Effect of radiation on serum anti-Müllerian hormone during hysterosalpingography in female infertility.

RESEARCH QUESTION: Does radiation exposure during hysterosalpingography (HSG) negatively affect serum anti-Müllerian hormone (AMH) levels in infertile women? DESIGN: Prospective cohort study conducted at Songklanagarind Hospital, Thailand, between April 2021 and May 2023. Thirty-two infertile women and 34 control participants were enrolled. Serum AMH levels were assessed in the infertile group at baseline before the HSG procedure and at 1 and 3 months after the procedure. Control participants, who self-reported no medical conditions, underwent the same AMH level assessments. Changes in serum AMH levels were compared. RESULTS: Infertile women had a mean age of 32.4 ± 3.8 years, body mass index of 21.2 ± 2.0 kg/m2 and baseline mean AMH level of 3.66 ng/ml (95% CI 3.00 to 4.32), which did not significantly differ from the control group. One month after HSG, mean AMH level significantly declined (0.33 ng/ml, 95% CI -0.65 to -0.01; P = 0.045) in the infertile group. The change in serum AMH levels between baseline and 1 month was significantly different in the HSG group compared with controls (-0.33 ng/ml, 95% CI -0.65 to -0.01 versus 0.36 ng/ml, 95% CI 0.06 to 0.67; P = 0.002). Changes in serum AMH levels from baseline to 3 months did not differ between the two groups. CONCLUSIONS: One month after the HSG, infertile women experienced a significant decrease in serum AMH levels compared with controls. The change in serum AMH levels between baseline and 3 months after HSG did not significantly differ from that of the control group.

Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study.

PURPOSE: To identify predictors and develop a scoring model to predict maternal near-miss (MNM) and maternal mortality. METHODS: A case-control study of 1,420 women delivered between 2014 and 2020 was conducted. Cases were women with MNM or maternal death, controls were women who had uneventful deliveries directly after women in the cases group. Antenatal characteristics and complications were reviewed. Multivariate logistic regression and Akaike information criterion were used to identify predictors and develop a risk score for MNM and maternal mortality. RESULTS: Predictors for MNM and maternal mortality (aOR and score for predictive model) were advanced age (aOR 1.73, 95% CI 1.25-2.39, 1), obesity (aOR 2.03, 95% CI 1.22-3.39, 1), parity ≥ 3 (aOR 1.75, 95% CI 1.27-2.41, 1), history of uterine curettage (aOR 5.13, 95% CI 2.47-10.66, 3), history of postpartum hemorrhage (PPH) (aOR 13.55, 95% CI 1.40-130.99, 5), anemia (aOR 5.53, 95% CI 3.65-8.38, 3), pregestational diabetes (aOR 5.29, 95% CI 1.27-21.99, 3), heart disease (aOR 13.40, 95%CI 4.42-40.61, 5), multiple pregnancy (aOR 5.57, 95% CI 2.00-15.50, 3), placenta previa and/or placenta-accreta spectrum (aOR 48.19, 95% CI 22.75-102.09, 8), gestational hypertension/preeclampsia without severe features (aOR 5.95, 95% CI 2.64-13.45, 4), and with severe features (aOR 16.64, 95% CI 9.17-30.19, 6), preterm delivery <37 weeks (aOR 1.65, 95%CI 1.06-2.58, 1) and < 34 weeks (aOR 2.71, 95% CI 1.59-4.62, 2). A cut-off score of ≥4 gave the highest chance of correctly classified women into high risk group with 74.4% sensitivity and 90.4% specificity. CONCLUSIONS: We identified predictors and proposed a scoring model to predict MNM and maternal mortality with acceptable predictive performance.

Combined maternal risk factors and the Quadruple test to predict late-onset preeclampsia in pregnant Thai women.

