Feedback intervention to doctors improves patient satisfaction among outpatients in Inner Mongolia Autonomous Region, China.

OBJECTIVES: The doctor-patient relationship (DPR) in China is known to be tense. We tested whether an intervention program providing individualized feedback to doctors by patients could improve patients' satisfaction in an outpatient setting. STUDY DESIGN: A non-randomized controlled prepost intervention study in a tertiary hospital. Six surgery clinics were chosen as the intervention group and eight internal medicine clinics as the control group. METHODS: Before the program started, patients attending each group of clinics were asked to fill in the Short-Form Patient Satisfaction Questionnaire (PSQ-18). In the experimental period, patients attending the intervention clinics were requested to rate their perception of the doctor's quality of care in various domains on an 8-question feedback card immediately after exiting from the examination room and to drop the completed card into the feedback box for the particular doctor. The cards were then collected by the doctor confidentially at the end of each day. There was no feedback in the control clinics. After the experimental period ended, the doctors in both groups of clinics were reassessed by a new series of patients using PSQ-18. The PSQ-18 scores were compared within the same group of clinics over time, and the changes in satisfaction score compared between intervention and control clinics. RESULTS: There were 189 and 190 responders in the intervention group and 190 and 200 in the control group, before and after the intervention period, respectively. Scores in all domains increased significantly (P < 0.001) in the intervention group but not in the control group. Significant improvement in the patient satisfaction scores in the intervention clinics compared with the control clinics was confirmed by mixed-effects linear regression controlling for the effects of gender, age, marital status, education, and household income in the domains of general satisfaction, technical quality, communication, and accessibility and convenience. CONCLUSIONS: Timely feedback to doctors of patients' perception of quality of care received can improve outpatient satisfaction in a Chinese hospital.

Chikungunya and dengue virus infections during pregnancy: seroprevalence, seroincidence and maternal-fetal transmission, southern Thailand, 2009-2010.

Limited information is available on the seroprevalence of chikungunya virus (CHIKV) infection and maternal-fetal transmission incidence of CHIKV and dengue virus (DENV) infections during the 2008-2009 CHIKV outbreak in southern Thailand. A community-based post-epidemic seroprevalence study was conducted in parturient women admitted to the Thepa District Hospital in Songkhla Province, Thailand, for delivery from November 2009 to May 2010. The women were tested for chikungunya (CHIK) IgM/IgG and dengue (DEN) IgM/IgG. Cord blood samples were also tested for CHIK IgM or DEN IgM in women who tested positive for CHIK IgM or DEN IgM, respectively. The seroprevalence of CHIKV infection (CHIK IgM or IgG positive) was 227/319 (71·2%) with pre-outbreak seroprevalence (IgM-/IgG+) of 43·6% and the seroprevalence of DENV infection was 288/319 (90·3%). Complications during pregnancy, newborn outcomes and congenital anomalies were not different in those who had recent, remote or no CHIKV infections. None of the newborns whose mothers were CHIK or DEN IgM positive had cord blood positive for both CHIK and DEN IgM. In conclusion, both CHIKV and DENV are endemic in southern Thailand; during the recent CHIKV outbreak CHIK seroprevalence increased from 43·6% to 71·2%.

Incidence of fetal bradycardia and effect of placental injury on fetal heart rate during second-trimester genetic amniocentesis.

A prospective study was conducted for comparing the incidence of fetal bradycardia and level of fetal heart rate change following a second-trimester genetic amniocentesis with and without placental injury. A total of 257 and 495 participants in injured and non-injured groups were analysed. The incidence of fetal bradycardia following amniocentesis was not statistically different between the two groups (1.17%, [95% CI 0.24, 3.37] and 0.20%, [95% CI 0.005, 1.12]) in injured and non-injured placenta groups, respectively; p = 0.118). The mean change in baseline fetal heart rate before and after amniocentesis was also not significantly different between the two groups (p = 0.844). No fetal death or pregnancy loss occurred within 4 weeks after the procedure. All 4 bradycardia participants were normal and healthy and had an appropriate weight for their gestational age. We conclude that placental injury during a second-trimester genetic amniocentesis due to advanced maternal age poses only a low risk of fetal bradycardia, and there is no evidence of differences between subjects with injured and non-injured placenta in the changes in fetal heart rate.

