Mortality Rates and a Clinical Predictive Model for the Elderly on Maintenance Hemodialysis: A Large Observational Cohort Study of 17,354 Asian Patients.

INTRODUCTION: Mortality following hemodialysis initiation may influence the decision to initiate hemodialysis in elderly patients. Our objective is to demonstrate mortality following hemodialysis initiation in elderly patients (≥70 years) and to derive a prediction risk score based on clinical and laboratory indicators to determine risk of all-cause mortality in patients aged ≥80 years. METHODS: We identified elderly patients (≥70 years) who initiated maintenance hemodialysis between January 2005 and December 2016 using data from the Thai Renal Replacement Therapy (TRT) registry. The mortality rate was determined based on age categories. A predictive risk score for all-cause mortality was created for 4,451 patients aged ≥80 years by using demographics, laboratory values, and interview-based parameters. Using a flexible parametric survival analysis, we predicted mortality 3 months, 6 months, 1 year, 5 years, and 10 years after hemodialysis initiation. RESULTS: 17,354 patients (≥70 years) were included, mean age 76.9 ± 5.1 years, 46.5% male, and 6,309 (36.4%) died. Patients aged <80 years had a median survival time of 110.6 months. A 9-point risk score was developed to predict mortality in patients aged ≥80 years: age >85 years, male, body mass index <18.5 kg/m2, hemoglobin <10.0 g/dL, albumin <3.5 g/dL, substantial assistance required in daily living (1 point each), and Karnofsky Performance Status (KPS) score <50 (3 points). C-statistic of 0.797 indicated high model discrimination. Internal validation demonstrated good agreement between observed and anticipated mortalities. CONCLUSIONS: Hemodialysis is appropriate for patients aged 70-80 years. A risk score for mortality in patients aged ≥80 years has been developed. The score is based on seven readily obtainable and evaluable clinical characteristics.

The Predictive Factors Associated with In-Hospital Mortality of Melioidosis: A Cohort Study.

Background and Objectives: Melioidosis is an infectious disease caused by Burkholderia pseudomallei, and it has a wide range of clinical symptoms. It is endemic in tropical areas, including Southeast Asia. Despite the availability of effective treatment, the mortality rate is still high, especially in patients presenting with septic shock. The aim of this study was to determine and explore clinical characteristics, microbiology, treatment outcomes, and factors associated with in-hospital mortality which could predict prognosis and provide a guide for future treatment. Materials and Methods: The population in this retrospective cohort study included all 262 patients with a diagnosis of melioidosis who were hospitalized at Surin Hospital, Surin, Thailand, from April 2014 to March 2017. We included patients older than 15 years with a positive culture for B. pseudomallei. Data regarding the clinical characteristics, microbiology, and treatment outcomes of the patients were collected and analyzed. The patients were divided into two groups dependent on outcome, specifically non-survival and survival. Logistic regression was performed to determine the risk factors associated with in-hospital mortality. Results: Out of the 262 patients with melioidosis during the study period, 117 (44.7%) patients died. The mean age was 57.2 ± 14.4 years, and 193 (73.7%) patients were male. The most common comorbidity was diabetes (123, 46.9%), followed by chronic kidney disease (35, 13.4%) and chronic liver disease (31, 11.8%). Four risk factors were found to be associated with in-hospital mortality, including age (adjusted odds ratio (aOR) 1.04, 95%CI: 1.01-1.07), respiration rate (aOR 1.18, 95%CI: 1.06-1.32), abnormal chest X-ray finding (aOR 4.79, 95%CI: 1.98-11.59), and bicarbonate levels (CO2) (aOR 0.92, 95%CI: 0.85-0.99). Conclusions: Our study identified age, respiration rate, abnormal chest X-ray finding, and CO2 levels are predictive factors associated with in-hospital mortality in melioidosis patients. Physicians should be aware of these factors, have access to aggressive treatment options, and closely monitor patients with these risk factors.

Predictive Model of Recovery to Prefracture Activities-of-Daily-Living Status One Year after Fragility Hip Fracture.