BACKGROUND: This study aimed to evaluate the predictive power of a model combining maternal risk factors and the Quadruple screen test for late-onset preeclampsia (PE). METHODS: All pregnant women that received the Quadruple test for Down syndrome at 15+ 0-20+ 6 weeks' gestation were recruited. Maternal serum α-fetoprotein, ß-human chorionic gonadotropin, unconjugated estriol, and inhibin A were measured as multiples of the median. A logistic regression model was used to identify predictors associated with late-onset PE with severe features. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to assess the model's predictive ability. RESULTS: Fifty-five of the 2,000 pregnant women had PE, and 31 of 55 women had late-onset PE. Multivariate analysis identified maternal age ≥ 35 years, inhibin A, history of previous PE, history of infertile, cardiac disease, chronic hypertension, and thyroid disease as significant risk factors. The area under the curve of the receiver operating characteristic curve was 0.78. The likelihood ratio to predict late-onset PE was 49.4 (total score > 60). CONCLUSIONS: Our model combining serum inhibin A with maternal risk factors was useful in predicting late-onset PE. Close monitoring of these patients is recommended.

The Health Impact of Long-Term Kratom (Mitragyna Speciosa) Use in Southern Thailand.

BACKGROUND: Mitragyna speciosa or Kratom has been used in Thailand traditionally for its medicinal value. Despite case reports of kratom consumption causing adverse effects, research on its long-term health impact is limited. This study examines the long-term health impact of kratom use among people in Southern Thailand. METHODS: Three community-based surveys were conducted from 2011 to 2015. In the first and second surveys (2011 and 2012) a total of 1,118 male respondents comprising 355 regular kratom users, 171 occasional kratom users, 66 ex-users, and 592 non-users aged 25 or above, were recruited from 40 villages. All respondents were followed up in this study. However, not all respondents were successfully followed up throughout the entire set of studies. RESULTS: Common health complaints were no more common among kratom users than ex- and non-users, but more regular than occasional users claimed kratom to be addictive. Those with high kratom dependence scores were more likely to experience intense withdrawal symptoms, which developed 1-12 h after the last kratom intake. Over half (57.9%) of regular users had experienced intoxication effects compared to only 29.3% of occasional users. Kratom users were less likely to have a history of chronic diseases such as diabetes, hypertension, dyslipidemia than ex- and non-users. CONCLUSION: Regular long-term chewing of fresh kratom leaves was not related to an increase in common health complaints, but may pose a drug dependence risk. Severe kratom dependents were more likely to suffer from intense withdrawal symptoms. Medical records revealed no death due to traditional kratom use, but the high prevalence of tobacco or/and hand rolled cigarette smoking among kratom users should be of concern.

Expected Years Of Life Lost Due To Alcohol Consumption In Thai Adults: A 16-Year Follow-Up Cohort Of National Health Examination Survey 2004-2019.

AIMS: Evidence of premature death attributable to alcohol, a modifiable risk factor, is crucial for guiding public health policy for alcohol control. The aim of this study was to estimate alcohol-related mortality and potential years of life lost (PYLL) in Thailand in 2004-2019. METHODS: We analysed data of the third National Health Examination Survey in 2004 linked to National Death Registry data of 2004-2019. Causes of death were based on International Classification of Diseases version 10. PYLL was calculated by cause of death, age group and sex. All analyses were weighted to take into account the probabilities for the multi-stage sampling of the 2004 Thai population aged ≥15 years. RESULTS: There were 10,704 deaths with a follow-up time of 507,771.7 person-years. The crude mortality rate of the initial sample was 868.6 per 100,000 population. The mortality rate attributable to alcohol was 18.6 per 100,000 population (30.7 per 100,000 population in males and 6.8 per 100,000 population in females). The top leading cause of alcohol-attributable deaths was unspecified liver diseases in both males and females (6.1 and 3.1 per 100,000 population, respectively). The total years of life lost (YLL) at baseline were 9.4 million years or 49.5 years per person on average, with significantly more years in males. Mortality rate and expected YLL were highest in ages of 30-44 years, followed by 15-29 years. CONCLUSION: Males were 4-fold more likely to die from all alcohol-attributable causes compared with females. Young adults had a greater loss of life years than older adults.

ABO blood group is not a predictive factor for the amount of early opioid consumption in postanesthesia care unit: a prospective cohort study in 3,316 patients.