Characterization of glucose homeostasis and lipid profile in adult, seizure-free, epileptic patients in Asian population.

BACKGROUND AND PURPOSE: The most common prescribed antiepileptic drugs (AEDs), phenytoin and valproate, are potent enzyme inducers and inhibitors of the cytochrome P450 system, which interfere with lipid profile and glucose homeostasis. Studies on this topic have suffered from inadequate assessment of confounders and have rarely included glucose homeostasis and lipid profile as well as both enzyme inducers and inhibitors in the same study. We sought to determine whether these drugs had an effect on lipid profile and glucose homeostasis in Thai epileptic patients. METHODS: We recruited 98 patients with epilepsy (45 taking phenytoin, 27 taking valproate, and 26 not taking any AED). Fasting blood samples were obtained to measure serum lipid, and glucose homeostasis was evaluated via the oral glucose tolerance test. We calculated the homeostasis model assessment index for each patient. RESULTS: Our study revealed that CYP450 was induced by AEDs, and that patients on phenytoin had an increased mean value of serum total cholesterol, serum total triglycerides, and serum LDL cholesterol when compared with patients with epilepsy taking valproate and those taking no AEDs. No statistical significant difference was observed between patients taking valproate and patients taking no AEDs. In addition, patients with epilepsy taking phenytoin had higher fasting plasma glucose levels at fasting state than both those taking valproate and those taking no AEDs. Thirty percent of the patients taking phenytoin exhibited insulin resistance. We have found a negative correlation between log insulin sensitivity and log TG, but not high-density lipoprotein (HDL). CONCLUSION: CYP450-induced phenytoin produces significant amelioration in several serologic markers of atherosclerosis. These findings suggest that phenytoin may substantially increase the risk of vascular events.

Risk factors for reintubation in the post-anaesthetic care unit: a case-control study.

BACKGROUND: Risk factors for reintubation in post-anaesthetic care units related to anaesthetic processes have not previously been reported. Our goal was to identify risk factors for reintubation in general surgical patients. METHODS: A time-matched, case-control study was conducted on anaesthetic patients between 2001 and 2011. One hundred and sixty-four reintubated patients were compared with 656 randomly selected controls. RESULTS: Independent risk factors for reintubation were age <1 yr vs age 30-49 yr [odds ratio (OR)=16.4, 95% confidence interval (CI)=5.7-47.7], chronic pulmonary disease (OR=2.1, CI=1.1-4.0), preoperative hypoalbuminaemia (OR=4.9, CI=2.4-10), creatinine clearance <24 vs >60 (OR=4.1, CI=1.2-13.4), emergency case (OR=1.8, CI=1.0-3.1), operative time >3 vs <1 h (OR=3.0, CI=1.5-6.2), airway surgery (OR=32.2, CI=13.6-76), head and neck surgery (OR=3.4, CI=1.8-6.2), cardiac surgery (OR=3.8, CI=1.1-13.4), thoracic surgery (OR=6.3, CI=1.9-21.2), cardiac catheterization (OR=2.5, CI=1.1-5.5), ASA physical status III (OR=3.8, CI=1.4-10), and the use of certain types of neuromuscular blocking agent (P<0.001). CONCLUSIONS: Age <1 yr, chronic pulmonary disease, preoperative hypoalbuminaemia, and renal insufficiency were patient factors for reintubation. Emergency case, head and neck, cardiothoracic and airway surgery, and operative time >3 h were operative factors, while certain neuromuscular blocking agents and ASA physical status III were anaesthetic factors for reintubation.

A Thai reference for normal fetal nasal bone length at 11-13(+6) weeks gestation.

