑’Ë 1)

ºŸâπ”™ÿ¡™π„π‡¢µ‡∑»∫“≈‡¡◊Õß à«π„À≠à¡’¿“«–°√–¥Ÿ°∫“ß√âÕ¬≈– 43.5 √Õß≈ß¡“¡’¿“«–°√–¥Ÿ°ª°µ‘ √âÕ¬≈– 30 ¿“«–°√–¥Ÿ°æ√ÿπ√âÕ¬≈– 23 ¿“«–°√–¥Ÿ°æ√ÿπÕ¬à“ß√ÿπ·√ß√âÕ¬≈– 3.5 µ“¡≈”¥—∫ (µ“√“ß∑’Ë2)

æƒµ‘°√√¡ ÿ¢¿“æ

°“√√—∫ª√–∑“πÕ“À“√ °≈ÿà¡∑’Ë¡’§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°º‘¥ª°µ‘ √âÕ¬≈– 75.6 ‰¡à¥◊Ë¡π¡π¡æ√àÕß¡—π‡π¬ ‚¬‡°‘√åµ ·≈–π¡‡ª√’È¬« √âÕ¬≈– 77.8‰¡à¥◊Ë¡π¡∂—Ë«‡À≈◊Õß À√◊ÕπÈ”‡µâ“ÀŸâ √âÕ¬≈– 70.5 ‰¡à√—∫ª√–∑“π∂—Ë«‡¡≈Á¥·Àâß ‡™àπ ∂—Ë«‡À≈◊Õß ∂—Ë«‡¢’¬« ∂—Ë«¥”∂—Ë«·¥ß ß“¢“« ß“¥” √«¡∑—Èßº≈‘µ¿—≥±å®“°∂—Ë« ‡™àπ‡µâ“ÀŸâ·¢Áß ‡µâ“ÀŸâÕàÕπ ¢π¡∂—Ë«µ—¥ ¢π¡ß“µ—¥ √âÕ¬≈–71.1 ‰¡à√—∫ª√–∑“π°ÿâßΩÕ¬ ª≈“°√Õ∫ ª≈“‡≈Á°ª≈“πâÕ¬ª≈“°√–ªÜÕß √âÕ¬≈– 73.3 ‰¡à√—∫ª√–∑“πº—°„∫‡¢’¬«‡™àπ º—°°«“ßµÿâß º—°§–πâ“ º—°°–‡©¥ „∫¬Õ º—°‚¢¡¡–‡¢◊Õæ«ß ·≈–º—°„∫‡¢’¬«Õ◊ËπÊ √âÕ¬≈– 95.9 ¡’°“√

√—∫ª√–∑“π‰¢à ·≈–√âÕ¬≈– 84.4 √—∫ª√–∑“π«‘µ“¡‘πÕ“À“√‡ √‘¡ª√–‡¿∑·§≈‡´’¬¡

‡¡◊ËÕæ‘®“√≥“§«“¡ —¡æ—π∏å√–À«à“ßæƒµ‘°√√¡°“√√—∫ª√–∑“πÕ“À“√°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°æ∫«à“ °“√¥◊Ë¡π¡∂—Ë«‡À≈◊Õß À√◊ÕπÈ”‡µâ“ÀŸâ ·≈–°“√√—∫ª√–∑“π«‘µ“¡‘π Õ“À“√‡ √‘¡ª√–‡¿∑·§≈‡´’¬¡ ¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (p = 0.009 ·≈– p = 0.0004µ“¡≈”¥—∫) (µ“√“ß∑’Ë 3)

°“√ÕÕ°°”≈—ß°“¬ °≈ÿà¡∑’Ë¡’§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°º‘¥ª°µ‘ √âÕ¬≈– 69.1 ¡’°“√ÕÕ°°”≈—ß°“¬20-30 π“∑’ √âÕ¬≈– 78.9 ‰¡àÕÕ°°”≈—ß°“¬®π‡Àπ◊ËÕ¬À—«„®‡µâπ‡√Á« √âÕ¬≈– 70.1 ‰¡à‡§≈◊ËÕπ‰À« À√◊Õ‡ª≈’Ë¬πÕ‘√‘¬“∫∂„π·µà≈–«—π ·≈–√âÕ¬≈– 70.8 ¡’°“√∑”ß“πÕ¥‘‡√° À√◊Õ∑”ß“π∫â“π ‡™àπ ´—°ºâ“ °«“¥∫â“π ∂Ÿ∫â“π√¥πÈ”µâπ‰¡â Õ¬à“ßµàÕ‡π◊ËÕßÕ¬à“ßπâÕ¬ 30 π“∑’ ‡¡◊ËÕæ‘®“√≥“§«“¡ —¡æ—π∏å√–À«à“ß°“√ÕÕ°°”≈—ß°“¬°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° æ∫«à“ ‰¡à¡’§«“¡ —¡æ—π∏å°—π„π∑ÿ°°‘®°√√¡ (µ“√“ß∑’Ë 4)

°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§°√–¥Ÿ°

æ√ÿπ °≈ÿà¡∑’Ë¡’§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°º‘¥ª°µ‘√âÕ¬≈– 74.6 √—∫ª√–∑“πÕ“À“√‡§Á¡ À√◊ÕÕ“À“√∑’Ë¡’‡°≈◊Õ‚´‡¥’¬¡ Ÿß ‡™àπ ª≈“‡§Á¡ ª≈“√â“ ‰ â°√Õ° ∫–À¡’Ë°÷Ëß ”‡√Á®√Ÿª √âÕ¬≈– 70.3 ¥◊Ë¡‡§√◊ËÕß¥◊Ë¡∑’Ë¡’§“‡øÕ’π‡™àπ ™“ °“·ø πÈ”Õ—¥≈¡ ‡§√◊ËÕß¥◊Ë¡™Ÿ°”≈—ß √âÕ¬≈–70.9 ‰¡à¥◊Ë¡‡§√◊ËÕß¥◊Ë¡·Õ≈°ÕŒÕ≈å ‡™àπ ÿ√“ ‡∫’¬√å‰«πå ·≈–√âÕ¬≈– 80.0 Ÿ∫∫ÿÀ√’Ë ‡¡◊ËÕæ‘®“√≥“§«“¡ —¡æ—π∏å√–À«à“ßæƒµ‘°√√¡°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° æ∫«à“‰¡à¡’§«“¡ —¡æ—π∏å°—π„π∑ÿ°°‘®°√√¡ (µ“√“ß∑’Ë 5)

«‘®“√≥å

°“√»÷°…“π’Èæ∫«à“ Õ“¬ÿ¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° (p- value < 0.001) Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ 0.05 (¥—ßµ“√“ß∑’Ë 1) Õ“®Õ∏‘∫“¬‰¥â«à“ª√–™“°√‡ªÑ“À¡“¬ à«π„À≠àÕ¬Ÿà„π°≈ÿà¡«—¬ ŸßÕ“¬ÿÀ√◊Õ¡’Õ“¬ÿµ—Èß·µà 60 ªï¢÷Èπ‰ª´÷Ëß Õ¥§≈âÕß°—∫

µ“√“ß∑’Ë 2 ®”π«π·≈–√âÕ¬≈–®”·π°§«“¡Àπ“·πàπ¢Õß

¡«≈°√–¥Ÿ°

§«“¡Àπ“·πàπ¢Õß ®”π«π√âÕ¬≈–

¡«≈°√–¥Ÿ° (§π)

°√–¥Ÿ°ª°µ‘ 60 30.0

°√–¥Ÿ°∫“ß 87 43.5

°√–¥Ÿ°æ√ÿπ 46 23.0

°√–¥Ÿ°æ√ÿπÕ¬à“ß√ÿπ·√ß 7 3.5

√«¡ 200 100



µ“√“ß∑’Ë 3 ®”π«π ·≈–√âÕ¬≈–¢ÕßºŸâπ”™ÿ¡™πÕ“¬ÿ 40 ªï¢÷Èπ‰ª ®”·π°µ“¡æƒµ‘°√√¡°“√√—∫ª√–∑“πÕ“À“√

°≈ÿà¡¡«≈°√–¥Ÿ°ª°µ‘ °≈ÿà¡¡«≈°√–¥Ÿ°º‘¥ª°µ‘

(N = 60) (N = 140) χ2 df p-value

®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈–

°“√¥◊Ë¡π¡ π¡æ√àÕß¡—π‡π¬

‚¬‡°‘√åµ π¡‡ª√’È¬«

‰¡à¥◊Ë¡ 21 24.4 65 75.6 2.24 1 0.135

¥◊Ë¡ 39 34.2 75 65.8

°“√¥◊Ë¡π¡∂—Ë«‡À≈◊Õß πÈ”‡µâ“ÀŸâ

‰¡à¥◊Ë¡ 24 22.2 84 77.8 6.67 1 0.009*

¥◊Ë¡ 36 39.1 56 60.9

°“√√—∫ª√–∑“π∂—Ë«‡¡≈Á¥·Àâß

·≈–º≈‘µ¿—≥±å®“°∂—Ë«

‰¡à√—∫ª√–∑“π 44 29.5 105 70.5 0.06 1 0.804

√—∫ª√–∑“π 16 31.4 35 68.6

°“√√—∫ª√–∑“π°ÿâßΩÕ¬ ª≈“°√Õ∫

ª≈“‡≈Á°ª≈“πâÕ¬ ª≈“°√–ªÜÕß

‰¡à√—∫ª√–∑“π 24 28.9 59 71.1 0.08 1 0.778

√—∫ª√–∑“π 36 30.8 81 39.2

°“√√—∫ª√–∑“πº—°„∫‡¢’¬«

‰¡à√—∫ª√–∑“π 8 26.7 22 73.3 0.19 1 0.066

√—∫ª√–∑“π 52 30.6 117 69.4

°“√√—∫ª√–∑“π‰¢à

‰¡à√—∫ª√–∑“π 7 23.3 23 76.7 2.99 1 0.083

√—∫ª√–∑“π 5 4.1 117 95.9

°“√√—∫ª√–∑“π«‘µ“¡‘π

Õ“À“√‡ √‘¡ª√–‡¿∑·§≈‡´’¬¡

‰¡à√—∫ª√–∑“π 48 39.0 75 61.0 12.39 1 0.0004*

√—∫ª√–∑“π 12 15.6 65 84.4


æƒµ‘°√√¡

°“√√—∫ª√–∑“πÕ“À“√

°“√»÷°…“¢Õß«‘‰≈«√√≥ ∑Õß‡®√‘≠ ·≈–§≥–11 ∑’Ëæ∫«à“Õ“¬ÿ¡’§«“¡ —¡æ—π∏å∑“ß∫«°°—∫‚√§°√–¥Ÿ°æ√ÿπ Õ’°∑—Èß„π«—¬ ŸßÕ“¬ÿ®–¡’§«“¡‡ ◊ËÕ¡¢Õß√à“ß°“¬‡æ‘Ë¡¢÷Èπ ·≈–§«“¡ “¡“√∂¢Õß≈”‰ â„π°“√¥Ÿ¥ ÷¡·§≈‡ ’¬¡≈¥≈ß12

®÷ß¡’‚Õ°“ ‡°‘¥¿“«–°√–¥Ÿ°æ√ÿπ‡æ‘Ë¡¢÷Èπ¥â«¬ °“√‰¥â

√—∫§”·π–π”„π°“√¥Ÿ·≈ àß‡ √‘¡ ÿ¢¿“æ‡æ◊ËÕªÑÕß°—π¿“«–°√–¥Ÿ°æ√ÿπ„π™à«ß«—¬∑’Ë ŸßÕ“¬ÿ Õ“®∑”„Àâ·§à‡æ’¬ß™–≈ÕÀ√◊Õ≈¥°“√ Ÿ≠‡ ’¬¡«≈°√–¥Ÿ°‰¡à„Àâ‡æ‘Ë¡¢÷Èπ‡∑à“π—Èπ‡Õß

„π·ßà¢Õß°“√√—∫ª√–∑“πÕ“À“√‡æ◊ËÕªÑÕß°—π‚√§

106

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

µ“√“ß∑’Ë 4 ®”π«π ·≈–√âÕ¬≈–¢ÕßºŸâπ”™ÿ¡™πÕ“¬ÿ 40 ªï¢÷Èπ‰ª ®”·π°µ“¡æƒµ‘°√√¡°“√ÕÕ°°”≈—ß°“¬

°≈ÿà¡¡«≈°√–¥Ÿ°ª°µ‘ °≈ÿà¡¡«≈°√–¥Ÿ°º‘¥ª°µ‘

(N = 60) (N = 140) χ2 df p-value

®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈–

°“√ÕÕ°°”≈—ß°“¬

< 20 π“∑’ 8 32.0 17 68.0 0.01 1 0.91620-30 π“∑’ 52 30.9 116 69.1

ÕÕ°°”≈—ß°“¬®π‡Àπ◊ËÕ¬

À—«„®‡µâπ‡√Á«

‰¡àªØ‘∫—µ‘ 8 21.1 30 78.9 2.22 1 0.136ªØ‘∫—µ‘ 52 33.5 103 66.5

‡§≈◊ËÕπ‰À«À√◊Õ‡ª≈’Ë¬πÕ‘√‘¬“∫∑

‡ ¡Õ„π·µà≈–«—π

‰¡àªØ‘∫—µ‘ 53 29.9 124 70.1 0.171*ªØ‘∫—µ‘ 7 43.8 9 56.2

°“√∑”ß“πÕ¥‘‡√° ß“π∫â“π

‰¡àªØ‘∫—µ‘ 15 38.5 24 61.5 1.24 1 0.265ªØ‘∫—µ‘ 45 29.2 109 70.8

*Fisher Extract test

æƒµ‘°√√¡

°“√ÕÕ°°”≈—ß°“¬

µ“√“ß∑’Ë 5 ®”π«π ·≈–√âÕ¬≈–¢ÕßºŸâπ”™ÿ¡™πÕ“¬ÿ 40 ªï¢÷Èπ‰ª ®”·π°µ“¡æƒµ‘°√√¡°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ßµàÕ°“√‡°‘¥

‚√§°√–¥Ÿ°æ√ÿπ

°≈ÿà¡¡«≈°√–¥Ÿ°ª°µ‘ °≈ÿà¡¡«≈°√–¥Ÿ°º‘¥ª°µ‘

(N = 60) (N = 140) χ2 df p-value

®”π«π √âÕ¬≈– ®”π«π √âÕ¬≈–

°‘πÕ“À“√‡§Á¡

‰¡à°‘π 43 31.4 94 68.6 0.70 1 0.401°‘π 15 25.4 44 74.6

¥◊Ë¡πÈ”™“ °“·ø πÈ”Õ—¥≈¡

‰¡à¥◊Ë¡ 22 31.0 49 69.0 0.04 1 0.848¥◊Ë¡ 38 29.7 90 70.3

¥◊Ë¡‡§√◊ËÕß¥◊Ë¡·Õ≈°ÕŒÕ≈å

‰¡à¥◊Ë¡ 52 29.1 127 70.9 1.02 1 0.312¥◊Ë¡ 8 40.0 12 60.0

°“√ Ÿ∫∫ÿÀ√’Ë

‰¡à Ÿ∫ 58 32.2 122 67.8 0.61 1 0.434 Ÿ∫ 2 20.0 8 80.0


°“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ß

µàÕ°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ



°√–¥Ÿ°æ√ÿπ æ∫«à“°“√¥◊Ë¡πÈ”‡µâ“ÀŸâ À√◊ÕπÈ”π¡ ∂—Ë«‡À≈◊Õß°“√√—∫ª√–∑“πÕ“À“√‡ √‘¡ª√–‡¿∑·§≈‡´’¬¡‡æ◊ËÕ∫”√ÿß°√–¥Ÿ°¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° (p-value = 0.009, p-value = 0.0004 µ“¡≈”¥—∫) Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ 0.05 Õ“®Õ∏‘∫“¬‰¥â«à“ª√–™“°√∑’Ë¡’Õ“¬ÿ 40 ªï¢÷Èπ‰ªµâÕß‰¥â√—∫·§≈‡´’¬¡ª√–¡“≥ 800-1,000 ¡‘≈≈‘°√—¡/«—π „πÕ“¬ÿ60 ªï¢÷Èπ‰ªµâÕß°“√·§≈‡´’¬¡ª√–¡“≥ 1,000-1,500¡‘≈≈‘°√—¡/«—π10 ·≈–¡’°“√ Ÿ≠‡ ’¬¡«≈°√–¥Ÿ°‰ª‡√◊ËÕ¬Êªï≈– 0.5-1% ∑—Èß„πÀ≠‘ß·≈–™“¬À≈—ß®“°Õ“¬ÿª√–¡“≥30 ªï¢÷Èπ‰ª13 ¥—ßπ—Èπ§«√¡’°“√ π—∫ πÿπ·≈–„Àâ§«“¡√Ÿâ°“√√—∫ª√–∑“πÕ“À“√‡ √‘¡ª√–‡¿∑·§≈‡´’¬¡À√◊Õ°“√¥◊Ë¡Õ“À“√ª√–‡¿∑πÈ”π¡ ∂—Ë«‡À≈◊Õß À√◊ÕπÈ”‡µâ“ÀŸâ·°àª√–™“°√∑’Ë¡’Õ“¬ÿ 40 ªï¢÷Èπ‰ª ‡æ◊ËÕ™à«¬™–≈Õ°“√ Ÿ≠‡ ’¬¡«≈°√–¥Ÿ°‡¡◊ËÕÕ“¬ÿ‡æ‘Ë¡¡“°¢÷Èπ ∂÷ß·¡â«à“∂—Ë«‡À≈◊Õß´÷Ëßπ”¡“º≈‘µ‡ªìππÈ”‡µâ“ÀŸâ ®–¡’ª√‘¡“≥·§≈‡´’¬¡µË”·µà®“°°“√»÷°…“ºŸâπ”™ÿ¡™π à«π„À≠àπ‘¬¡√—∫ª√–∑“π¡“° ‡π◊ËÕß®“°‡ªìπº≈‘µ¿—≥±å∑’Ë√“§“∂Ÿ°·≈–À“ßà“¬¿“¬„π™ÿ¡™π ®÷ß‡ªìπ‰ª‰¥â«à“ºŸâπ”™ÿ¡™π„π°≈ÿà¡∑’Ë¥◊Ë¡πÈ”‡µâ“ÀŸâ‰¥â√—∫ª√‘¡“≥·§≈‡´’¬¡¡“°°«à“

¥â“π°“√ÕÕ°°”≈—ß°“¬‡æ◊ËÕªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπæ∫«à“°“√ÕÕ°°”≈—ß°“¬¢ÕßºŸâπ”™ÿ¡™π ¢“¥§«“¡µàÕ‡π◊ËÕß‰¡à√Ÿâ ÷°‡Àπ◊ËÕ¬·≈–À—«„®‰¡à‡µâπ‡√Á«¢÷Èπ°«à“ª°µ‘·≈–¡’°“√‡§≈◊ËÕπ‰À«À√◊Õ‡ª≈’Ë¬πÕ‘√‘¬“∫∂Õ¬Ÿà‡ ¡Õ„π·µà≈–«—π‰¡à¡’§«“¡ —¡æ—π∏å°—∫§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ° (p-value = 0.916, p-value = 0.136, p-value= 0.171 µ“¡≈”¥—∫) ‰¡à¡’π—¬ ”§—≠∑“ß ∂‘µ‘∑’Ë√–¥—∫ 0.05Õ“®Õ∏‘∫“¬‰¥â«à“°“√ÕÕ°°”≈—ß°“¬‰¡à∑’Ëµ‘¥µàÕ°—πÕ¬à“ßµàÕ‡π◊ËÕß®π√Ÿâ ÷°‡Àπ◊ËÕ¬·≈–À—«„®‰¡à‡µâπ‡√Á«¢÷Èπ°«à“ª°µ‘√«¡∂÷ß°“√‡§≈◊ËÕπ‰À«À√◊Õ‡ª≈’Ë¬πÕ‘√‘¬“∫∂Õ¬Ÿà‡ ¡Õ„π·µà≈–«—π‰¡à™à«¬„Àâ§ßÀ√◊Õ¥”√ß¡«≈°√–¥Ÿ°∑’Ë – ¡Õ¬Ÿà‡µÁ¡∑’Ë·≈â«„ÀâÕ¬ŸàÕ¬à“ßπ—Èπ‡∑à“∑’Ë®–‡ªìπ‰ª‰¥â13,14

¥—ßπ—Èπ®÷ß§«√„Àâ¡’°“√ÕÕ°°”≈—ß°“¬®π√Ÿâ ÷°‡Àπ◊ËÕ¬·≈–À—«„®¡’°“√‡µâπ‡√Á«°«à“ª°µ‘ ·≈–§«√∑”µàÕ‡π◊ËÕßÕ¬à“ß ¡Ë”‡ ¡Õ ‡æ◊ËÕ™–≈Õ°“√ Ÿ≠‡ ’¬¡«≈°√–¥Ÿ° Õ¥§≈âÕß°“√»÷°…“¢Õß ÿ«‘™“ ∏’√‚√®π«ß»å1 ´÷Ëßæ∫«à“ µ√’«—¬°àÕπÀ¡¥ª√–®”‡¥◊Õπ‰¡à “¡“√∂ÕÕ°°”≈—ß°“¬

‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ∑”„Àâ§«“¡Àπ“·πàπ¡«≈°√–¥Ÿ°≈¥≈ß ·≈–®“°°“√»÷°…“¢Õß∫ÿªº“ Õ‘πµä–·°â«16

∑’Ëæ∫«à“°≈ÿà¡µ—«Õ¬à“ß à«π„À≠à¡’°“√ÕÕ°°”≈—ß°“¬‰¡à ¡Ë”‡ ¡Õ Õ“®‡π◊ËÕß®“°°≈ÿà¡µ—«Õ¬à“ß à«π¡“°µâÕß∑”ß“ππÕ°∫â“π „π¢≥–‡¥’¬«°—πµâÕß¥Ÿ·≈§√Õ∫§√—«·≈–√à«¡ß“π„π —ß§¡ ®÷ß‰¡à¡’‡«≈“„π°“√ÕÕ°°”≈—ß°“¬ ”À√—∫æƒµ‘°√√¡∑’Ë‡°’Ë¬«¢âÕß°—∫ªí®®—¬‡ ’Ë¬ß æ∫«à“°≈ÿà¡∑’Ë¡’§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°º‘¥ª°µ‘ à«π„À≠à√—∫ª√–∑“πÕ“À“√‡§Á¡ ¥◊Ë¡™“ °“·ø ¥◊Ë¡‡§√◊ËÕß¥◊Ë¡·Õ≈°ÕŒÕ≈å ·≈– Ÿ∫∫ÿÀ√’Ë∂÷ß√âÕ¬≈– 74.6, 70.3, 70.9·≈– 80.0 µ“¡≈”¥—∫ Õ“®‡π◊ËÕß®“°«à“™“ °“·ø ¡’º≈∑”„Àâªí “«–¡“°¢÷Èπ ®÷ß∑”„Àâ°“√¢—∫∂à“¬·§≈‡´’¬¡∑“ß‰µ‡æ‘Ë¡¢÷Èπ17 ‡™àπ‡¥’¬«°—∫°“√¥◊Ë¡‡§√◊ËÕß¥◊Ë¡∑’Ë¡’·Õ≈°ÕŒÕ≈å ´÷Ëß¡’√“¬ß“π°“√»÷°…“ æ∫«à“ Ethanol∑”„Àâ§«“¡Àπ“·πàπ¢Õß¡«≈°√–¥Ÿ°≈¥≈ß‰¥â18

¢âÕ‡ πÕ·π–∑’Ë‰¥â®“°°“√»÷°…“ ¡’¥—ßπ’È§«√®—¥ ÿ¢»÷°…“‡º¬·æ√à§«“¡√Ÿâ¢âÕ¡Ÿ≈∑—π ¡—¬

‡°’Ë¬«°—∫‚√§°√–¥Ÿ°æ√ÿπ ‡™àπ °“√®—¥π‘∑√√»°“√ ®—¥∑”‡Õ° “√∑“ß«‘™“°“√ °“√π”‡ πÕº≈°“√«‘®—¬„À¡àÊ‚¥¬‡πâπ„Àâ‡ÀÁπ«à“‚√§°√–¥Ÿ°æ√ÿπ “¡“√∂ªÑÕß°—π‰¥â‚¥¬°“√‡√‘Ë¡ – ¡·§≈‡´’¬¡µ—Èß·µà«—¬‡¥Á° °“√À≈’°‡≈’Ë¬ßªí®®—¬‡ ’Ë¬ßµà“ß Ê ·≈–°“√√—∫ª√–∑“πÕ“À“√∑’Ë¡’·§≈‡´’¬¡ Ÿß ‚¥¬‡©æ“–°“√¥◊Ë¡π¡ À√◊ÕπÈ”‡µâ“ÀŸâ π¡∂—Ë«‡À≈◊Õß ®–‡ªìπ°“√™à«¬™–≈Õ°“√ Ÿ≠‡ ’¬¡«≈°√–¥Ÿ°´÷Ëß‡ªìπ°“√ªÑÕß°—π‚√§æ√–¥Ÿ°æ√ÿπ

π—∫ πÿπ°“√¡’ à«π√à«¡¢Õß™ÿ¡™π„π°‘®°√√¡‡°’Ë¬«°—∫°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ ‡™àπ °“√ÕÕ°°”≈—ß°“¬ °“√√—∫ª√–∑“πÕ“À“√∑’Ë¡’·§≈‡´’¬¡ Ÿß ªØ‘∫—µ‘‡ªìπª√–®” ¡Ë”‡ ¡Õ

§«√π”º≈°“√»÷°…“§√—Èßπ’È‰ª»÷°…“·∫∫°÷Ëß∑¥ Õß(Quasi-experimental research) ‚¥¬®—¥∑”‚§√ß°“√ àß‡ √‘¡æƒµ‘°√√¡°“√ªÑÕß°—π‚√§°√–¥Ÿ°æ√ÿπ„π‡¥Á°π—°‡√’¬πÀ≠‘ß «—¬√ÿàπ «—¬ºŸâ„À≠à ·≈–«—¬ ŸßÕ“¬ÿ

√ÿª

ºŸâ ŸßÕ“¬ÿ‡ªìπ‚√§°√–¥Ÿ°æ√ÿπ¡“°°«à“«—¬Õ◊ËπÊ §«√ π—∫ πÿπ·≈–°√–µÿâπ„ÀâÕÕ°°”≈—ß°“¬ √—∫ª√–∑“π

108

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

Õ“À“√∑’Ë¡’·§≈‡´’¬¡ Ÿß‡ªìπª√–®” ¡Ë”‡ ¡Õ ·≈–≈¥ªí®®—¬‡ ’Ë¬ß¢Õß°“√‡°‘¥‚√§°√–¥Ÿ°æ√ÿπ ‰¥â·°à ∫ÿÀ√’Ë‡§√◊ËÕß¥◊Ë¡∑’Ë¡’·Õ≈°ÕŒÕ≈å ·≈–§“‡øÕ’π

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥π“¬·æ∑¬å∫√√‡®‘¥ ®ß‡®√‘≠°¡≈ ºŸâÕ”π«¬°“√‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å∑’Ë„Àâ∑”°“√»÷°…“«‘®—¬·≈–‡º¬·æ√à¢âÕ¡Ÿ≈ ·≈–¢Õ¢Õ∫§ÿ≥ º».¥√.¿—∑√–· π‰™¬ ÿ√‘¬“ ¿“§«‘™“‚¿™π«‘∑¬“ §≥– “∏“√≥ ÿ¢»“ µ√å ¡À“«‘∑¬“≈—¬¢Õπ·°àπ ∑’Ë°√ÿ≥“„Àâ¢âÕ¡Ÿ≈∑’Ë¡’ª√–‚¬™πå √«¡∑—Èß„Àâ§”·π–π”„π°“√«‘®—¬§√—Èßπ’È

8. æ—™√’ ¬‘È¡√—µπ∫«√, √—™»‘√‘ ‡À≈◊Õß¢«—≠, Õ—ß§≥“ æ—π∏ÿ≈’ ·≈–§≥–. √“¬ß“πª√–®”ªï ß∫ª√–¡“≥ 2549 ‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å. ∫ÿ√’√—¡¬å: Àπà«¬º≈‘µ‡Õ° “√ °≈ÿà¡ß“πæ—≤π“√–∫∫∫√‘°“√ ÿ¢¿“æ ‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å; 2550. Àπâ“ 100-1.