BACKGROUND: Immediate postoperative pain in the postanesthesia care unit (PACU) is common. Titration of opioid is the most popular strategy for controlling early postoperative pain. ABO blood group has been found to be associated with pain perception. We aimed to find the factors including ABO blood group for predicting the amount of opioid requirement in PACU. METHODS: This prospective cohort study was performed in 3316 patients who underwent various kinds of anesthetic techniques and received immediate postoperative care in PACU. Preoperative, intraoperative and PACU data were collected. A directed acyclic graph (DAG) representing the hypothesized causal pathways of preoperative, intraoperative and PACU data were compiled prior to conducting multinomial logistic regression analysis. Statistical significance in all models was defined as a P-value < 0.05. RESULTS: Female sex, body mass index, preoperative use of gabapentin, preoperative anxiety score, anesthetic techniques, type of operation, amount of consumed intraoperative opioids, intraoperative use of paracetamol, parecoxib and ondansetron, duration of anesthesia and surgery, amount of blood loss, pain upon PACU arrival, use of paracetamol and parecoxib in PACU were found to be factors influencing amount of opioid consumption in PACU. ABO blood group was not associated with early postoperative opioid requirement. CONCLUSIONS: A significant number of factors are related to amount of opioid requirement in PACU. Some factors can be adjusted to provide better pain relief in early postoperative period. However, ABO blood group is not identified to be a predictive factor for early postoperative opioid consumption in PACU.

Low-dose aspirin for prevention of preeclampsia: Implementation of the NICE guideline in Thailand.

AIM: To evaluate the effectiveness of a preeclampsia (PE) screening program using the National Institute for Health and Care Excellence (NICE) guideline in pregnant Thai women. METHODS: A total of 2552 pregnancies received antenatal care and were delivered at Songklanagarind Hospital between November 2016 and April 2020. PE screening with the NICE guideline was used to identify mothers at risk. In cases of positive screening results, a daily dose of 81 mg aspirin was prescribed. Pregnancy outcomes were compared with 2783 participants who had maternity care before the implementation of the screening program. The effectiveness of aspirin prophylaxis following the NICE guideline was assessed by a logistic regression model to compare the risk of PE development between before and after guidance. RESULTS: The screening positive rate by NICE was 8.3%. Of these, 77.36% of the participants received aspirin prophylaxis according to the NICE recommendation. After the implementation of the PE screening program, the incidence of PE slightly decreased (from 4.31% to 3.72%, p = 0.274). The chance of PE in pregnancies who had high-risk factors was reduced after using low-dose aspirin prophylaxis, even though the difference was not statistically significant. CONCLUSIONS: Screening with the NICE guidelines followed by prescription of low-dose aspirin (81 mg/day) was probably not an effective strategy for the prevention of PE in our population. Combining biophysical and biochemical markers to identify pregnant women who subsequently develop PE, concurrently with an increased dose of aspirin prophylaxis, may provide a better outcome in clinical practice.

A new risk score model to predict preeclampsia using maternal factors and mean arterial pressure in early pregnancy.

The purpose of this study was to establish a multivariable risk-scoring model for preeclampsia (PE) prediction based on maternal characteristics and mean arterial pressure (MAP). Multivariate logistic regression analysis from 4600 pregnancies during a 10-year period was used to create the best fitting model. Significant risk factors and weighted scores consisted of age ≥30 years (3), BMI ≥25 kg/m2 (2), multifetal pregnancy (9), history of PE (9), adverse perinatal outcomes (6), pregnancy interval >10 years (5), nulliparous (5), underlying renal disease (10), chronic hypertension (6), autoimmune disease (5), diabetes (2) and MAP ≥95 mmHg (5). The model achieved an ROC area 0.771 with detection rates of 34%, 44%, 53% and 58% at 5%, 10%, 15% and 20% fixed false-positive rates, respectively. The new risk score model could be a clinically useful screening tool for PE. Pregnant women who have total scores of 9-13 (high risk) and more than 14 (very high risk) should receive aspirin prophylaxis.Impact StatementWhat is already known on this subject? Preeclampsia (PE) is the major cause of maternal and perinatal mortality and morbidity; it can be prevented by antiplatelet agents.What the results of this study add? A new model for identifying maternal at risk for PE using clinical risk factors and MAP was created. Weighted scores were defined for each variable for easy use in clinical practice. According to their probability for PE, pregnant women were classified into three subgroups: low risk (score 0-8), high risk (score 9-13) and very high risk groups (score ≥ 14). Aspirin should be prescribed to high risk and very high risk groups. For safety concerns, very high risk pregnancies should have close antenatal surveillance in a tertiary care hospital to reduce adverse outcomes during pregnancy and childbirth.What the implications are of these findings for clinical practice and/or further research? This new model for identifying pregnant women at high risk for PE has the potential to reduce the morbidity and mortality associated with this disease.

