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Cell therapy is the promising therapeutic tool for the next decade. "Regenerative Medicine" based on cell and tissue replacement therapy is proposed as a revolutionary approach to various chronic and incurable conditions. The first key step for successful cell therapy is the establishment of clinical grade human Embryonic Stem Cell (hESC) lines. This article provides a concise summary on conventional and novel methods for hESC line derivation. There is also discussion on progression, future direction and problems in hESC line development. In Thailand, more advance knowledge, skill, and technology are required to develop the first human embryonic stem cell line and step forward to make cell therapy a reality.

Cell therapy is a promising therapeutic tool for the next decade. It has a potential to cure a number of chronic diseases and conditions related to aging processes or degenerative changes. In addition, it could be used to replace cells and tissues in injured organs. Furthermore, it may provide a novel approach to congenital anomalies and genetic disorders where current therapeutic options are limited However, many crucial questions need answers to ensure a safe, effective and successful solution in the field of cell therapy. In Thailand, innovative knowledge and expertise in stem cell biology and technology are required as the key elements to make cell therapy a "real" hope.

Stem cell research has obtained more attention during the last decade because of its strong potential as a new tool to cure many chronic diseases. In addition, stem cell knowledge is an important basis for understanding pathophysiology at the cellular level and developing disease models for experimental research. There are different limitations on resources, budget, policy and regulation among countries. As a result, each country has particular advantages and disadvantages in stem cell research. This result in the establishment of international networks and collaborations to coordinate and promote stem cell research aimed at medical applications.

Embryonic stem cell is the promising novel therapeutic tool for various degenerative diseases and tissue injuries. With the concept of cell and tissue therapy, many chronic disorders will be curable. The present article provides basic knowledge of stem cell in areas of definition, classification and future clinical applications. In addition, stem cell application is not only focusing on regenerative purpose, but also concentrating on more understanding about the early human development and the pathophysiology of genetic diseases at the cellular level. However, there are some technical problems and ethical concern that should be resolved before applying stem cells into clinical practice.

Our simple definition of ethics is good thought, speak and action. Epistemology means the hypothesis of facts about thought, speech and action. Medical practice is all means of medicine. Medicine classifies people into normal and abnormal. The abnormal are the sick. They loose some organs or those normal looking organs are dysfunctional. They are social problems, some can be treated, and some do not get the appropriate care. The problems of society of normal people are overeating and obesity, abortion, drug abuse, promiscuity, torture, terrorism, disobeying rules and order, corruption, brain-washing and unethical advertisements, etc. On the other hand, the social problems of the abnormal are down, deafness, blindness, dumb, hypertension, hypercholesterolemia, diabetes mellitus and cancer, etc. An example of the social-doctor problem is the mal distribution of doctors in rural areas. It was reported by the ministry of public health that the ratio of doctor to population to be 1:800 in Bangkok and 1:5, 700 in some rural areas in the north eastern part of Thailand. The doctors, themselves, are at a high grade of worker and intelligent quotient. They know all the problem and, at the same time, create problems, both, faster than the general population can do. It affects good and bad in the society. In the past, present and the foreseeable future the medical students get their studies in the western style. Their medical schools are situated in big cities. These schools are old and famous. They learn their medical procedure in a big hospital of more than 400 beds in the inpatient department wards. Their instructors and professors are highly qualified, are middle class people and well accepted in the society. Their families are lovely and warm. Their children study in the first class schools in town. The medical students feel very happy and appreciate seeing their professors in television routinely at prime time. In conclusion, their professors are an example of role model for them to follow. Everyone looks for security in her/his profession. Facts need no proof and reference. People with justice in mind should believe and understand the above mentioned. This leads to the problem of mal distribution of doctors in rural areas, why do doctors live in big cities or wish to be in the private sector? In fact, not many a number of doctors serve in the rural area. About 4-5 of them, their name will be announced yearly as the best rural doctor award. After the big ceremony, lasted not longer than a month, it is hard to remember their name. They are proud to be praised, it pushes them into stress intentionally with all the best of their intelligence and the total of their body strength to work harder in rural. Unfortunately their earning, the security of their profession, the increased chance of being sued, to get caught in the medical litigation, the expenses of their family social status and the study of their children cannot be compared to of those doctors in big city and/or in the private sector. Mal distribution of doctors in remote rural areas has been a persisting unresolved problem in many parts of the world, why not apply the principles of ethics and epistemology? They have been left, untouched forever.