9. ÿπ∑√ ∫«√√—µπ‡«™. °√–¥Ÿ°æ√ÿπ§ÿ°§“¡À≠‘ß‰∑¬. 2550.from www.knc.ac.th/gapa.html

10. Tussing L, Chapman-Novakofski K. Osteoporosis

prevention education; behavior theories and calcium

intake. J Am Dietet Assoc 2005; 105:92-7.

11. «‘‰≈«√√≥ ∑Õß‡®√‘≠, ¡®‘πµå ‡æ™√æ—π∏å»√’, ·«àπ„®π“§– ÿ«√√≥ ·≈–Õÿ…“ ™Ÿ —ß¢å. √“¬ß“π°“√-«‘®—¬ªí®®—¬‡ ’Ë¬ß§«“¡√Ÿâ ·≈–æƒµ‘°√√¡ªÑÕß°—π¿“«–°√–¥Ÿ°æ√ÿπ¢Õß µ√’«—¬À¡¥ª√–®”‡¥◊Õπ·≈– µ√’«—¬ ŸßÕ“¬ÿ. °√ÿß‡∑æœ: ¡À“«‘∑¬“≈—¬¡À‘¥≈; 2539.

12. Kowarski S, Schachter D. Vitamin D-dependent

particulate calcium binding activity and intestinal

calcium transport. Am J Physio 1975; 229:1198.

13. ∂“∫—π‡«™»“ µ√åºŸâ ŸßÕ“¬ÿ, °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢. °“√¥Ÿ·≈√—°…“‚√§ºŸâ ŸßÕ“¬ÿ·∫∫ À “¢“.æ‘¡æå§√—Èß∑’Ë 1. °√ÿß‡∑æœ: ™ÿ¡™π À°√≥å°“√‡°…µ√·Ààßª√–‡∑»‰∑¬; 2548.

14. Susan A. The role of physical activity in development

and maintenance of bone health throughout the lifecycle.

Medscape Today 2001: 1-5.

15. ÿ«‘™“ ∏’√‚√®π«ß»å. ªí®®—¬∑’Ë¡’§«“¡ —¡æ—π∏å°—∫æƒµ‘°√√¡°“√ªÑÕß°—π¿“«–°√–¥Ÿ°æ√ÿπ¢Õß µ√’«—¬°àÕπÀ¡¥ª√–®”‡¥◊Õπ. «‘∑¬“π‘æπ∏åª√‘≠≠“æ¬“∫“≈»“ µ√¡À“∫—≥±‘µ,¡À“«‘∑¬“≈—¬¡À‘¥≈; 2544.

16. ∫ÿªº“ Õ‘πµä–·°â«. µ—«°”Àπ¥§«“¡‡™◊ËÕ¥â“π ÿ¢¿“æ·≈–æƒµ‘°√√¡°“√ªÑÕß°—π‚√§ °√–¥Ÿ°æ√ÿπ ¢Õß µ√’«—¬À¡¥ª√–®”‡¥◊Õπ. «‘∑¬“π‘æπ∏åª√‘≠≠“æ¬“∫“≈»“ µ√¡À“∫—≥±‘µ, ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à; 2544.

17. Lane JM, Buss DD. Bone metabolism : normal

physiology and disease. Orthopaedic Knowledge

Update - I. Chicago : American Academy of Orthopaedic

Surgeon 1984 : 15.

18. Gonzales-Calvin, Jorge L, et al. Mineral metabolism,

osteoblastic function and bone mass in chronic

alcoholism. Oxford J 1993; 25:571.

∫√√≥“πÿ°√¡

1. World Health Organization. Guidelines for preclinical

evaluation and clinical trials in osteoporosis. Geneva:

World Health Organization; 1998.

2. Peterson JA. Osteoporosis overview. Geriatric Nursing

2001; 22:17-21.

3. National Osteoporosis Foundation. Osteopo-rosis.

[online] Retrieved July 20, 2005, from http://www.

nof.org.

4. °Õ∫®‘µµå ≈‘¡ªæ–¬Õ¡. «—¬À¡¥√–¥Ÿ. (æ‘¡æå§√—Èß∑’Ë 1).°√ÿß‡∑æœ: ‡√◊Õπ·°â«°“√æ‘¡æå; 2543.

5. Rajatanavin R. Epidemiology of osteoporosis in

Thailand. Paper presented at The 1st. Thai Osteoporosis

Foundation (TOPF) Annual Scientific Meeting 2003.

6. Lane NE. Epidemiology, etiology, and diagnosis of

osteoporosis. Am J Obstet Gynecol 2006; 194:3-11.

7. Suriyawongpaisal P, Siriwongpairat P, Loahacha-

reonsombat W, et al. A multicenter study on hip

fractures in Thailand. J Med Assoc Thai 1994; 77:488

-95.




°“√ª√–‡¡‘π°“√„™â¬“∑√“ ∑Ÿ´Ÿ·¡∫„π ∂“∫—π¡–‡√Áß·Ààß™“µ‘Õ¡√√—µπå «‘®‘µ√≈’≈“°≈ÿà¡ß“π‡¿ —™°√√¡ ∂“∫—π¡–‡√Áß·Ààß™“µ‘

Abstract Drug Use Evaluation of Trastuzumab in National Cancer InstituteVijitleela A.

Division of Pharmacy, National Cancer Institute, Bangkok, Thailand


The objective of this study is the evaluation of the suitability of the prescribing of Trastuzumabwithin the standard criteria of National Cancer Institute, Department of Medical Services, Ministry of PublicHealth. The data in the study were retrospective collected from the patient profiles of January, 2003 toDecember, 2007. There were 11 patients in this study. The average age of the patients was 47.3 years old. Andthere were 7 patients under the civil servant medical benefit scheme (63.6%). There were 4 patient s(36.4%)under the proper medical prescription for metastatic breast cancer. And there were 7 patients (63.6%) underthe inappropriate use for adjuvant therapy. Every patient had passed the assess performance scale(ECOG0-2). There were 9 patients (81.8%) had passed the criteria of left ventricular ejection fraction (LVEF ≥ 50%).Every patient (100%) had been prescribed the appropriate dosage regimen. There were 4 patients (36.3%)had been treated by Trastuzumab for 1 year. There were 2 patients (18.2%) who stopped Trastuzumab sincethe progression of disease. And there were 2 patients (18.2%) who had discontinued Trastuzumab from thecardiac events. There was 1 patient (9.1%) recording death after the medication. And there was 1 patient(9.1%) still ongoing treatment process. This study indicated that the doctors prescribed Trastuzumabaccording to the current information rather than the evidence-based medicine during that time.

Key words: Trastuzumab, drug use evaluation

‡√◊ËÕß¬àÕ °“√»÷°…“π’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕª√–‡¡‘π≈—°…≥–°“√ —Ëß„™â¬“·≈–§«“¡‡À¡“– ¡¢Õß°“√„™â¬“∑√“ ∑Ÿ´Ÿ·¡∫(Trastuzumab) ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫À≈—°‡°≥±å°“√„™â¬“∑’Ë°”Àπ¥¢÷Èπ„π ∂“∫—π¡–‡√Áß·Ààß™“µ‘ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢°“√‡°Á∫¢âÕ¡Ÿ≈‡ªìπ°“√‡°Á∫¢âÕ¡Ÿ≈¬âÕπÀ≈—ß®“°‡«™√–‡∫’¬πºŸâªÉ«¬ µ—Èß·µà ¡°√“§¡ æ.». 2546 - ∏—π«“§¡ æ.». 2550 ¡’®”π«πºŸâªÉ«¬11 √“¬ æ∫«à“ ºŸâªÉ«¬¡’Õ“¬ÿ‚¥¬‡©≈’Ë¬ ‡∑à“°—∫ 47.3 ªï ·≈–„™â ‘∑∏‘√—°…“æ¬“∫“≈ «— ¥‘°“√¢â“√“™°“√ 7 √“¬(√âÕ¬≈– 63.6) ¡’ºŸâªÉ«¬4 √“¬ (√âÕ¬≈– 36.4) ∑’Ë°“√„™â¬“‡À¡“– ¡µ“¡¢âÕ∫àß„™â„π‚√§¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬ ∑’Ë‡À≈◊Õ 7 √“¬ (√âÕ¬≈– 63.6) „™â‡ªìπ¬“√—°…“‡ √‘¡√à«¡°—∫°“√ºà“µ—¥·≈–/À√◊Õ√—ß ’√—°…“ ºŸâªÉ«¬∑ÿ°√“¬¡’°“√ª√–‡¡‘π ¿“æ√à“ß°“¬ºà“π‡°≥±å∑’Ë°”Àπ¥ (ECOG 0-2)·µà¡’ºŸâªÉ«¬‡æ’¬ß 9 √“¬∑’Ë¡’º≈°“√∑”ß“π¢ÕßÀ—«„®ºà“π‡°≥±å∑’Ë°”Àπ¥ (LVEF ≥ √âÕ¬≈– 50) §‘¥‡ªìπ√âÕ¬≈– 81.8 ºŸâªÉ«¬∑ÿ°√“¬(√âÕ¬≈– 100) ‰¥â√—∫¬“„π¢π“¥∑’Ë‡À¡“– ¡ ºŸâªÉ«¬®”π«π 4 √“¬ (√âÕ¬≈– 36.3) ‰¥â√—∫¬“§√∫ 1 ªï ¡’ºŸâªÉ«¬À¬ÿ¥¬“®“°°“√∑’Ë‚√§≈ÿ°≈“¡ 2 √“¬ (√âÕ¬≈– 18.2) ·≈–À¬ÿ¥¬“®“°º≈°“√∑”ß“π¢ÕßÀ—«„®≈¥≈ßµË”°«à“§à“ª°µ‘ 2 √“¬ (√âÕ¬≈– 18.2) ‡™àπ°—π à«πºŸâªÉ«¬‡ ’¬™’«‘µÀ≈—ß®“°‰¥â√—∫¬“ 1 √“¬ (√âÕ¬≈– 9.1) ·≈–¬—ßÕ¬Ÿà√–À«à“ß°“√√—°…“1 √“¬ (√âÕ¬≈– 9.1) ‡∑à“°—π °“√»÷°…“π’È· ¥ß„Àâ‡ÀÁπ∂÷ß≈—°…≥–°“√ —Ëß„™â¬“¢Õß·æ∑¬å∑’Ë„™âµ“¡¢âÕ¡Ÿ≈„À¡àÊ ∑’Ë‰¥â√—∫¡“°°«à“®–æ‘®“√≥“¢âÕ¡Ÿ≈∑’Ë¡’À≈—°∞“π‡™‘ßª√–®—°…å„π™à«ß‡«≈“π—Èπ

§” ”§—≠: ∑√“ ∑Ÿ´Ÿ·¡∫ °“√ª√–‡¡‘π°“√„™â¬“

110

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

°“√ª√–‡¡‘π‡∑§‚π‚≈¬’‡ªìπ°“√»÷°…“‡™‘ßπ‚¬∫“¬‚¥¬æ‘®“√≥“Õß§åª√–°Õ∫¥â“πµà“ßÊ ‡™àπ§«“¡ª≈Õ¥¿—¬ —¡ƒ∑∏‘º≈ ª√– ‘∑∏‘º≈ ª√– ‘∑∏‘¿“æ µ≈Õ¥®πº≈°√–∑∫∑’Ë‡°‘¥®“°°“√„™â‡∑§‚π‚≈¬’∑“ß°“√·æ∑¬å ‡æ◊ËÕ™à«¬ºŸâµ—¥ ‘π„®„π°“√‡≈◊Õ°„™â °“√®—¥À“ °“√®—¥ √√∑√—æ¬“°√ °“√‡∫‘°®à“¬ „Àâ‡À¡“– ¡µ“¡ ∂“π°“√≥åÀπ÷ËßÊ1

°“√∑’ËµâÕß¡’°“√ª√–‡¡‘π‡∑§‚π‚≈¬’ ‡π◊ËÕß®“°§«“¡®√‘ß∑“ß‡»√…∞»“ µ√å∑’Ë«à“ ç∑√—æ¬“°√¡’Õ¬ŸàÕ¬à“ß®”°—¥(Scarcity of Resources)é §◊Õ ÿ¢¿“æª√–™“™π‡ªìπ ‘Ëß ”§—≠ ·µàÀ“°„™â∑√—æ¬“°√∑—ÈßÀ¡¥∑’Ë¡’‰ª∑“ß°“√·æ∑¬å®πÀ¡¥ °Á®–‰¡à‡À≈◊Õ∑√—æ¬“°√∑’Ë®–„™â‡æ‘Ë¡æŸπ§ÿ≥¿“æ™’«‘µ·≈–§«“¡‡ªìπÕ¬Ÿà¢Õßª√–™“™π„π∑“ß¥â“πÕ◊ËπÊ ‰¥â ‡™àπ °“√»÷°…“ °“√§¡π“§¡ ‡ªìπµâπ¥—ßπ—ÈπºŸâ∑’Ë‡°’Ë¬«¢âÕß∑—ÈßºŸâ°”Àπ¥π‚¬∫“¬ ºŸâ´◊ÈÕ∫√‘°“√µ≈Õ¥®πºŸâ„Àâ∫√‘°“√∑“ß°“√·æ∑¬å ®÷ßµâÕßµ√–Àπ—°·≈–æ¬“¬“¡„™â‡∑§‚π‚≈¬’µà“ßÊ „Àâ‰¥âª√– ‘∑∏‘¿“æ Ÿß ÿ¥

¬“π—∫‡ªìπ‡∑§‚π‚≈¬’∑“ß°“√·æ∑¬åÕ¬à“ßÀπ÷Ëß‡æ◊ËÕ„Àâ°“√„™â¬“‡ªìπ‰ªÕ¬à“ß‡À¡“– ¡ ª≈Õ¥¿—¬·≈–¡’ª√– ‘∑∏‘¿“æ ®÷ß¡’§«√ª√–‡¡‘π°“√„™â¬“∑’ËµâÕßªØ‘∫—µ‘Õ¬à“ßµàÕ‡π◊ËÕß ¡’‚§√ß √â“ß°“√¥”‡π‘πß“π·≈–¡’°“√π”º≈°“√ª√–‡¡‘π¡“‡ª√’¬∫‡∑’¬∫°—∫À≈—°‡°≥±å¡“µ√∞“π´÷Ëß‰¥âæ‘®“√≥“Õ¬à“ß‡À¡“– ¡ °“√§—¥‡≈◊Õ°¬“∑’Ë®–π”¡“ª√–‡¡‘π®–æ‘®“√≥“®“°ªí≠À“∑’Ëπà“®–‡°‘¥®“°¬“π—Èπ·≈–‡ªìπªí≠À“∑’ËÕ“® àßº≈°√–∑∫µàÕºŸâªÉ«¬ ‡™àπ ¬“∑’Ë¡’Õ—µ√“°“√„™â Ÿß ¬“∑’Ë¡’√“§“·æß À√◊Õ¬“∑’Ë¡’‚Õ°“ ‡°‘¥Õ“°“√Õ—π‰¡àæ÷ßª√– ß§å∑’Ë√ÿπ·√ß‡ªìπµâπ

∂“∫—π¡–‡√Áß·Ààß™“µ‘‡ªìπ ∂“∫—π∑“ß°“√·æ∑¬å‡©æ“–∑“ß ¡’°“√„™â¬“∑’Ë‡ªìπ‡∑§‚π‚≈¬’„À¡àÊ„π°“√√—°…“‚√§¡–‡√ÁßÕ¬ŸàÀ≈“¬√“¬°“√ ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß¬“∑’ËÕÕ°ƒ∑∏‘ÏµàÕ‡´≈≈å‡ªÑ“À¡“¬ (Targeted Therapy)¡’º≈µàÕ°“√√—°…“¥’¢÷Èπ¡“°°«à“¬“‡¥‘¡ ™à«¬‡æ‘Ë¡√–¬–‡«≈“°“√Õ¬Ÿà√Õ¥‡©≈’Ë¬ ‡æ‘Ë¡√–¬–‡«≈“‚√§§ß∑’Ë À√◊Õ≈¥º≈¢â“ß‡§’¬ß≈ß ·µà¬“‡À≈à“π’È¡’§à“„™â®à“¬„π°“√√—°…“§àÕπ¢â“ß Ÿß¡“° ‡™àπ ¬“∑√“ ∑Ÿ´Ÿ·¡∫ (Trastuzumab)§à“„™â®à“¬‚¥¬‡©≈’Ë¬ª√–¡“≥· π∫“∑µàÕ‡¥◊Õπ ·≈–

µâÕß„™â‡ªìπ√–¬–‡«≈“ª√–¡“≥ 1 ªïÀ√◊Õ®π°«à“‚√§®–≈ÿ°≈“¡®÷ß®–À¬ÿ¥„Àâ¬“

∑√“ ∑Ÿ´Ÿ·¡∫ (Trastuzumab) ‡ªìπ¬“√—°…“‚√§¡–‡√Áß°≈ÿà¡ targeted therapy ∑’Ë‡ªìπ monoclonalantibody ™π‘¥ recombinant DNA-derivedhumanized ∑’Ë®—∫°—∫ human epidermal growth factorreceptor 2 protein (HER2 receptor)2,3

HER2 proto-oncogene À√◊ÕÕ’°™◊ËÕÀπ÷Ëß§◊Õ c-erbB2 ¡’‚§√ß √â“ß‡°’Ë¬«æ—π “¡“√∂‡¢â“‰ª®—∫°—∫epidermal growth factor receptor ´÷Ëß¡’°“√»÷°…“æ∫«à“ ºŸâªÉ«¬∑’Ë‡ªìπ¡–‡√Áß‡µâ“π¡„π√–¬–‡√‘Ë¡·√° ª√–¡“≥√âÕ¬≈– 20-25 ¡’ HER2 gene ¡“°°«à“ª°µ‘ ∑”„Àâª√‘¡“≥¢ÕßHER2 ‚ª√µ’π∑’Ë®–‡¢â“‰ª®—∫°—∫ epidermalgrowth factor receptor (HER2 receptor) ∫πº‘«¢Õß°âÕπ¡–‡√Áß‡æ‘Ë¡¡“°¢÷Èπ ·≈–ºŸâªÉ«¬°≈ÿà¡∑’Ë¡’ HER2‚ª√µ’π¡“°°«à“ª°µ‘π’È ®–¡’√–¬–‡«≈“ª≈Õ¥‚√§(disease-free survival) πâÕ¬°«à“°≈ÿà¡ºŸâ∑’Ë‰¡à¡’ HER2‚ª√µ’π¡“°°«à“ª°µ‘2,3

®“°°“√»÷°…“∑¥≈Õß∑—Èß in vitro ·≈– in vivoæ∫«à“¬“ Trastuzumab “¡“√∂¬—∫¬—Èß°“√·∫àßµ—«¢Õß‡´≈≈å¡–‡√Áß¢Õß¡πÿ…¬å∑’Ë¡’ HER2 ‚ª√µ’π¡“°°«à“ª°µ‘πÕ°®“°π’È°“√»÷°…“ in vitro ¬—ßæ∫«à“¬“ Trastuzumab‡ªìπ ◊ËÕ¢Õß°“√∑”≈“¬‡´≈≈å¡–‡√Áß¥â«¬°≈‰° antibody-dependent cell-mediated cytotoxicity (ADCC)∑”„Àâ “¡“√∂¬—∫¬—Èß°“√·∫àßµ—«¢Õß‡´≈≈å¡–‡√Áß∑’Ë¡’ HER2‚ª√µ’π¡“°°«à“ª°µ‘‰¥â¥’°«à“‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫‡´≈≈å¡–‡√Áß∑’Ë‰¡à¡’ HER2 ‚ª√µ’π¡“°°«à“ª°µ‘

°“√»÷°…“∑“ß‡¿ —™®≈π»“µ√å∑’Ë¿“«–§ß∑’Ë „π°“√»÷°…“ Phase I, Phase II ·≈– pivotal Phase III „Àâ¬“Trastuzumab §√—Èß·√°„π¢π“¥ 4 ¡‘≈≈‘°√—¡ (¡°.)/°‘‚≈°√—¡ (°°.) ¢ÕßπÈ”Àπ—°µ—«µ“¡¥â«¬¢π“¥ 2 ¡°./°°.¢ÕßπÈ”Àπ—°µ—« ∑ÿ° 2 —ª¥“Àå æ∫«à“°“√¢®—¥ÕÕ°¢Õß¬“ ‡∑à“°—∫ 0.225 ≈‘µ√/«—π ·≈–¡’§à“°“√°√–®“¬¬“‡∑à“°—∫ 2.95 ≈‘µ√ ‚¥¬¡’Ë§à“§√÷Ëß™’«‘µ ÿ¥∑â“¬‡ªìπ 28.5«—π (25.5-32.8 «—π ∑’Ë§«“¡‡™◊ËÕ¡—Ëπ 95%) §à“ AUC ‡ªìπ578 ¡°.«—π/≈‘µ√ §«“¡‡¢â¡¢âπ Ÿß ÿ¥∑’Ë 110 ¡°./≈‘µ√·≈–§«“¡‡¢â¡¢âπµË” ÿ¥∑’Ë 66 ¡°./≈‘µ√ ¿“¬„π 143



«—πÀ√◊Õª√–¡“≥ 20 —ª¥“Àå ·µà®“°°√≥’∑’ËºŸâªÉ«¬‚√§¡–‡√Áß‡µâ“π¡√–¬–‡√‘Ë¡·√°‰¥â√—∫¬“ Trastuzumab¢π“¥‡√‘Ë¡µâπ∑’Ë 8 ¡°./°°. (πÈ”Àπ—°µ—«) µ“¡¥â«¬¢π“¥6 ¡°./°°. (πÈ”Àπ—°µ—«) ∑ÿ° 3 —ª¥“Àå ‡ªìπ√–¬–‡«≈“13 √Õ∫¢Õß°“√√—°…“ æ∫«à“§à“§«“¡‡¢â¡¢âπ¢Õß¬“„π‡≈◊Õ¥∑’Ë√–¥—∫§ß∑’Ë §◊Õ 63 ¡°./≈‘µ√ ´÷Ëß„°≈â‡§’¬ß°—∫§à“§«“¡‡¢â¡¢âπ∑’Ëæ∫„π√“¬ß“π®“°ºŸâªÉ«¬‚√§¡–‡√Áß‡µâ“π¡√–¬–≈ÿ°≈“¡

Trastuzumab ¡’¢âÕ∫àß„™â (Indication) „π°“√√—°…“ºŸâªÉ«¬∑’Ë‡ªìπ¡–‡√Áß‡µâ“π¡„π√–¬–≈ÿ°≈“¡‚¥¬°âÕπ¡–‡√ÁßµâÕß¡’º≈µ√«® HER2 ‡ªìπ 3+ ‚¥¬ IHC(Immunohistochemistry) À√◊Õ‡ªìπ∫«° (+) ‚¥¬«‘∏’fluorescence in situ hybridization (FISH) ·≈–∑“ß ”π—°ß“π§≥–°√√¡°“√Õ“À“√·≈–¬“ °√–∑√«ß “∏“√≥ ÿ¢ Õπÿ¡—µ‘¢âÕ∫àß„™â‡æ‘Ë¡‡µ‘¡„π‡Õ° “√°”°—∫¬“©∫—∫‡¥◊Õπ¡‘∂ÿπ“¬π 2550 „Àâ„™â‰¥â„πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·√° ∑’Ë°âÕπ¡–‡√Áß¡’º≈µ√«® HER2 ‡ªìπ∫«° (+)‚¥¬«‘∏’ FISH ·≈–¡’°“√°√–®“¬‰ª¬—ßµàÕ¡πÈ”‡À≈◊Õß¿“¬À≈—ß°“√ºà“µ—¥ °“√‰¥â√—∫‡§¡’∫”∫—¥ (°“√√—°…“‡ √‘¡°àÕπ°“√√—°…“À≈—° À√◊Õ °“√√—°…“‡ √‘¡¿“¬À≈—ß°“√√—°…“À≈—°) ·≈– √—ß ’√—°…“ (À“°¡’)2-6

¢π“¥·≈–«‘∏’°“√„™â¬“ Trastuzumab “¡“√∂„Àâ¬“‡ªìπ∑ÿ° —ª¥“Àå À√◊Õ∑ÿ° “¡ —ª¥“Àå ‚¥¬°“√„Àâ¬“∑ÿ° —ª¥“Àå®–„Àâ¢π“¥¬“§√—Èß·√° §◊Õ 4 ¡°./°°.¢ÕßπÈ”Àπ—°µ—« „Àâ·∫∫À¬¥‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¿“¬„π‡«≈“ 90 π“∑’ ·≈–¢π“¥¬“§√—ÈßµàÕ‰ª§◊Õ 2 ¡°./°°.¢ÕßπÈ”Àπ—°µ—« Õ“®„Àâ¬“¿“¬„π 30 π“∑’‰¥â∂â“ºŸâªÉ«¬ “¡“√∂∑πµàÕº≈¢â“ß‡§’¬ß¢Õß°“√„Àâ¬“§√—Èß°àÕπ‰¥â¥’°√≥’°“√„Àâ¬“∑ÿ° “¡ —ª¥“Àå ¢π“¥¬“§√—Èß·√°∑’Ë„Àâ§◊Õ8 ¡°./°°.¢ÕßπÈ”Àπ—°µ—« ·≈â«µ“¡¥â«¬ 6 ¡°./°°.¢ÕßπÈ”Àπ—°µ—« ∑ÿ° “¡ —ª¥“Àå„Àâ·∫∫À¬¥‡¢â“∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¿“¬„π‡«≈“ 90 π“∑’ „π°“√„™â√—°…“ºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·√° ®–„Àâ¬“‡ªìπ√–¬–‡«≈“1 ªï À√◊Õ®π°√–∑—Ëß¡’°“√°≈—∫¡“¢Õß‚√§ (recurrence)

¢âÕ§«√√–«—ß„π°“√„Àâ¬“ Trastuzumab ‡∑à“∑’Ë¡’√“¬ß“πÕ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â¬“ ‚¥¬∑—Ë«‰ªæ∫«à“ ¡’Õ“°“√À“¬„®≈”∫“° §«“¡¥—π‚≈À‘µµË” À“¬„®

¢—¥ À≈Õ¥≈¡À¥‡°√Áß À—«„®‡µâπ‡√Á« ª√‘¡“≥ÕÕ°´‘‡®πÕ‘Ë¡µ—«πâÕ¬≈ß °“√°¥°“√À“¬„® ¿“«–πÈ”∑à«¡ªÕ¥π‘«¡Õ‡π’¬ ªÕ¥Õ—°‡ ∫ ªÕ¥¡’°“√∫«¡‡©’¬∫æ≈—π ´÷ËßÕ“°“√‡À≈à“π’È∑”„Àâ‡°‘¥°“√µ“¬‰¥â πÕ°®“°π’È¬—ßæ∫Õ“°“√º‘¥ª°µ‘¢Õß°“√∑”ß“π¢ÕßÀ—«„®„π√–¥—∫ª“π°≈“ß∂÷ß√ÿπ·√ß (New York Heart Association,NYHA) Class II -IV „πºŸâªÉ«¬∑’Ë‰¥â√—∫¬“ Trastuzumab‡¥’Ë¬« À√◊Õ ‰¥â√à«¡°—∫¬“‡§¡’∫”∫—¥°≈ÿà¡ Taxane ¿“¬À≈—ß‡§¬‰¥â√—∫°“√√—°…“¥â«¬¬“°≈ÿà¡ Anthracycline ‡™àπDoxorubicin À√◊Õ Epirubicin5,7-9