Obstructive sleep apnea and sudden unexpected death in epilepsy in unselected patients with epilepsy: are they associated?

PURPOSE: We aimed to determine (1) the frequency of high-risk sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy who have had obstructive sleep apnea (OSA) in different stages of sleep using the revised SUDEP risk inventory (rSUDEP-7) score instrument and (2) the factors associated with high risk SUDEP in patients with epilepsy who have had OSA. METHODS: We conducted a cross-sectional study of consecutive subjects who are more than 15 years old without known sleep disorders, recruited from a single epilepsy clinic in a tertiary care facility. Participants underwent polysomnography. Scoring was performed by two blinded board-certified sleep physicians. The relationships between rSUDEP-7 scores and OSA measures were evaluated using Wilcoxon rank-sum test, chi-squared test, and quantile regression. RESULTS: Our study population consisted of 95 participants. Overall median (IQR) apnea-hypopnea index (AHI) of our populations was 2.3 (0.7,7.5) events rate per hour; 12 (75%) patients had moderate OSA and 4 (25%) patients had severe OSA. Nine patients had a rSUDEP-7 score of 5 to 7. There was no significant difference between total rSUDEP-7 score or rSUDEP-7 score of > 5 or < 5 and total AHI, supine AHI, non-supine AHI, NREM AHI, or REM AHI; similarly, (2) there was no significant difference in total rSUDEP-7 score between AHI of < 15 or > 15. CONCLUSION: Our study reveals no association between AHI score, OSA, and total rSUDEP-7 score or rSUDEP-7 score of > 5. The pathophysiology underlying SUDEP appears complex. We need further studies on SUDEP to help elucidate the cardiorespiratory mechanisms and predisposing factors.

Factors influencing precautions against antineoplastic drug exposure among nurses and nurse assistants in Thailand.

BACKGROUND: Antineoplastic drugs (AD) are important chemical risks for healthcare workers. Precautions against AD exposure include the use of appropriate personal protective equipment (PPE). Evaluation of PPE usage during patient care processes has not been reported in Thailand. We aimed to evaluate the level of PPE usage and factors predicting PPE usage among nurses and nurse assistants in Thailand. METHODS: A cross-sectional survey was conducted in a university hospital and two general hospitals. The questionnaires covered demographic characteristics, self-reported use of PPE and 7 predictive factors. Mixed-effects modeling was used to determine the association between standardized score of predictive factors and PPE usage score. RESULTS: The response rate was 78.6% and 884 participants were left for analysis after data cleaning. Among nurses (n = 499), higher PPE usage score was associated with self-efficacy (ß = 0.28, 95% CI 0.21, 0.34), workplace safety climate (ß = 0.27, 95% CI 0.20, 0.34), and conflict of interest (ß = - 0.07, 95% CI - 0.14, - 0.01). Among nurse assistants (n = 385), higher PPE usage score was associated with self-efficacy (ß = 0.27, 95% CI 0.18, 0.36), interpersonal influence (ß = 0.14, 95% CI 0.04, 0.24), workplace safety climate (ß = 10.29, 95% CI 0.19, 0.38), and conflict of interest (ß = - 0.14, 95% CI - 0.24, - 0.03). CONCLUSIONS: Several factors were associated with PPE usage among nurses and nurse assistants. Improved PPE usage against AD can be promoted through interventions that modify those factors.