Objective: To compare the efficacy, side effects and patient satisfaction between 800 microg versus 400 microg intravaginal misoprostol for anembryonic pregnancy., Material and Method: Women who had diagnosed as anembryonic pregnancy were treated as IPD case and randomly assigned to receive either 800 microg or 400 microg intravaginal misoprostol. The second dose was administered in the equal dose if there was no evidence of abortion in 24 hr. The treatment failure was determined by no complete abortion within 48 hr. If spontaneous abortion had not occurred, or had heavy vaginal bleeding or evidence of incomplete abortion either by clinical manifestation or sonographic finding then dilatation and curettage was performed., Results: Fifty patients were enrolled into the study, 25 patients were randomized to receive 800 mg and 25 patients were received 400 mg intravaginal misoprostol. Complete abortion within 48 hr was not different between the 2 groups (72%). However complete abortion within 12 hr was significantly higher in the 800 mg group than in the 400 mg group (64% versus 20%, respectively, p = 0.016). The median time to abortion in the 800 mg group was significantly shorter than in the 400 mg group (9.0 hr versus 16.0 hr, respectively, p = 0.01). There was no significant difference in the side effects and patients' satisfaction between both groups., Conclusion: Vaginal misoprostol can be used for termination of pregnancy in case of anembryonic pregnancy with high successful rate of complete abortion and no serious adverse effects. We recommend the 800 microg vaginal misoprostol regimen because within 12 hr the complete abortion rate was higher and the median time to abortion was shorter than the 400 microg regimen with no difference in side effects. This may decrease the suffering time of both physical and psychological trauma to the patient before complete abortion has occurred.

Intravenously administered magnesium sulfate is effective in reducing the incidence of eclampsia in women with severe preeclampsia. However, the routine use of magnesium sulfate in all cases of preeclampsia is not justified as the incidence of eclampsia is likely to be lower in milder cases than in those with severe disease, and also in view of the adverse effects of magnesium sulfate. Magnesium sulfate should be considered for women with preeclampsia for whom there is concern about the risk of eclampsia, such as hyperreflexia, frontal headache, blurred vision, and epigastric tenderness. As it is an inexpensive drug, it is especially suitable for use in low income countries. Intravenous administration is preferable, where there are appropriate resources, as side effects and injection site problems seem lower. Duration of treatment should not normally exceed 24 hours, and if the intravenous route is used for maintenance therapy the dose should not exceed 1 g/hour Serum monitoring is not necessary. Clinical monitoring of respiration, tendon reflexes and urine out put are enough for monitoring of magnesium toxicity. Administration and clinical monitoring of magnesium sulfate can be done by medical, a midwife or nursing staff provided they are appropriately trained. However, the use of magnesium sulfate should not be misconstrued as a license for reduced surveillance of preeclamptic women. Progression from mild to severe disease and development of serious maternal complications during antepartum, intrapartum and postpartum cannot be predicted without close maternal surveillance. Therefore, continued close antepartum, intrapartum, and postpartum surveillance is crucial for optimal maternal and perinatal outcomes.

Aim: To compare the efficacy, side effects and patient satisfaction between 800 microg versus 400 microg intravaginal misoprostol for early pregnancy failure., Material and Method: Women diagnosed as early pregnancy failure were randomly assigned to receive either 800 microg or 400 microg intravaginal misoprostol. The second dose was administered if there was no evidence of abortion in 24 h. The treatment failure was reffered to no complete abortion within 48 h. Dilatation and curettage was performed if the patients had heavy vaginal bleeding or evidence of incomplete abortion or no complete abortion., Results: 25 patients were randomized to receive 800 microg and 25 patients were to receive 400 microg misoprostol. Complete abortion was not significantly different between the 2 groups (72%, 76% respectively). Although median time to abortion in the 800 microg group was significantly shorter, the patients experienced more side effects especially fever which was significantly different (P = 0.04). In the 800 microg group, 2 patients had heavy vaginal bleeding and one patient developed endometritis. There was no significant difference in the patients' satisfaction between both groups., Conclusions: 400 microg of vaginal misoprostol are as effective as 800 microg in producing complete abortion in early pregnancy failure with less side effects and similar patient satisfaction.