AIM: The purpose of this study was to establish a Thai reference for normal fetal nasal bone length (NBL) at 11-13(+6) weeks gestation. METHODS: The fetal nasal bone was measured by sonography in pregnant women at 11-13(+6) weeks gestation. All neonates who showed normal karyotypes were examined after delivery to confirm the absence of congenital abnormalities. RESULTS: A total of 255 pregnant women were recruited. Forty-seven pregnant women were excluded from the analysis because of technically unsatisfactory examination or absent nasal bone and chromosomal abnormalities. The mean ± SD of NBL was 1.79 ± 0.33 mm and increased significantly with crown-rump length (CRL) and gestational age (p < 0.001). The best-fit equation for NBL in euploid fetuses in relation to CRL was: NBL (mm) = (0.030 × CRL (mm)) - 0.016. CONCLUSION: NBL in Thai fetuses at 11-13(+6) weeks was found to be on average shorter than that in Caucasian, African-American and Chinese populations, but similar to those reported in Korean and Latin-American populations.

Sensitivity of pooled serum testing for screening antibody of schistosomiasis japonica by IHA in a mountainous area of Yunnan, China.

Pooled sample testing (PST) as a strategy for avoiding testing the majority of individual negative samples has been proposed for screening of diseases in low prevalence areas. There has been no standard guideline for PST in screening of Schistosoma japonicum infection of Yunnan, China. To document the optimum pool size with acceptable sensitivity of PST for screening of Schistosoma japonicum infection in this setting, an experimental pooling of each of 31 positive sera by IHA with various numbers of 24 negative sera was done. The results were used to create a statistical model which was subsequently used for simulation to predict sensitivity of the pooled serum tests in the population with varying prevalence and pool size. We found that to keep the sensitivity of PST above 90%, 1:05 should be the maximum dilution, that is, the optimum pool size should not be greater than 6. Antigen will have rather little interference if the prevalence of infection is low e.g. 1% or the antigen:antibody ratio is 1:100 or below. Pooled serum testing by IHA is an acceptable sensitive method for detecting antibody for Schistosoma japonicum infection in this area.

The effect of geographical distance on TB patient delays in a mountainous province of China.

SETTING: One hundred and twenty-nine counties in Yunnan, a mountainous province in China. OBJECTIVE: To document the relationship between patient delays and distance to local county tuberculosis (TB) centres. DESIGN: A computerised medical record-based study of a cohort of 10356 new smear-positive TB cases in 2005. RESULTS: The median total delay was 71 days (interquartile range [IQR] 38-128), with a median long patient delay of 60 days (IQR 28-111) and a relatively short median health care system delay of 4 days (IQR 2-13). Older age (>40 years), being an agriculturer and poor economic status were significantly associated with longer patient delays. Risk of delay increased with increasing geographical distance, with a greater effect on relatively shorter patient delays. Using the first quartile of distance as the reference group, hazard ratios for subsequent quartiles were 0.61 (0.57-0.65), 0.30 (0.28-0.33) and 0.15 (0.14-0.17) for short patient delays (60 days). CONCLUSION: Patients living in remote areas need support to overcome the barrier posed by geographical distance, which has a greater effect in the initial phases of the disease.

Assessment of the physical properties of laparoscopic myoma-fixation devices.

BACKGROUND: The physical properties of three commercial 5-mm myoma-fixation devices available for clinical use (short-pitch corkscrew, long-pitch corkscrew, buttress-thread screw) and a standard wood screw were examined. METHODS: Fresh specimens of uterine leiomyoma masses were used to test the maximum traction force obtained from each device on 31 occasions. The myoma tissue at each traction site was evaluated histologically to determine its density. The maximal traction forces in each myoma density group were compared using a generalized estimating equations approach to linear regression based on repeated measures within each myoma. The bending strength also was determined for each device. RESULTS: A wide range of maximum traction forces with a mean of 130.8 +/- 71.5 N (range, 21.6-341.6 N) over all devices and tissue densities was recorded. The mean maximum traction force provided by the short-pitch corkscrew (159.2 +/- 12.2 N) was significantly higher (p < 0.01) than that of the other devices in medium-density myomas, and not significantly lower than that of other devices in low-density myomas. The mean maximum traction force provided by the buttress-thread screw was significantly lower than that of the short-pitch corkscrew only in medium density myomas, and did not differ significantly from that of the wood screw in any density group. The wood screw provided the highest bending strength (6.73 x 10(4) N/m) (whereas the short- and long-pitch corkscrew provided the lowest (9.70 x 10(2) N/m and 1.95 x 10(3) N/m, respectively) and the buttress-thread screw an intermediate (2.24 x 10(4) N/m) strength (p < 0.0005 for all comparisons except for the two corkscrews). CONCLUSIONS: Screw-type myoma-fixation devices can provide comparable traction force with high bending strength. A long-pitch corkscrew should not be used for laparoscopic myomectomy because of its low traction force and bending strength. When a commercial screw is not available, a standard wood screw can be used with acceptable traction force and very high strength for bending.