A Context-Specific Instrument to Record Drinking Behaviour: A Pilot Study on Implications of Identifying the Context of Risky Drinking.

A context-specific quantity-frequency (CSQF) questionnaire has been developed to accurately measure alcohol consumption using probing questions on drinking context. The study aimed to describe the drinking context associated with different drinking intensities in a community of southern Thailand using the CSQF. A cross-sectional survey was conducted among adults aged > 15 years in Songkhla Province, Thailand. Among 804 participants, there were 183 current drinkers with 412 drinking events (215 low-, 79 medium-, and 118 high-intensity). More than half of these events occurred in special situations (i.e., holiday, party, and cultural drinking). About half of the drinking events occurred outside the drinker's house and most drinking events occurred among friends. Higher drinking intensity was associated with higher level of education [adjusted odds ratio (aOR) 4.74 for medium- and aOR 5.23 for high-intensity] and with a special drinking situation (aOR 2.46 for medium- and aOR 2.78 for high-intensity).

Distribution of uterocervical angles in the second trimester of pregnant women at low risk for preterm delivery.

The uterocervical angle (UCA) has recently been studied as a parameter to identify women at risk for spontaneous preterm birth (sPTB). This study aimed to investigate the distribution of UCA values by transvaginal sonography (TVS) in the second trimester of women at low risk for sPTB. TVS was performed in 450 low-risk pregnant women at gestational age (GA) 160/7-240/7 weeks. The UCA distribution by GA was visualised using a scatter plot. The range of UCA values and their relationship with GA were assessed using quantile regression analysis. p < .05 was considered statistically significant. A total of 242 participants with anteflexed uterus, no history of caesarean section and term delivery were analysed. The normal range of UCA (5th and 95th percentiles) was from 63.0 degrees (95% CI, 53.1-72.9) to 148.8 degrees (95% CI, 139.5-158.0) with no significant changes during this GA period (-0.3 degrees per week, p = .757).Impact statementWhat is already known on this subject? Spontaneous preterm birth (sPTB) is a major problem in obstetrics. A screening strategy using history of sPTB and cervical length (CL) measurement is the current standard to identify women at risk for sPTB and provide adequate prevention. However, a third of women who are identified as low risk go on to have sPTB, so a better means needs to be found to more reliably identify women at risk. Various studies have found that a wide uterocervical angle (UCA) was associated with sPTB, and thus the UCA has been proposed as a potential sPTB screening parameter. However, to date there is a lack of prospective studies evaluating this proposal, and no consensus about the proper gestational age to perform UCA measurements to identify women at risk of sPTB.What do the results of this study add? This study reports the distribution of UCA at the GA of 160/7-240/7 weeks of low-risk singleton pregnancy women who delivered at term. The mid-90% values ranged from 63.0 degrees to 148.8 degrees with no significant differences in this GA period.What are the implications of these findings for clinical practice and/or further research? Because of the wide range of UCA values at GA 160/7-240/7 weeks, more studies regarding UCA values in various gestational ages are required to fully understand the trend of UCA values along pregnancy and confirm whether or not the UCA would be a useful parameter for sPTB prediction and if so at what gestational age it would have to be assessed.

Prevalence and risk factors of strongyloidiasis in patients with systemic lupus erythematosus in Southern Thailand.

Background: Strongyloidiasis can be fatal in systemic lupus erythematosus (SLE) patients, but few epidemiological studies have investigated the burden of this tropical disease among the SLE population. This study aimed to assess the prevalence and associated factors of strongyloidiasis among SLE patients in Southern Thailand. Methods: A cross-sectional study was conducted on 180 SLE patients attending the Rheumatology Clinic at Songklanagarind Hospital. Stool specimens were collected and examined using the direct smear technique and agar plate culture technique. Serum anti-Strongyloides stercoralis IgG was measured by IgG-ELISA. Results: The overall prevalence of strongyloidiasis by combined parasitologyl and/or serology was 15.6%. The prevalence of strongyloidiasis by parasitological methods was 2.2%. Positive parasitology and/or serology was associated with male sex and a SLE disease duration of less than two years. Conclusion: Strongyloidiasis is highly prevalent among the SLE population. A combination of serological and parasitological methods increases the rate of diagnosis of strongyloidiasis in SLE patients.

