Electrolyte disturbances and abnormal urine analysis in children with dengue infection.

Serum electrolytes and urine analysis results were retrospectively reviewed in children with either dengue fever (DF) or dengue hemorrhagic fever (DHF). Children who had positive serology for dengue infection and serum electrolytes determined before starting intravenous fluid were included in the study. During the years 2004-2007, 73 DF patients, age 9.29 +/- 3.62 years, and 77 DHF patients, age 10.04 +/- 3.64 years were enrolled in the study. The patients were admitted to the hospital on average on days 4.12 +/- 1.1 and 4.25 +/- 1.4 of febrile illness for DF and DHF, respectively. The prevalence of hyponatremia in patients with DF was 61% and DHF was 72% (p = 0.149). The mean serum sodium levels in patients with DF and DHF were 133.5 +/- 3.52 and 133.5 +/- 3.20 mEq/l (p = 0.938), respectively. The prevalence of hyponatremia in patients with mild (grade I), moderate (grade II) and severe (grade III-IV) DHF were 70, 77, and 78% (p = 0.729), respectively, and the mean serum sodium levels were 134.1 +/- 3.05, 132.9 +/- 3.33, and 132.5 +/- 3.28 (p = 0.189), respectively. The prevalence of hypokalemia in patients with DF was 14% and 17% in patients with DHF (p = 0.588). A high urine specific gravity reflecting dehydration was found in 63% of patients with DF and 60% of patients with DHF (p = 0.77). The prevalences of hematuria in patients with DF and DHF were 18% and 27% (p = 0.182), respectively and proteinuria were 15% and 27% (p = 0.072), respectively. The prevalences of hematuria and proteinuria were not different among patients with mild, moderate and severe DHF. No patients had gross hematuria or developed acute renal failure requiring dialysis. Mild hyponatremia is a common electrolyte disturbance and renal involvement is mild in patients with DF and DHF.

Prevalence of significant weight loss and hypernatremia in breast feeding jaundice infants readmitted to Phramongkutklao Hospital within 1 month of age.

BACKGROUND: Neonatal jaundice, especially breast feeding jaundice is the most common cause of neonatal re-admission within the first month of life. Good maternal support and closed follow-up of newborn infants can promote successful breast feeding without causing any complications. OBJECTIVE: To determine the rate of significant weight loss and hypernatremia in infants with breast feeding jaundice readmitted to Phramongkutklao Hospital within 1 month of age. MATERIAL AND METHOD: Cross-sectional descriptive study was conducted in infants of gestational age > or = 35 weeks and birth weight > or = 2,000 grams who had breast feeding jaundice readmitted between January, 1st and December 31st, 2008. Maternal and neonatal history, laboratory result, complications and treatment were reviewed. STATISTICAL ANALYSIS: Rates of significant weight loss and hypernatremia were calculated. The associations between weight loss and factors, serum sodium, serum bilirubin and weight loss were analyzed using Chi-square and Mann-Whitney U test. RESULTS: There were 30 infants in the study. 12 (40%) were male. The median gestational age and birth weight were 37 (35-40) weeks and 2,945 (2,100-3,810) grams, respectively. Three infants had significant weight loss more than 10% of birth weights. No infant had hyperbilirubinemia. Severity of weight loss was associated with weight loss at the time before discharge from hospital. Weight loss was not associated with gestational age, sex, parity, cesarean section, exclusive breast feeding, serum sodium level, and serum bilirubin level. CONCLUSION: Complications of dehydration such as hypernatremia was not observed in infants with breast feeding jaundice in this study. Maternal education, serial weight measurements and awareness of breast-feeding jaundice problems are helpful strategies to promote successful breast feeding.

Perception of medical personnel on informed consent for research participation in Phramongkutklao Hospital and Phramongkutklao College of Medicine.