Acardiac twin is a rare event with high perinatal mortality rate and the management strategies remain controversial. The authors report 4 cases of twin pregnancies associated with one acardiac twin diagnosed at King Chulalongkorn Memorial Hospital during the period 1993 to 2002. Two cases were expectantly managed and intrauterine interventions were performed in order to occlude umbilical artery of the acardiac twin in 2 cases, by using Guglielmi detachable coil (GDC) embolization and absolute alcohol injection. Overall, the perinatal mortality rate for the pump twin was 50% and the survival rate of expectant management in the present series was 100%. GDC embolization was judged to be technically successful since it completely occluded the circulation to the acardiac twin. However, the pump twin was dead which might have resulted from the compromised state due to cardiac failure. At present, it seems that conservative management with close antenatal surveillance is the treatment of choice when the twin-weight ratios are substantially less than 70%. Invasive techniques should be considered when there is ultrasound evidence of hydramnios or congestive heart failure of the pump twin at a previable gestational age.

Objective: To establish the reference ranges for first trimester umbilical cord and vessel diameters of Thai fetuses., Material and Method: A prospective study was performed on normal pregnant women between 10(+0) and 13(+6) weeks of gestation who underwent ultrasound examination. The diameter measurements were obtained by a 7.5 MHz vaginal--or a 3.75 MHz abdominal transducer. Statistics were analyzed using SPSS computer program., Results: Records of 184 pregnancies were analyzed and the outcome demonstrated a strong correlation between umbilical cord diameter and gestational age (r = 0.90; p < 0.001). Umbilical vessel diameters were also correlated with gestational age., Conclusion: First trimester umbilical cord and vessel diameters of Thai fetuses are related to gestational age. The presented reference ranges might be useful for further studies, such as prediction of adverse pregnancy outcome or combination with biochemical or other ultrasound markers for fetal aneuploidy screening.

The objective was to assess the value of uterine artery notching as a screening test for preeclampsia and fetal growth restriction in a low-risk population of healthy pregnant women. Color Doppler ultrasound was used to examine both uterine arteries in 322 healthy pregnant women at 24.9 +/- 1.9 (range 22-28) weeks of gestation. The criterion for abnormal results was a unilateral or bilateral presence of an early diastolic notch. The major end points were preeclampsia and small for gestational age (SGA) infants. Of the 322 women, 19 (5.9%) developed preeclampsia and six of them (1.9%) delivered SGA infants. An early diastolic notch was detected in 58 women (18%). The risk of developing preeclampsia and SGA infants in an abnormal Doppler study group was found to be greater than in that of a normal group (P<0.05). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detecting preeclampsia were 36.8, 83.2, 12.1, and 95.5%, respectively; whereas detecting SGA infants were 67, 82.9, 6.9, and 99.2%, respectively. Women with an early diastolic notch have considerably a higher risk of developing preeclampsia and SGA infants. On the other hand, women with normal uterine artery waveforms are unlikely to develop preeclampsia and SGA infants. The test may be useful to minimize unnecessary interventions.

Objective: To determine whether 4-hour urine protein value correlates with 24-hour urine protein value in women with hypertensive disorders in pregnancy., Study Design: Cross-sectional study was performed in 38 in-patient pregnant women who were initially diagnosed as having hypertensive disorders in pregnancy. Urine samples were collected within 24 hours in 2 successive periods: the first 4-hour and the next 20-hour urine, in separate containers. The urine volume, urine protein and creatinine concentrations were thus separately measured. The 4- and 24-hour urine proteins were calculated and the correlation between both groups was determined by simple linear regression analysis., Results: A total of 38 patients were recruited into the study, 26 had mild preeclampsia, 5 had severe preeclampsia, and 7 had superimposed preeclampsia. The result of the 4-hour urine protein was found to correlate with those of the 24-hour urine protein for patients with hypertensive disorders in pregnancy (p < 0.001)., Conclusion: Total protein values of 4-hour samples positively correlated with values of 24-hour samples of patients with hypertensive disorders in pregnancy. This might be modified and used for urine protein collection in outpatients to improve the compliance.