Screening for pre-eclampsia: Performance of National Institute for Health and Care Excellence guidelines versus American College of Obstetricians and Gynecologists recommendations.

AIM: The purpose of this study was to compare the accuracy of the National Institute for Health and Care Excellence (NICE) guidelines and the American College of Obstetricians and Gynecologists (ACOG) recommendations for pre-eclampsia (PE) screening. METHODS: This retrospective study included 4600 Thai pregnant women who received maternity care between January 2006 and December 2015 at Songklanagarind Hospital, a tertiary care center in southern Thailand. The medical data of each participant were assessed using the NICE and ACOG criteria to identify maternal risk for PE. The sensitivity, specificity, positive likelihood ratio and negative likelihood ratio for detecting pregnancies complicated with PE according to each guideline were calculated. Receiver operating characteristic (ROC) curves were constructed to compare the predictive performance. RESULTS: Pre-eclampsia was found in 167 cases (3.63%). The ACOG recommendations achieved ROC area 0.70 (58.1% sensitivity with 82.4% specificity) for PE at any gestation and ROC area 0.66 (62.9% sensitivity with 69.0% specificity) for PE which required delivery before 37 weeks' gestation. ROC areas based on the NICE guidelines were 0.64 (35.3% sensitivity with 92.5% specificity) and 0.59 (34.8% sensitivity with 83.4% specificity) for all PE and preterm PE, respectively. The ACOG criteria were significantly more accurate than the NICE criteria for detecting maternal risk for all PE, preterm PE and nulliparity cases (P values <0.05). CONCLUSION: For Thai pregnant women, screening for PE with maternal risk factors according to the ACOG recommendations was more effective in identifying high-risk pregnancies than the NICE guidelines.

Comparison of drinking prevalence among Thai youth before and after implementation of the Alcoholic Beverage Control Act.

BACKGROUND: Underage drinking contributes to numerous health and social problems among adolescents. The Alcoholic Beverage Control Act, issued in Thailand in 2008, contains several clauses aiming at preventing underage and novice drinking, such as raising the minimum legal purchasing age from 18 to 20, banning alcohol sale and consumption in places frequented by youth, and banning alcohol advertisements. OBJECTIVES: To estimate the changes in the prevalence of alcohol consumption and perceptions of drinking norms among high-school students 8 years after the Act was implemented. METHODS: Data from the Thai national high-school surveys in 2007 (N = 50,033; 49.9% female) and 2016 (N = 38,535; 49.8% female), using similar questionnaires, were analyzed. Prevalence rates and group norms toward drinking were compared between the two surveys, using weighted Poisson regression and prevalence ratios. RESULTS: Drinking prevalence significantly increased in females, with prevalence ratios ranging from 1.2 for 30-day intoxication to 2.1 for 30-day binging. In males, the 12-month drinking prevalence increased in 2016, but a non-significant change for binge drinking and a 40% decrease for intoxication was seen. Higher proportions of students in 2016 perceived that most of their friends also drank alcohol compared to students in 2007 (16.8% vs. 11.2%; 49.8% increase). A significant effect of the year of survey on drinking patterns was seen across all school levels. CONCLUSION: Drinking rates decreased among males, but increased in females. These changes may be somewhat due to the Act, or to changes in the social environment in Thailand over this 8-year period.

Alcohol Advertisements, Hazard Warnings, Knowledge of Alcohol-Related Harm and Health-Profession Students' Drinking in Inner Mongolia.