OBJECTIVE: To evaluate the perception of medical personnel and medical cadets toward informed consent obtained from potential research participants. MATERIAL AND METHOD: The authors conducted a study using self-administered questionnaires which included questions about perception on informed consent regarding its objectives, investigator's role, vulnerable subjects, family involvement and children's assent. The answer for each question was graded into 5 scales. RESULTS: A selection of 380, 30.5%, 37.6% and 31.8% of 669 were attending staff residents, and medical cadets, respectively. A total of 85.5% agreed that informed consent in therapeutic trials should be obtained by their own doctors. A total of 75.3% agreed that the primary objective of informed consent was to protect investigators from lawsuits. A total of 60.8% agreed that participant spouses had to be involved in the informed consent process. A total of 79.5% agreed that permission from children was necessary in research conducted in children. CONCLUSION: The role of investigators in therapeutic clinical trial, primary objectives of informed consent, and role of spouse were misunderstood among medical personnel and medical cadets. Education on research ethics should concentrate on these issues.

Improved pregnant women's understanding of research information by an enhanced informed consent form: a randomised controlled study nested in neonatal research.

OBJECTIVE: This study aimed to test the applicability and effectiveness of the enhanced informed consent form (ICF) methodology, proposed by the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER), in neonatal research requiring maternal consent. DESIGN: A single-centre open-label randomised controlled study. SETTING: Antenatal care clinics at Phramongkutklao Hospital, Thailand. PATIENTS: 234 pregnant women who were at risk of preterm labour were enrolled; 232 individuals completed the study. INTERVENTIONS: The participants were randomly assigned to read either the SIDCER ICF or the conventional ICF. MAIN OUTCOME MEASURES: The participants' understanding of essential trial-related information was assessed using 25 closed-ended questions. The primary endpoint was the proportion of the participants who obtained the satisfactory level of understanding at 80% (score of ≥20/25). RESULTS: 72.5% (87/120) of the participants in the SIDCER ICF group and 59.8% (67/112) of the conventional ICF group achieved the primary endpoint (relative risk (RR)=1.212, 95% CI 1.005 to 1.462, p=0.041). The superiority of the SIDCER ICF over the conventional ICF was significant, particularly among the participants whose education was at the high school level or below (63.5% vs 44.1%, RR=1.441, 95% CI 1.022 to 2.030, p=0.031). CONCLUSIONS: The SIDCER ICF methodology is applicable to neonatal research requiring maternal consent. The SIDCER ICF significantly improved the understanding of pregnant women, particularly among those with lower levels of education. The present study confirms the value of the SIDCER ICF methodology in research involving individuals with a limited academic background.

A randomized study of 3 umbilical cord care regimens at home in thai neonates: comparison of time to umbilical cord separation, parental satisfaction and bacterial colonization.

OBJECTIVE: To compare time to cord separation, parental satisfaction and bacterial colonization, among 3 regimens of cord care at home. STUDY DESIGN: Randomized controlled trial. MATERIAL AND METHOD: Term infants were randomly assigned based on cord care regimens at home: 1) triple dye, 2) alcohol, and 3) no antiseptic agent. Timing of cord separation, and parental satisfaction were evaluated during the first month of age. RESULTS: 185 infants were recruited. Time to cord separation in infants of group I was significantly longer than in group 2 (p = 0.036) and group 3 (p = 0.003). The satisfaction scores of group I were significantly lower than those of group 2 and group 3. 180 culture specimens were performed and positive in all but none had omphalitis. CONCLUSION: Triple dye delayed time to cord separation and was less satisfactory. The authors conclude that using alcohol or dry clean could be alternative ways of umbilical cord care at home.

Incidence of neonatal infection in newborn infants with a maternal history of premature rupture of membranes (PROM) for 18 hours or longer by using Phramongkutklao Hospital Clinical Practice Guideline (CPG).