Risk factors for postcesarean surgical site infection.

OBJECTIVE: To determine postcesarean complications and identify independent risk factors for surgical site infection. METHODS: We studied a cohort of 969 women delivered by cesarean between May and August 1997. Infections were determined by examinations during ward rounds, reviews of laboratory results, and follow-up for 30 days after discharge. Risk factors were identified by multiple logistic regression. RESULTS: Surgical complications were rare. There were febrile morbidity and infection complications in 16.2% and 12.4% of subjects, respectively. Eighty-five subjects had 95 surgical site infections (9.8%), and seven risk factors were independently associated with infection. Risk factors included preoperative remote infection (adjusted odd ratio [OR] 16.5, 95% confidence interval [CI] 2.1, 128.3); chorioamnionitis (OR 10.6, 95% CI 2.1, 54.2); maternal preoperative condition (OR 5.3 for those with severe systemic disease [American Society of Anesthesiologists score > or =31, 95% CI 1.2, 24.0); preeclampsia (OR 2.3, 95% CI 1.1, 4.9); higher body mass index (OR 2.0 for every five-unit increment, 95% CI 1.3, 3.0); nulliparity (OR 1.8, 95% CI 1.1, 3.2); and increased surgical blood loss (OR 1.3 for every 100-mL increment, 95% CI 1.1, 1.5). CONCLUSION: Host susceptibility and existing infections were important predictors of surgical site infection after cesarean delivery. Further intervention should target this high-risk group to reduce the clinical effect of surgical site infection.

Postoperative hospital-acquired infection in Hungvuong Obstetric and Gynaecological Hospital, Vietnam.

A prospective study was conducted following 1364 major operations at the 450-bed Hungvuong Obstetric and Gynaecological Hospital in HoChiMinh City, Vietnam, from 1 May to 30 September 1997 to characterize postoperative hospital-acquired infections. These infections were identified by ward rounds, review of laboratory results and patient follow-up until 30 days after discharge. During the study period, 194 infections were identified, yielding a rate of 14.2 infections per 100 operations. The most common sites were surgical wound and urinary tract, contributing together 95.9% of all hospital-acquired infections. The four most common pathogens were Staphylococcus aureus (29.6%), Escherichia coli (20.4%), Enterococci (16.7%) and Staphylococcus epidermidis (14.8%).

Predictors for the risk of hookworm infection: experience from endemic villages in southern Thailand.

To assess the role of defaecation pattern in predicting the level of risk for hookworm infection in southern Thailand, 4 villages in different geographical settings in endemic areas were studied. Close observation and stool examinations for hookworm were carried out. The first village was used for exploring the risk factors for hookworm infection. The resultant statistical model was then tested using the other 3 villages. Only 23-40% of the sample regularly defaecated in a latrine. The pattern of defaecation did not differ between the sexes, but was associated with age and site of residence. In the first village, the following variables were not statistically significant: sex, age, level of past education, household income, having neighbouring houses within 20 m, latrine availability, site of defaecation. The only statistically significant protective factor was shoe wearing, which showed an exposure-outcome severity relationship. Similar results were obtained in the other 3 villages. These results refute the protective effect of latrine use on the individual user, who may still get infection from the faeces of other community members. Promotion of shoe-wearing, which provides individual protection, should be an important supplementary strategy for hookworm control programmes in such areas.

Infant death rates and animal-shed delivery in remote rural areas of Nepal.