Information to make patients fully aware of all the details of treatments is an important part of the medical practice before obtaining patient's signature in the consent form. Explanation may be detailed enough to make patients understand the process of treatment. However, sometime it may not be inclusive enough to cover all major statements that give pros and cons of the treatment. Perhaps detailed explanation may reveal too much information that may discourage patients to receive treatments and cause fear, anxiety, and hopelessness. If health care personnels do not mention all the risks involved in medical treatments, they may be subjected to an accusation of concealing the truth that should be made known to patients. This is one of many ways of looking at the problems. There is no easy answer to the problem of what 'appropriate' explanation should be. Most of our patients are from all walks of life which are not medical profession, and they do not have knowledge to understand technical terms. How should we approach patients in order to be safe from an accusation of that we are not over supporting, not giving the patients false hope? Therefore, we would like to present a guideline for informing and explaining to the patients under the following headings (15): 1. Diseases or major symptoms which are diagnosed. 2. The necessity to receive treatments for the benefits of patients or fetus. 3. If possible, determine the duration of treatments. 4. Methods of treatment, evaluation, and schedule for next appointment. 5. Inform about necessary investigations. 6. Inform about complications of risks, and cost of investigations 7. Usefulness and results of investigations. 8. If options of treatments are available, they should be explained in details, the pros and cons, the risks, and the costs, etc. 9. Maintaining medical confidentiality and the use of patient chart by medical personnel and other related health care providers, for instance, hospital staffs from all levels, medical students, technical medical students, and social workers, etc.

Color pulsed Doppler ultrasound was used to examine the uterine arteries of a total of 265 normal pregnant women during 22-28 weeks' gestation at the Division of Maternal-Fetal Medicine, King Chulalongkorn Memorial Hospital. Reference ranges for pulsatility index (PI) were determined and throughout this gestational range, the mean values were nearly constant and lower than 0.9 and the upper limit of 95 per cent confidence interval (CI) for the PI values were lower than 1.0. In conclusion, the authors have established the reference ranges for PI of uterine arteries in the late second to early third trimester of pregnancy in Thai pregnant women. This could be beneficial for the baseline data in the evaluation of pregnant women complicated with preeclampsia and fetal growth restriction.

Objective: To assess the value of humerus length shortening for prenatal detection of Down syndrome in a Thai population., Methods: A prospective study was performed on 3053 women undergoing second-trimester amniocentesis, between 16 and 24 weeks gestation, for the indications of advanced maternal age and a past history of chromosomal abnormality. Biparietal diameter (BPD) and humerus length measurements were obtained before the procedures. Regression equations relating BPD to humerus length were used to calculate observed humerus length/expected humerus length ratio in chromosomally normal and Down syndrome fetuses. Sensitivity, specificity, false-positive rate and likelihood ratio of a positive test result at various observed humerus length/expected humerus length ratios for detection of Down syndrome were calculated. A receiver-operator characteristic curve was used to determine the threshold screening ratio., Results: There were 3003 chromosomally normal pregnancies and 24 fetuses with Down syndrome. The relationship between humerus length and BPD was: expected humerus length = 0.7403BPD - 5.1057, R2= 0.77, P < 0.001. Humerus length in Down syndrome fetuses was significantly shorter than in normal fetuses (P < 0.001). A ratio of 0.91 for observed humerus length/expected humerus length yielded a sensitivity of 41.7%, specificity of 88.3%, a false-positive rate of 11.7% and likelihood ratio of a positive test result of 3.63 (95% confidence interval 2.24-5.88) for detection of Down syndrome., Conclusions: Humerus length shortening in the second trimester appears to be a useful adjunctive screening parameter for fetal Down syndrome in a Thai population.

Thailand, which is barely recovering from the 1997 economic collapse, has passed a new constitution, has a new government and all of this will have a profound effect on the way doctors practice and interact with their patients. Some of the factors that have been responsible for this are 1) Passage of a patient's rights bill 2) Legal definition of what is a proper consent form 3) The public's demand for openness, better communication and transparency in medicine These concepts, which now have a legal as well as moral basis, will impact directly on doctors and nurses as their practices will be subject to increasingly intense scrutiny and criticism. Doctors and nurses in past generations were among the most respected members of Thai society. They were trusted almost without exception and their judgment was not questioned. Only rare cases of malfeasance and malpractice came to public notice though, no doubt, they existed but to a much lesser degree. A physicians' life was much simpler for our teachers, fathers and grandfathers. Life was inexpensive, families were less demanding and the doctor did not have to surround himself with expensive foreign-made apparatus which can bankrupt the doctor as well as the patients who have to pay the bills. Medical decisions were made mostly on the basis of observation, past experience at the bedside and not in the laboratory or imaging rooms. Honest errors in diagnosis were common, treatment was limited and simple and this was all tolerated or expected by the public. Few if any disappointments on the part of patients ended up before a judge.