BACKGROUND: Phramongkutklao CPG was developed for detecting infants with maternal PROM > or = 18 hours who had a high risk of infection. OBJECTIVE: To determine efficacy of the CPG, and risk factors of infection. STUDY DESIGN: Prospective cohort study. MATERIAL AND METHOD: Eligible infants were categorized into group I (symptomatic), group II (chorioamnionitis) or group III (asymptomatic). Infants in group I, II and those in group III who had scores > or = 3 were treated with antibiotics. Infants were followed-up until 28 days of age. RESULTS: 104 infants were recruited into the present study. 29 of 104 (27.88%) infants had infection. Risk factors were Apgar scores < or = 5, PROM > 72 hours, gestational age < 34 weeks, and low birth weight. The success rate of using CPG was 98.08% and antibiotic use was reduced by 53.08%. CONCLUSION: Phramongkutklao CPG on PROM is safe and cost saving. All risk factors should be included in the guideline.

Sensitivity of clinical assessment in term neonates by general pediatric residents.

OBJECTIVES: To determine the accuracy of physical examination in detecting congenital heart diseases by pediatric residents and identify risk factors of congenital heart diseases. MATERIAL AND METHOD: Five hundred term infants (GA > or = 37wks) who were born at Phramongkutklao Hospital from July 1st, 1999 to June 3th, 2000 were examined by pediatric residents and pediatric cardiologists within the first week of life. The echocardiography was performed in all 500 infants for definite diagnosis. The accuracy of physical examination was determined by comparing with echocardiographic finding and presented as sensitivity and specificity. RESULTS: Congenital heart diseases were found in 18 of 500 term infants (3.6%). The physical examination by pediatric residents and pediatric cardiologists showeds a sensitivity of 39% and 94% and the specificity of 98% and 97%, respectively. After excluding spontaneously closed PDA within 2 weeks, the first and second most common congenital heart diseases in infants were Ventricular septum defect (VSD) (44%) and Patent ductus arteriosus (PDA) (33%). The positive other cardiovascular signs, such as cyanosis or abnormal pulses with heart murmur were significantly associated to diagnosis of congenital heart diseases. CONCLUSION: Although echocardiography is the major tool to determine the definite diagnosis, most congenital heart diseases can be well detected during physical examination by skilled physicians. As a result, the value of physical examination of the cardiovascular system should be emphasized in training general pediatricians concerning lower costs and early detection of congenital heart diseases.

Subdural hematoma in term infants.

Subdural hematomas are uncommon in term infants. The study objectives were to evaluate risk factors for and clinical significance of small subdural hematomas observed on computerized tomography. During a 3-year period, 26 near-term and term nonasphyxiated infants were found to have a subdural hematoma on computed tomography. Clinical indications for computed tomography were respiratory symptoms in 15 infants and neurologic symptoms in 10 infants; one infant had a skull fracture. Subdural hematomas were less than 3-mm maximum transverse dimensions in all infants: location was infratentorial (n = 7), supratentorial (n = 7), and in both sites (n = 12). Four infants also had evidence of edema and hemorrhage within the anterior temporal lobe. Delivery was vaginal in 25 of 26 infants, and forceps were used in 13 (50%) infants. Twenty-five infants were managed expectantly; one infant underwent surgical elevation of a depressed skull fracture. No infant required surgical evacuation of the subdural hematoma. At discharge, nine infants with subdural hematoma exhibited an abnormal examination, i.e., mild hypotonia (n = 7) and Erb's palsy (n = 2). The clinical syndrome attributed to subdural hematoma was most often a subtle clinical problem. The presence of subdural hematoma documented by computed tomography is not necessarily always indicative of birth trauma and may occur as sequelae of an otherwise uncomplicated delivery.

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS): a case report in Thailand.

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare congenital disease with high mortality rate. The authors report a case of a female term infant with massive abdominal distension at birth. Abdominal ultrasonography revealed a huge cystic mass resolved after urinary catheterization. Exploratory laparotomy was performed and intraoperative findings were an enlarged urinary bladder, microcolon, short bowel and malrotation of the small intestine. Ladd's procedure, ileostomy and vesicostomy were performed. Pathological findings of rectal biopsy revealed normal ganglion cells. Although prokinetic drugs were given for promoting bowel motility, enteral feedings were not tolerated. She died from septicemia at the age of 50 days.