°“√„™â¬“ Trastuzumab ®÷ß§«√„™â¥â«¬§«“¡√–¡—¥√–«—ßÕ¬à“ß Ÿß ‡¡◊ËÕ„™â√—°…“ºŸâªÉ«¬∑’Ë‡§¬¡’Õ“°“√À—«„®≈â¡‡À≈« ¡’ª√–«—µ‘§«“¡¥—π‚≈À‘µ Ÿß À√◊Õ‡§¬‡ªìπ‚√§∑’Ë‡°’Ë¬«°—∫À≈Õ¥‡≈◊Õ¥·¥ß∑’Ë¡“‡≈’È¬ßÀ—«„® ·≈–ºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·√°∑’Ë¡’ LVEF (Left VentrocularEjection Fraction) πâÕ¬°«à“À√◊Õ‡∑à“°—∫√âÕ¬≈– 55‚¥¬‡©æ“–Õ¬à“ß¬‘ËßºŸâªÉ«¬∑’Ë‡§¬‰¥â√—∫°“√√—°…“¥â«¬¬“°≈ÿà¡Anthracycline ·≈–¬“ Cyclophosphamide §«√‰¥â√—∫°“√µ√«®°“√∑”ß“π¢ÕßÀ—«„®¥â«¬ EKG (Electro-cardiogram), Echocardiogram ·≈–/À√◊Õ MUGAscan (Multiple Gated Acquisition Scan) √«¡∑—Èß√–À«à“ß°“√√—°…“§«√¡’°“√µ√«®°“√∑”ß“π¢ÕßÀ—«„®‡ªìπ√–¬–¥â«¬

°“√»÷°…“∑“ß§≈‘π‘°„πºŸâªÉ«¬∑’Ë‡ªìπ¡–‡√Áß‡µâ“π¡„π√–¬–≈ÿ°≈“¡ (·æ√à°√–®“¬) ∑’Ë¡’ HER2 ‡ªìπ 3+‚¥¬IHC (Immunohistochemistry) À√◊Õ‡ªìπ∫«° (+)‚¥¬«‘∏’fluorescence in situ hybridization (FISH)‚¥¬„Àâ¬“ Trastuzumab √à«¡°—∫¬“‡§¡’∫”∫—¥Õ◊Ëπ(°≈ÿà¡taxanes) ‡ª√’¬∫‡∑’¬∫°—∫°“√„Àâ¬“µ—«‡¥‘¡„π°≈ÿà¡taxanes æ∫«à“ Õ—µ√“°“√µÕ∫ πÕßµàÕ¬“∑—ÈßÀ¡¥(overall response rate) ‡∑à“°—∫√âÕ¬≈– 27-32 ·≈–√–¬–‡«≈“√Õ¥™’«‘µ‡©≈’Ë¬ (median survival) ‡∑à“°—∫7-8.5 ‡¥◊Õπ

à«π°“√»÷°…“∑“ß§≈‘π‘°„πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·√°∑’Ë¡’ HER2 ‡ªìπ∫«° (+) ¡’°“√°√–®“¬¢Õß‡´≈≈å¡–‡√Áß‰ª¬—ßµàÕ¡πÈ”‡À≈◊Õß æ∫«à“ „π HERA trial(Herceptin Adjuvant trial) §«“¡‡ ’Ë¬ß„π°“√°≈—∫

112

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

¡“‡ªìπ´È”¢Õß‚√§ (disease free survival) ·≈–≈¥§«“¡‡ ’Ë¬ß„π°“√‡ ’¬™’«‘µ≈ß (risk of death) √âÕ¬≈– 33‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√√—°…“¥â«¬¬“‡§¡’∫”∫—¥Õ◊ËπÕ¬à“ß‡¥’¬« à«π„π°“√»÷°…“ BCIRG (TheBreast Cancer International Research Group) 006,NCCTG(North Central Cancer Treatment Group)9831, NSABP(National Surgical Adjuvant Breastand Bowel Project) B31 æ∫«à“ºŸâªÉ«¬°≈ÿà¡∑’Ë‰¥â√—∫¬“‡§¡’∫”∫—¥√à«¡°—∫¬“ Trastuzumab ®–™à«¬‡æ‘Ë¡√–¬–‡«≈“¢Õß°“√ª≈Õ¥‚√§ (√–¬–°“√°≈—∫¡“‡ªìπ È”¢Õß‚√§π“π¢÷Èπ) ·≈–‡æ‘Ë¡Õ—µ√“°“√√Õ¥™’«‘µ ‡¡◊ËÕ‡∑’¬∫°—∫ºŸâªÉ«¬°≈ÿà¡∑’Ë‰¥â√—∫¬“‡§¡’∫”∫—¥Õ¬à“ß‡¥’¬«3

°“√»÷°…“π’È¡’«—µ∂ÿª√– ß§å‡æ◊ËÕª√–‡¡‘π≈—°…≥–°“√ —Ëß„™â¬“·≈–§«“¡‡À¡“– ¡¢Õß°“√„™â¬“ Trastuzumab„π ∂“∫—π¡–‡√Áß·Ààß™“µ‘ ‚¥¬‡ª√’¬∫‡∑’¬∫°—∫À≈—°‡°≥±å°“√„™â¬“ (criteria) ∑’Ë°”Àπ¥¢÷Èπ

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“·∫∫‡°Á∫¢âÕ¡Ÿ≈¬âÕπÀ≈—ß (Retro-spective Study) ‚¥¬‡°Á∫¢âÕ¡Ÿ≈ºŸâªÉ«¬∑’Ë√—∫°“√√—°…“¥â«¬¬“ Trastuzumab ≥. ∂“∫—π¡–‡√Áß·Ààß™“µ‘ µ—Èß·µà¡°√“§¡ æ.». 2546 - ∏—π«“§¡ æ.». 2550 ®”π«π11 √“¬ ·µà‡π◊ËÕß®“° 1 °ÿ¡¿“æ—π∏å æ.». 2548 ∂“∫—π¡–‡√Áß·Ààß™“µ‘®—¥∑”‡°≥±å¡“µ√∞“π„π°“√„™â¬“Trastuzumab ®÷ß∑”„Àâ µ—Èß·µà 1 °ÿ¡¿“æ—π∏å æ.». 2548¡’¢âÕ¡Ÿ≈ºŸâªÉ«¬∑’Ë¡’°“√»÷°…“ª√–‡¡‘π°“√„™â¬“·∫∫‰ª¢â“ßÀπâ“ (Prospective DUE Study)

«‘∏’°“√¥”‡π‘πß“π∑∫∑«π«√√≥°√√¡∑’Ë‡°’Ë¬«¢âÕß°—∫°“√»÷°…“ °“√

„™â¬“·≈–¢âÕ¡Ÿ≈¢Õß¬“ Trastuzumab ‚¥¬»÷°…“®“°«√√≥°√√¡∑’Ë≈ß„πÀπ—ß ◊Õ «“√ “√ ·≈–∞“π¢âÕ¡Ÿ≈Õ‘π‡µÕ√å‡πÁµ

®—¥‡°Á∫¢âÕ¡Ÿ≈‚¥¬»÷°…“¢âÕ¡Ÿ≈∑’Ëπà“‡™◊ËÕ∂◊ÕÀ√◊Õ¡’°“√√—∫√Õß‚¥¬ ”π—°ß“π§≥–°√√¡°“√Õ“À“√·≈–¬“∑—Èßª√–‡∑»‰∑¬·≈–ª√–‡∑» À√—∞Õ‡¡√‘°“

®—¥∑”‡°≥±å¡“µ√∞“π„π°“√„™â¬“ Trastuzumab¢Õß ∂“∫—π¡–‡√Áß·Ààß™“µ‘ æ√âÕ¡∑—Èß‡ πÕ„Àâ§≥–

°√√¡°“√·æ∑¬å∑’Ë‰¥â√—∫°“√·µàßµ—Èß‡ªìπºŸâ«‘π‘®©—¬§à“¬“πÕ°∫—≠™’¬“À≈—°·Ààß™“µ‘µ“¡√–‡∫’¬∫°√–∑√«ß°“√§≈—ßæ‘®“√≥“„™â‡ªìπ‡°≥±å«‘π‘®©—¬

2.4 ‡ °Á ∫ ¢â Õ ¡Ÿ ≈ ºŸâ ªÉ « ¬ ∑’Ë ¡’ ° “ √ —Ë ß „ ™â ¬ “Trastuzumab

2.5 ª√–‡¡‘πº≈¢âÕ¡Ÿ≈∑’Ë√«∫√«¡‰¥â‡°≥±å¡“µ√∞“π„π°“√„™â¬“ Trastuzumab ¢Õß

∂“∫—π¡–‡√Áß·Ààß™“µ‘ (‡√‘Ë¡„™âµ—Èß· µà 1°ÿ¡¿“æ—π∏åæ.».2548) „™â„πºŸâªÉ«¬¡–‡√Áß√–¬–·æ√à°√–®“¬(Metastatic Breast Cancer) ‚¥¬¡’¢âÕ∫àß„™â ¥—ßπ’È

“¡“√∂æ‘®“√≥“„™â¬“ Trastuzumab „πºŸâªÉ«¬≈—°…≥–¥—ßµàÕ‰ªπ’È

¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬µâÕß¡’º≈°“√µ√«® HER2 ‡ªìπ 3+ ‚¥¬«‘∏’

Immunohistochemistry (IHC) À√◊Õ‡ªìπ∫«° ‚¥¬«‘∏’FISH (fluorescence in situ hybridization)

¿“æºŸâªÉ«¬ ECOG (Eastern Coopera-tive Oncology Group) ‡∑à“°—∫ 0-2

¡’º≈°“√µ√«®°“√∑”ß“π¢ÕßÀ—«„®¥â«¬«‘∏’EKG (Electrocardiogram), Echocardiogram ·≈–/À√◊Õ MUGA scan ‚¥¬¡’LVEF ‰¡àπâÕ¬°«à“√âÕ¬≈– 50

§Ÿà¡◊Õ„π°“√„™â¬“ Trastuzumab ¢Õß°√¡∫—≠™’°≈“ß °√–∑√«ß°“√§≈—ß10 (‡√‘Ë¡„™âµ—Èß·µà 1 °—π¬“¬πæ.». 2549) „™â„πºŸâªÉ«¬¡–‡√Áß√–¬–·æ√à°√–®“¬(Metastatic Breast Cancer) ‚¥¬¡’¢âÕ∫àß„™â ¥—ßπ’È

“¡“√∂æ‘®“√≥“„™â¬“ Trastuzumab „πºŸâªÉ«¬≈—°…≥–¥—ßµàÕ‰ªπ’È

¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬µâÕß¡’º≈°“√µ√«® HER2 ‡ªìπ 3+ ‚¥¬«‘∏’

Immunohistochemistry À√◊Õ‡ªìπ∫«° ‚¥¬«‘∏’ FISH ¿“æºŸâªÉ«¬ ECOG ‡∑à“°—∫ 0-2‰¡à¡’‚√§À—«„®‚¥¬¡’§”·π–π”„π°“√„™â¬“¥—ßπ’È “¡“√∂æ‘®“√≥“„Àâ Trastuzumab ‡ªìπ

¬“≈”¥—∫·√°‚¥¬„™â√à«¡°—∫¬“°≈ÿà¡ Taxane (Paclitaxel,Docetaxel) „πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬„πºŸâ∑’Ë‡§¬‰¥â√—∫¬“ Anthracycline ‡ªìπ°“√√—°…“‡ √‘¡



¡“°àÕπ ºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬∑’Ë‰¡à‡§¬‰¥â√—∫°“√√—°…“¡“°àÕπ §«√‰¥â√—∫¬“‡§¡’∫”∫—¥°≈ÿà¡Anthracycline-containing regimen ·≈–/À√◊Õ CMF(Cyclophosphamide Methotrexate Fluorouracil,ºŸâ‡¢’¬π) ºŸâªÉ«¬§«√‰¥â√—∫°“√√—°…“¥â«¬¬“µâ“πŒÕ√å‚¡π¡“°àÕπ „π°√≥’∑’Ë¡’º≈°“√µ√«® Hormone receptor‡ªìπ∫«°

Trastuzumab monotherapy : “¡“√∂·π–π”„Àâ„™â‰¥â„πºŸâªÉ«¬∑’Ë‰¡àµÕ∫ πÕßµàÕ¬“‡§¡’∫”∫—¥¡“·≈â«Õ¬à“ßπâÕ¬ 2 regimens ´÷Ëßª√–°Õ∫¥â«¬Doxorubicin ·≈– Taxane ¡“·≈â« „π°√≥’∑’ËºŸâªÉ«¬¡’º≈°“√µ√«®ŒÕ√å‚¡π‡ªìπ∫«° §«√‰¥â√—∫¬“°≈ÿà¡Hormonal therapy ¡“·≈â«¥â«¬

ºŸâªÉ«¬∑’Ë‰¡àµÕ∫ πÕßµàÕ¬“Trastuzumabmonotherapy À√◊Õ combination °Áµ“¡ ‰¡à·π–π”„Àâ„™â Trastuzumab µàÕ‡π◊ËÕß√à«¡°—∫¬“µ—«Õ◊Ëπ(‡π◊ËÕß®“°‰¡à¡’ Clinical control study)

ºŸâªÉ«¬∑’Ë‰¡àµÕ∫ πÕßµàÕ°“√√—°…“ ·π–π”„Àâ„™â Trastuzumab ‡ªìπ√–¬–‡«≈“∑—Èß ‘Èπ‰¡à‡°‘π 1 ªï(‡π◊ËÕß®“°‰¡à¡’¢âÕ¡Ÿ≈°“√„™â¬“√–¬–¬“«®–‰¥âª√–‚¬™πå·µà¡’º≈¢â“ß‡§’¬ßµàÕ°≈â“¡‡π◊ÈÕÀ—«„®¡“°¢÷Èπ)

‰¡à·π–π”„Àâ„™â Trastuzumab ‡ªìπ¬“√—°…“

‡ √‘¡ „π¡–‡√Áß‡µâ“π¡√–¬–‡√‘Ë¡µâπ „πºŸâªÉ«¬∑’Ë‰¡àµÕ∫ πÕßµàÕTrastuzumab

combination therapy À√◊Õ Monotherapy ¡“·≈â«‰¡à·π–π”„Àâ„™â Trastuzumab µàÕ‡π◊ËÕß√à«¡°—∫¬“‡§¡’∫”∫—¥™π‘¥Õ◊ËπÊ µàÕ‰ª

º≈

°“√ª√–‡¡‘π°“√„™â¬“ Trastuzumab µ“¡¢âÕ∫àß„™âπ—Èπ „™â‡°≥±å¡“µ√∞“π¢Õß ∂“∫—π¡–‡√Áß·Ààß™“µ‘°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ ´÷Ëß Õ¥§≈âÕß°—∫‡°≥±å§Ÿà¡◊Õ„π°“√„™â¬“ Trastuzumab ¢Õß°√¡∫—≠™’°≈“ß °√–∑√«ß°“√§≈—ß ∑’Ë°”Àπ¥„Àâ„™â¬“ Trastuzumab„πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬ µâÕß¡’º≈°“√µ√«® HER2 ‡ªìπ 3+ ‚¥¬«‘∏’ IHC À√◊Õ‡ªìπ∫«° ‚¥¬«‘∏’FISH ‡¡◊ËÕ¥Ÿ ¿“æºŸâªÉ«¬®–µâÕß¡’ ECOG √–¥—∫ 0-2·≈–‰¡à¡’‚√§À—«„® ‚¥¬¡’ LVEF ‰¡àπâÕ¬°«à“√âÕ¬≈– 50®“°°“√ª√–‡¡‘π°“√„™â¬“ Trastuzumab ‚¥¬°“√√«∫√«¡¢âÕ¡Ÿ≈®“°‡«™√–‡∫’¬πºŸâªÉ«¬„π ∂“∫—π¡–‡√Áß·Ààß™“µ‘ µ—Èß·µà ¡°√“§¡ æ.». 2547 - ∏—π«“§¡ æ.».2550 æ∫«à“ ¡’ºŸâªÉ«¬∑’Ë„™â¬“ Trastuzumab ®”π«π 20√“¬ ·µà‡ªìπºŸâªÉ«¬∑’Ë¡“ª√–‡¡‘π°“√„™â¬“ Trastuzumab11 √“¬ ‡π◊ËÕß®“°ºŸâªÉ«¬Õ’° 9 √“¬Õ¬Ÿà„π°≈ÿà¡»÷°…“«‘®—¬

µ“√“ß∑’Ë 1 ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâªÉ«¬

¢âÕ¡Ÿ≈ºŸâªÉ«¬ ®”π«πºŸâªÉ«¬ (N = 11) √âÕ¬≈–

1. Õ“¬ÿ

≤ 40 ªï 3 27.3

40-50 ªï 4 36.4

50-60 ªï 4 36.4

Õ“¬ÿ‚¥¬‡©≈’Ë¬ = 47.3 ªï

2. ‘∑∏‘°“√√—°…“æ¬“∫“≈

«— ¥‘°“√¢â“√“™°“√ 7 63.6

ª√–°—π ÿ¢¿“æ 1 9.1

™”√–‡ß‘π‡Õß (√«¡ª√–°—π —ß§¡∑’Ë‰¡à¡’„∫ àßµ—«) 3 27.3

114

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

Õ¬à“ßÕ◊Ëπ (ºà“µ—¥ ·≈–/À√◊Õ √—ß ’√—°…“) §‘¥‡ªìπ√âÕ¬≈–63.4 ·≈–ºŸâªÉ«¬∑ÿ°√“¬∑’Ë„™â¬“ Trastuzumab ¡’º≈°“√µ√«® HER2 ‡ªìπ 3+ («‘∏’IHC)

ºŸâªÉ«¬∑ÿ°√“¬∑’Ë‰¥â√—∫¬“ Trastuzumab ¡’°“√ª√–‡¡‘π ¿“æ√à“ß°“¬ºà“π‡°≥±å∑’Ë°”Àπ¥ (ECOG0-2) §‘¥‡ªìπ√âÕ¬≈– 100 à«π°“√µ√«® ¿“æ°“√∑”ß“π¢ÕßÀ—«„®æ∫«à“ ¡’ºŸâªÉ«¬∑’Ëºà“π‡°≥±å¡’ LVEF(Left Ventrocular Ejection Fraction) ‰¡àπâÕ¬°«à“√âÕ¬≈– 50 Õ¬Ÿà®”π«π 9 √“¬ §‘¥‡ªìπ√âÕ¬≈– 81.8·≈–ºŸâ∑’Ë‰¡àºà“π‡°≥±å®”π«π 1 √“¬ §‘¥‡ªìπ√âÕ¬≈– 9.1

°“√„™â¬“ Trastuzumab ∑“ß§≈‘π‘° (clinical trial) ®÷ß‰¡à‰¥â∂Ÿ°π”¡“ª√–‡¡‘π°“√„™â¬“

à«π∑’Ë 1 ¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕßºŸâªÉ«¬ (µ“√“ß∑’Ë 1) à«π∑’Ë 2 °“√ª√–‡¡‘π°“√„™â¬“ Trastuzumab

®“°°“√ª√–‡¡‘π°“√„™â¬“ Trastuzumab æ∫«à“¡’ºŸâªÉ«¬∑’Ë¡’°“√„™â¬“∑—ÈßÀ¡¥ 11 √“¬ ‡ªìπºŸâªÉ«¬∑’Ë¡’Õ“°“√¢Õß‚√§Õ¬Ÿà„π√–¬–≈ÿ°≈“¡µ“¡¢âÕ∫àß„™â 4 √“¬´÷Ëßºà“π‡°≥±å¢âÕ∫àß„™â‡À¡“– ¡ §‘¥‡ªìπ√âÕ¬≈– 36.4∑’Ë‡À≈◊ÕÕ’° 7 √“¬ ‰¡à‡À¡“– ¡µ“¡¢âÕ∫àß„™â ‚¥¬‡ªìπºŸâªÉ«¬∑’Ë„™â¬“ Trastuzumab ‡ √‘¡√à«¡°—∫°“√√—°…“

µ“√“ß∑’Ë 2 °“√ª√–‡¡‘π°“√„™â¬“ Trastuzumab

º≈°“√ª√–‡¡‘π ®”π«πºŸâªÉ«¬ (N = 11) √âÕ¬≈–

1. ¢âÕ∫àß„™â

‡À¡“– ¡ („™â„π¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬) 4 36.4

‰¡à‡À¡“– ¡(„™â‡ªìπadjuvant therapy„π¡–‡√Áß‡µâ“π¡√–¬–·√° 7 63.6

2. º≈°“√µ√«® HER2 ‡ªìπ 3+ («‘∏’ IHC) 11 100

3. ¿“æºŸâªÉ«¬

‡À¡“– ¡ (ECOG = 0-2) 11 100

‰¡à‡À¡“– ¡ (ECOG = 3-4) 0 0

4. º≈°“√∑”ß“π¢ÕßÀ—«„®

‡À¡“– ¡ (LVEF ≥ √âÕ¬≈– 50) 9 81.8

‰¡à‡À¡“– ¡ (LVEF < √âÕ¬≈– 50) 1 9.1

‰¡à¡’º≈°“√µ√«® 1 9.1

5. ¢π“¥°“√„™â¬“

‡À¡“– ¡ 11 100

‰¡à‡À¡“– ¡ 0 0

6. ®”π«πºŸâªÉ«¬∑’Ë‰¥â√—∫¬“

§√∫·ºπ°“√√—°…“ 1 ªï 4 36.3

À¬ÿ¥¬“‡π◊ËÕß®“°‚√§≈ÿ°≈“¡ 2 18.2

À¬ÿ¥¬“‡π◊ËÕß®“°º≈µàÕÀ—«„® 2 18.2

‡ ’¬™’«‘µ 1 9.1

À¬ÿ¥¬“‡π◊ËÕß®“° “‡ÀµÿÕ◊Ëπ 1 9.1

Õ¬Ÿà√–À«à“ß°“√√—°…“ 1 9.1



‚¥¬¡’ºŸâªÉ«¬®”π«π 1 √“¬‰¡à¡’º≈°“√µ√«® ¿“æ°“√∑”ß“π¢ÕßÀ—«„®§‘¥‡ªìπ√âÕ¬≈– 9.1

‡¡◊ËÕæ‘®“√≥“®”π«πºŸâªÉ«¬∑’Ë‰¥â√—∫¬“ Trastuzumab§√∫µ“¡·ºπ°“√√—°…“ 1 ªï ¡’®”π«π 4 √“¬ §‘¥‡ªìπ√âÕ¬≈– 36.4 ºŸâªÉ«¬∑’Ë®”‡ªìπµâÕßÀ¬ÿ¥„™â¬“‡π◊ËÕß®“°Õ“°“√¢Õß‚√§≈ÿ°≈“¡¡“°¢÷Èπ¡’®”π«π 2 √“¬ §‘¥‡ªìπ√âÕ¬≈– 18.2 ‡∑à“°—π°—∫ºŸâªÉ«¬∑’ËµâÕßÀ¬ÿ¥„™â¬“‡π◊ËÕß®“°º≈µàÕÀ—«„®∑”„Àâ°“√∑”ß“π¢ÕßÀ—«„®≈¥≈ß¡’ LVEFµË”°«à“∑’Ë°”Àπ¥§◊Õ√âÕ¬≈– 50 ®”π«π 2 √“¬ §‘¥‡ªìπ√âÕ¬≈– 18.2 ·≈–¡’ºŸâªÉ«¬∑’ËÀ¬ÿ¥„™â¬“ Trastuzumab®“° “‡ÀµÿÕ◊Ëπ®”π«π 1 √“¬ ·≈–ºŸâªÉ«¬‡ ’¬™’«‘µ 1√“¬À≈—ß®“°‰¥â√—∫¬“ §‘¥‡ªìπ√âÕ¬≈– 9.1 ·≈– 9.1 ‡∑à“°—π à«πºŸâªÉ«¬Õ’° 1 √“¬Õ¬Ÿà√–À«à“ß°“√√—°…“ §‘¥‡ªìπ√âÕ¬≈– 9.1 (µ“√“ß∑’Ë 2)

«‘®“√≥å

°“√ª√–‡¡‘π°“√„™â¬“ Trastuzumab „π ∂“∫—π¡–‡√Áß·Ààß™“µ‘®“°‡«™√–‡∫’¬π¢ÕßºŸâªÉ«¬µ—Èß·µà ¡°√“§¡æ.». 2546 - ∏—π«“§¡ æ.». 2550 ¡’®”π«π 11 √“¬‚¥¬‡ª√’¬∫‡∑’¬∫°—∫‡°≥±å¡“µ√∞“π„π°“√„™â¬“¢Õß ∂“∫—π¡–‡√Áß·Ààß™“µ‘ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ ¡’°“√„™â¬“‡À¡“– ¡∑ÿ°√“¬ ‡¡◊ËÕæ‘®“√≥“º≈°“√µ√«® HER2 ‡ªìπ 3+ («‘∏’ IHC) ‡π◊ËÕß®“°¬“Trastuzumab ‡ªìπ monoclonal antibody ∑’Ë®—∫°—∫human epidermal HER2 receptor ·æ∑¬å®÷ßµâÕß‡≈◊Õ°ºŸâªÉ«¬„Àâ‡À¡“– ¡°—∫°“√ÕÕ°ƒ∑∏‘Ï∑“ß‡¿ —™«‘∑¬“‡¡◊ËÕª√–‡¡‘π¢âÕ∫àß„™â∑’Ë°”Àπ¥„Àâ„™â„πºŸâªÉ«¬¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬ ¡’ºŸâªÉ«¬®”π«π 4 √“¬ §‘¥‡ªìπ√âÕ¬≈–36.4 ∑’Ëºà“π°“√ª√–‡¡‘π§«“¡‡À¡“– ¡ (´÷Ëß¡’ 2 √“¬∑’Ë‡ªìπ‚√§¡–‡√Áß√–¬–‡√‘Ë¡µâπ·≈–¡’‚Õ°“ „π°“√°≈—∫§◊π¡“¢Õß‚√§§àÕπ¢â“ß Ÿß ·æ∑¬åµâÕß°“√„™â¬“ Trastuzumab‡ªìπ adjuvant therapy „π‚√§¡–‡√Áß√–¬–·√°‡√‘Ë¡ ·µà‡π◊ËÕß®“°µ‘¥ªí≠À“‰¡à‡ªìπµ“¡¢âÕ∫àß„™â ®÷ß‰¡àºà“π°“√Õπÿ¡—µ‘„Àâ„™â¬“‰¥âµ“¡ «— ¥‘°“√°“√√—°…“æ¬“∫“≈¢Õß¢â“√“™°“√ ·≈â«√–À«à“ßπ—ÈπºŸâªÉ«¬¡’°“√°≈—∫¡“¢Õß‚√§‡√Á«°àÕπ 1 ªïæ√âÕ¡°—∫¡’°“√·æ√à°√–®“¬‰ªµ—∫ ®÷ß‰¥â„™â¬“ Trastuzumab µ√ßµ“¡¢âÕ∫àß„™â„π¡–‡√Áß‡µâ“π¡

√–¬–·æ√à°√–®“¬) à«πºŸâªÉ«¬®”π«π 7 √“¬„™â¬“ Trastuzumab

‰¡à‡À¡“– ¡‡π◊ËÕß®“°„™â‡ªìπ adjuvant therapy „π‚√§¡–‡√Áß√–¬–·√°‡√‘Ë¡§‘¥‡ªìπ√âÕ¬≈– 63.6 „π®”π«π7 √“¬π’È¡’Õ¬Ÿà 2 √“¬µâÕßÀ¬ÿ¥„™â¬“ Trastuzumab‡π◊ËÕß®“°º≈¢â“ß‡§’¬ß¢Õß¬“∑’Ë¡’µàÕ°“√∑”ß“π¢ÕßÀ—«„®§‘¥‡ªìπ√âÕ¬≈– 18.2 ¢Õß®”π«πºŸâªÉ«¬∑—ÈßÀ¡¥ à«πºŸâªÉ«¬®”π«π 4 √“¬‰¥â√—∫¬“§√∫µ“¡·ºπ°“√√—°…“1 ªï §‘¥‡ªìπ√âÕ¬≈– 36.3 ·≈–ºŸâªÉ«¬®”π«π 1 √“¬ ¬—ßÕ¬Ÿà√–À«à“ß°“√√—°…“¥â«¬¬“ Trastuzumab §‘¥‡ªìπ√âÕ¬≈– 9.1