Background and Objectives: Achieving prefracture functional status is a critical objective following a hip fracture, yet fewer than half of patients reach this milestone. The adoption of tools for assessing functional outcomes is increasingly recognized as essential for evaluating recovery following treatment for fragility hip fractures. We developed multivariable clinical prediction criteria to estimate the likelihood of patients regaining their prefracture activities-of-daily-living (ADL) status one year after sustaining a fragility hip fracture. Materials and Methods: A retrospective cohort of patients treated for fragility hip fractures at a university-affiliated tertiary care center between February 2017 and April 2019 served as the basis for developing and internally validating the clinical prediction criteria. We applied a multivariable fractional polynomial method to integrate several continuous predictors into a binary logistic regression model. Results: The study included 421 patients, 324 (77%) of whom reported regaining their prefracture activities-of-daily-living level one year after experiencing fragility hip fractures. Significant predictors, such as the prefracture Barthel index, EQ-VAS score, and treatment modality, were incorporated into the predictive model. The model demonstrated excellent discriminative power (AuROC of 0.86 [95% CI 0.82-0.91]) and satisfactory calibration. Conclusions: The predictive model has significant discriminative ability with good calibration and provides clinicians with a means to forecast the recovery trajectories of individual patients one year after a fragility hip fracture, which could be useful because prompt clinical decision-making is aided by this information. Patients and caregivers can also be counseled and encouraged to follow up with the medical activities and interventions deemed essential by doctors who used the prediction tool. Access to the model is provided through a web application. External validation is warranted in order to prove its applicability and generalizability.

Prognostic factors of postoperative Hirschsprung-associated enterocolitis: a cohort study.

PURPOSE: To identify prognostic factors of postoperative Hirschsprung-associated enterocolitis (HAEC). METHOD: A retrospective cohort study of Hirschsprung patients between 2006 and 2021 was conducted. Patients with anorectal malformation and non-definitive surgery were excluded. Associated factors for postoperative HAEC were reported with hazard ratio (HR) and 95% confidence interval (CI). RESULTS: Forty-nine patients were excluded due to concurrent anorectal malformation and incomplete data. Of 274 patients, 75 patients (27.4%) had at least one episode of postoperative HAEC. There were 28 patients (37.3%) who had multi-episodes of HAEC. The total episodes of post-operative HAEC in this study were 121 episodes (36.8%). In multivariable survival analysis, significant factors associated with postoperative HAEC were the aganglionic level above sigmoid colon (HR = 3.47, p = 0.023, 95% CI 1.19-10.09), and total colonic aganglionosis (HR = 14.83, p = 0.004, 95% CI 2.33-94.40). The patients who experienced clinical enterocolitis before 2 weeks after surgery significantly developed more postoperative HAEC (HR = 5.32, p = 0.038, % CI 1.09-25.92). The incidence of postoperative HAEC was increase in patients with postoperative obstructive symptoms (48.0%). One patient died due to severe sepsis from postoperative HAEC, while three others required intensive care. CONCLUSIONS: The long involvement of aganglionic segment and early postoperative HAEC was significantly associated with postoperative HAEC. Frequent follow-up, parental education, and early treatment are recommended in these individuals, particularly in the first year after surgery.

A comparison of the success rate of pneumatic reduction in intussusception between general anesthesia and deep sedation: a randomized controlled trial.

PURPOSE: This study was aimed to compare the success rate between patients who underwent general anesthesia and deep sedation. METHODS: Patients who were diagnosed with intussusception and had no contraindications would receive non-operative treatment first by undergoing pneumatic reduction. The patients were then split in to two groups: one group underwent general anesthesia (GA group), while the other underwent deep sedation (SD group). This study was a randomized controlled trial which compared success rate between two groups. RESULTS: A total of 49 episodes diagnosed with intussusception were random into 25 episodes in GA group and 24 episodes in SD group. There was no significant difference in baseline characteristic between the two groups. The success rates of GA group and SD group were equally 88.0% (p = 1.00). Sub-analysis of the success rate was lower in the patients with high-risk score for failed reduction. (Chiang Mai University Intussusception (CMUI) failed score in success VS failed = 6.9 ± 3.2 vs. 10.3 ± 3.0 p = 0.017). CONCLUSION: General anesthesia and deep sedation offered similar success rates. In cases of high risk of failure, general anesthesia should be considered to accommodate the switch to surgical management in the same setting if the non-operative approach fails. The appropriate treatment and sedative protocol also increase the success of reduction.