This article outlines a community-based retrospective study in a remote area of Nepal and describes local birth practices and their impact on infant mortality. Data collection was carried out in two steps, a household survey from September to October 1996 and a qualitative research phase. Data collected include socio-economic background, reproductive history, birth practices and child survival. Among 3007 live-born children, 660 (22%) died before their first birthday. In keeping with local customs, approximately half of the children were delivered in an animal shed and the other half in the home. Children born in an animal shed were at significantly higher risk of dying than were those born in the home even after adjusting for socio-economic status and biological variables. The association was stronger in the neonatal period (OR = 2.8, 95% CI 1.9-4.1) than during the post-neonatal period (OR= 1.3, 95% CI 1.02-1.6). The preparation of the delivery place was inadequate and thereby facilitated infection of both the newborn and the mother. Traditional norms and animal-shed delivery practices are common in the Jumla community. The reasons addressed for giving birth in the animal shed included (1) Household Deity's anger if delivery takes place in the home and (2) easy to clean the shed following the birth.

The effect of heavy maternal workload on fetal growth retardation and preterm delivery. A study among southern Thai women.

Heavy maternal workloads are considered to be hazardous to the fetus. The effects of physical activity during pregnancy on low birth weight (LBW), small for gestational age (SGA), and prematurity were assessed from a sample of 1797 women in a follow-up study at the antenatal clinic of two hospitals in southern Thailand. The women were interviewed twice, at 17 and 32 gestational weeks. Outcome data were obtained from medical records and the newborn gestational age determined using Dubowitz's score. The risk of SGA was elevated for women working > 50 hours/week, squatting in work, commuting > 1 hour/day, and having high psychological job demands; the risk of preterm delivery was increased with obstetrical complications. Women who worked long hours and had demanding work conditions had an elevated risk of giving birth to SGA infants but not of preterm delivery.

Total body irradiation using a modified standing technique: a single institution 7 year experience.

We describe a simple standing technique for delivering total body irradiation (TBI) using large horizontal fields, made possible by the off-centre installation of a non-dedicated treatment unit in a pre-existing bunker. Patients are treated using anterior and posterior fields with customized lung compensators. This technique enables the dose to the lung to be accurately calculated and modified to avoid overdose and to minimize the risk of pneumonitis. From February 1991 to December 1997, 94 patients with a variety of haematological malignancies were given fractionated TBI using this technique prior to allogenic or autologous bone marrow transplantation. Patients received a total dose of 14.4 Gy given in eight fractions over 4 days, with at least 6 h between fractions. The prescribed dose to the lungs was reduced to 12 Gy in eight fractions. The technique was well tolerated, took less than 10 min to set up and did not disrupt the daily routine use of the machine. Doses to all measured points on the trunk and head were within +/-6% of the prescribed dose. Doses to the lungs were within +/-5% of the prescribed dose. There were no early respiratory deaths in the 37 autologous transplant patients. There were 10 (17%) respiratory deaths in the 57 allogeneic transplant patients, 3 of confirmed infectious aetiology.

Conformal rotation therapy with central axis beam block is a feasible alternative to intensity-modulated radiotherapy for chordomas of the cervical spine.

AIMS: Paraspinal tumours, such as chordoma, represent a treatment challenge for oncologists, requiring high dose to the target volume without exceeding the tolerance dose of the spinal cord. Intensity-modulated radiotherapy (IMRT) is helpful in achieving sharp dose gradients and conformation of dose to the target volume. We present a simpler technique--conformal rotation therapy with a central axis beam block (CRT + BB), which can provide similar dose distributions. MATERIALS AND METHODS: A patient with a cervical chordoma developed postoperative recurrence and was treated with high-dose palliative radiotherapy. Treatment was delivered using CRT + BB, with three fixed beams and three coplanar arcs. A dose of 62 Gy in 31 fractions was delivered to the 100% isodose, giving a maximum spinal cord dose of 49.6 Gy. The patient relapsed 2 years later, and was re-treated using the same technique to a dose of 57 Gy in 30 fractions. Estimates of spinal cord repair rates in primates were used to determine the tolerance dose of the spinal cord for re-treatment. The patient remained well for a further 25 months before developing local recurrence, which was treated with palliative chemotherapy. RESULTS: Re-treatment plans using CRT + BB and IMRT were compared. Dose-volume histograms show equivalence of dose to the spinal cord, although the IMRT plan delivered a slightly higher dose to tumour and lower dose to surrounding soft tissues. CONCLUSION: Treatment using CRT + BB requires careful planning and discussion with neurosurgeons before surgery. The normal curvature of the cervical spine must be eliminated if possible, and the patient must be immobilised with the neck horizontal. If these geometric constraints can be satisfied, then CRT + BB can be used as a safe and effective alternative treatment to IMRT for tumours at this site.