ºŸâªÉ«¬∑ÿ°√“¬§‘¥‡ªìπ√âÕ¬≈– 100 ‰¥â√—∫¬“‡À¡“– ¡µ“¡¢π“¥¬“∑’Ë·π–π” ‡π◊ËÕß®“° Trastuzumab‡ªìπ¬“√—°…“‚√§¡–‡√Áß ´÷Ëß¬“°≈ÿà¡π’ÈµâÕß„Àâ„π¢π“¥∑’Ë‡À¡“– ¡ ∂â“„Àâ¬“„π¢π“¥∑’ËπâÕ¬‡°‘π‰ªÕ“®∑”„Àâ‰¡à¡’ª√– ‘∑∏‘º≈ „™â¬“¡“°‡°‘π‰ª°Á®–‡°‘¥º≈¢â“ß‡§’¬ß¢Õß°“√„™â¬“∑’Ë‡ªìπÕ—πµ√“¬µàÕºŸâªÉ«¬ ®÷ß∑”„Àâ¡’°“√„™â¬“„π¢π“¥∑’Ë‡À¡“– ¡‡æ◊ËÕª√–‚¬™πå Ÿß ÿ¥·°àºŸâªÉ«¬

ºŸâªÉ«¬°≈ÿà¡∑’Ë‡ªìπ‚√§¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬¡’Õ¬Ÿà®”π«π 2 √“¬∑’ËÀ¬ÿ¥„™â¬“‡π◊ËÕß®“°¡’°“√≈ÿ°≈“¡¢Õß‚√§ ∑”„Àâ ¿“æ√à“ß°“¬ºŸâªÉ«¬ÕàÕπ·Õ≈ß ‰¡àæ√âÕ¡√—∫º≈¢â“ß‡§’¬ß‚¥¬‡©æ“–º≈µàÕ°“√∑”ß“π¢ÕßÀ—«„®∑’ËÕ“®‡°‘¥¢÷Èπ‰¥â®“°¬“ ·æ∑¬å®÷ß‰¥âÀ¬ÿ¥„Àâ°“√√—°…“„Àâ°“√√—°…“¥â«¬¬“‡§¡’∫”∫—¥µ—«Õ◊Ëπ √à«¡°—∫°“√√—°…“·∫∫ª√–§—∫ª√–§Õß®π°√–∑—ËßºŸâªÉ«¬‡ ’¬™’«‘µ §‘¥‡ªìπ√âÕ¬≈– 18.2 ·≈–¡’ºŸâªÉ«¬ 1 √“¬‡π◊ËÕß®“°ºŸâªÉ«¬¡’°“√°≈—∫¡“¢Õß‚√§¡–‡√ÁßÀ≈—ß®“°°“√√—°…“‡ √Á® ‘Èπª√–¡“≥5 ‡¥◊Õπ ·≈–¡’ ¿“æ√à“ß°“¬·¢Áß·√ß¥’¡“° ·æ∑¬å®÷ß‰¡à√Õ àßµ√«® MUCA scan ‡æ◊ËÕ¥Ÿ°“√∑”ß“π¢ÕßÀ—«„®°àÕπ„™â¬“ Trastuzumab ‡¡◊ËÕºŸâªÉ«¬‰¥â√—∫¬“Trastuzumab√à«¡°—∫¬“ Docetaxel ºŸâªÉ«¬¡’Õ“°“√‡Àπ◊ËÕ¬ÀÕ∫ º≈°“√µ√«® EKG æ∫«à“Õ—µ√“°“√‡µâπ¢ÕßÀ—«„®º‘¥ª°µ‘ µàÕ¡“‡ ’¬™’«‘µ §‘¥‡ªìπ√âÕ¬≈– 9.1·≈–¡’ºŸâªÉ«¬®”π«π 1 √“¬µâÕßÀ¬ÿ¥„™â¬“®“° “‡ÀµÿÕ◊Ëπ§◊Õ

ªí≠À“°“√¢ÕÕπÿ¡—µ‘„™â¬“®“°°√¡∫—≠™’°≈“ß∑’ËÕπÿ¡—µ‘„™â¬“§√—Èß≈– 3 ‡¥◊Õπ·≈â«µâÕß≈ß∑–‡∫’¬π¢ÕµàÕ

116

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

Õ“¬ÿ ‡¡◊ËÕ·æ∑¬å≈ß∑–‡∫’¬π‰¡àµàÕ‡π◊ËÕß ®÷ß∑”„ÀâºŸâªÉ«¬‰¥â√—∫¬“‰¡àµàÕ‡π◊ËÕß ·æ∑¬å‡ÀÁπ§«√À¬ÿ¥„™â¬“ §‘¥‡ªìπ√âÕ¬≈– 9.1

‡π◊ËÕß®“°¬“ Trastuzumab ‡ªìπ monoclonalantibody µàÕ HER2 ¥—ßπ—Èπ¬“®–ÕÕ°ƒ∑∏‘Ï‰¥â¥’ºŸâªÉ«¬µâÕß¡’º≈°“√µ√«® HER2 ‡ªìπ 3+ ‚¥¬«‘∏’ Immuno-histochemistry À√◊Õ‡ªìπ∫«°‚¥¬«‘∏’ FISH (fluores-cence in situ hybridization) ∑”„ÀâºŸâªÉ«¬®”π«π 11√“¬ ®÷ß¡’º≈°“√µ√«® HER2 ºà“π‡°≥±å∑’Ë°”Àπ¥§‘¥‡ªìπ√âÕ¬≈– 100 ·≈–‡¡◊ËÕ¡“æ‘®“√≥“ ¿“æ√à“ß°“¬ºŸâªÉ«¬∑ÿ°√“¬¡’°“√ª√–‡¡‘π ¿“æ√à“ß°“¬∑’Ë ECOG(Eastern Cooperative Oncology Group) ºà“π‡°≥±å∑’Ë°”Àπ¥ §◊ÕÕ¬Ÿà√–À«à“ß 0-2 §‘¥‡ªìπ√âÕ¬≈– 100‡™àπ°—π

Õ“°“√‰¡àæ÷ßª√– ß§å®“°°“√„™â¬“ Trastuzumab∑’Ë ”§—≠§◊Õ º≈µàÕ§«“¡º‘¥ª°µ‘¢ÕßÀ—«„® ¥—ßπ—Èπ°àÕπ°“√„™â¬“ Trastuzumab ®÷ßµâÕß¡’°“√µ√«®°“√∑”ß“π¢ÕßÀ—«„® ·≈–§«√µâÕß¡’°“√µ√«®‡ªìπ√–¬– ‚¥¬¡’§”·π–π”«à“§«√µ√«®°“√∑”ß“π¢ÕßÀ—«„®∑ÿ° 3 ‡¥◊Õπ¬°‡«âπºŸâªÉ«¬∑’Ë‡√‘Ë¡¡’Õ“°“√º‘¥ª°µ‘¢ÕßÀ—«„®Õ“®µ‘¥µ“¡º≈„Àâ¡’°“√µ√«®∫àÕ¬¢÷Èπ ‡ªìπ∑ÿ° 6-8 —ª¥“Àå ‚¥¬∑—Ë«‰ª·π–π”„ÀâºŸâªÉ«¬‚√§¡–‡√Áß‡µâ“π¡√–¬–·√°∑’Ë®–„™â¬“ Trastuzumab §«√¡’ LVEF (Left VentrocularEjection Fraction) ¡“°°«à“√âÕ¬≈– 55 ·µà‡π◊ËÕß®“°‡°≥±å¡“µ√∞“π°“√„™â¬“¢Õß ∂“∫—π¡–‡√Áß·Ààß™“µ‘„Àâ„™â„πºŸâªÉ«¬‚√§¡–‡√Áß‡µâ“π¡√–¬–·æ√à°√–®“¬ ‡æ◊ËÕÀ«—ß«à“®–™à«¬¬◊¥Õ“¬ÿºŸâªÉ«¬„Àâπ“π¢÷Èπ ®÷ß°”Àπ¥‡æ’¬ß„ÀâºŸâªÉ«¬¡’º≈°“√∑”ß“π¢ÕßÀ—«„® LVEF ∑’Ë‡ªìπ§à“ª°µ‘§◊Õ ¡“°°«à“√âÕ¬≈– 50 ´÷Ëßæ∫«à“¡’ºŸâªÉ«¬®”π«π9 √“¬ §‘¥‡ªìπ√âÕ¬≈– 81.8 ºà“π‡°≥±å∑’Ë°”Àπ¥ ¡’ºŸâªÉ«¬®”π«π 1 √“¬∑’Ë¡’ LVEF πâÕ¬°«à“√âÕ¬≈– 50§‘¥‡ªìπ√âÕ¬≈– 9.1 ·≈–¡’ 1 √“¬∑’Ë‰¡à¡’º≈°“√∑”ß“π¢ÕßÀ—«„®°àÕπ„™â¬“ Trastuzumab §‘¥‡ªìπ√âÕ¬≈– 9.1

®“°°“√»÷°…“π’È®–‡ÀÁπ‰¥â«à“°“√„™â¬“ Trastu-zumab ∑’Ë‰¡à‡À¡“– ¡¡“°∑’Ë ÿ¥ ‡°‘¥®“°°“√„™â¬“‡ªìπadjuvant therapy „πºŸâªÉ«¬‚√§¡–‡√Áß‡µâ“π¡√–¬–·√°‡√‘Ë¡ §◊Õ√âÕ¬≈– 63.6 ·µà‡π◊ËÕß®“°¬“µ—«π’È¡’√“§“

§àÕπ¢â“ß·æß §à“„™â®à“¬¥â“π¬“¡“°°«à“· π∫“∑µàÕ‡¥◊Õπ °“√°”Àπ¥À≈—°‡°≥±å°“√„™â¬“ Trastuzumab¢Õß ∂“∫—π¡–‡√Áß·Ààß™“µ‘·≈–°√¡∫—≠™’°≈“ß¥â“π¢âÕ∫àß„™â®÷ß‡¢â¡ß«¥ ‚¥¬»÷°…“®“°¢âÕ¡Ÿ≈À≈—°∞“π‡™‘ßª√–®—°…å‡æ◊ËÕ„Àâ¡’°“√„™â¬“Õ¬à“ß∂Ÿ°µâÕß §ÿâ¡§à“ ‡À¡“– ¡ ¥—ßπ—Èπ‡¡◊ËÕ°“√„™â¬“∑’Ë¬—ß‰¡à¡’¢âÕ¡Ÿ≈∑’Ë¡’§«“¡πà“‡™◊ËÕ∂◊Õ‡æ’¬ßæÕÀ√◊Õ¬—ßÕ¬Ÿà„π¢—ÈπµÕπ°“√»÷°…“«‘®—¬®÷ß¬—ß‰¡à “¡“√∂π”¡“„™â‡ªìπÀ≈—°‡°≥±å‰¥â ·µà«à“‡¡◊ËÕ‡«≈“ºà“π‰ª°“√»÷°…“π—Èπ‡ √Á® ¡∫Ÿ√≥åÀ√◊Õ¡’°“√»÷°…“ π—∫ πÿπ¡“°¢÷Èπ ®÷ßµâÕßæ‘®“√≥“ª√—∫ª√ÿßÀ≈—°‡°≥±å„Àâ¡’§«“¡∑—π ¡—¬Õ¬Ÿà‡ ¡Õµ“¡‡∑§‚π‚≈¬’∑’Ë¡’°“√‡ª≈’Ë¬π·ª≈ßµ≈Õ¥‡«≈“ ¥—ß‡™àπ°“√„™â¬“ Trastuzumab ∑’Ë¡’º≈°“√»÷°…“∑’Ë‡™◊ËÕ∂◊Õ‰¥âÕÕ°¡“ π—∫ πÿπ«à“°“√„Àâ¬“Trastuzumab ‡ªìπ adjuvant therapy „πºŸâªÉ«¬‚√§¡–‡√Áß‡µâ“π¡√–¬–·√°‡√‘Ë¡∑’Ë¡’°“√°√–®“¬¢Õß‡´≈≈å¡–‡√Áß‰ª¬—ßµàÕ¡πÈ”‡À≈◊Õß√à«¡°—∫¬“‡§¡’∫”∫—¥Õ◊ËπÀ√◊Õ„Àâµ“¡À≈—ß°“√„Àâ¬“‡§¡’∫”∫—¥‡ √‘¡ ∑”„Àâ§«“¡‡ ’Ë¬ß„π°“√°≈—∫‡ªìπ´È”≈¥≈ß ·≈–Õ—µ√“°“√√Õ¥™’«‘µ‡æ‘Ë¡¢÷ÈπÕ¬à“ß¡’π—¬ ”§—≠°«à“°≈ÿà¡ºŸâªÉ«¬∑’Ë‰¡à‰¥â√—∫¬“ Tras-tuzumab ¥—ßπ—Èπ®÷ß§«√¡’°“√ª√—∫ª√ÿßÀ≈—°‡°≥±å„Àâ¡’¢âÕ∫àß„™â„π¡–‡√Áß‡µâ“π¡√–¬–·√°∑’Ë¡’ HER2 «‘∏’ IHC‡ªìπ 3+ À√◊Õ«‘∏’ FISH ‡ªìπ∫«° (+) ¡’°“√°√–®“¬¢Õß‡´≈¡–‡√Áß‰ª¬—ßµàÕ¡πÈ”‡À≈◊Õß µ“¡∑’Ë∑“ß ”π—°§≥–°√√¡°“√Õ“À“√·≈–¬“ ‰¥âÕπÿ≠“µ„Àâ¢÷Èπ∑–‡∫’¬π‡æ‘Ë¡‡µ‘¡ ‡¡◊ËÕ ¡‘∂ÿπ“¬π æ.». 2550

Õ¬à“ß‰√°Áµ“¡°“√„™â¬“¬—ßµâÕß§”π÷ß∂÷ß§«“¡ª≈Õ¥¿—¬„π°“√„™â¬“¢ÕßºŸâªÉ«¬‡ªìπ ”§—≠ ¥—ßπ—Èπ®÷ßµâÕß√–¡—¥√–«—ß„π°“√„™â¬“ „Àâ ∑” MUGA scan À√◊ÕEchocardiogram ‡æ◊ËÕª√–‡¡‘π°“√∫’∫µ—«¢ÕßÀ—«„®°àÕπ°“√„™â¬“ √«¡∑—Èß§«√µâÕßµ√«®°“√ª√–‡¡‘π°“√∑”ß“π¢ÕßÀ—«„®∑ÿ° 3 ‡¥◊Õπ¥â«¬


1. ¡‡°’¬√µ‘ ‚æ∏‘ —µ¬å,∫√√≥“∏‘°“√. §Ÿà¡◊Õª√–‡¡‘π‡∑§‚π‚≈¬’∑“ß°“√·æ∑¬å ©∫—∫ª√—∫ª√ÿß. æ‘¡æå§√—Èß∑’Ë 3. ππ∑∫ÿ√’: ”π—°æ—≤π“«‘™“°“√·æ∑¬å °√¡°“√·æ∑¬å; 2548.

2. Herceptin (trastuzumab): full prescribing information.



South San Francisco, CA: Genentech, 2004. (Cited

2007 June 11): [11 screens] Available from : URL;

http://www.gene.Com/gene/ products/information/

oncology/ herceptin/insert.jsp.

3. Hudis CA. Trastuzumab: mechanism of action and use

in clinical practice. NEJM 2007; 357:39-51.

4. Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton

V, Bajamonde. Use of chemotherapy plus a monoclonal

antibody against HER2 for metastatic breast cancer

that overexpresses HER2. NEJM 2001; 344:783-92.

5. Vogel CL, Cobleigh MA, Tripathy D, Gutheil JC,

Harris LN, Fehrenbacher L. Efficacy and safety of

trastuzumab as a single agent in first-line treatment of

HER2-overexpressing metastatic breast cancer. J Clin

Oncol 2002; 20:719-26.

6. Smith I, Procter M, Gelber RD, Guillaume S,

Feyereislova A, Dowsett M. 2-Year follow-up of

trastuzumab after adjuvant chemotherapy in HER2-

positive breast cancer: a randomised controlled trial.

Lancet 2007; 369:29-36.

7. Seidman A, Hudis C, Pierri MK. Cardiac dysfunction

in the trastuzumab clinical trials experience. J Clin

Oncol 2002; 20:1215-21.

8. Perez EA, Rodeheffer R. Clinical cardiac tolerability

of trastuzumab. J Clin Oncol 2004; 22:322-9.

9. Keefe DL. Trastuzumab-associated cardiotoxicity.

Cancer 2002; 95:1592-600.

10. À≈—°‡°≥±å°“√‡∫‘°®à“¬‡ß‘π «— ¥‘°“√‡°’Ë¬«°—∫°“√√—°…“æ¬“∫“≈µ“¡‚§√ß°“√‡∫‘°®à“¬µ√ß ”À√—∫ºŸâªÉ«¬‚√§¡–‡√Áß∑’Ë·æ∑¬åºŸâ∑”°“√√—°…“¡’·ºπ°“√√—°…“¥â«¬¬“πÕ°∫—≠™’¬“À≈—°·Ààß™“µ‘∑’Ë¡’§à“„™â®à“¬ Ÿß 6 ™π‘¥„πºŸâªÉ«¬ 7 °≈ÿà¡.°“√‡∫‘°®à“¬‡ß‘π «— ¥‘°“√‡°’Ë¬«°—∫°“√√—°…“æ¬“∫“≈µ“¡‚§√ß°“√‡∫‘°®à“¬µ√ß ”À√—∫ºŸâªÉ«¬‚√§¡–‡√Áß,Àπ—ß ◊Õ°√–∑√«ß°“√§≈—ß¥à«π∑’Ë ÿ¥∑’Ë °§ 0417/« 69. (≈ß«—π∑’Ë 31 ‘ßÀ“§¡ 2549.)

118

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å


°“√≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√®“°‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬ ŸßÕ“¬ÿ ÿ§π∏“ ªí∑¡ ‘ßÀå ≥ Õ¬ÿ∏¬“ æ.∫.°≈ÿà¡ß“π®—°…ÿ«‘∑¬“ ‚√ßæ¬“∫“≈ ß¶å

Abstract Visual Impairment Reduction in Common Elderly Eye DiseasesPattamasingh Na Ayuthaya S.

Faculty of Eye, Priest Hospital


Blindness situation from cataract in Thailand has been brought under satisfactory control. Ingovernmental sector alone, the cataract surgical output has now reached over 67,000 cases per year, while theestimated incidence of new blinding cataract cases are 60,000 cases per year. It is expected that there will beno cataract backlogs left in 5 years from now on. And now, the new leading causes of blindness are those thatfall into unavoidable and untreatable blindness such as glaucoma, age-related macular degeneration (AMD)and diabetic retinopathy (DR). Blindness from now on will be hard to prevent and cure. It needs continuingefforts in new technology and knowledge development. The common characteristics of these non-communicablediseases are aging and getting worsen by environments. Life style acts decisively to prognosis. In addition,the issue much relies on a financing system because of lifelong care and high cost maintenance. Therefore itis necessary to provide health education in the elderly, especially prevention from many high risk factors androutine check up is the first priority for early detection.

Key words: visual impairment, common elderly eye diseases

‡√◊ËÕß¬àÕ ‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“‚¥¬∑∫∑«π«√√≥°√√¡Õ¬à“ß‡ªìπ√–∫∫ „π¥â“π “‡Àµÿ¢Õß‚√§µ“∫Õ¥ °“√ªÑÕß°—π ·≈–°“√—°…“ ªí≠À“µ“∫Õ¥·≈– “¬µ“æ‘°“√¢Õßª√–‡∑»‰∑¬ §◊Õ “¬µ“æ‘°“√®“°‚√§µ“∑’Ë‰¡àµ‘¥µàÕ ´÷Ëß‡°‘¥®“° “‡Àµÿ∑“ßæ—π∏ÿ°√√¡ ¿“«–·«¥≈âÕ¡ §«“¡‡ ◊ËÕ¡µ“¡«—¬ ·≈–æƒµ‘°√√¡∑’Ë‡ª≈’Ë¬π‰ª¢Õßª√–™“™π ‚√§„π°≈ÿà¡π’È∑’Ëæ∫∫àÕ¬‰¥â·°à µâÕÀ‘π ®Õª√– “∑µ“ à«π°≈“ß‡ ◊ËÕ¡ (age-related macular degeneration; AMD) ·≈–‡∫“À«“π„π®Õª√– “∑µ“ (diabetic retinopathy; DR)÷Ëß‚√§‡À≈à“π’Èæ∫‰¥â∫àÕ¬„πºŸâ ŸßÕ“¬ÿ ‡ªìπ‚√§∑’Ëº≈°“√√—°…“¢÷Èπ°—∫√–¬–‡«≈“∑’Ëæ∫·æ∑¬å‰¥â‡√Á«À√◊Õ™â“ Õ’°∑—Èßº≈°“√√—°…“¡—°‰¡àÀ“¬¢“¥

µâÕßµ‘¥µ“¡º≈°“√√—°…“Õ¬à“ß ¡Ë”‡ ¡Õ ‡ªìπ°“√„™â ∑√—æ¬“°√¡“°„π°“√√—°…“ºŸâªÉ«¬ ®÷ß ¡§«√„Àâ§«“¡√Ÿâ·°àª√–™“™π „Àâ∑√“∫∂÷ßªí®®—¬‡ ’Ë¬ßµà“ßÊ„π°“√‡°‘¥‚√§‡À≈à“π’È‡æ÷ËÕ®–‰¥âÀ“«‘∏’ªÑÕß°—π∑’Ë‡À¡“– ¡ §«√¡’°“√·π–π”·≈– àß‡ √‘¡„Àâ¡’°“√µ√«® ÿ¢¿“æµ“ª√–®”ªï„πºŸâ ŸßÕ“¬ÿ ‡æ◊ËÕ°“√µ√«®æ∫§«“¡º‘¥ª°µ‘‰¥âµ—Èß·µà„π√–¬–·√°‡√‘Ë¡ ´÷Ëß°“√√—°…“¬àÕ¡®–‰¥âº≈¥’°«à“ ‡ªìπ°“√™à«¬≈¥§«“¡ Ÿ≠‡ ’¬∑’Ë®–‡°‘¥µ“¡¡“∑—Èß¥â“π ÿ¢¿“æµ“·≈–§ÿ≥¿“æ™’«‘µ Õ’°∑—Èß§à“„™â®à“¬·≈–‡«≈“„π°“√¥Ÿ·≈√—°…“ ÷Ëß®– àßº≈°√–∑∫∂÷ß§√Õ∫§√—« —ß§¡ ·≈–ª√–‡∑»™“µ‘µ“¡¡“

§” ”§—≠: “¬µ“æ‘°“√ ‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿ



∫∑π”

ºŸâªÉ«¬ “¬µ“æ‘°“√°«à“ 161 ≈â“π§π1 ‚¥¬¡’§πµ“∫Õ¥®”π«π 37 ≈â“π§π ·≈– “¬µ“‡≈◊Õπ√“ß®”π«π124 ≈â“π§π Õ’°∑—Èßæ∫«à“¡’§πµ“∫Õ¥‡æ‘Ë¡¢÷Èπªï≈– 1-2≈â“π§π „πªï §.». 2020 §“¥°“√≥å«à“®–¡’§πµ“∫Õ¥‡æ‘Ë¡¢÷Èπ‡ªìπ 2 ‡∑à“¢Õßªí®®ÿ∫—π ®“° ∂‘µ‘„πªï §.». 2002æ∫«à“ “‡ÀµÿÀ≈—°¢Õßµ“∫Õ¥„π‚≈°π’È §◊Õ µâÕ°√–®°æ∫‰¥â∂÷ß√âÕ¬≈– 47.8 ”À√—∫ª√–‡∑»‰∑¬ ®“°°“√ ”√«®¿“«–µ“∫Õ¥2-4 ·≈– “¬µ“æ‘°“√√«¡∑—Èß‚√§∑’Ë‡ªìπ “‡Àµÿ ”§—≠¢Õßµ“∫Õ¥„π 3 §√—Èß∑’Ëºà“π¡“§◊Õ „πªïæ.». 2527, æ.». 2530 ·≈– æ.». 2537 æ∫«à“§«“¡™ÿ°¢Õßµ“∫Õ¥„π§π‰∑¬≈¥≈ß®“°√âÕ¬≈– 1.14 ‡ªìπ√âÕ¬≈– 0.57 ·≈– 0.31 µ“¡≈”¥—∫ ®“°°“√ ”√«®∑—Èß3 §√—Èßπ—Èπ æ∫«à“ “‡Àµÿ¢Õßµ“∫Õ¥„πºŸâ ŸßÕ“¬ÿ∑’Ë ”§—≠§◊Õ µâÕ°√–®° ·≈–¡’ºŸâªÉ«¬µâÕ°√–®°∑’Ë¬—ß‰¡à‰¥â√—∫°“√ºà“µ—¥Õ’°‡ªìπ®”π«ππ—∫· π§π „πªí®®ÿ∫—πÕ—µ√“°“√ºà“µ—¥µâÕ°√–®°¡’¡“°°«à“Õ—µ√“¢ÕßµâÕ°√–®°∑’Ë∑”„ÀâºŸâªÉ«¬µ“∫Õ¥·≈â« §“¥«à“¿“¬„π√–¬–‡«≈“ 5 ªï®–‰¡à¡’ºŸâªÉ«¬µâÕ°√–®°µ°§â“ßÕ’°µàÕ‰ª ∂◊Õ‡ªìπ§«“¡ ”‡√Á®¢Õß°√–∑√«ß “∏“√≥ ÿ¢∑’Ë “¡“√∂§«∫§ÿ¡ avoidableblindness ‰¥â‡À¡◊Õπ°≈ÿà¡ª√–‡∑»∑’Ëæ—≤π“·≈â«

ªí≠À“µ“∫Õ¥·≈– “¬µ“æ‘°“√ ‡ªìπªí≠À“ “∏“√≥ ÿ¢∑’Ë ”§—≠ ‡π◊ËÕß®“° àßº≈°√–∑∫µàÕ∫ÿ§§≈§√Õ∫§√—« ‡»√…∞°‘®·≈– —ß§¡ ∂“π°“√≥åªí≠À“µ“∫Õ¥·≈– “¬µ“æ‘°“√¢Õßª√–‡∑»‰∑¬„πªí®®ÿ∫—π‰¥â‡ª≈’Ë¬π·ª≈ß‰ª®“°‡¥‘¡¡“° ®“° avoidable blindness´÷Ëß‡ªìπ°≈ÿà¡¢Õß‚√§µ‘¥‡™◊ÈÕ ‡™àπ‚√§√‘¥ ’¥«ßµ“ ·≈–‚√§¢“¥ “√Õ“À“√ ‡™àπ ‚√§¢“¥«‘µ“¡‘π‡Õ (vitamin Adeficiency) Õ’°∑—Èß‚√§µâÕ°√–®° ´÷Ëß‡ªìπ‚√§∑’Ë “¡“√∂ªÑÕß°—π√—°…“‰¡à„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬ “¬µ“À√◊Õµ“∫Õ¥π—Èπ

ªí®®ÿ∫—π·π«‚πâ¡ ¿“æªí≠À“¢Õß‚√§µ“„πª√–‡∑»‰∑¬ ¡’≈—°…≥–‡ªìπ‚√§µ“∫Õ¥∑’ËÀ≈’°‡≈’Ë¬ß‰¡à‰¥â¡“°¢÷Èπ (unavoidable blindness) ´÷Ëß‰¥â·°à ‚√§µâÕÀ‘π ‚√§®Õª√– “∑µ“ ‚√§‡∫“À«“π ‡ªìπµâπ ∂“π°“√≥å¢Õß‚√§µà“ßÊ ‡À≈à“π’È‰¥â‡°‘¥°“√·ª√‡ª≈’Ë¬π‰ªµ“¡ ¿“«–‡»√…∞°‘® —ß§¡ ·≈–‚§√ß √â“ßª√–™“°√‚≈°∑’Ë¡’Õ“¬ÿ¬◊π¬“«¢÷Èπ ‰¥â‡°‘¥°“√‡ª≈’Ë¬π·ª≈ß®“°‚√§