Background: Consumption of alcohol among adults in Inner Mongolia is high even among health professionals. Little is known of the alcohol consumption patterns of health-profession students. Objectives: To assess the association of knowledge of alcohol-related harm (KAH), and exposure to media-based promotional alcohol sales advertisements (PASA) and alcohol hazard warnings (AHW) with drinking frequency of health-profession university students. Methods: Health-profession students (N = 1277) in the Medical University of Inner Mongolia were interviewed in 2017 regarding their alcohol drinking frequency, KAH, and exposure to PASA and AHW. Multinomial logistic regression was used to evaluate associations between exposure and drinking frequency. Results: Overall, 9% were nondrinkers, 35% occasional drinkers, and 56% frequent drinkers. Females were slightly less commonly drinkers but more commonly frequent drinkers. The prevalence of drinking decreased with age. Mongolians were more commonly frequent drinkers than Han. A majority of students had low KAH. Exposure to PASA was more common among drinkers, and exposure to AHW more common among nondrinkers. The main reason for drinking was social gathering. The relative probability of being an occasional or frequent drinker was lower among older students, those with higher KAH, and those exposed to AHW on television and internet but higher among those exposed to PASA in mini-supermarkets on campus. Conclusions: Students' drinking behavior was associated with low KAH and exposure to alcohol advertisements and warning media messages. Prevalence of frequent drinking might be reduced by wider use of AHW on internet and television and improving the level of knowledge of alcohol-related harm.

Using Clinical Profiles and Complete Blood Counts to Differentiate Causes of Acute Febrile Illness during the 2009-11 Outbreak of Typhoid and Chikungunya in a Dengue Endemic Area.

BACKGROUND AND AIMS: After the 2009-11 outbreak of typhoid and chikungunya (CHIK) in Thailand, an effort was made to use complete blood counts and clinical profiles to differentiate these diseases to facilitate earlier specific treatment. METHODS: Patients aged 2-15 years having fever on first visit ≤3 days without localizing signs were enrolled retrospectively. Typhoid fever was confirmed by hemoculture, dengue by nonstructural protein-1 or polymerase chain reaction (PCR), and CHIK by PCR. Febrile children with negative results for these infections were classified as other acute febrile illness (AFI). RESULTS: Of the 264 cases, 56, 164, 25 and 19 had typhoid fever, dengue viral infection (DVI), CHIK and other AFI, respectively. Arthralgia had sensitivity, specificity, positive predictive value (PPV) and negative predictive value of 0.96, 0.97, 0.80 and 0.99, respectively, to differentiate CHIK from the others. After excluding CHIK by arthralgia, the PPV of the WHO 1997 and 2009 criteria for DVI increased from 0.65 and 0.73 to 0.95 and 0.84, respectively. Children with one of myalgia, headache or leukopenia had sensitivity of 0.84, specificity of 0.76 and PPV of 0.92 to differentiate DVI from typhoid and other AFIs. Patients with one of abdominal pain, diarrhea or body temperature >39.5°C were more likely to have typhoid fever than another AFI with PPV of 0.90. CONCLUSION: Using this flow chart can help direct physicians to perform more specific tests to confirm the diagnosis and provide more specific treatment. Nevertheless, clinical follow-up is the most important tool in unknown causes of febrile illness.

Severity and Mortality Predictors of Pediatric Acute Respiratory Distress Syndrome According to the Pediatric Acute Lung Injury Consensus Conference Definition.