Needle sharing and high-risk sexual behaviors among IV drug users in Southern Thailand.

This study sought to determine the prevalence of needle sharing and high HIV risk sexual behaviors and to identify characteristics associated with these practices in southern Thailand. Data were obtained using a structured questionnaire from 298 male intravenous drug users (IVDUs) seen in a methadone clinic during the previous year. The prevalence of HIV was 37%, and that of needle-sharing in the preceding months was 45%, although only 10% claimed to have had unsafe sex with a casual partner or prostitute in the same period. Determinants for needle sharing included shorter duration of drug injection, diminished knowledge of HIV prevention, a carefree attitude toward risk of HIV infection, and lower levels of income. Young single IVDUs with a low knowledge of HIV prevention were most likely not to use a condom. In conclusion, needle sharing among the study subjects was still a common practice, whereas high HIV risk sexual behavior was not. Attitudinal change may be necessary to reduce needle-sharing behavior and not just information on disease transmission.

Characteristics of repeat aborters in Vietnam.

Two hundred and sixty married women seeking induced abortion service in Hanoi, Vietnam were interviewed to determine the magnitude of repeat induced abortion and explore selected characteristics of the repeat aborters. Seventy-one percent of the sample reported having had at least one previous induced abortion. After adjustment for age and number of living children, poor attitudes toward contraception, low use of modern contraceptives and failure of contraception were shown to be significantly associated with repeat induced abortion. Woman's age, number of living children, contraceptive knowledge and experience and desire for no more children were positively related to repeat induced abortion. Socio-demographic characteristics were not related to repeat induced abortion. Improvement of attitudes toward contraception, persuasion to use modern contraception and promotion of contraceptive effectiveness are recommended strategies to prevent repeat induced abortion.

Follow up of water use in a tin mining area affected with arsenic poisoning.

Ron Phibun district in southern Thailand has been known as an endemic area for arsenic contamination. The government has been trying to improve the situation by encouraging the use of rainwater and piped water. This study aimed to document the change of water use and to identify factors associated with safe water use in 1997 compared to that in 1994. Home visits and face-to-face questionnaire interviews were undertaken. Information on water use for drinking, cooking, washing food and washing utensils in 1994 and 1997 was obtained. Among 3,849 households from which data could be obtained (estimated 79% of total households), the percentages of using safe water (including water from bottled rain water, piped and artesian well water) for drinking and cooking rose from 72.5 and 57.9 in 1994 to 93.6 and 80.9 in 1997, respectively. The percentages for washing foods and for washing utensils rose from 28.6 and 20.5 to 59.1 and 53.8, respectively. In 1997, percentage of households using piped water for drinking and cooking was still low (3.6 and 12.3) compared to those using piped water for washing food and utensils (39.1 and 43.6). Multivariate analysis shows that independent factors of the household predicting safe water use are: high arsenic area, near main road and having piped water installed. The influence of these factors (as judged by the level of odds ratio) operates more or less equally on water use for all purposes, except that installation of piped water has more influence on washing water than drinking and cooking water. We conclude that safe water supply in the area is still inadequate. Even if piped water is installed, it is often not used for drinking and cooking. The reasons for not using piped water for drinking and cooking need to be identified.

A study of 111 cases of globus hystericus.

Videofluorography (VFG) and manometry were used to evaluate 111 patients who were diagnosed with globus hystericus. Most of the globus patients were affected by functional diseases and the underlying pathology could be revealed by VFG in 73.9 per cent of the series and by manometry in 80.2 per cent. There were 10.8 per cent of the series in which VFG and manometry yieled normal findings. The most common abnormality determined by manometry was esophageal aperistalsis. The most common abnormality revealed by VFG was cricopharyngeal bar. VFG was sensitive for morphologic detection while manometry was sensitive for motility study. Functional disorders can result in morphologic abnormality and vice versa. Therefore, VFG and manometry complement each other and are invaluable tools in the investigation of globus patients.