µ“∑’ËªÑÕß°—π·≈–√—°…“‰¥â Ÿà‚√§µ“∑’Ë√—°…“¬“°¢÷Èπ ‘Èπ‡ª≈◊Õß¡“°¢÷Èπ ·≈–À≈’°‡≈’Ë¬ß‰¡à‰¥â ¥—ßπ—Èπ°“√„Àâ∫√‘°“√∑“ß®—°…ÿ®÷ßµâÕß„™â°≈¬ÿ∑∏ ”§—≠„π°“√∑’Ë®– “¡“√∂º “πß“π∫√‘°“√≈ß„π·ºπß“π §«∫§ÿ¡‚√§‰¡àµ‘¥µàÕ·Ààß™“µ‘ ‚¥¬¡’‡ªÑ“À¡“¬¡ÿàßµ√ß‡¢â“À“ª√–™“™π∑ÿ°§πµ“¡°≈ÿà¡Õ“¬ÿ ‡πâπ„Àâ¡’°“√ àß‡ √‘¡ ÿ¢¿“æ·≈–ªÑÕß°—π‚√§µ“∑’Ë®–æ∫µ“¡°≈ÿà¡Õ“¬ÿµà“ßÊ ¡ÿàß‡πâπ„Àâ™ÿ¡™π¡’ ÿ¢¿“æµ“∑’Ë¥’¢÷Èπ ·≈–°“√¥Ÿ·≈‚√§µ“„πºŸâ ŸßÕ“¬ÿ„Àâ¡“°¢÷Èπ

°“√»÷°…“„π§√—Èßπ’È‡ªìπ°“√»÷°…“‡©æ“–‚√§µ“∑’Ëæ∫∫àÕ¬∑’Ë∑”„Àâ‡°‘¥¿“«– “¬µ“æ‘°“√„πºŸâªÉ«¬ ŸßÕ“¬ÿ ‚¥¬»÷°…“∂÷ß “‡Àµÿ·≈–ªí®®—¬‡ ’Ë¬ßµà“ßÊ ¢Õß‚√§µ“∑’Ëæ∫∫àÕ¬ „πºŸâªÉ«¬ ŸßÕ“¬ÿ∑’Ë∑”„Àâ‡°‘¥ “¬µ“æ‘°“√ ·≈–»÷°…“ ‚§√ß √â“ßÕ«—¬«–¢Õßµ“·≈–√“¬≈–‡Õ’¬¥‡°’Ë¬«°—∫‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâªÉ«¬ ŸßÕ“¬ÿ ‡æ◊ËÕ»÷°…“·π«∑“ß°“√ªÑÕß°—π·≈–√—°…“‡æ◊ËÕ≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√„πºŸâªÉ«¬ ŸßÕ“¬ÿ‡À≈à“π’È

«—µ∂ÿ·≈–«‘∏’°“√

‡ªìπ°“√»÷°…“‡™‘ßæ√√≥π“ ‚¥¬∑∫∑«π«√√≥-°√√¡∑’Ë‡°’Ë¬«¢âÕßÕ¬à“ß‡ªìπ√–∫∫ (Systematic Review)®“°π—Èπ∑”°“√ —ß‡§√“–Àåªí≠À“‚√§Õ—π¥—∫µâπÊ ∑’Ë‡ªìπ “‡Àµÿ¢Õß “¬µ“æ‘°“√„πºŸâªÉ«¬ ŸßÕ“¬ÿ ‰¥â·°à ‚√§µâÕ°√–®° µâÕÀ‘π ®Õª√– “∑µ“ à«π°≈“ß‡ ◊ËÕ¡ ·≈–‡∫“À«“π„π®Õª√– “∑µ“ ªí®®—¬‡ ’Ë¬ßµà“ßÊ∑’Ë∑”„Àâ‡°‘¥‚√§ ·≈–°“√ªÑÕß°—π‡æ◊ËÕ≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√„πºŸâªÉ«¬ ŸßÕ“¬ÿ‡À≈à“π’È

º≈

·π«∑“ß°“√≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√®“°‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿ æ‘®“√≥“‰¥â‡ªìπ 2·π«∑“ß §◊Õ °“√√—°…“·≈–°“√ªÑÕß°—π√«¡∂÷ß°“√§—¥°√ÕßºŸâªÉ«¬ ®“°°“√»÷°…“æ∫«à“ “‡Àµÿ¢Õßµ“∫Õ¥„πª√–‡∑»æ—≤π“·≈â«°—∫ª√–‡∑»°”≈—ßæ—≤π“®–¡’≈—°…≥–µà“ß°—π§◊Õ „πª√–‡∑»∑’Ëæ—≤π“·≈â«¡’Õ—µ√“µ“∫Õ¥ª√–¡“≥√âÕ¬≈– 0.05-0.2 “‡Àµÿ à«π„À≠à‡ªìπ¿“«–‡ ◊ËÕ¡µ“¡ (chronic degenerative conditions)

120

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

´÷ËßÕ—µ√“µ“∫Õ¥„π‡¢µ‡¡◊Õß·≈–™π∫∑®–‰¡à·µ°µà“ß°—π¡“° ‚√§∑’Ë√—°…“·≈–ªÑÕß°—π‰¡à„Àâµ“∫Õ¥‰¥â®–æ∫πâÕ¬ ‡™àπ ‚√§µâÕ°√–®° ‚√§∑“ßµ“®“°¿“«–∑ÿ‚¿™π“°“√·≈–‚√§µ‘¥‡™◊ÈÕ ‡À≈à“π’È®–æ∫πâÕ¬ ‡π◊ËÕß®“°ª√–™“°√„πª√–‡∑»æ—≤π“·≈â« à«π„À≠à¡’Õ“¬ÿ¬◊π ¥—ßπ—Èπ‚√§„πºŸâ ŸßÕ“¬ÿ ·≈–‚√§‡√◊ÈÕ√—ß∫“ß‚√§°Á®–æ∫‰¥â Ÿß¢÷Èπ ‡™àπ‚√§®Õª√– “∑µ“‡ ◊ËÕ¡„πºŸâ ŸßÕ“¬ÿ ‚√§‡∫“À«“π ·≈–‚√§µâÕÀ‘π ÷Ëß‚√§‡À≈à“π’È°Áæ∫‰¥â„πª√–‡∑»°”≈—ßæ—≤π“·µà„π —¥ à«π∑’Ëµà“ß°—π ª√–‡∑»∑’Ë°”≈—ßæ—≤π“¡’Õ—µ√“µ“∫Õ¥ª√–¡“≥√âÕ¬≈– 0.5-2.0 ·≈–„π‡¢µ™π∫∑∑’ËÀà“ß‰°≈ Õ—µ√“µ“∫Õ¥Õ“® Ÿß∂÷ß√âÕ¬≈– 5 ´÷Ëß “‡Àµÿ à«π„À≠à§◊ÕµâÕ°√–®°¥—ß∑’Ë‰¥â°≈à“«·≈â«

”À√—∫ª√–‡∑»‰∑¬æ∫Õ—µ√“µ“∫Õ¥√âÕ¬≈– 1.14®“°°“√ ”√«®‡¡◊ËÕªï æ.». 2526 ·≈–≈¥≈ß‡À≈◊Õ√âÕ¬≈–0.56 ®“°°“√ ”√«®„πªï æ.». 2530 ·≈–„π°“√ ”√«®§√—Èß≈à“ ÿ¥‡¡◊ËÕªï æ.». 2537 Õ—µ√“µ“∫Õ¥≈¥≈ß‡À≈◊Õ‡æ’¬ß√âÕ¬≈– 0.31 ®÷ßÕ¬Ÿà°÷Ëß°≈“ß√–À«à“ßª√–‡∑»∑’Ëæ—≤π“·≈â«°—∫ª√–‡∑»∑’Ë°”≈—ßæ—≤π“ ‚√§∑’ËªÑÕß°—π·≈–√—°…“‰¥â‰¥â≈¥≈ß¡“° ·≈–¡’·π«‚πâ¡∑’Ë ®–æ∫‚√§‡√◊ÈÕ√—ß„πºŸâ ŸßÕ“¬ÿ‡æ‘Ë¡¡“°¢÷Èπ¥—ß‡™àπ„πª√–‡∑» ∑’Ëæ—≤π“·≈â«

·π«∑“ß°“√√—°…“·≈–ªÑÕß°—π “¬µ“æ‘°“√®“°‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿ5 ´÷Ëß‰¥â·°à‚√§µàÕ‰ªπ’È §◊Õ

1. µâÕ°√–®° (cataract)2. µâÕÀ‘π (glaucoma)3. ‚√§®Õµ“ à«π°≈“ß‡ ◊ËÕ¡ (age-related

macula degeneration; AMD)4. ‚√§‡∫“À«“π∑’Ë®Õª√– “∑µ“ (eiabetic

retinopathy; DR)µâÕ°√–®°

®“°°“√∑’Ë°√–∑√«ß “∏“√≥ ÿ¢‰¥â¥”‡π‘π‚§√ß°“√ªÑÕß°—πµ“∫Õ¥·≈–§«∫§ÿ¡ “¬µ“æ‘°“√Õ¬à“ßµàÕ‡π◊ËÕßπ—∫µ—Èß·µàªï æ.». 2521 ‡ªìπµâπ¡“ ª√“°Øº≈ ”‡√Á®§◊Õ “¡“√∂≈¥Õ—µ√“µ“∫Õ¥¢Õßª√–‡∑»≈ß¥—ß°≈à“«·≈â«·≈–‡ªìπº≈„Àâ¡’°“√®—¥µ—ÈßÀπà«¬∫√‘°“√ ”À√—∫¥Ÿ·≈√—°…“µ“ ‚¥¬‡ªìπ à«πÀπ÷Ëß¢Õß°“√„Àâ∫√‘°“√µ“¡√–∫∫ “∏“√≥ ÿ¢¡Ÿ≈∞“π¢÷ÈπÕ¬à“ß§√Õ∫§≈ÿ¡Õ¬Ÿàµ“¡¿Ÿ¡‘¿“§µà“ßÊ ¢Õßª√–‡∑» ªí®®ÿ∫—π‚√§µâÕ°√–®°´÷Ëß®—¥Õ¬Ÿà„π

ª√–‡¿∑ avoidable blindness ¬—ß§ß‡ªìπ “‡Àµÿ ”§—≠¢Õßªí≠À“µ“∫Õ¥·≈– “¬µ“æ‘°“√¢Õßª√–‡∑»‰∑¬ ‚¥¬∑’Ë¢π“¥¢Õßªí≠À“Õ¬Ÿà„π√–¥—∫∑’Ë “¡“√∂®—¥°“√‰¥â¥â«¬¢’¥§«“¡ “¡“√∂¢Õß°“√„Àâ∫√‘°“√„π√–¥—∫ªí®®ÿ∫—π ∂‘µ‘‡¡◊ËÕªï æ.».2538 æ∫«à“°“√„Àâ∫√‘°“√ºà“µ—¥µâÕ°√–®°„πª√–‡∑»‰∑¬¡’®”π«π∑—Èß ‘Èπ 63,510 √“¬´÷Ëß‡ªìπ°“√ª√–¡“≥¢—ÈπµË” ¢≥–∑’Ëª√–¡“≥°“√µ—«‡≈¢¢Õß§«“¡µâÕß°“√°“√ºà“µ—¥µâÕ°√–®°¢Õßª√–™“°√‰∑¬‡æ◊ËÕ‰¡à„Àâ‡°‘¥¿“«–µ“∫Õ¥®“°µâÕ°√–®°µ°§â“ß„π·µà≈–ªï‡∑à“°—∫ 60,000 √“¬ ®–‡ÀÁπ«à“∂â“¡’√–∫∫§âπÀ“·≈– π—∫ πÿπ„ÀâºŸâªÉ«¬∑’Ë®”‡ªìπµâÕß‰¥â√—∫°“√ºà“µ—¥„Àâ‡¢â“√—∫∫√‘°“√‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ·≈â« √–¥—∫°“√„Àâ∫√‘°“√„πªí®®ÿ∫—π°Áπ—∫«à“‡æ’¬ßæÕ„π°“√·°â‰¢ªí≠À“µ“∫Õ¥¢Õßª√–‡∑»‰¥â

Õ¬à“ß‰√°Áµ“¡ ªí≠À“∑’Ëæ∫§◊Õ ‚Õ°“ „π°“√‡¢â“∂÷ß∫√‘°“√¢Õßª√–™“™π¬—ß‰¡à‡∑à“‡∑’¬¡°—π „π∫√√¥“®”π«πºŸâªÉ«¬∑’Ë‰¥â√—∫∫√‘°“√ºà“µ—¥‰ªπ—Èπ à«π„À≠à‡ªìπºŸâ∑’Ë¡’‚Õ°“ ¥’°«à“®÷ß‰¥â√—∫°“√√—°…“‡√Á«‚¥¬∑’Ë√–¥—∫°“√¡Õß‡ÀÁπ¬—ß‰¡à∂÷ß¢÷Èπµ“∫Õ¥ ¢≥–∑’ËºŸâ∑’Ë§«√‰¥â√—∫°“√√—°…“∑’Ë‡¢â“¢—Èπµ“∫Õ¥Õ’°¡“° °≈—∫‡¢â“‰¡à∂÷ß∫√‘°“√®÷ß¡’§«“¡®”‡ªìπ∑’Ë®–µâÕßæ—≤π“√–∫∫∫√‘°“√ ‡æ◊ËÕ·°â‰¢ªí≠À“§«“¡‡À≈◊ËÕ¡≈È”·≈–‰¡à‡ªìπ∏√√¡π’È6

ªí®®ÿ∫—π¬—ß‰¡à¡’¬“ ”À√—∫√—°…“µâÕ°√–®° °“√√—°…“∑’Ë‰¥âº≈¥’ ”À√—∫‚√§π’È§◊Õ°“√ºà“µ—¥ ´÷Ëß “¡“√∂∑”‰¥âÀ≈“¬«‘∏’ ·µà∑’Ëπ‘¬¡∑’Ë ÿ¥§◊Õ°“√ ≈“¬µâÕ°√–®°¥â«¬§≈◊Ëπ‡ ’¬ß (phacoemulsification) √à«¡°—∫°“√„ à‡≈π å·°â«µ“‡∑’¬¡ °“√ºà“µ—¥«‘∏’π’È®–‰¥â·º≈‡≈Á°¡“°´÷ËßÕ“®‰¡à®”‡ªìπµâÕß¡’°“√‡¬Á∫·º≈ ·≈–Õ“®‰¡à®”‡ªìπµâÕß©’¥¬“™“ ºŸâªÉ«¬®– “¡“√∂‡ÀÁπ™—¥‰¥â∑—π∑’À≈—ß‡ªî¥µ“„π«—π√ÿàß¢÷Èπ ”À√—∫°“√√—°…“µâÕ°√–®°‚¥¬°“√„™â¬“¢≥–π’È¬—ß‰¡à¡’¬“„¥Ê ∑’Ë®– “¡“√∂√—°…“µâÕ°√–®°„ÀâÀ“¬‰¥â

°“√ªÑÕß°—πµâÕ°√–®° ¬—ß‰¡à “¡“√∂ªÑÕß°—πµâÕ°√–®°‰¥â ¥â“π°“√≈¥§«“¡‡ ’Ë¬ß¢Õß°“√‡°‘¥µâÕ°√–®° ´÷Ëß‰¥â·°à °“√ß¥∫ÿÀ√’Ë À≈’°‡≈’Ë¬ß· ßÕ“∑‘µ¬å¥â«¬°“√ «¡·«àπ°—π·¥¥ §«∫§ÿ¡√–¥—∫πÈ”µ“≈·≈–‰¢¡—π„πÀ≈Õ¥‡≈◊Õ¥ À≈’°‡≈’Ë¬ß°“√„™â¬“∫“ßª√–‡¿∑ ‡™àπ



°≈ÿà¡ ‡µ’¬√Õ¬¥å √–«—ßÕÿ∫—µ‘‡Àµÿ∑“ßµ“ „Àâ°‘πÕ“À“√∑’Ë¡’ª√–‚¬™πå ‡™◊ËÕ«à“ antioxidants ‡™àπ carotenes «‘µ“¡‘π ’·≈– Õ’ ™à«¬™–≈Õ°“√¥”‡π‘π¢Õß‚√§π’È‰¥â

°“√§—¥°√ÕßºŸâªÉ«¬µâÕ°√–®° “¡“√∂™à«¬≈¥®”π«πºŸâªÉ«¬µ“∫Õ¥®“°‚√§π’È‰¥â ‚¥¬‡©æ“–ºŸâªÉ«¬∑’ËÕ¬ŸàÀà“ß‰°≈§«“¡‡®√‘≠·≈–Õ¬Ÿà„π™π∫∑∑’ËÀà“ß‰°≈À√◊Õ¡’∞“π–¬“°®π‰¡à “¡“√∂‡¢â“∂÷ß°“√√—°…“„π‚√ßæ¬“∫“≈‰¥â°“√§âπÀ“ª√–™“™π∑’Ë¡’ªí≠À“‡À≈à“π’ÈµâÕßÕ“»—¬Àπà«¬ß“πÀ≈“¬Àπà«¬ß“π√à«¡¡◊Õ°—π ‡√‘Ë¡®“°Õ“ “ ¡—§√ “∏“√≥ ÿ¢™à«¬§âπÀ“ºŸâ∑’Ë¡Õß‡ÀÁπ‰¡à™—¥‡®π §—¥°√Õßªí≠À“‚¥¬°“√µ√«®∑’Ë ∂“π’Õπ“¡—¬‡∫◊ÈÕßµâπ ·≈– àßµàÕ‰ª¬—ß‚√ßæ¬“∫“≈™ÿ¡™π ®“°π—Èπ àßµàÕ‰ª¬—ß®—°…ÿ·æ∑¬å„π‚√ßæ¬“∫“≈∑—Ë«‰ªÀ√◊Õ‚√ßæ¬“∫“≈»Ÿπ¬å‡æ◊ËÕ√—∫°“√√—°…“ºà“µ—¥·°â‰¢ ”À√—∫ªí≠À“‡°’Ë¬«°—∫‡»√…∞“π– À√◊Õ¢âÕ®”°—¥¥â“π°“√‡ß‘π ªí®®ÿ∫—π‚§√ß°“√ª√–°—π ÿ¢¿“æ “¡“√∂§√Õ∫§≈ÿ¡∂÷ß°“√ºà“µ—¥‚√§π’È¥â«¬ °√–∑√«ß “∏“√≥ ÿ¢‰¥â®—¥„Àâ¡’°“√∫√‘°“√®—°…ÿ‡§≈◊ËÕπ∑’Ë ºà“µ—¥µâÕ°√–®°‡§≈◊ËÕπ∑’Ë‰ª„π∑âÕß∂‘Ëπ∑ÿ√°—π¥“√·≈–Àà“ß‰°≈Õ’°¥â«¬µà“ßÊ ‡À≈à“π’È ™à«¬„Àâ “¡“√∂≈¥Õ—µ√“ “¬µ“æ‘°“√®“°µâÕ°√–®°‰¥â

µâÕÀ‘π

°“√≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√®“°‚√§µâÕÀ‘π ∑’Ë ”§—≠§◊Õ °“√µ√«®æ∫§«“¡º‘¥ª°µ‘¢Õß§«“¡¥—π¿“¬„π≈Ÿ°µ“µ—Èß·µà√–¬–‡√‘Ë¡·√° ÷Ëß¡—°µ√«®æ∫‰¥â‚¥¬°“√µ√«® ÿ¢¿“æµ“ª√–®”ªï„πª√–™“°√Õ“¬ÿ¡“°°«à“ 40 ªï ‡π◊ËÕß®“°„π√–¬–·√°¢Õß‚√§π’È®–‰¡à¡’Õ“°“√· ¥ß∑’Ëº‘¥ª°µ‘·µàÕ¬à“ß„¥ ”À√—∫°≈ÿà¡§π∑’Ë¡’§«“¡‡ ’Ë¬ßµàÕ‚√§π’È ‰¥â·°à§π∑’Ë¡’ª√–«—µ‘‡ªìπ‚√§π’È„π§√Õ∫§√—« ºŸâªÉ«¬‡∫“À«“π ºŸâ¡’ “¬µ“ —Èπ¡“° §«√‰¥â√—∫°“√µ√«® ÿ¢¿“æµ“∫àÕ¬¢÷Èπ

°“√√—°…“∑’Ë‰¥âº≈¥’∑’Ë ÿ¥§◊Õ °“√µ√«®æ∫‚√§µ—Èß·µà√–¬–‡√‘Ë¡·√°∑’Ë¬—ß‰¡à∑”≈“¬ª√– “∑µ“ ®–‰¡à¡’°“√ Ÿ≠‡ ’¬¢Õß “¬µ“·µàÕ¬à“ß„¥7-9 µâÕÀ‘π‡√◊ÈÕ√—ß à«π„À≠à‰¡à√Ÿâ “‡Àµÿ™—¥‡®π ‡ªìπ “‡Àµÿ¢Õßµ“∫Õ¥·≈– “¬µ“‡≈◊Õπ√“ß∑’Ë ”§—≠¢Õßª√–™“°√À“°µ√«®æ∫·≈–„Àâ°“√√—°…“™â“ºŸâªÉ«¬®–µ“∫Õ¥‚¥¬‰¡à¡’∑“ß·°â‰¢

°“√«‘π‘®©—¬Õ“»—¬Õ“°“√· ¥ß∑’Ë ”§—≠ 3 Õ¬à“ß

‰¥â·°à §«“¡¥—πµ“ Ÿß §«“¡º‘¥ª°µ‘¢Õß optic disc cup·≈–≈“π “¬µ“∑’Ëº‘¥ª°µ‘ °“√§—¥°√Õß‚√§π’È¥â«¬°“√«—¥§«“¡¥—πµ“‡ªìπ«‘∏’∑’Ëßà“¬∑’Ë ÿ¥ Õ¬à“ß‰√°Áµ“¡§«“¡®”‡ªìπ„π°“√«—¥§«“¡¥—πµ“‡æ◊ËÕ§—¥°√ÕßÀ“‚√§¬—ß‡ªìπ∑’Ë∂°‡∂’¬ß°—πÕ¬Ÿà ‡π◊ËÕß®“°¢“¥ªí®®—¬¥â“π∫ÿ§≈“°√·≈–‡§√◊ËÕß¡◊Õ°“√«—¥§«“¡¥—π §«“¡ ”§—≠Õ¬Ÿà∑’Ë°“√«‘π‘®©—¬‰¥âµ—Èß·µà√–¬–‡√‘Ë¡·√° ®–‰¥âº≈¥’∑’Ë ÿ¥

°“√√—°…“ ‚¥¬ √ÿª·≈â«°“√«—¥§«“¡¥—πµ“ ∂â“æ∫«à“ Ÿß°«à“ª°µ‘§«√√—∫°“√µ√«® optic disc ·≈–µ√«®≈“π “¬µ“ ‡æ◊ËÕ°“√«‘π‘®©—¬∑’Ë·πàπÕπ°àÕπ„Àâ°“√√—°…“ ”À√—∫ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√µ√«®«‘π‘®©—¬«à“‡ªìπµâÕÀ‘π‡√◊ÈÕ√—ß™—¥‡®π·≈â« §«√‡√‘Ë¡°“√√—°…“¥â«¬¬“≈¥§«“¡¥—πµ“ Õ“®‡ªìπ¬“≈¥°“√ √â“ß aqueous À√◊Õ°“√‡æ‘Ë¡ outflow ¬“∑’Ë„™âÕ“®·∫àß‡ªìπ°≈ÿà¡µà“ßÊ ‰¥â·°àcholinergic agonist, adrenergic agonist, beta blocker·≈– oral carbonic anhydrase inhibitor µ≈Õ¥®π¬“µ—«„À¡à selective α2 adrenergic agonist ·≈–topical carbonic anhydrase inhibitor Õ¬à“ß‰√°Áµ“¡°“√„™â¬“¥—ß°≈à“«¢â“ßµâπµâÕß„™â°—πµ≈Õ¥™’«‘µæ∫«à“ºŸâªÉ«¬¡—°®–„™â¬“‰¡à ¡Ë”‡ ¡Õ∂÷ß√âÕ¬≈– 11.8 ®÷ß‡ªìπ‡Àµÿ„Àâ°“√§«∫§ÿ¡§«“¡¥—πµ“∑”‰¥â‰¡à¥’ ∑—Èßπ’È à«πÀπ÷Ëß§ß‡°‘¥®“°º≈¢â“ß‡§’¬ß¢Õß¬“„π°≈ÿà¡‡À≈à“π’È¥â«¬

°“√√—°…“¥â«¬· ß‡≈‡´Õ√å ∑’Ë‡√’¬°«à“ argon lasertrabeculoplasty „πºŸâªÉ«¬µâÕÀ‘π‡√◊ÈÕ√—ß·¡â®–¡’√“¬ß“π«à“‰¥âº≈¥’æÕ ¡§«√ ·µàº≈¢Õß°“√≈¥§«“¡¥—πµ“®–§àÕ¬Ê ≈¥≈ß ‡¡◊ËÕµ‘¥µ“¡º≈„π√–¬–¬“« æ∫«à“ªï·√° “¡“√∂≈¥§«“¡¥—πµ“‰¥â√âÕ¬≈– 79 ·µà¿“¬„π 7 ªï§«“¡ “¡“√∂„π°“√≈¥§«“¡¥—π‡À≈◊Õ‡æ’¬ß√âÕ¬≈– 45®“°°“√»÷°…“„πºŸâªÉ«¬¢Õßº°“π“Æ·≈–§≥– æ∫«à“ “¡“√∂§«∫§ÿ¡§«“¡¥—πµ“¡‰¥â√âÕ¬≈– 81.8 „π 6‡¥◊Õπ·√° ·≈–≈¥≈ß‡À≈◊Õ√âÕ¬≈– 72.7 „π‡«≈“ 1 ªï·µà‡ªìπ‡æ’¬ß°“√»÷°…“ºŸâªÉ«¬„π®”π«ππâÕ¬‡∑à“π—Èπ‚¥¬ √ÿª°“√√—°…“¥â«¬· ß‡≈‡´Õ√å„π√–¬–¬“«¬—ß‰¡à·πàπÕπ ‚¥¬∑—Ë«‰ª®—°…ÿ·æ∑¬å‰∑¬∂◊Õ«à“°“√„™â· ß‡≈‡´Õ√å„πºŸâªÉ«¬µâÕÀ‘π‡√◊ÈÕ√—ß‡ªìπ∑“ß‡≈◊Õ°Õ—πÀπ÷Ëß°àÕπ∑’Ë®–‰ª∂÷ß«‘∏’ºà“µ—¥