Effective Dose Range of Intrathecal Isobaric Bupivacaine to Achieve T5-T10 Sensory Block Heights for Elderly and Overweight Patients: An Observational Study.

Background and Objectives: The dose selection for isobaric bupivacaine determines the success of spinal anesthesia (SA). A dose higher than the optimal dose causes high SA, whereas an underdose leads to inadequate spread of cephalad. As it involves anatomical and physiological alterations, the dosing should be reduced with advancing age and body mass index values. Therefore, this study aimed to demonstrate the association between the isobaric bupivacaine dose and block height, and to determine the dose intervals of bupivacaine to achieve the T5-T10 sensory block with a low probability of high SA in elderly and overweight patients. Material and Methods: This retrospective observational study recruited 1079 adult patients who underwent SA with 0.5% isobaric bupivacaine from 2018 to 2021. The patients were divided into four categories: category 1 (age < 60, BMI < 25), category 2 (age < 60, BMI ≥ 25), category 3 (age ≥ 60, BMI < 25), and category 4 (age ≥ 60, BMI ≥ 25). The bupivacaine dose and sensory block height (classified into three levels: high (T1-T4), favorable (T5-T10), and low (T11-L2)) were recorded. Results: The sensory block level increased significantly with increasing doses of bupivacaine for patients in categories 1 and 2. The suggested dose ranges for the favorable block heights were 15-17 and 10.5-16 mg in patient categories 1-2 and 3-4, respectively. In these dose ranges, the probability range of high SA was 10-15%. Conclusions: The sensory block height following SA was associated with the bupivacaine dose in patients aged <60 years. Regardless of the BMI, the suggested dose ranges of 0.5% isobaric bupivacaine are 15-17 mg (3.0-3.4 mL) and 10.5-16 mg (2.1-3.2 mL) for patients aged <60 and ≥60 years, respectively.

Efficacy of Phrenic Nerve Block and Suprascapular Nerve Block in Amelioration of Ipsilateral Shoulder Pain after Thoracic Surgery: A Systematic Review and Network Meta-Analysis.

Background and Objectives: Ipsilateral shoulder pain (ISP) is a common complication after thoracic surgery. Severe ISP can cause ineffective breathing and impair shoulder mobilization. Both phrenic nerve block (PNB) and suprascapular nerve block (SNB) are anesthetic interventions; however, it remains unclear which intervention is most effective. The purpose of this study was to compare the efficacy and safety of PNB and SNB for the prevention and reduction of the severity of ISP following thoracotomy or video-assisted thoracoscopic surgery. Materials and methods: Studies published in PubMed, Embase, Scopus, Web of Science, Ovid Medline, Google Scholar and the Cochrane Library without language restriction were reviewed from the publication's inception through 30 September 2022. Randomized controlled trials evaluating the comparative efficacy of PNB and SNB on ISP management were selected. A network meta-analysis was applied to estimate pooled risk ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Results: Of 381 records screened, eight studies were eligible. PNB was shown to significantly lower the risk of ISP during the 24 h period after surgery compared to placebo (RR 0.44, 95% CI 0.34 to 0.58) and SNB (RR 0.43, 95% CI 0.29 to 0.64). PNB significantly reduced the severity of ISP during the 24 h period after thoracic surgery (WMD -1.75, 95% CI -3.47 to -0.04), but these effects of PNB were not statistically significantly different from SNB. When compared to placebo, SNB did not significantly reduce the incidence or severity of ISP during the 24 h period after surgery. Conclusion: This study suggests that PNB ranks first for prevention and reduction of ISP severity during the first 24 h after thoracic surgery. SNB was considered the worst intervention for ISP management. No evidence indicated that PNB was associated with a significant impairment of postoperative ventilatory status.

Association between diabetes mellitus and risk of infection after trigger finger release: a systematic review and meta-analysis.