We developed a nomogram for transverse cerebellar diameter (TCD) in Thai fetuses by recruitment of 153 normal pregnant women in the first trimester. The gestational age calculated by the certain last menstrual period and the first trimester ultrasound were in agreement. The pregnant women were stratified into 4 groups and scanned at four weekly intervals: group A was first scanned at 14 weeks, group B at 15 weeks, group C at 16 weeks, and group D at 17 weeks. A total of 699 measurements from 14 to 40 weeks of gestation were obtained. The data were analyzed for mean and standard deviation; and the best fit mathematical model was derived. The TCD grew progressively along gestational age. The growth rate was slightly less than that of a Western study after 28 weeks of gestation. This could serve as the basis for gestational dating in fetuses with aberrant fetal growth.

The purpose of this study was to determine the incidence of vaginal vault granulation after total abdominal hysterectomy using polyglactin (Vicryl) for vault closure. Fifty women who underwent total abdominal hysterectomy for benign and elective conditions were included into the study. Standard surgical technique of total abdominal hysterectomy was employed except for closure of the vaginal vault performed by interrupted figure-of-eight sutures using No. 1 polyglactin. All patients were prospectively followed-up at approximately 6 weeks postoperatively and vaginal vault granulation was diagnosed as present or absent. It was found that 5 patients had vaginal vault granulation without any symptoms, giving the incidence of 10 per cent. One patient who developed vault granulation had postoperative morbidity from cuff cellulitis. The remaining 49 patients had no immediate postoperative complications.

Objective: To determine the sonographic appearances in pregnant women who presented with vaginal bleeding in the first 20 weeks of gestation., Method: Pregnant women of under 20 gestational weeks diagnosed clinically as threatened abortion were recruited for ultrasound scan at the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University. The sonographic findings were reported as viable pregnancy, anembryonic pregnancy, embryonic death, incomplete abortion, complete abortion, ectopic pregnancy, molar pregnancy and inconclusive findings. Patients with inconclusive findings were followed weekly until final diagnoses were established. All patients were followed-up to 20 weeks or until the final outcomes were revealed., Results: Two hundred and sixty eight pregnant patients were enrolled. Ultrasound scans demonstrated 100 viable fetuses (37.3%), 73 embryonic deaths (27.3%), 46 anembryonic pregnancies (17.2%), 6 molar pregnancies (2.2%), 3 ectopic pregnancies (1.1%), 14 complete abortions (5.2%) and 26 inconclusive findings (9.7%). Follow-up scan on patients with inconclusive findings revealed 9 anembryonic pregnancies (3.3%), 9 incomplete abortions (3.3%), 1 embryonic death (0.4%) and 1 viable pregnancy (0.4%). Six patients (2.3%) were lost to follow-up. The viable pregnancy rate according to maternal age was highest at the maternal age of 25 to 29 years old (49%), whereas, it was lowest at the maternal age of 40 to 44 years old (0%). The viable pregnancy rate according to gestational age was highest at 6 to 8 weeks (61.2%), whereas, it was lowest at 18 to 20 weeks (20%)., Conclusion: Sonographic findings in patients with clinically diagnosed threatened abortion demonstrated viable pregnancies in around one-third of the cases. Use of ultrasound in clinically diagnosed threatened abortion may assist clinicians in establishing a definite diagnosis so that appropriate care could be offered to the patients.

Short fetal acoustic stimulation test (FAST) was prospectively studied in 604 high risk pregnancies after 28 weeks of gestation. Fetal heart rates were recorded 3 minutes before and 5 minutes after fetal acoustic stimulation. The results of the tests performed within a week of delivery were compared with perinatal outcomes. Reactive response to short FAST occurred in 597 cases (98.8%) while nonreactive response was found in 7 cases (1.2%). Nine fetuses were considered poor outcomes. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of short FAST to predict poor fetal outcomes were 66.7, 99.8, 85.7, 99.5, and 99.3 per cent, respectively. Short FAST has high specificity, negative predictive value and accuracy for prediction of poor perinatal outcome. This rapid test should be used as a screening method for antepartum assessment of fetal well-being in a busy antenatal clinic.