°“√ºà“µ—¥ filtering surgery ‡ªìπ∑“ß‡≈◊Õ°Õ—π

122

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

ÿ¥∑â“¬¢Õß°“√√—°…“µâÕÀ‘π™π‘¥π’È ‚¥¬À≈—°°“√·≈â«„™â«‘∏’ºà“µ—¥‡¡◊ËÕ°“√√—°…“¥â«¬¬“‡µÁ¡∑’Ë·≈â«‰¡à‰¥âº≈À√◊ÕºŸâªÉ«¬„™â¬“‰¡à ¡Ë”‡ ¡Õ Õ¬à“ß‰√°Áµ“¡¥â«¬¿“«–‡»√…∞°‘®µ≈Õ¥®π§«“¡¥âÕ¬°“√»÷°…“·≈–§«“¡‰¡à‡¢â“„®∂÷ß°“√¥”‡π‘π¢Õß‚√§ „π∫“ß™ÿ¡™πÕ“®µâÕßæ‘®“√≥“√—°…“µâÕÀ‘π™π‘¥π’È¥â«¬°“√ºà“µ—¥µ—Èß·µà·√°‡≈¬°“√ªÑÕß°—π «‘∏’‡¥’¬«∑’Ë®–ªÑÕß°—π°“√ Ÿ≠‡ ’¬ “¬µ“®“°‚√§π’È §◊Õ °“√µ√«®√à“ß°“¬·≈–µ√«®µ“‡ªìπª√–®”∑ÿ°ªï „π°≈ÿà¡ª√–™“°√Õ“¬ÿ¡“°°«à“ 40 ªï ‡æ◊ËÕ®–‰¥âµ√«®æ∫§«“¡º‘¥ª°µ‘µ—Èß·µà¬—ß‰¡à‡°‘¥°“√∑”≈“¬¢Õßª√– “∑µ“ „π°√≥’∑’Ë‡ªìπ‚√§π’È·≈â« ∂â“√—°…“‚¥¬°“√„™â¬“µâÕßÀ¬Õ¥¬“ µ≈Õ¥™’«‘µ·≈–µ‘¥µ“¡°“√√—°…“Õ¬à“ßµàÕ‡π◊ËÕß ¡Ë”‡ ¡Õ ‰¡à§«√¢“¥¬“ ”À√—∫ºŸâªÉ«¬∑’Ë‰¥â√—∫°“√√—°…“¥â«¬°“√ºà“µ—¥À√◊Õ‚¥¬°“√„™â· ß‡≈‡´Õ√å·≈â«¬—ßµâÕßæ∫·æ∑¬å ¡Ë”‡ ¡Õ ‡æ◊ËÕµ√«®¥Ÿ«à“ “¡“√∂§«∫§ÿ¡§«“¡¥—πµ“‰¥âª°µ‘¥’À√◊Õ‰¡à‡æ’¬ß„¥

°“√§—¥°√Õß‚√§ ¬—ß‰¡à¡’°“√»÷°…“∑’Ë π—∫ πÿπÀ√◊Õ§—¥§â“π°“√µ√«®§—¥°√ÕßÀ“‚√§µâÕÀ‘π‡√◊ÈÕ√—ß ¥â«¬«‘∏’«—¥§«“¡¥—πµ“‚¥¬∫ÿ§≈“°√„π ∂“πæ¬“∫“≈√–¥—∫ª∞¡¿Ÿ¡‘ (primary health care) °“√«‘π‘®©—¬∑’Ë·¡àπ¬”·≈–∂Ÿ°µâÕß¢Õß‚√§π’ÈµâÕßÕ“»—¬®—°…ÿ·æ∑¬å‡∑à“π—Èπ Õ’°∑—Èß¬—ßµâÕß°“√‡§√◊ËÕß¡◊Õ∑’Ë§√∫∂â«π ªí≠À“®÷ßÕ¬Ÿà∑’Ë«à“·¡âµâÕÀ‘π®–‡ªìπ “‡Àµÿµ“∫Õ¥∑’Ë ”§—≠ ·µà°“√«‘π‘®©—¬§àÕπ¢â“ß¬ÿàß¬“° µâÕß„™â®—°…ÿ·æ∑¬å ÷Ëß¡’¬—ß‰¡àæÕ‡æ’¬ßµ≈Õ¥®πÕÿª°√≥å∑’Ë‡æ’¬ßæÕ πÕ°®“°π—Èπ¬—ß¢÷Èπ°—∫Õÿ∫—µ‘°“√≥å¢Õß‚√§π’È«à“¡’¡“°πâÕ¬‡æ’¬ß„¥ °“√µ√«®§—¥°√Õß‡æ◊ËÕµ√«®§âπÀ“µâÕÀ‘π·µà√–¬–·√° ®–™à«¬„Àâ°“√√—°…“‡æ◊ËÕªÑÕß°—π°“√ Ÿ≠‡ ’¬ “¬µ“‰¥â À“°®–‡¥‘π “¬°≈“ß‚¥¬°“√µ√«®§—¥°√Õßª√–™“°√∑’Ë¡’§«“¡‡ ’Ë¬ß ‰¥â·°à ºŸâ¡’Õ“¬ÿ¡“°°«à“ 40 ªï ºŸâ∑’Ë¡’ª√–«—µ‘‚√§π’È„π§√Õ∫§√—« ºŸâ∑’Ë‡ªìπ‡∫“À«“π “¬µ“ —Èπ πà“®–‡À¡“– ¡¥’°«à“ ·≈–‡¡◊ËÕæ∫ºŸâªÉ«¬°Á√’∫„Àâ°“√√—°…“∑—π∑’Õ“®‡√‘Ë¡¥â«¬¬“À¬Õ¥µ“À√◊Õ√à«¡°—∫¬“√—∫ª√–∑“πµ“¡¥â«¬· ß‡≈‡´Õ√å µ≈Õ¥®π∂÷ß°“√ºà“µ—¥„π∑’Ë ÿ¥10

‚√§®Õª√– “∑µ“‡ ◊ËÕ¡

„πª√–‡∑»∑’Ëæ—≤π“·≈â« æ∫Õ—µ√“µ“∫Õ¥√âÕ¬≈–0.2 ‰¥â·°àµ“∫Õ¥®“°°“√µ‘¥‡™◊ÈÕÀ√◊Õ°“√¢“¥ “√Õ“À“√

∂Ÿ°§«∫§ÿ¡‰¥â·≈â« ∂“π∫√‘°“√∑“ßµ“¡’¡“°æÕ ¥—ßπ—Èπ®–‡À≈◊Õµ“∫Õ¥‡π◊ËÕß®“° biological factors ·≈–behavioral factors ¡“°°«à“ ®—¥‡ªìπ‚√§∑’ËªÑÕß°—π‰¡à‰¥â(unpreventable) ·≈–√—°…“‰¡à‰¥â (incurable) √«¡‡√’¬°«à“ unavoidable blindness ‡™àπ ‚√§®Õª√– “∑µ“‡ ◊ËÕ¡ ·≈–‚√§‡∫“À«“π∑’Ë®Õª√– “∑µ“ ´÷Ëßæ∫‰¥â§àÕπ¢â“ß∫àÕ¬

ªí®®ÿ∫—πæ∫ª√–™“°√‚≈°ª√–¡“≥ 25-30 ≈â“πºŸâªÉ«¬‚√§®Õª√– “∑µ“‡ ◊ËÕ¡ „πÕ‡¡√‘°“æ∫ºŸâªÉ«¬„À¡à∑’Ë‡ªìπ‚√§π’È 1 √“¬„π∑ÿ° 3 π“∑’ ‚√§π’È®–‰¡à∑”„Àâ “¬µ“∂÷ß°—∫∫Õ¥ π‘∑ ·µà∑”„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬¢Õß°“√‡ÀÁπ„π∫√‘‡«≥»Ÿπ¬å°≈“ß¢Õß¿“æ‡∑à“π—Èπ à«π∫√‘‡«≥¢Õ∫Ê‚¥¬√Õ∫¢Õß¿“æ¬—ß‡ÀÁπ‰¥âÕ¬Ÿà ºŸâªÉ«¬®–√Ÿâ ÷°≈”∫“°„π°“√Õà“πÀπ—ß ◊Õ ¢—∫√∂ À√◊Õ∑”ß“π∑’ËµâÕß°“√§«“¡≈–‡Õ’¬¥

‡π◊ËÕß®“°„πªí®®ÿ∫—π¬—ß‰¡à∑√“∫∂÷ß “‡Àµÿ∑’Ë·∑â®√‘ß¢Õß‚√§ ¥—ßπ—Èπ°“√√—°…“·≈–ªÑÕß°—π‰¡à„Àâ‡ªìπ‚√§π’È®÷ß¬—ß∑”‰¡à‰¥â «‘∏’‡¥’¬«∑’Ë™à«¬‰¥â§◊Õ °“√µ√«®æ∫§«“¡º‘¥ª°µ‘µ—Èß·µà√–¬–‡√‘Ë¡·√° ‚√§®Õª√– “∑µ“‡ ◊ËÕ¡·∫àß‰¥â‡ªìπ 2 ™π‘¥§◊Õ ™π‘¥·Àâß (dry form) æ∫‰¥âª√–¡“≥√âÕ¬≈– 90 ·≈–™π‘¥·©– (wet form) æ∫ª√–¡“≥√âÕ¬≈– 10 „π™π‘¥·Àâß¡—°‰¡à∑”„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬¢Õß “¬µ“ ·µà„π™π‘¥·©– “¡“√∂∑”„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬ “¬µ“¿“¬„π 3 ‡¥◊Õπ À√◊Õ„π√“¬∑’Ë√ÿπ·√ßÕ“® Ÿ≠‡ ’¬ “¬µ“‰¥â¿“¬„π 2-3 «—π‡∑à“π—Èπ ·¡â®–¬—ß‰¡à∑√“∫ “‡Àµÿ∑’Ë·∑â®√‘ß¢Õß‚√§ ·µàæ∫ªí®®—¬‡ ’Ë¬ß´÷Ëß∑”„Àâ‡°‘¥§«“¡‡ ’Ë¬ß„π°“√‡°‘¥‚√§π’È ‰¥â·°à ∫ÿÀ√’ËÕ“À“√‰¢¡—π Ÿß · ß·¥¥ ‚√§§«“¡¥—π‚≈À‘µ Ÿß ‘Ëßµà“ßÊ¥—ß°≈à“«π’È “¡“√∂§«∫§ÿ¡‰¥â ·µà¬—ß¡’§«“¡‡ ’Ë¬ßÕ’°À≈“¬Õ¬à“ß∑’Ë‰¡à “¡“√∂§«∫§ÿ¡‰¥â ‰¥â·°à

Õ“¬ÿ ®“° U.S. National Eye Instituteª√–¡“≥°“√≥å«à“™à«ßÕ“¬ÿ 50 ªï æ∫‚√§®Õª√– “∑µ“‡ ◊ËÕ¡‰¥â√âÕ¬≈– 2 ·≈–‡¡◊ËÕÕ“¬ÿ‡æ‘Ë¡¡“°¢÷Èπ‡ªìπ 75 ªï®–æ∫‚√§®Õª√– “∑µ“‡ ◊ËÕ¡‰¥â∂÷ß√âÕ¬≈– 30

æ—π∏ÿ°√√¡ ∂â“æàÕ·¡à‡ªìπ‚√§π’È ≈Ÿ°¡’‚Õ°“ ‡ªìπ‰¥â∂÷ß 3 ‡∑à“¢Õß§πª°µ‘ ·≈–‡¡◊ËÕæ∫‚√§®Õª√– “∑µ“‡ ◊ËÕ¡„πµ“¢â“ßÀπ÷Ëß ‚Õ°“ ∑’Ë®–æ∫„πµ“Õ’°¢â“ß®–



·≈–°“√√—Ë«´÷¡¢ÕßÀ≈Õ¥‡≈◊Õ¥º‘¥ª°µ‘„µâ™—Èπ macula3. °“√ºà“µ—¥ (Surgery) ‡æ◊ËÕºà“µ—¥À≈Õ¥‡≈◊Õ¥

∑’Ëº‘¥ª°µ‘ À√◊Õ·º≈‡ªìπ À√◊Õ‡≈◊Õ¥∑’Ëµ°§â“ßÕ¬Ÿà„µâ™—Èπmacula ÕÕ°‰ª14

4. °“√ª≈Ÿ°∂à“¬Õ«—¬«– (Transplants) µ—«Õ¬à“ß‡™àπ retinal cells transplant ‡æ◊ËÕ·∑π∑’Ë‡´≈≈å‡°à“∑’Ë∂Ÿ°∑”≈“¬‰ª À√◊Õ stem cells transplant ‡æ◊ËÕ∑”„Àâ‡°‘¥retinal cells ¢÷Èπ¡“„À¡à

5. ‡≈‡´Õ√å (Lasers) ‡æ◊ËÕ°”®—¥ drusen „π‚√§®Õª√– “∑µ“‡ ◊ËÕ¡™π‘¥·Àâß À√◊Õ∑”≈“¬ feedervessels „π‚√§®Õª√– “∑µ“‡ ◊ËÕ¡™π‘¥·©– À√◊Õ‚¥¬«‘∏’ Transpupillary thermotherapy (TTT) ‡ªìπ°“√„™âlong wavelength infrared light ‡æ◊ËÕÀ¬ÿ¥°“√√—Ë«´÷¡¢ÕßÀ≈Õ¥‡≈◊Õ¥∑’Ë‰ª‡≈’È¬ß macula

‚√§‡∫“À«“π∑’Ë®Õª√– “∑µ“

‚√§‡∫“À«“π‡ªìπ‚√§‰¡àµ‘¥µàÕ∑’Ë ”§—≠‚√§Àπ÷Ëß¢Õßª√–‡∑» ∑’Ë§«“¡™ÿ°¢Õß‚√§¡’·π«‚πâ¡‡æ‘Ë¡ Ÿß¢÷Èπ ®“°¢âÕ¡Ÿ≈°“√ ”√«®¢Õß°√–∑√«ß “∏“√≥ ÿ¢„πªïæ.». 2534 æ∫«à“ª√–™“°√∑’Ë¡’Õ“¬ÿ¡“°°«à“ 35 ªï ¡’§«“¡™ÿ°¢Õß‚√§‡∫“À«“π√âÕ¬≈– 5.7 ·≈–„πªï æ.».2540 æ∫«à“¡’§«“¡™ÿ°‡æ‘Ë¡ Ÿß¢÷Èπ‡ªìπ√âÕ¬≈– 8.1 ·≈–®“°¢âÕ¡Ÿ≈°“√»÷°…“¢Õß Inter ASIA „πªï æ.». 2543„πª√–™“°√∑’Ë¡’Õ“¬ÿµ—Èß·µà 35 ªï¢÷Èπ‰ª æ∫«à“§«“¡™ÿ°¢Õß‚√§‡∑à“°—∫√âÕ¬≈– 9.6 ·≈–ª√–¡“≥°“√«à“ªí®®ÿ∫—π„πª√–‡∑»‰∑¬ ¡’ºŸâªÉ«¬‡∫“À«“πª√–¡“≥ 2-3 ≈â“π§π ·≈–‡ªìπ “‡Àµÿ ”§—≠¢Õß°“√ Ÿ≠‡ ’¬ªï ÿ¢¿“«–(Disability Adjusted Life Years: DALY) ‡ªìπÕ—π¥—∫ 5 „π‡æ»™“¬ (√âÕ¬≈– 3) ·≈–Õ—π¥—∫ 3 „π‡æ»À≠‘ß (√âÕ¬≈– 7) πÕ°®“°π’È¬—ßæ∫«à“ª√–¡“≥√âÕ¬≈– 50 ‰¡à√Ÿâµ—««à“‡ªìπ‡∫“À«“π ‚√§‡∫“À«“π‡ªìπ‚√§‡√◊ÈÕ√—ß ∑’Ë°àÕ„Àâ‡°‘¥¿“«–·∑√°´âÕπ„πÀ≈“¬√–∫∫¢Õß√à“ß°“¬ ‚¥¬‡©æ“–Õ¬à“ß¬‘Ëß∑”„Àâ‡°‘¥¿“«–·∑√°´âÕπ∑’Ë®Õª√– “∑µ“´÷Ëß‡√’¬°°—π∑—Ë«‰ª«à“‡∫“À«“π¢÷Èπµ“´÷Ëß‡ªìπ “‡Àµÿ∑’Ë∑”„Àâµ“∫Õ¥‡ªìπÕ—π¥—∫ Õß√Õß®“°µâÕ°√–®°‚¥¬‡©≈’Ë¬æ∫«à“¿“«–·∑√°´âÕπ®“°‚√§‡∫“À«“π‡¢â“®Õª√– “∑µ“‡°‘¥¢÷Èπª√–¡“≥√âÕ¬≈– 20 ¢ÕßºŸâªÉ«¬‡∫“À«“π ¥—ßπ—Èπ §“¥«à“®–¡’ºŸâªÉ«¬‡∫“À«“π‡¢â“®Õ

‡æ‘Ë¡ Ÿß¢÷Èπ‡™◊ÈÕ™“µ‘ æ∫¡“°„π§π¬ÿ‚√ª ‚¥¬‡©æ“–ºŸâÀ≠‘ß

Õ“¬ÿ¡“°°«à“ 60 ªï·≈–„π§π∑’Ë¡’¡à“πµ“ ’øÑ“„πºŸâ∑’Ë¡’ “¬µ“¬“«¡“° (severe hyperopia) ‚√§

π’È‡ªìπ¿—¬§ÿ¡§“¡∑’Ë‰¡à√Ÿâµ—« ®÷ß¡’§«“¡ ”§—≠∑’Ë®–µâÕßµ√«® ÿ¢¿“æµ“‡ªìπª√–®” ‚¥¬‡©æ“–„π°≈ÿà¡Õ“¬ÿ40-65 ªï §«√‰¥â√—∫°“√µ√«®µ“∑ÿ° 2 ªï à«πºŸâ∑’ËÕ“¬ÿ¡“°°«à“ 65 ªï §«√µ√«®µ“∑ÿ° 1 ªï ‡æ◊ËÕ«‘π‘®©—¬„π√–¬–‡√‘Ë¡·√° (early detection) À√◊Õ∂â“æ∫§«“¡º‘¥ª°µ‘„π°“√‡ÀÁπ §«√√’∫æ∫·æ∑¬å∑—π∑’

°“√√—°…“ ”À√—∫‚√§®Õª√– “∑µ“‡ ◊ËÕ¡™π‘¥·Àâß ªí®®ÿ∫—π¬—ß‰¡à®”‡ªìπµâÕß∑”°“√√—°…“ ‡π◊ËÕß®“°Õ“®‰¡à¡’Õ“°“√· ¥ß∑’Ëº‘¥ª°µ‘„¥Ê ·π–π”„Àâæ∫·æ∑¬å‡ªìπª√–®” ¡Ë”‡ ¡Õ·≈–∂â“æ∫§«“¡º‘¥ª°µ‘„π°“√¡Õß‡ÀÁπ„Àâ√’∫æ∫·æ∑¬å∑—π∑’ ·¡â®–‰¡à¡’°“√√—°…“„π‚√§®Õª√– “∑µ“‡ ◊ËÕ¡™π‘¥·Àâß ‡æ√“–«à“‚√§π’È¡’°“√‡ª≈’Ë¬π·ª≈ßÕ¬à“ß™â“Ê °“√‡ÀÁπ®–§àÕ¬Ê ≈¥≈ß‚¥¬Õ“®‰¡à√Ÿâµ—« ·µà‡æ◊ËÕ§«“¡ª≈Õ¥¿—¬‰¥â¡’°“√·π–π”„ÀâºŸâªÉ«¬√—∫ª√–∑“π high doses of zinc ·≈–antioxidant vitamins ‡™àπ «‘µ“¡‘π´’ «‘µ“¡‘πÕ’ ·≈–‡∫µ“·§‚√∑’π ´÷Ëß‡™◊ËÕ«à“ “¡“√∂≈¥§«“¡‡ ’Ë¬ß¢Õß°“√¥”‡π‘π¢Õß‚√§‰¥â∂÷ß√âÕ¬≈– 2511 πÕ°®“°π’ÈÕ“À“√ ÿ¢¿“æ∑—ÈßÀ≈“¬ ‰¡à«à“®–‡ªìπæ◊™º—°„∫‡¢’¬«µà“ßÊ ‡™◊ËÕ«à“ “¡“√∂™à«¬∂πÕ¡ “¬µ“‰¥â‡™àπ°—π ·≈–§«√ß¥Õ“À“√®”æ«°‰¢¡—π·≈–πÈ”µ“≈ à«π°“√√—°…“‚√§®Õª√– “∑µ“‡ ◊ËÕ¡™π‘¥·©– ªí®®ÿ∫—π„™â«‘∏’ photo-dynamic therapy ‡ªìπ°“√„™â· ß‡≈‡´Õ√å ·≈–photosensitive drug ‡æ◊ËÕ∑”≈“¬À≈Õ¥‡≈◊Õ¥∑’Ëº‘¥ª°µ‘æ∫«à“‰¥âº≈¥’„π ºŸâªÉ«¬∫“ß√“¬‡∑à“π—Èπ12 °“√√—°…“‚√§®Õª√– “∑µ“‡ ◊ËÕ¡«‘∏’„À¡àÊ ÷ËßÕ¬Ÿà√–À«à“ß°“√«‘®—¬·≈–°“√∑¥≈Õß ‰¥â·°à

1. °“√√—°…“¥â«¬¬“ (Pharmaceutical) ®”æ«°anti-angiogenesis drugs ‰¥â·°à Macugan ·≈–Lucentis ‡æ◊ËÕ§«∫§ÿ¡°“√‡®√‘≠¢ÕßÀ≈Õ¥‡≈◊Õ¥∑’Ëº‘¥ª°µ‘„π‚√§®Õª√– “∑µ“‡ ◊ËÕ¡™π‘¥·©– ¬“„À¡à∑—Èß Õßµ—«π’È°”≈—ß‡ªìπ∑’Ë π„®Õ¬à“ß¡“°„π¢≥–π’È13

2. °“√©“¬· ß (Radiation) „™â‡æ◊ËÕÀâ“¡‡≈◊Õ¥

124

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

ª√– “∑µ“Õ¬Ÿàª√–¡“≥ 5 · π§π∑—Ë«ª√–‡∑» „π¢≥–∑’Ëªí®®ÿ∫—π ª√–‡∑»‰∑¬ª√– ∫ªí≠À“¢“¥·§≈π®—°…ÿ·æ∑¬å ∑”„Àâ¡’ºŸâªÉ«¬‡∫“À«“π‡æ’¬ß√âÕ¬≈– 20 ‡∑à“π—Èπ∑’Ë‰¥â√—∫°“√µ√«®µ“µ“¡¡“µ√∞“π

°“√√—°…“ ®–„Àâ‰¥âº≈¥’∑’Ë ÿ¥§◊ÕµâÕß«‘π‘®©—¬æ∫µ—Èß·µà√–¬–·√°‡√‘Ë¡ ®“°°“√»÷°…“æ∫«à“ “¡“√∂≈¥°“√ Ÿ≠‡ ’¬¢Õß “¬µ“‰¥â∂÷ß√âÕ¬≈– 94 ‡π◊ËÕß®“°‡∫“À«“π “¡“√∂∑”„Àâ‡°‘¥¿“«–‚√§·∑√° âÕπ∑“ßµ“‰¥âµ≈Õ¥‡«≈“ ¥—ßπ—Èπ°“√µ√«®µ“ ¡Ë”‡ ¡Õ®÷ß™à«¬‰¥â¡“°„π·ßà¢Õß°“√ªÑÕß°—π‰¡à„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬¢Õß “¬µ“‚¥¬‡©æ“–°“√√—°…“∑’Ë‰¥âº≈¥’¡“°„π√–¬–‡√‘Ë¡·√°π’ÈºŸâªÉ«¬‡∫“À«“π∑’Ë§«∫§ÿ¡√–¥—∫πÈ”µ“≈‰¥â¥’‡∑à“§πª°µ‘ “¡“√∂≈¥°“√‡°‘¥¿“«–‚√§·∑√°´âÕπ∑“ßµ“·≈–∑“ß‰µ‰¥â∂÷ß√âÕ¬≈– 70 °“√√—°…“ DR ∑”‰¥â 2 «‘∏’ §◊Õ1. laser surgery 2. Vitrectomy °“√√—°…“∑—Èß 2 «‘∏’π’È‰¥âº≈¥’¡“° ·¡â„πºŸâªÉ«¬ advanced DR æ∫«à“¬—ß§ß “¡“√∂√—°…“ ¿“æ°“√¡Õß‡ÀÁπ‰«â‰¥â∂÷ß√âÕ¬≈– 90¬°‡«âπ„πºŸâªÉ«¬∑’Ë®Õª√– “∑µ“∂Ÿ°∑”≈“¬‰ª¡“°·≈â«´÷Ëß®–‰¡à “¡“√∂√—°…“„Àâ§◊π ¿“æ‰¥â

°“√ªÑÕß°—π ºŸâªÉ«¬‡∫“À«“π∑ÿ°§π §«√æ∫®—°…ÿ·æ∑¬å‡ªìπª√–®” Õ¬à“ßπâÕ¬ªï≈– 1 §√—Èß À√◊Õµ“¡§«“¡‡ÀÁπ¢Õß·æ∑¬å ‡æ◊ËÕµ√«®À“§«“¡º‘¥ª°µ‘„πµ“µ—Èß·µà√–¬–‡√‘Ë¡·√° ÷Ëß®–∑”„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬ “¬µ“πâÕ¬∑’Ë ÿ¥ ·µà∑’Ë ”§—≠‰¡à·æâ°—π §◊Õ °“√§«∫§ÿ¡√–¥—∫πÈ”µ“≈„π°√–· ‡≈◊Õ¥„ÀâÕ¬Ÿà„π‡°≥±åª°µ‘ ·≈–æ¬“¬“¡≈¥ªí®®—¬‡ ’Ë¬ßµà“ßÊ ∑’Ë®–∑”„Àâ‡°‘¥¿“«–‚√§·∑√°´âÕπ¢Õß‡∫“À«“π ‰¥â·°à §«“¡¥—π‚≈À‘µ Ÿß ‰¢¡—π Ÿß„π‡ âπ‡≈◊Õ¥ ∫ÿÀ√’Ë §«“¡‡§√’¬¥ πÈ”Àπ—°¡“° ·≈–µâÕßÀ¡—ËπÕÕ°°”≈—ß°“¬‡ªìπª√–®” √—∫ª√–∑“π·µàÕ“À“√∑’Ë¡’ª√–‚¬™πå ‡™àπ º—° ¥ ·≈–º≈‰¡â ∑’Ë‰¡àÀ«“π¡“°

°“√√—°…“´÷ËßÕ¬Ÿà√–À«à“ß°“√«‘®—¬ ‡™◊ËÕ«à“«‘µ“¡‘πÕ’·≈–¬“®”æ«° Aldose reductase inhibitors ‡™àπEpalrestat, Tolrestat, Sorbinol ™à«¬ªÑÕß°—π‚√§‡∫“À«“π∑’Ë®Õª√– “∑µ“ À√◊Õ∑”„Àâ°“√¥”‡π‘π¢Õß‚√§™â“≈ß‰¥â πÕ°®“°π’È¬“·Õ ‰æ√‘π (aspirin) ·≈–«‘µ“¡‘π∫’ 12 (vitamin B12) ·≈–‰∑Õ“¡’π (thiamine)°Á‡™◊ËÕ«à“Õ“®™à«¬√—°…“‚√§π’È‰¥â

°“√§—¥°√ÕßºŸâªÉ«¬ ‡π◊ËÕß®“°‡∫“À«“π‡ªìπªí≠À“ “∏“√≥ ÿ¢„πª√–™“°√‰∑¬ æ∫Õ—µ√“ªÉ«¬·≈–Õ—µ√“µ“¬‡æ‘Ë¡ Ÿß¢÷Èπ∑ÿ°ªï °“√·°â‰¢ªí≠À“‚¥¬°“√„Àâ∫√‘°“√√—°…“Õ¬à“ßµàÕ‡π◊ËÕß ‡æ◊ËÕ„ÀâºŸâªÉ«¬‡∫“À«“π§«∫§ÿ¡√–¥—∫πÈ”µ“≈„Àâ‰¥â À√◊Õ√—°…“°“√ Ÿ≠‡ ’¬¢Õß “¬µ“‡¡◊ËÕ‡∫“À«“π¢÷Èπ®Õµ“ π—∫‡ªìπ°“√·°âªí≠À“∑’Ëª≈“¬∑“ß ¡§«√‡√àß√—¥¡“µ√°“√¥â“π°“√ªÑÕß°—π´÷Ëß‰¥â°≈à“«‰ª·≈â« ·≈–∑’Ë ”§—≠Õ’°‡√◊ËÕß§◊Õ °“√§—¥°√ÕßºŸâªÉ«¬‡∫“À«“π„π°≈ÿà¡∑’Ë¡’§«“¡‡ ’Ë¬ß ‡™àπ Õ“¬ÿ¡“°°«à“40 ªï Õâ«π ‰¢¡—π„π‡≈◊Õ¥ Ÿß ·≈–§«“¡¥—π‚≈À‘µ Ÿß‡æ◊ËÕ„Àâ°“√√—°…“Õ¬à“ß∂Ÿ°µâÕß·µà·√° √«¡∂÷ß„π°≈ÿà¡∑’Ë‡ªìπ‚√§·≈â« µâÕß„Àâ§«“¡ ”§—≠°—∫°“√§—¥°√Õß¿“«–‚√§·∑√° âÕπ ‡™àπ °“√µ√«®µ“Õ¬à“ß ¡Ë”‡ ¡Õ„πºŸâªÉ«¬‡∫“À«“π∑ÿ°√“¬ µ—Èß·µà‡√‘Ë¡‡ªìπ‚√§π’È15