PURPOSE: To investigate the association between diabetes mellitus and risk of infection after trigger finger release. METHODS: Reports of adult trigger finger patients who had undergone trigger finger release that included details of patient diabetic status and post-surgery infections were included in the study. Reports of congenital trigger finger release and incomplete data on either diabetic status or infection after surgery were excluded. Search engines were PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science from inception to third December 2021. The risk of infection after trigger finger release was compared between diabetic and non-diabetic patients by evaluating the pooled risk ratio (RR) with a 95% confident interval (CI) under random effects modeling. Risk of bias in each study was assessed using Newcastle-Ottawa Scale (NOS). RESULTS: A total of 213,071 trigger finger patients described in seven studies were identified. Overall, patients with diabetes mellitus had a 65% higher risk of infection after trigger finger release compared to non-diabetic patients (RR 1.65; 95% CI, 1.39-1.95). Diabetes mellitus increased the risk of infection following trigger finger surgery in both young and old age groups as well as obese and non-obese patients who underwent open release surgery. The risk of bias in each of the included studies was estimated as moderate to high. CONCLUSION: Meta-analysis results demonstrated that diabetes mellitus increases the risk of infection after trigger finger release. Glycemic control and percutaneous rather than open surgery might be strategies to the reduce risk of infection after trigger finger release in diabetic patients.

A Prospective, randomized comparative study between ultrasound-guided posterior quadratus lumborum block and ultrasound-guided ilioinguinal/iliohypogastric nerve block for pediatric inguinal herniotomy.

BACKGROUND: Ilioinguinal/iliohypogastric nerve block is commonly performed to control postherniotomy pain. The posterior quadratus lumborum block has been recently described as an effective analgesic technique for pediatric low abdominal surgery. No data were found regarding the use of posterior quadratus lumborum block in comparison with the traditional ilioinguinal/iliohypogastric nerve block in pediatric inguinal surgery. AIM: This randomized assessor-blinded study compared postoperative analgesic effects between ultrasound-guided posterior quadratus lumborum block and ilioinguinal/iliohypogastric nerve block in pediatric inguinal herniotomy. METHODS: One- to seven-year-old children scheduled for unilateral open herniotomy were randomly assigned to receive either ultrasound-guided posterior quadratus lumborum block with 0.25% bupivacaine 0.5 mL/kg or ultrasound-guided ilioinguinal/iliohypogastric nerve block with 0.25% bupivacaine 0.2 mL/kg after induction of general anesthesia. The primary outcome was the proportion of patients who received postoperative oral acetaminophen. The required fentanyl in the recovery room, 24-hour acetaminophen consumption, success rate of regional blocks, block performance data, block-related complications, postoperative pain intensity, and parental satisfaction were assessed. RESULTS: This study included 40 patients after excluding four cases who were ineligible. The number of patients who required postoperative oral acetaminophen was significantly lower in the posterior quadratus lumborum block group (15.8% vs 52.6%; OR: 5.9; 95% CI: 1.3, 27.3; P = .022). The pain scores at 30 minutes, 1, 2, 6, 12, and 24 hours were similar between groups. There was no evidence of between-group differences in block performance time, the number of needle passes, block-related complications, and parental satisfaction. CONCLUSION: The posterior quadratus lumborum block with 0.25% bupivacaine 0.5 mL/kg provided better pain control than the ilioinguinal/iliohypogastric nerve block with 0.25% bupivacaine 0.2 mL/kg after open herniotomy in children. The ultrasound guidance technique for the posterior quadratus lumborum block is safe and as simple as the ultrasound-guided ilioinguinal/iliohypogastric nerve block for pediatric patients.

Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study.

Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.

Foreign Body Ingestion in Pediatrics: Distribution, Management and Complications.

Background and Objectives: Foreign body (FB) ingestion is a common problem in children, causing serious complications. This study aimed to identify the distribution of types and locations of these foreign bodies and create Chiang Mai University (CMU) Guidelines. Materials and Methods: A retrospective descriptive study was conducted. All patients under 15 years old with foreign body ingestion (International Statistical Classification of Diseases and Related Health Problems; ICD-10 codes T18) treated in CMU Hospital from January 2006 to December 2017 were included. The data were analyzed using descriptive statistics. The guidelines were created, which paralleled the standard guidelines. Results: In total, 194 episodes of FB ingestion were recorded. These included 53.6% males and 46.4% females with a median age of 43.5 months. A history of foreign body ingestion complaints occurred in 77.8% of cases. Presentation was divided into asymptomatic (44.3%) and symptomatic (55.7%). The most common symptom was vomiting (23.2%). In the majority of cases, foreign bodies were located in the esophagus (37%). The most common type of foreign body was a coin (41.2%). Management included spontaneous passing (60.3%), endoscopy (35.6%), and others (3.1%). Complications before treatment were recorded in 9.3% of cases and after treatment in 2.1% of cases. Conclusions: Foreign body ingestion is common among children younger than four years old. Coins are the most common foreign body found, and the esophagus is the most common location. We recommend our created CMU Guidelines for management.