OBJECTIVES: The objective of this study was to assess the prevalence, severity, and outcomes of pediatric acute respiratory distress syndrome in a resource-limited country. In addition, we sought to explore the predisposing factors that predicted the initial severity, a change from mild to moderate-severe severity, and mortality. DESIGN: Retrospective study. SETTING: PICU in Songklanagarind Hospital, Songkhla, Thailand. PATIENTS: Children 1 month to 15 years old with acute respiratory failure admitted to the PICU from January 2013 to December 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From a total of 1,738 patients admitted to PICU, 129 patients (prevalence 7.4%) were diagnosed as pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition. The patients were categorized by severity. Fifty-seven patients (44.2%) were mild, 35 (27.1%) were moderate, and 37 (28.1%) were severe. After multivariable analysis was performed, factors significantly associated with moderate to severe disease at the initial diagnosis were Pediatric Risk of Mortality III score (odds ratio, 1.08; 95% CI, 1.03-1.15; p = 0.004), underlying oncologic/hematologic disorder (odds ratio, 0.32; 95% CI, 0.12-0.77; p = 0.012), and serum albumin level (odds ratio, 0.46; 95% CI, 0.27-0.80; p = 0.006), whereas underlying oncologic/hematologic disorder (odds ratio, 5.33; 95% CI, 1.33-21.4) and hemoglobin (odds ratio, 0.63; 95% CI, 0.44-0.89) predicted the progression of this syndrome within 7 days. The 30-day all-cause mortality rate was 51.2% (66/129). The predictors of mortality were the Pediatric Risk of Mortality III score (odds ratio, 1.12; 95% CI, 1.02-1.24; p = 0.017), underlying oncologic/hematologic disorder (odds ratio, 7.81; 95% CI, 2.18-27.94; p = 0.002), receiving systemic steroids (odds ratio, 4.04; 95% CI, 1.25-13.03; p = 0.019), having air leak syndrome (odds ratio, 5.45; 95% CI, 1.57-18.96; p = 0.008), and presenting with multiple organ dysfunction (odds ratio, 7.41; 95% CI, 2.00-27.36; p = 0.003). CONCLUSIONS: The prevalence and mortality rate of pediatric acute respiratory distress syndrome in a developing country are high. The oncologic/hematologic comorbidity had a significant impact on the severity of progression and mortality.

Does burst-suppression achieve seizure control in refractory status epilepticus?

BACKGROUND: The general principles in the administration of anesthetic drugs entail not only the suppression of seizure activity but also the achievement of electroencephalography burst suppression (BS). However, previous studies have reported conflicting results, possibly owing to the inclusion of various anesthetic agents, not all patients undergoing continuous electroencephalography (cEEG), and the inclusion of anoxic encephalopathy. This study aimed to analyze the effects of midazolam-induced BS on the occurrence outcomes in refractory status epilepticus patients. METHODS: Based on a prospective database of patients who had been diagnosed with status epilepticus via cEEG, multivariate Poisson regression modules were used to estimate the effect of midazolam-induced BS on breakthrough seizure, withdrawal seizure, intra-hospital complications, functional outcome at 3 months, and mortality. Modules were based on a pre-compiled directed acyclic graph (DAG). RESULTS: We included 51 non-anoxic encephalopathy, refractory status epilepticus patients. Burst suppression was achieved in 26 patients (51%); 25 patients (49%) had non-burst suppression on their cEEG. Breakthrough seizure was less often seen in the burst suppression group than in the non-burst suppression group. The incidence risk ratio [IRR] was 0.30 (95% confidence interval = 0.13-0.74). There was weak evidence of an association between BS and increased withdrawal seizure, but no association between BS and intra-hospital complications, mortality or functional outcomes was observed. CONCLUSION: This study provides evidence that BS is safe and associated with less breakthrough seizures. Additionally, it was not associated with an increased rate of intra-hospital complications or long-term outcomes.

Diagnostic scoring system for tuberculous meningitis among adult patients with non-suppurative and non-bacterial meningitis.

Tuberculous meningitis (TBM) is the most severe form of extra-pulmonary tuberculosis. The definite diagnosis of this disease is difficult and can result in delayed treatment. Conventional culture yields low sensitivity while high-sensitivity diagnostic techniques are costly and unpractical. Adenosine deaminase (ADA) is used to diagnose several settings of extra-pulmonary tuberculosis but it is limited in TBM especially among HIV-infected patients. We retrospectively reviewed the data of patients with non-suppurative meningitis and compared the patient data with TBM and other causes including carcinomatous, lymphomatous, lymphocytic and fungal meningitis. We found that HIV infection, diabetes mellitus, duration of symptoms <14 days, radiologic findings of hydrocephalus, and CSF ADA level >10 IU were associated with TBM. The scoring system based on these parameters and their coefficients in the final model achieved an area under the receiver operating characteristic curve of 0.95,625. The indices were HIV infection = 5, diabetes mellitus = 3, duration of symptoms <14 days = 5, hydrocephalus = 4, and ADA in CSF >10 IU = 5. Based on the assumed costs of the patients with false negative and false positive, an appropriate cut off value of 10 was selected and the sensitivity was 92% and specificity was 89%.