«‘®“√≥å

‚¥¬¿“æ√«¡·≈â« ª√–‡∑»‰∑¬„πªí®®ÿ∫—π¡’°“√æ—≤π“§«“¡√Ÿâ∑“ß¥â“π®—°…ÿ«‘∑¬“ (clinical ophthal-mology) ∑’Ë°â“«Àπâ“¡“° „π¥â“π¢Õßß“π∫√‘°“√ Ÿàª√–™“™π·≈–™ÿ¡™π °Á¡’‚§√ß √â“ß∑’Ë¡—Ëπ§ßµ—Èß·µà√–¥—∫∫π®π∂÷ß√–¥—∫≈à“ß „π√–¥—∫°“√¥Ÿ·≈ª∞¡¿Ÿ¡‘ ∑’Ëπà“æÕ„®·µà¬—ß§ßµâÕß‡™◊ËÕ¡§«“¡√Ÿâ·≈–ß“π∫√‘°“√‡À≈à“π’È‡¢â“¥â«¬°—πÕ¬à“ß‡Àπ’¬«·πàπ¥â«¬®—°…ÿ “∏“√≥ ÿ¢ ·≈–æ—≤π“°“√√–∫∫ àßµàÕ∑’Ë¡’ª√– ‘∑∏‘¿“æ ·≈–¥â«¬À≈—°°“√°“√∫√‘°“√ ÿ¢¿“æ¥â«¬§«“¡‡ ¡Õ¿“§ ¡’§ÿ≥¿“æ·≈–¡’ª√– ‘∑∏‘¿“æÕ¬à“ßµàÕ‡π◊ËÕß ‚¥¬ªí≠À“‡√◊ËÕß‡ß‘πÀ√◊Õ§à“„™â®à“¬„π°“√¥Ÿ·≈√—°…“ µâÕß‰¡à„™à ‘Ëß°’¥¢«“ß„π°“√‡¢â“∂÷ß∫√‘°“√¢Õßª√–™“™π ‡¡◊ËÕπ—Èπ ÿ¢¿“æ¥«ßµ“¢Õßª√–™“™π‰∑¬®–‰¥â√—∫°“√ª√–°—π ‚¥¬ “¡“√∂¡’¥«ßµ“∑’Ë·®à¡„ ‰«â¥Ÿ‚≈°∑’Ë «¬ß“¡„∫π’Èµ≈Õ¥‰ª

ªí≠À“‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿ∑’Ë‡ªìπ “‡Àµÿ¢Õß “¬µ“æ‘°“√ ·∫àß‰¥â‡ªìπ 2 ª√–‡¿∑§◊Õ

‚√§´÷Ëß “¡“√∂√—°…“À“¬·≈–°≈—∫¡“‡ÀÁπ‰¥â§◊Õ ‚√§µâÕ°√–®° ´÷Ëßµ“∫Õ¥®“°µâÕ°√–®°¡’®”π«π¡“°∑’Ë ÿ¥ ®“° ∂‘µ‘∑’Ë‰¥â®“° ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“µ‘ ( ª ™.) ªí®®ÿ∫—π¡’µâÕ°√–®°∑’Ë‡ªìπcataract blind ( “¬µ“µË”°«à“ 20/200) ∑’Ë¬—ßµ°§â“ßÕ¬Ÿà



ª√–¡“≥ 100,000-120,000 √“¬ °“√ºà“µ—¥µâÕ°√–®°∑—Ë«ª√–‡∑» “¡“√∂∑”‰¥âªï≈–ª√–¡“≥ 80,000 (∑—Èß¿“§√—∞·≈–‡Õ°™π) „π·µà≈–ªï¡’ª√–™“°√¢ÕßµâÕ°√–®°‡°‘¥„À¡àª√–¡“≥ 65,000 §π §‘¥‡ªìπ√âÕ¬≈–0.1 ¢Õßª√–™“°√ „πªïπ’È ª ™. ‰¥â®—¥ß∫ª√–¡“≥‡æ‘Ë¡¢÷Èπ‡æ◊ËÕ®–ºà“µ—¥µâÕ°√–®°∑’Ë¬—ßµ°§â“ß„Àâ‰¥â‡æ‘Ë¡¢÷ÈπÕ’°20,000 √“¬ ‡æ‘Ë¡®“°®”π«π 80,000 √“¬∑’Ë∑”‰¥âÕ¬Ÿà·≈â«√«¡‡ªìπ 100,000 √“¬ ∂â“ “¡“√∂∑”°“√ºà“µ—¥ºŸâªÉ«¬¥â«¬ ∂‘µ‘π’ÈµàÕ‰ª ¿“¬„π√–¬–‡«≈“ 5 ªï®–‰¡à¡’µâÕ°√–®°µ°§â“ßÕ’°µàÕ‰ª ∂◊Õ‡ªìπ§«“¡ ”‡√Á®¢Õß‚§√ß°“√ªÑÕß°—πµ“∫Õ¥∑’Ë “¡“√∂§«∫§ÿ¡ avoidableblindness ‰¥â‡À¡◊Õπ°≈ÿà¡ª√–‡∑»∑’Ëæ—≤π“·≈â«16

‚√§´÷Ëß¬“°·°à°“√√—°…“·≈–À≈’°‡≈’Ë¬ß‰¡à‰¥â ´÷Ëß‰¥â·°à ‚√§µâÕÀ‘π ‚√§®Õª√– “∑µ“ à«π°≈“ß‡ ◊ËÕ¡·≈–‚√§‡∫“À«“π„π®Õª√– “∑µ“ ªí®®ÿ∫—π¡’·π«‚πâ¡æ∫¡“°¢÷Èπ·≈–∑«’§«“¡ ”§—≠¡“°¬‘Ëß¢÷Èπ §«“¡æ‘°“√∑’Ë‡°‘¥¢÷Èππ’È à«πÀπ÷Ëß “¡“√∂ªÑÕß°—πÀ√◊Õ™–≈Õ„Àâ‡°‘¥™â“≈ß·≈–≈¥§«“¡√ÿπ·√ß¢Õß§«“¡æ‘°“√≈ß‰¥â À“°ª√–™“™π√Ÿâ®—°¥Ÿ·≈ ÿ¢¿“æµ“¢Õßµπ‡Õß ªØ‘∫—µ‘√—°…“„Àâ∂Ÿ°µâÕß „π‡«≈“∑’Ë‡À¡“– ¡ ®÷ß®”‡ªìπµâÕß§‘¥§âπæ—≤π“√Ÿª·∫∫°“√„Àâ∫√‘°“√„À¡à‡æ◊ËÕ‡ √‘¡‡æ‘Ë¡‡µ‘¡®“°‡¥‘¡ ∑’Ë‡πâπ„Àâ∫√‘°“√µ—Èß√—∫Õ¬Ÿà∑’Ë ∂“π∫√‘°“√ ¡“‡ªìπ√Ÿª·∫∫°“√ªÑÕß°—π·≈– àß‡ √‘¡ ÿ¢¿“æµ“ ·≈–‡ª≈’Ë¬π‡ªÑ“À¡“¬‡ªìπª√–™“°√∑—ÈßÀ¡¥ ÷Ëß√«¡∑—ÈßºŸâ∑’Ë‡®Á∫ªÉ«¬·≈â«·≈–ºŸâ∑’Ë¬—ß‰¡à‡°‘¥‚√§ ‚¥¬‡πâπ°“√¡’ à«π√à«¡¢Õßª√–™“™πÀ√◊Õ™ÿ¡™π ‡æ◊ËÕ„Àâ™ÿ¡™π “¡“√∂æ÷Ëßæ“µπ‡Õß‰¥â ·≈– “¡“√∂¥Ÿ·≈·°â‰¢ªí≠À“ ÿ¢¿“æµ“¢Õßµπ‡Õß„π‡∫◊ÈÕßµâπ‰¥â °àÕπ®–µâÕß¡“æ÷Ëßæ“∫√‘°“√„π ∂“πæ¬“∫“≈¢Õß√—∞·π«∑“ß∑’Ë‡À¡“– ¡‡æ◊ËÕ∑’Ë®–√—∫¡◊Õ°—∫ªí≠À“ “∏“√≥ ÿ¢∑“ßµ“µàÕ‰ª ®÷ß‡ªìπ·π«∑“ß¢Õß°“√ªÑÕß°—π·≈– àß‡ √‘¡ ÿ¢¿“æµ“17

°“√≈¥Õ—µ√“°“√‡°‘¥¿“«– “¬µ“æ‘°“√®“°‚√§µ“∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿπ—Èπ ∑”‰¥â‚¥¬°“√„Àâ°“√√—°…“·≈–°“√ªÑÕß°—π ÷Ëß°“√√—°…“∂◊Õ‡ªìπ°“√·°âªí≠À“∑’Ëª≈“¬‡Àµÿ À—«„® ”§—≠Õ¬Ÿà∑’Ë°“√ªÑÕß°—π‰¡à„Àâ‡°‘¥°“√ Ÿ≠‡ ’¬¢Õß “¬µ“ ¥—ßπ—ÈπµâÕß‡πâπ„π°“√„Àâ§«“¡√Ÿâ„π¥â“π ÿ¢Õπ“¡—¬ ·≈–Õ—πµ√“¬®“°‚√§µà“ßÊ ¥—ß°≈à“« ¡’

°“√µ√«®§—¥°√Õß„π°≈ÿà¡§π∑’Ë¡’§«“¡‡ ’Ë¬ß µàÕ°“√‡°‘¥‚√§Õ—π®–π”‰ª Ÿà¿“«– “¬µ“æ‘°“√ ‡™àπ

µâÕ°√–®° §«√¡’°“√§—¥°√Õß‡¢â“‰ª„π∂‘Ëπ∑ÿ√°—π¥“√„π™π∫∑∑’ËÀà“ß‰°≈ ‡æ◊ËÕ àßºŸâªÉ«¬‡¢â“¡“√—∫°“√√—°…“°àÕπ∑’Ë‚√§®–≈ÿ°≈“¡‰ª∂÷ß¢—Èπµ“∫Õ¥ À√◊Õ¡’‚√§·∑√°´âÕπ®π°√–∑—Ëß√—°…“‰¡à‰¥â

µâÕÀ‘π §«√¡’°“√§—¥°√ÕßºŸâ∑’Ë¡’§«“¡‡ ’Ë¬ß ŸßµàÕ‚√§π’È ‡™àπ „π§πÕ“¬ÿ¡“°°«à“ 40 ªï ∑’Ë¡’ª√–«—µ‘„π§√Õ∫§√—«‡ªìπµâÕÀ‘π ‡∫“À«“πÀ√◊Õ¡’ “¬µ“ —Èπ¡“°§«√‰¥â√—∫°“√µ√«®«—¥§«“¡¥—π≈Ÿ°µ“Õ¬à“ß ¡Ë”‡ ¡Õ

‚√§®Õª√– “∑µ“‡ ◊ËÕ¡®—¥‡ªìπ‚√§ unavoidableæ∫¡“°„π§πÕ“¬ÿ 65 ªï¢÷Èπ‰ª ‡π◊ËÕß®“° “‡Àµÿ ·≈–°“√¥”‡π‘π¢Õß‚√§‰¡à™—¥‡®π ®÷ß¬—ß‰¡à¡’°“√∑”°“√§—¥°√Õß„π¢≥–π’È «‘∏’ªÑÕß°—π∑’Ë¥’∑’Ë ÿ¥§◊Õ°“√µ√«® ÿ¢¿“æµ“‡ªìπª√–®”Õ¬à“ßπâÕ¬ªï≈– 1 §√—Èß ·≈–°“√√—°…“ ÿ¢¿“æ√à“ß°“¬„Àâ·¢Áß·√ß ‡≈◊Õ°√—∫ª√–∑“π·µàÕ“À“√∑’Ë¡’ª√–‚¬™πåÀ√◊Õ Õ“À“√ ÿ¢¿“æ ‡ªìπª√–®”

DR „Àâ¡’°“√§—¥°√Õß„πºŸâªÉ«¬‡∫“À«“π‚¥¬‡©æ“–·π–π”„ÀâºŸâªÉ«¬§«∫§ÿ¡√–¥—∫πÈ”µ“≈„π‡≈◊Õ¥„Àâ‡∑à“§πª°µ‘ ·≈–¡’°“√æ∫·æ∑¬å ‡æ◊ËÕµ√«®µ“‡ªìπª√–®”Õ¬à“ßπâÕ¬ªï≈– 1 §√—Èß À√◊Õµ“¡§«“¡‡ÀÁπ¢Õß·æ∑¬å

°‘µµ‘°√√¡ª√–°“»

ºŸâ‡¢’¬π¢Õ¢Õ∫§ÿ≥ §≥“®“√¬å∑’Ëª√÷°…“·Ààß«‘∑¬“≈—¬ªÑÕß°—π√“™Õ“≥“®—°√ ∑’Ë„Àâ°“√ π—∫ πÿπ «‘‡§√“–Àå«‘®“√≥å „π°“√®—¥∑”‡Õ° “√«‘®—¬π’È ´÷Ëß‡Õ° “√π’È‡ªìπ‡æ’¬ß à«πÀπ÷Ëß¢Õß‡Õ° “√«‘®—¬ «ªÕ. ·≈–¢Õ¢Õ∫§ÿ≥Õ“®“√¬å·æ∑¬åÀ≠‘ß «—≤π’¬å ‡¬Áπ®‘µ√ ∑’Ë‰¥â„Àâ¢âÕ¡Ÿ≈ ”À√—∫ß“ππ’ÈÕ¬à“ß¡“°


1. WHO. Magnitude and visual impairment. Fact Sheet

282, Nov. 2004.

2. Õ¿‘™“µ‘ ‘ß§“≈«≥‘™ ·≈–§≥–. ®—°…ÿ«‘∑¬“. °√ÿß‡∑æœ:∫√‘…—∑ ‚Œ≈‘ µ‘° æ—∫≈‘™™‘Ëß®”°—¥; 2540.

126

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

“∏“√≥ ÿ¢ 2544; 15: 179-82.11. Clinical trial of high-dose supplementation with

vitamins C, E, betacarotine and Zn for AMD. Arch

Ophthalmol 2001; 119:1417-36.

12. Treatment of AMD with photodynamic therapy. Arch

Ophthalmol 1999; 117:1329-45.

13. Gragoudas ES, et al. Pegaptanib for neovascular AMD.

N Engl J Med 2004;351:2805-16.

14. Submacular Surgery Trials Reserch Group. Surgery

for hemorrhagic choroidal neovasular lesions of AMD.

Ophthalmology 2004; 111:1993-2006.

15. ≥—∞™—¬ π‘∏‘Õ¿‘≠≠“ °ÿ≈ ·≈–§≥–. °“√§—¥°√Õß¿“«–‡∫“À«“π‡¢â“®Õª√– “∑µ“„π‚√ßæ¬“∫“≈™ÿ¡™π. ®—°…ÿ‡«™ “√2004; 18:103-10.

16. π‘¬¡ §Õπ¬“¡“. ‚§√ß°“√ªÑÕß°—πµ“∫Õ¥„πª√–‡∑»‰∑¬.®—°…ÿ “∏“√≥ ÿ¢ 2543;14:167-92.

17. æ—≤πåæß…å °ÿ≈“¬“ππ∑å ‚§√ß°“√‡¡◊Õß ÿ¢¿“æµ“¥’ ®—°…ÿ “∏“√≥ ÿ¢ 1998; 12:120-31.

3. §≥–∑”ß“π‚§√ß°“√ªÑÕß°—πµ“∫Õ¥·≈–§«∫§ÿ¡ “¬µ“æ‘°“√°√–∑√«ß “∏“√≥ ÿ¢. °“√ª√–‡¡‘πº≈‚§√ß°“√ªÑÕß°—πµ“∫Õ¥·≈–§«∫§ÿ¡ “¬µ“æ‘°“√ æ.». 2539. ≈”ª“ß;°‘®‡ √’°“√æ‘¡æå; 2540.

4. «‘π—¬ ™—¬¥√ÿ≥. °“√ºà“µ—¥µâÕ°√–®°„πª√–‡∑»‰∑¬. ®—°…ÿ‡«™ “√ 2543; 14:109-17.

5. Taylor A, Jacques PF, Epstein EM. Relation among

ageing antioxidant status, and cataract. Am J Clin Nutr

1995; 62:1439-47.

6. π‘¬¡ §Õπ¬“¡“. √–∫“¥«‘∑¬“µâÕ°√–®°·≈–π‚¬∫“¬∫√‘°“√√—°…“·≈–ß“πªÑÕß°—πµ“∫Õ¥. ®—°…ÿ “∏“√≥ ÿ¢ 2544;15:77-81.

7. Scheie and Albert. Textbook of ophthalmology.

Philadelphia; W.B. Saunders Co.; 1997.

8. Shields MB. Textbook of glaucoma. Baltimore:

Williams and Wilkins; 1992.

9. Kolker AE, Becker-Shaffers. Diagnosis and therapy of

glaucoma. St. Louis: CV Mosby Co.; 1976.

10. °“«√—µπå §ÿ≥“«‘»√ÿµ. °“√§—¥°√ÕßµâÕÀ‘π‡√◊ÈÕ√—ß. ®—°…ÿ




æƒµ‘°√√¡°“√¥Ÿ·≈µπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß „π‡¢µ‡∑»∫“≈‡¡◊Õß®—ßÀ«—¥©–‡™‘ß‡∑√“«‘‰≈≈—°…≥å «‘√‘¬–æ—π∏ÿå æ¬.∫.¬ÿæ‘π Àß…å«–™‘π «∑.¡. ”π—°ß“π “∏“√≥ ÿ¢®—ßÀ«—¥ ©–‡™‘ß‡∑√“

Abstract Self-caring Behavior among Hypertension Cases in Muang Chachoengsao Municipality,Chachoengsao Province

Viriyapun V., Hongwachin Y.

Chachoengsao Provincial Health Office


Survey research study with the objective to study the overall general basic knowledge,acknowledgement and self-caring behavior of hypertension patients along with the study of the relationshipbetween basic knowledge, acknowledgement and self-caring behavior in the amount of 347 hypertensionpatient’s. We conducted the research of the hypertension patients in Muang Chachoengsao Municipality,Amphur muang, Chachoengsao province. The result that 61.1% are female (average age are 60.4 years),65.7% are married, 26.5% have high-school education, 28.9% are house wife, 53.3% have less 5,000 bathaverage income per month and 49% don’t have medical problem. The average age that the sample patientstarted to have high blood pressure in 56.1 years, the illness period are around 5.1 years, 35.4% does not haveother sickness, 58.2% do not have the record of other family members having the same illness, 33.4% receivelimited help from family members, 60.5% of the samples have moderate basic disease knowledge, 75.8% havemoderate acknowledge of the sickness. 75.8% has moderate self-caring behavior by controlling the meal andweight, do the exercise and relief their tension with the average of 1.43, 1.31 and 1.27 respectively. In addition,basic knowledge, acknowledge and self-caring behavior of the patients statistically do not have the significantrelationship between each other (p-value > 0.5). Recommendation in solving hypertension problem need tohave basic information in knowledge, thinking, acknowledge and self-caring behavior according to follow upprovide the necessary suggestion individually. Therefore, officers will be able to improve their basic skills,regarding the service for quality and effectiveness hypertension patients. The suggestion for the next researchshould study in other factors that effect the self-health caring behavior of the hypertension patients and focuson the involvement of the health volunteer regarding in caring of hypertensive patients.

Key words: self-caring behavior, hypertension patients

128

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

∫∑π”

∂“π°“√≥å‚√§§«“¡¥—π‚≈À‘µ Ÿß„πª√–‡∑»‰∑¬æ∫«à“¡’®”π«πºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿßª√–¡“≥6 ≈â“π§π1 ·≈–æ∫§«“¡™ÿ°¢Õß‚√§§«“¡¥—π‚≈À‘µ Ÿß√âÕ¬≈– 5.4 ”À√—∫°≈ÿà¡Õ“¬ÿ 30 ªï¢÷Èπ‰ª æ∫§«“¡™ÿ° Ÿß∂÷ß√âÕ¬≈– 7.7 §«“¡™ÿ°‡æ‘Ë¡¢÷Èπ‡¡◊ËÕÕ“¬ÿ¡“°¢÷ÈπÀ√◊ÕπÈ”Àπ—°µ—«‡æ‘Ë¡¢÷Èπ2 ®“° ∂‘µ‘ “∏“√≥ ÿ¢¢Õßª√–‡∑»‰∑¬ªï æ.». 2541 æ∫¡’ºŸâ‡ ’¬™’«‘µ®“°‚√§§«“¡¥—π‚≈À‘µ Ÿß∂÷ß«—π≈– 22 §π ®“°®”π«πµ“¬¥â«¬°≈ÿà¡ “‡Àµÿµ“¡∫—≠™’µ“√“ß‚√§æ◊Èπ∞“π‡©≈’Ë¬µàÕ«—π 1 «—π ÷ËßÕ¬Ÿà„πÕ—π¥—∫∑’Ë 4 ®“° 5 Õ—π¥—∫3 ·≈–„πªï æ.». 2548 æ∫Õ—µ√“µ“¬¥â«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß‡ªìπ 16.4 µàÕ· πª√–™“°√(µ“√“ß∑’Ë 1) ®“°°“√»÷°…“«‘‡§√“–Àå√“¬ß“π ·≈–°“√ —¡¿“…≥å æ∫«à“ ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß∑’Ë¡“√—∫∫√‘°“√„π®—ßÀ«—¥©–‡™‘ß‡∑√“ à«π„À≠à‡ªìπ™π‘¥∑’Ë‰¡à∑√“∫ “‡Àµÿ ‡ªìπºŸâªÉ«¬À≠‘ß¡“°°«à“ºŸâªÉ«¬™“¬ Õ“¬ÿ‡©≈’Ë¬Õ¬Ÿà√–À«à“ß 40-68 ªï ¿“«–·∑√°´âÕπ∑’Ëæ∫∫àÕ¬ §◊Õ‚√§À—«„® À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ° ‚√§‰µ ºŸâªÉ«¬ à«π„À≠à √âÕ¬≈– 75 ¡“√—∫°“√√—°…“ ¡Ë”‡ ¡Õ √âÕ¬≈–20 ¡’√–¥—∫§«“¡¥—π‚≈À‘µ‰¡à·πàπÕπ §«∫§ÿ¡√–¥—∫§«“¡¥—π‚≈À‘µ‰¡à¥’‡∑à“∑’Ë§«√ ‡π◊ËÕß®“°¡’‚√§Õ◊ËπÊ √à«¡¥â«¬ ‡™àπ ‚√§‰µ ‚√§À—«„® ‚√§‡∫“À«“π ªí®®—¬∑’Ë¡’º≈∑”„ÀâºŸâªÉ«¬§«“¡¥—π‚≈À‘µ Ÿß¡’¿“«–·∑√°´âÕπ·≈–Õ—πµ√“¬ ‰¥â·°à ¢“¥°“√ÕÕ°°”≈—ß°“¬ °“√§«∫§ÿ¡Õ“À“√ ·≈–°“√ºàÕπ§≈“¬§«“¡‡§√’¬¥

«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“∂÷ß≈—°…≥–∑—Ë«‰ª¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß·≈–æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß „π‡¢µ‡∑»∫“≈‡¡◊Õß©–‡™‘ß‡∑√“ Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥©–‡™‘ß‡∑√“ ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√π”æƒµ‘°√√¡°“√ªØ‘∫—µ‘µ—«∑’Ë‡ªìπ “‡Àµÿ ∑”„Àâ‰¡à “¡“√∂§«∫§ÿ¡√–¥—∫§«“¡¥—π‚≈À‘µ Ÿß‰¥â π”‰ª«“ß·ºπª√—∫‡ª≈’Ë¬πæƒµ‘°√√¡ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß „Àâ¡’æƒµ‘°√√¡ ÿ¢¿“æ∑’Ë‡Õ◊ÈÕµàÕ°“√§«∫§ÿ¡√–¥—∫§«“¡¥—π‚≈À‘µµàÕ‰ª Õ—π®– àßº≈µàÕ°“√ªÑÕß°—π°“√‡°‘¥¿“«–·∑√°´âÕπ ·≈–≈¥Õ—µ√“°“√µ“¬¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π ‚≈À‘µ Ÿß‰¥â

«—µ∂ÿ·≈–«‘∏’°“√

°“√»÷°…“§√—Èßπ’È‡ªìπ°“√‡™‘ß ”√«® (SurveyResearch) ª√–™“°√∑’Ë„™â„π°“√»÷°…“§√—Èßπ’È§◊Õ ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß™π‘¥‰¡à∑√“∫ “‡Àµÿ∑’Ë‰¥â√—∫°“√µ√«®«‘π‘®©—¬®“°·æ∑¬å«à“‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿßµ—Èß·µà 1 ªï¢÷Èπ‰ª ®”π«π 2,593 √“¬ ‚¥¬Õ“»—¬Õ¬Ÿà„π‡¢µ‡∑»∫“≈‡¡◊Õß©–‡™‘ß‡∑√“ Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥©–‡™‘ß‡∑√“ ÿà¡µ—«Õ¬à“ß·∫∫ßà“¬ (Simple RandomSampling) ®“°ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß™π‘¥‰¡à∑√“∫ “‡Àµÿ ¢Õß™ÿ¡™π„π‡¢µ‡∑»∫“≈‡¡◊Õß©–‡™‘ß‡∑√“∑—ÈßÀ¡¥ 18 ™ÿ¡™π ®”π«π 347 √“¬ ®π§√∫·≈–‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈®“°°≈ÿà¡µ—«Õ¬à“ß∑’Ë»÷°…“

‡§√◊ËÕß¡◊Õ∑’Ë„™â„π°“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈„π°“√

‡√◊ËÕß¬àÕ ‡ªìπ°“√»÷°…“‡™‘ß ”√«®¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“≈—°…≥–∑—Ë«‰ª §«“¡√Ÿâ °“√√—∫√Ÿâ·≈–æƒµ‘°√√¡„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß µ≈Õ¥®π»÷°…“§«“¡ —¡æ—π∏å√–À«à“ß§«“¡√Ÿâ °“√√—∫√Ÿâ °—∫æƒµ‘°√√¡ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ®”π«π 347 √“¬ º≈°“√»÷°…“ æ∫«à“ ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß „π‡¢µ‡∑»∫“≈‡¡◊Õß©–‡™‘ß‡∑√“Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥©–‡™‘ß‡∑√“ ‡ªìπ‡æ»À≠‘ß√âÕ¬≈– 61.1 Õ“¬ÿ‡©≈’Ë¬ 60.4 ªï Õ“¬ÿ‡©≈’Ë¬∑’ËªÉ«¬‡ªìπ‚√§ 56.1 ªï √–¬–‡«≈“∑’Ë‡ªìπ‚√§‡©≈’Ë¬ 5.1 ªï §«“¡√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß¢ÕßºŸâªÉ«¬ æ∫«à“Õ¬Ÿà„π√–¥—∫ª“π°≈“ß√âÕ¬≈– 60.5 °“√√—∫√ŸâÕ¬Ÿà„π√–¥—∫ª“π°≈“ß√âÕ¬≈– 75.8 æƒµ‘°√√¡ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡ÕßÕ¬Ÿà„π‡°≥±åª“π°≈“ß√âÕ¬≈– 75.8 Õ“®°≈à“«‰¥â«à“®”‡ªìπÕ¬à“ß¬‘Ëß∑’Ë®–µâÕß√Ÿâ¢âÕ¡Ÿ≈æ◊Èπ∞“π‡∫◊ÈÕßµâπ„π¥â“π§«“¡√Ÿâ §«“¡§‘¥ °“√√—∫√Ÿâ·≈–°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß√“¬∫ÿ§§≈ ‡æ◊ËÕ®–‰¥âµ‘¥µ“¡·≈–„Àâ§”·π–π”µ“¡§«“¡®”‡ªìπ °“√æ—≤π“∑—°…–æ◊Èπ∞“π·°à‡®â“Àπâ“∑’Ë∑’ËªØ‘∫—µ‘ß“π„π™ÿ¡™π „π°“√∫√‘°“√ºŸâ∑’Ë¡’¿“«–§«“¡¥—π‚≈À‘µ Ÿß ‰¥âÕ¬à“ß¡’§ÿ≥¿“æ·≈–¡’ª√– ‘∑∏‘¿“æ