Diagnostic applications of newborn screening for α-thalassaemias, haemoglobins E and H disorders using isoelectric focusing on dry blood spots.

BACKGROUND: Neonatal screening for haemoglobin (Hb) disorders is a standard of care in several developed countries with the main objective to detect Hb S. Such practice has not been established in Thailand where α-thalassaemia and haemoglobin E (Hb E) are highly prevalent. Early identification of thalassaemias could be helpful and strengthen the programme for prevention and control for severe thalassaemias. METHODS: Data from isoelectric focusing (IEF) and Isoscan® for detecting types and amount (%) of each haemoglobin in 350 newborn's dried blood spots were analysed and compared with the comprehensive genotype analysis by DNA studies as a gold standard. RESULTS: Based on genetic profiles, there were 10 different categories: (1) normal (n = 227), (2) α(+)-thalassaemia trait (n = 14), (3) α(0)-thalassaemia trait (n = 13), (4) ß(0)-thalassaemia trait (n = 7), (5) Hb E trait (n = 72), (6) Hb E trait with α(0)-thalassaemia or homozygous α(+)-thalassaemia (n = 5), (7) Hb E trait with α(+)-thalassaemia trait (n = 5), (8) homozygous Hb E (n = 3), (9) homozygous Hb E with α(0)-thalassaemia trait (n = 1) and (10) Hb H disease (n = 3). The presence of Hb Bart's and Hb E were used to identify cases with α-thalassaemia and Hb E, respectively. We set 0.25% of Hb Bart's and 1.5% of Hb E as a cut-off level to detect α(+)-thalassaemia trait (sensitivity 92.86% and specificity 74.0%) and Hb E trait with 100% of both sensitivity and specificity for IEF diagnosis. CONCLUSION: Although molecular diagnosis seems to be better for definitive diagnosis of thalassaemia syndromes at birth, however, using our reference range described herein, IEF can be applied in a resource-limiting setting with acceptable reliability.

Apoptosis and white matter injury in preterm infants.

White matter injury in premature infants with or without intraventricular hemorrhage (IVH) remains an important cause of neonatal mortality and neurologic morbidity. The contribution of apoptosis to the cellular death in white matter injury in the preterm infant is unclear. The objective of this study was to determine whether apoptosis contributes to the cellular death in premature infants with cranial ultrasound (US) evidence of IVH and asymmetric periventricular echogenicity (PVE). Brain tissue incorporating frontoparietal white matter was obtained from 21 infants: 6 infants with severe IVH and asymmetric PVE (grade 1V IVH) on US (group 1); 9 infants with minimal IVH or normal US who died within 21 days (group II); and 6 infants with minimal IVH or normal US who died later (group III). The presence of DNA fragmentation, typical of apoptosis, was determined using a terminal deoxytransferase-mediated dUTD nick-end labeling (TUNEL) assay. The TUNEL index for group I infants was significantly greater, i.e., 2.75 +/- 1.94% versus 0.84 +/- 0.70% for group II and 0.42 +/- 0.22 for group III infants (P = 0.004). Most cells showing reactivity had morphologic characteristics consistent with astrocytes and oligodendroglia. The number of white matter cells showing morphologic changes consistent with apoptosis, such as nuclear blebs and karyorrhexis, was also quantitated and was significantly more numerous in group I than in group II infants, i.e., 0.51 +/- 0.64% versus 0.02 +/- 0.05% (P = 0.0005), and group III infants, i.e., 0.10 +/- 0.18% (P = 0.03). These findings implicate apoptosis as a contributing mechanism for the cellular death in infants with IVH and asymmetric PVE. Strategies aimed at preventing the white matter injury will need to incorporate methods of inhibiting the ongoing process of apoptosis.