§” ”§—≠: æƒµ‘°√√¡°“√¥Ÿ·≈µπ‡Õß ºŸâªÉ«¬§«“¡¥—π‚≈À‘µ Ÿß



»÷°…“‡ªìπ·∫∫ —¡¿“…≥å ª√–°Õ∫¥â«¬ à«π∑’Ë 1 ¢âÕ¡Ÿ≈∑—Ë«‰ª‡°’Ë¬«°—∫ºŸâ„Àâ —¡¿“…≥å ‰¥â·°à

‡æ» Õ“¬ÿ ∂“π¿“æ ¡√ °“√»÷°…“ Õ“™’æ √“¬‰¥âªí≠À“‡√◊ËÕß§à“„™â®à“¬„π°“√√—°…“ Õ“¬ÿ∑’Ë‡√‘Ë¡ªÉ«¬ √–¬–‡«≈“∑’Ë‡ªìπ‚√§ ª√–«—µ‘‚√§ª√–®”µ—« ª√–«—µ‘‚√§∫ÿ§§≈„π§√Õ∫§√—« ·≈–°“√‰¥â√—∫§«“¡™à«¬‡À≈◊Õ®“° ¡“™‘°„π§√Õ∫§√—« ®”π«π 10 ¢âÕ

à«π∑’Ë 2 °“√«—¥√–¥—∫§«“¡√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß ‡ªìπ¥—™π’„π°“√·∫àß√–¥—∫§«“¡√Ÿâ

à«π∑’Ë 3 °“√«—¥√–¥—∫°“√√—∫√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß ‡ªìπ¥—™π’„π°“√·∫àß√–¥—∫°“√√—∫√Ÿâ

à«π∑’Ë 4 °“√»÷°…“‡°’Ë¬«°—∫æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß«‘‡§√“–Àå‡ªìπ¥—™π’„π°“√·∫àß√–¥—∫æƒµ‘°√√¡

à«π∑’Ë 5 °“√»÷°…“§«“¡ —¡æ—π∏å√–À«à“ß§«“¡√Ÿâ°“√√—∫√Ÿâ °—∫æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß °“√«‘‡§√“–Àå¢âÕ¡Ÿ≈„™â ∂‘µ‘‡™‘ßæ√√≥π“·≈– ∂‘µ‘‡™‘ßª√–¬ÿ°µå

º≈

≈—°…≥–∑—Ë«‰ª

°“√»÷°…“≈—°…≥–∑—Ë«‰ª¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß º≈°“√ —¡¿“…≥åºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß

À√◊ÕºŸâ¥Ÿ·≈·∫∫µ—«µàÕµ—« ®”π«π∑—ÈßÀ¡¥ 347 √“¬æ∫«à“ ‡ªìπ‡æ»À≠‘ß (√âÕ¬≈– 61.1) ·≈–¡’Õ“¬ÿÕ¬Ÿà„π™à«ß 60-69 ªï (√âÕ¬≈– 34.0) ∂“π¿“æ‡ªìπºŸâ ¡√ ·≈â« (√âÕ¬≈– 65.7) ®∫°“√»÷°…“√–¥—∫¡—∏¬¡»÷°…“(√âÕ¬≈– 26.5) ·≈–ª√–°Õ∫Õ“™’æß“π∫â“π¡“°∑’Ë ÿ¥(√âÕ¬≈– 28.5) √Õß≈ß¡“§◊ÕÕ“™’æ§â“¢“¬ (√âÕ¬≈– 27.7)¡’√“¬‰¥â‡©≈’Ë¬µàÕ‡¥◊ÕππâÕ¬°«à“ 5,000 ∫“∑ (√âÕ¬≈–53.3) ·≈–æ∫«à“‰¡à¡’ªí≠À“‡√◊ËÕß§à“„™â®à“¬„π°“√√—°…“æ¬“∫“≈ (√âÕ¬≈– 49.0) Õ“¬ÿ∑’Ë‡√‘Ë¡ªÉ«¬‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿß¡“°∑’Ë ÿ¥§◊ÕÕ¬Ÿà„π™à«ßÕ“¬ÿ 50-59 ªï(√âÕ¬≈– 45.2)

®”π«πºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß∑—ÈßÀ¡¥ ¡’√–¬–‡«≈“∑’Ë‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿß¡“ 5-9 ªï (√âÕ¬≈– 52.2)‚¥¬√–¬–‡«≈“∑’ËªÉ«¬‡ªìπ‚√§§«“¡¥—π‚≈À‘µ ŸßµË” ÿ¥ 1ªï ·≈– Ÿß ÿ¥ 24 ªï à«π√–¬–‡«≈“‡©≈’Ë¬∑’ËªÉ«¬‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿß‡∑à“°—∫ 5.1 ªï ”À√—∫ª√–«—µ‘‚√§ª√–®”µ—«¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿßπ—Èπ æ∫«à“ à«π„À≠à‡ªìπ§«“¡¥—π‚≈À‘µ ŸßÕ¬à“ß‡¥’¬«‰¡à¡’‚√§ª√–®”µ—«Õ◊Ëπ√à«¡¥â«¬ (√âÕ¬≈– 35.4) ·≈–‰¡à¡’ª√–«—µ‘∫ÿ§§≈„π§√Õ∫§√—«ªÉ«¬‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿß(√âÕ¬≈– 58.2) ‡¡◊ËÕªÉ«¬‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿß·≈â« à«π„À≠à®–‰¥â√—∫§«“¡™à«¬‡À≈◊Õ®“° ¡“™‘°„π§√Õ∫§√—«‡≈Á°πâÕ¬ (√âÕ¬≈– 33.4)

µ“√“ß∑’Ë 1 Õ—µ√“°“√µ“¬¥â«¬‚√§∑’Ë ”§—≠ 5 ‚√§µàÕª√–™“°√ 100,000 §π æ.». 2542 - æ.». 2548

æ.». “‡Àµÿ

2542 2543 2544 2545 2546 2547 2548

1. ‚√§À—«„®∑—ÈßÀ¡¥ 54.7 56.0 58.5 62.5 69.2 79.5 71.8

2. Õÿ∫—µ‘‡Àµÿ·≈–°“√‡ªìπæ‘… 45.6 48.5 52.7 61.5 61.5 64.3 62.2

3. ¡–‡√Áß∑ÿ°™π‘¥ 41.2 43.5 45.0 48.9 50.9 51.7 52.0

4. §«“¡¥—π‡≈◊Õ¥ Ÿß·≈– 15.9 16.9 16.4 15.7 16.1 16.2 16.4

‚√§À≈Õ¥‡≈◊Õ¥À—«„®

5. ¶à“µ—«µ“¬ ∂Ÿ°¶à“µ“¬ 14.4 15.2 14.7 11.1 13.3 14.6 13.4

·À≈àß∑’Ë¡“ : à«π¢âÕ¡Ÿ≈ “∏“√≥ ÿ¢ ”π—°π‚¬∫“¬·≈–·ºπ “∏“√≥ ÿ¢ °√–∑√«ß “∏“√≥ ÿ¢3

130

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

§«“¡√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß¢ÕßºŸâªÉ«¬

‚√§§«“¡¥—π‚≈À‘µ Ÿß

ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß∑ÿ°§π à«π„À≠à¡’§«“¡√Ÿâ ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ ŸßÕ¬Ÿà „π√–¥—∫ª“π°≈“ß ®”π«π 210 √“¬ (√âÕ¬≈– 60.5) √–¥—∫§«“¡√Ÿâ√–¥—∫ µË”·≈– Ÿß„°≈â‡§’¬ß°—π §◊Õ®”π«π 86 √“¬(√âÕ¬≈– 24.8) ·≈– 51 √“¬ (√âÕ¬≈– 14.7) µ“¡≈”¥—∫æ∫«à“‡√◊ËÕß∑’ËºŸâªÉ«¬¡’§«“¡√Ÿâ¡“°∑’Ë ÿ¥ „π‡√◊ËÕß§π∑’Ë‡ªìπ‚√§§«“¡¥—π‚≈À‘µ Ÿß§«√ß¥Õ“À“√‡§Á¡∑ÿ°™π‘¥ (§à“‡©≈’Ë¬‡∑à“°—∫ 0.91) ·≈–‡√◊ËÕß∑’ËºŸâªÉ«¬ à«π„À≠à¬—ß‡¢â“„®‰¡à∂Ÿ°µâÕß‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß §◊Õ ‡√◊ËÕß‚√§§«“¡¥—π‚≈À‘µ Ÿß‡ªìπ‚√§‡√◊ÈÕ√—ß ‰¡àÀ“¬¢“¥ §«√‰ªæ∫·æ∑¬å‡¡◊ËÕ¡’Õ“°“√º‘¥ª°µ‘‡∑à“π—Èπ (§à“‡©≈’Ë¬‡∑à“°—∫ 0.53)

°“√√—∫√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß

ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß à«π„À≠à ¡’√–¥—∫°“√√—∫√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ ŸßÕ¬Ÿà„π√–¥—∫ª“π°≈“ß∂÷ß√âÕ¬≈– 75.8 ¡’°“√√—∫√ŸâÕ¬Ÿà„π√–¥—∫ Ÿß ·≈–°“√√—∫√ŸâÕ¬Ÿà„π√–¥—∫µË”„π®”π«π·≈–√âÕ¬≈–‡∑à“°—π§◊Õ √âÕ¬≈–12.1 (3.2) °“√»÷°…“√–¥—∫°“√√—∫√Ÿâ¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ®”·π°µ“¡À¡«¥¢Õß°“√√—∫√Ÿâ æ∫«à“ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ¡’°“√√—∫√Ÿâ‡°’Ë¬«°—∫‚Õ°“ ‡ ’Ë¬ßµàÕ ¿“«–·∑√°´âÕπ¢Õß‚√§ §«“¡√ÿπ·√ß¢Õß‚√§·≈–°“√√—∫√Ÿâ‚¥¬√«¡Õ¬Ÿà„π√–¥—∫ª“π°≈“ß °“√√—∫√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß ºŸâªÉ«¬¡’°“√√—∫√Ÿâ‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß¡“°∑’Ë ÿ¥„π‡√◊ËÕß¿“«–·∑√°´âÕπÕ—πµ√“¬∑’Ë‡°‘¥®“°‚√§§«“¡¥—π‚≈À‘µ Ÿß §◊ÕÀ≈Õ¥‡≈◊Õ¥„π ¡Õß·µ°À√◊Õµ’∫ (§–·ππ‡©≈’Ë¬‡∑à“°—∫ 1.90) √Õß≈ß¡“§◊Õ À≈Õ¥‡≈◊Õ¥·µ°À√◊Õµ’∫µ—π„π ¡Õß∑’Ë‡°‘¥®“°‚√§§«“¡¥—π‚≈À‘µ ŸßÕ“®∑”„Àâµ“¬À√◊Õæ‘°“√‰¥â(§–·ππ‡©≈’Ë¬ ‡∑à“°—∫ 1.80)

æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß ¢ÕßºŸâªÉ«¬‚√§

§«“¡¥—π‚≈À‘µ Ÿß

ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ¡’æƒµ‘°√√¡°“√ªØ‘∫—µ‘‡°’Ë¬«°—∫°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß „π√–¥—∫ª“π°≈“ß‡ªìπ à«π„À≠à∂÷ß√âÕ¬≈– 75.8 ¡’æƒµ‘°√√¡°“√ªØ‘∫—µ‘Õ¬Ÿà„π√–¥—∫¥’√âÕ¬≈– 13.8 ·≈–¡’æƒµ‘°√√¡°“√ªØ‘∫—µ‘Õ¬Ÿà„π√–¥—∫µË”‡æ’¬ß√âÕ¬≈– 10.4 ®”·π°µ“¡À¡«¥

æƒµ‘°√√¡°“√ªØ‘∫—µ‘ æ∫«à“ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß¡’æƒµ‘°√√¡°“√ªØ‘∫—µ‘‡°’Ë¬«°—∫‚√§§«“¡¥—π‚≈À‘µ Ÿß„πÀ¡«¥ °“√§«∫§ÿ¡Õ“À“√·≈–πÈ”Àπ—° À¡«¥°“√ÕÕ°°”≈—ß°“¬ À¡«¥°“√æ—°ºàÕπ·≈–§≈“¬§«“¡‡§√’¬¥Õ¬Ÿà„π√–¥—∫ª“π°≈“ß ·µà¡’æƒµ‘°√√¡°“√ªØ‘∫—µ‘„πÀ¡«¥°“√√—∫ª√–∑“π¬“·≈–°“√√—°…“Õ¬Ÿà„π√–¥—∫¥’·≈–æƒµ‘°√√¡°“√ªØ‘∫—µ‘‚¥¬√«¡Õ¬Ÿà„π√–¥—∫ª“π°≈“ß(§à“‡©≈’Ë¬‡∑à“°—∫ 1.42) æ‘®“√≥“√“¬≈–‡Õ’¬¥‡ªìπ√“¬¢âÕ æ∫«à“ºŸâªÉ«¬¡’æƒµ‘°√√¡ªØ‘∫—µ‘°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß‡ªìπª√–®”·≈–∫àÕ¬§√—Èß„π‡√◊ËÕß °“√¡“µ√«®µ“¡·æ∑¬åπ—¥Õ¬à“ß ¡Ë”‡ ¡Õ (§–·ππ‡©≈’Ë¬‡∑à“°—∫1.84) √Õß≈ß¡“§◊Õ°“√À≈’°‡≈’Ë¬ßÀ√◊Õ≈¥°“√√—∫ª√–∑“πÕ“À“√∑’Ë¡’√ ‡§Á¡ (§–·ππ‡©≈’Ë¬‡∑à“°—∫ 1.73) ”À√—∫æƒµ‘°√√¡∑’ËºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ªØ‘∫—µ‘°—ππâÕ¬¡“°À√◊Õ‰¡à‡§¬ªØ‘∫—µ‘‡≈¬‡°’Ë¬«°—∫°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß‰¥â·°à °“√§«∫§ÿ¡‰¡à„Àâ¡’Õ“√¡≥å‚°√∏ Àßÿ¥Àß‘¥ À√◊Õ‰¡à ∫“¬„® (§–·ππ‡©≈’Ë¬‡∑à“°—∫ 1.03) √Õß≈ß¡“§◊Õ°“√À“Àπ∑“ß·°â‰¢ªí≠À“ ‡¡◊ËÕ‰¡à ∫“¬„® À√◊Õ¡’§«“¡‡§√’¬¥ (§–·ππ‡©≈’Ë¬‡∑à“°—∫ 1.12)

§«“¡ —¡æ—π∏å√–À«à“ß§«“¡√Ÿâ °“√√—∫√Ÿâ °—∫

æƒµ‘°√√¡°“√ªØ‘∫—µ‘ „π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢Õß

ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß

æ∫«à“ §«“¡√Ÿâ¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß °—∫æƒµ‘°√√¡°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ‰¡à¡’§«“¡ —¡æ—π∏å°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ À√◊ÕÕ“®°≈à“«‰¥â«à“ ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß∑’Ë¡’§«“¡√Ÿâ‡√◊ËÕß‚√§§«“¡¥—π‚≈À‘µ Ÿß„π√–¥—∫∑’Ë·µ°µà“ß°—π ¡’æƒµ‘°√√¡„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß∑’Ë‰¡à·µ°µà“ß°—π §«“¡ —¡æ—π∏å√–À«à“ß§«“¡√Ÿâ°“√√—∫√Ÿâ °—∫æƒµ‘°√√¡°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß æ∫«à“§«“¡√Ÿâ¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß °—∫æƒµ‘°√√¡°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß‰¡à¡’§«“¡ —¡æ—π∏å°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘(p-value > .05) ·≈–æ∫«à“°“√√—∫√Ÿâ¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß °—∫æƒµ‘°√√¡°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß‰¡à¡’§«“¡



—¡æ—π∏å°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘ (p-value > .05)

«‘®“√≥å

®“° √ÿªº≈°“√»÷°…“ æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß „π‡¢µ‡∑»∫“≈‡¡◊Õß©–‡™‘ß‡∑√“ Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥©–‡™‘ß‡∑√“ æ∫«à“ºŸâªÉ«¬ à«π„À≠à ¡’§«“¡√Ÿâ °“√√—∫√Ÿâ ·≈–æƒµ‘°√√¡°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß Õ¬Ÿà„π√–¥—∫ª“π°≈“ß´÷Ëß Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß™≈π°ÿ≈ §”π÷ß5 ∑—Èßπ’ÈÕ“®‡ªìπº≈¡“®“°°“√¥”‡π‘πß“πªÑÕß°—π·≈–§«∫§ÿ¡‚√§‰¡àµ‘¥µàÕ¢Õß®—ßÀ«—¥©–‡™‘ß‡∑√“‡ªìππ‚¬∫“¬ „Àâ‡√àß¥”‡π‘πß“π‡™‘ß√ÿ° ‚¥¬‡©æ“–ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß·≈–‡∫“À«“π°àÕπ‡ªìπÕ—π¥—∫·√° ®÷ß àßº≈„Àâª√–™“™π‰¥â√—∫§«“¡√Ÿâ §”·π–π”„π°“√ªØ‘∫—µ‘µ—«‡°’Ë¬«°—∫æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß

§«“¡ —¡æ—π∏å√–À«à“ß§«“¡√Ÿâ °“√√—∫√Ÿâ °—∫æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß æ∫«à“ §«“¡√Ÿâ °“√√—∫√Ÿâ ‰¡à¡’§«“¡ —¡æ—π∏å°—∫æƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ´÷Ëß‰¡à‡ªìπ‰ªµ“¡ ¡¡ÿµ‘∞“π∑’Ëµ—Èß‰«â·µà Õ¥§≈âÕß°—∫°“√»÷°…“¢Õß ®ÿ±“æ√ ‡ ’¬ß°≈¡∑—Èßπ’ÈÕ“®‡π◊ËÕß®“° ª√–™“°√∑’Ë»÷°…“ à«π„À≠à ¡’ ¿“ææ◊Èπ∑’Ë∑“ß —ß§¡ µ≈Õ¥®π«—≤π∏√√¡ ·≈– ‘Ëß·«¥≈âÕ¡∑’Ë„°≈â‡§’¬ß°—π ®÷ß∑”„Àâæƒµ‘°√√¡°“√ªØ‘∫—µ‘„π‡√◊ËÕßµà“ßÊ¬àÕ¡§≈â“¬§≈÷ß°—π √«¡∂÷ß°“√ªØ‘∫—µ‘‡°’Ë¬«°—∫°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß ÷Ëßæ∫«à“¡’°“√ªØ‘∫—µ‘∑’Ë‰¡à·µ°µà“ß°—π ¥—ßπ—Èπ „π°“√·°â‰¢ªí≠À“‡™‘ß√ÿ°¥â“π ÿ¢¿“æ ®÷ß®”‡ªìπÕ¬à“ß¬‘Ëß∑’Ë®–µâÕß√Ÿâ¢âÕ¡Ÿ≈æ◊Èπ∞“π‡∫◊ÈÕßµâπ„π¥â“π§«“¡√Ÿâ §«“¡§‘¥ °“√√—∫√Ÿâ·≈–°“√ªØ‘∫—µ‘„π°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß√“¬∫ÿ§§≈‡æ◊ËÕ®–‰¥âµ‘¥µ“¡·≈–„Àâ§”·π–π”µ“¡§«“¡®”‡ªìπ´÷Ëß·µà≈–§π‰¡à‡À¡◊Õπ°—π ∑”„Àâ‡°‘¥°“√æ—≤π“∑—°…–æ◊Èπ∞“π·°à‡®â“Àπâ“∑’Ë∑’ËªØ‘∫—µ‘ß“π„π™ÿ¡™π

°“√»÷°…“§√—ÈßµàÕ‰ª §«√¡’°“√«—¥√–¥—∫ §«“¡¥—π‚≈À‘µ·≈–°“√™—ËßπÈ”Àπ—° §«∫§Ÿà‰ª°—∫°“√»÷°…“æƒµ‘°√√¡°“√ªØ‘∫—µ‘ ‡æ◊ËÕ¬◊π¬—πº≈°“√§«∫§ÿ¡√–¥—∫§«“¡¥—π‚≈À‘µ®“°°“√ªØ‘∫—µ‘µπ¢ÕßºŸâªÉ«¬

§«√¡’°“√»÷°…“∂÷ßªí®®—¬ ∑’Ë¡’º≈µàÕæƒµ‘°√√¡°“√¥Ÿ·≈ ÿ¢¿“æµπ‡Õß ¢ÕßºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß‡æ‘Ë¡‡µ‘¡ ‡æ◊ËÕ®–∑”„Àâ∑√“∫¢âÕ‡∑Á®®√‘ß¢Õßªí®®—¬µà“ßÊ·≈–π”§«“¡√Ÿâ®“°°“√»÷°…“‰ªª√–¬ÿ°µå„™â„π°“√«“ß·ºπ¥Ÿ·≈√—°…“·≈–æ—≤π“√Ÿª·∫∫°“√„Àâ§«“¡√Ÿâ ·≈–§”·π–π”·°àºŸâªÉ«¬ µ≈Õ¥®π≠“µ‘À√◊ÕºŸâ¥Ÿ·≈„°≈â™‘¥„Àâ™à«¬°—π¥Ÿ·≈ª√—∫æƒµ‘°√√¡ ÿ¢¿“æ¢ÕßºŸâªÉ«¬ ®π‡°‘¥º≈¥’„π°“√§«∫§ÿ¡√–¥—∫§«“¡¥—π‚≈À‘µ‰¥â¡“°°«à“‡¥‘¡

§«√¡’°“√»÷°…“°“√¡’ à«π√à«¡„π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§§«“¡¥—π‚≈À‘µ Ÿß¢ÕßÕ“ “ ¡—§√ “∏“√≥ ÿ¢‡π◊ËÕß®“°‡ªìπºŸâ∑’ËÕ¬Ÿà„°≈â™‘¥°—∫ºŸâªÉ«¬

√ÿª

æƒµ‘°√√¡°“√¥Ÿ·≈µπ‡Õß¢ÕßºŸâªÉ«¬§«“¡¥—π‚≈À‘µ Ÿß „π‡¢µ‡∑»∫“≈‡¡◊Õß©–‡™‘ß‡∑√“ Õ”‡¿Õ‡¡◊Õß ®—ßÀ«—¥©–‡™‘ß‡∑√“ “¡“√∂∫Õ° ∂“π-°“√≥å·≈–æƒµ‘°√√¡°“√¥Ÿ·≈µπ‡Õßæ√âÕ¡∑—Èß “¡“√∂π”º≈∑’Ë‰¥â¡“«“ß·ºπª√—∫ª√ÿßæ—≤π“ª√—∫‡ª≈’Ë¬πæƒµ‘°√√¡°≈ÿà¡‡ ’Ë¬ß„Àâ‡°‘¥æƒµ‘°√√¡„π∑“ß∑’Ë¥’¢÷Èπ “¡“√∂¢¬“¬º≈·≈–ª√—∫„™â„πæ◊Èπ∑’Ë„π®—ßÀ«—¥Õ◊Ëπ‰¥â

°‘µµ‘°√√¡ª√–°“»

¢Õ¢Õ∫§ÿ≥ π“¬·æ∑¬å«—≤π“ °“≠®π°“¡≈π“¬·æ∑¬å “∏“√≥ ÿ¢®—ßÀ«—¥©–‡™‘ß‡∑√“, §ÿ≥‰æ‡√“–‰µ√µ‘≈“π—π∑å ¥â“π àß‡ √‘¡æ—≤π“, §ÿ≥ ¡ƒ¥’ ÿ¢Õÿ¥¡ “∏“√≥ ÿ¢Õ”‡¿Õ»√’√“™“ ®—ßÀ«—¥™≈∫ÿ√’ °≈ÿà¡µ—«Õ¬à“ß¢Õß™ÿ¡™π‡∑»∫“≈‡¡◊Õß ©–‡™‘ß‡∑√“∑ÿ°∑à“π ∑’Ë™à«¬Õ”π«¬§«“¡ –¥«°·≈–„Àâ§«“¡√à«¡¡◊Õ„π°“√‡°Á∫¢âÕ¡Ÿ≈°“√»÷°…“§√—Èßπ’È‡ªìπÕ¬à“ß¥’


1. ÿ√‡°’¬√µ‘ Õ“™“πÿ¿“æ. ªí≠À“‡«™ªØ‘∫—µ‘„π°“√¥Ÿ·≈ºŸâªÉ«¬§«“¡¥—π‚≈À‘µ Ÿß. «“√ “√§≈‘π‘° 2544:185 -6.

132

ªï∑’Ë 32 ©∫—∫∑’Ë 1 ¡°√“§¡-¡’π“§¡ 2550«“√ “√°√¡°“√·æ∑¬å

4. ”π—°ß“π “∏“√≥ ÿ¢®—ßÀ«—¥©–‡™‘ß‡∑√“. √“¬ß“πª√–®”ªï2548 ©–‡™‘ß‡∑√“. °≈ÿà¡ß“πæ—≤π“¬ÿ∑∏»“ µ√å “∏“√≥ ÿ¢ ”π—°ß“π “∏“√≥ ÿ¢®—ßÀ«—¥©–‡™‘ß‡∑√“, 2548.

5. ™≈π°ÿ≈ §”π÷ß. °“√√—∫√Ÿâ·≈–°“√¥Ÿ·≈µπ‡Õß¢Õß∫ÿ§§≈∑’Ë‡ªìπ‚√§§«“¡¥—π‚≈À‘µ. «‘∑¬“π‘æπ∏åª√‘≠≠“æ¬“∫“≈»“ µ√å¡À“∫—≥±‘µ “™“«‘™“°“√æ¬“∫“≈ºŸâ„À≠à. ¢Õπ·°àπ:∫—≥±‘µ«‘∑¬“≈—¬ ¡À“«‘∑¬“¢Õπ·°àπ; 2544.

2. ‡æÁ≠®—π∑√å ª√–¥—∫¡ÿ¢. ªØ‘ —¡æ—π∏å¢Õß§√Õ∫§√—«·≈–™ÿ¡™π°—∫°“√‡®Á∫ªÉ«¬‡√◊ÈÕ√—ß °“√∑∫∑«πÕß§å§«“¡√Ÿâ ∂“π°“√≥å ·≈–ªí®®—¬∑’Ë ‡°’Ë¬«¢âÕß. æ‘¡æå§√—Èß∑’Ë 2.°√ÿß‡∑æ¡À“π§√: ‚√ßæ‘¡æå™ÿ¡πÿ¡ À°√≥å°“√‡°…µ√·Ààßª√–‡∑»‰∑¬; 2542.

3. ”π—°ß“πª≈—¥°√–∑√«ß “∏“√≥ ÿ¢ ”π—°ß“ππ‚¬∫“¬·≈–·ºπ. ∂‘µ‘ “∏“√≥ ÿ¢ 2548. æ‘¡æå§√—Èß∑’Ë 1. 2548.

Documents

Content-Jan50 - dms.moph.go.th · PDF fileQuality for Dengue Hemorrhagic Fever Patients in Sakon Nakhon Province Pornchai Channgam, M.D. Pailin Nadsantia, M.Ns. 16 Home Exercise Program