Physicians' and nurses' thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study.

BACKGROUND: Neonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure. METHODS: In-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes. RESULTS: Six themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented. CONCLUSIONS: Thai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.

Natural Course of Fetal Axillary Lymphangioma Based on Prenatal Ultrasound Studies.

This series and literature review aimed to prenatally characterize the nature of axillary lymphangioma. A total of 30 cases, including our 5 cases, were analyzed. Insights gained from this review are as follows: Septate and nonseptate cysts seem to be different entities. The nonseptate type tends to be small and transient but more highly associated with aneuploidies. Septate cysts are very rarely associated with other abnormalities and hydrops fetalis, unlike cystic hygroma colli, but are more progressive with gestational age and associated with adverse outcomes. The cases with high flow have a higher risk of intralesional hemorrhage. Prenatal diagnosis is important for the route of timely delivery and possibly prenatal interventions. Shoulder dystocia is common and should always be taken into account for decisions on the route of delivery.

The factors associated with successful early enteral feeding in gastroschisis.

BACKGROUND: Gastroschisis is the most common congenital abdominal wall defect. Due to the exposure of midgut to amniotic fluid, the recovery of bowel function is often delayed. This study aimed to identify the factors associated with the successful early enteral feeding in gastroschisis and to develop further guidelines of treatment. METHODS: A retrospective cohort study of gastroschisis babies from January 2006 to December 2015 was done. Exclusion criteria were incomplete data and death. Successful early enteral feeding was defined when full feeding was achieved within 21 days of life. RESULTS: One hundred and five gastroschisis patients were divided into a successful early-feeding group (n = 56, 53%) and a non-successful early-feeding group (n = 49, 46%). In multivariable analysis, significant factors for successful feeding clustered by primary treatment were female (RR = 1.38, P value < 0.001), gestational age > 36 weeks (RR = 1.23, P value < 0.001), age at surgery less than 10 h (RR = 1.15, P value < 0.001), postoperative extubation time < 4 days (RR = 1.39, P value < 0.001), and age when feeding started less than 10 days (RR = 35.69, P value < 0.001). CONCLUSION: Several factors were found to be associated with successful early enteral feeding. The modifiable factors found in this study were surgery within 10 h, early postoperative extubation within 4 days, and feeding started before 10 days of life. These will guide the management of gastroschisis to achieve successful early enteral feeding.

Adenovirus infection: A potential risk for developing intussusception in pediatric patients.

The pathogenesis of intussusception without obvious anatomical leading points remains unclear. The objective of this study was to determine a feasibility of association between certain gastroenteritis viruses and intussusception. This was a prospective cohort study. Forty intussusception cases and 136 acute gastroenteritis controls with comparable age and gender were separately consecutively enrolled and relevant clinical data of both groups were recorded. The clinical specimens collected from all patients were screened for adenovirus, rotavirus, norovirus, and astrovirus by PCR and RT-PCR using specific primers. The genomes of detected viruses were characterized further to identify their genotypes by nucleotide sequencing. In 40 intussusception cases, adenovirus, rotavirus, and norovirus were detected in 12 (30.0%), 2 (5.0%), and 2 (5.0%), respectively while astrovirus was undetectable. In contrast, 136 acute gastroenteritis patients, adenovirus, rotavirus, and norovirus were detected in 11 (8.1%), 24 (17.7%), and 24 (17.7%) patients, respectively and again astrovirus was undetectable. The detection of adenovirus in intussusception patients was significantly higher than those in the control group (P < 0.001) with an odd ratio of 4.87 (95%CI: 1.95, 12.16). Interestingly, molecular analysis of adenovirus genome demonstrated that all of adenovirus detected in intussusception patients belonged to adenovirus C. This could be a potential risk factor or pathogenesis for developing intussusception in the cases of those without apparent anatomical leading points. J. Med. Virol. 88:1930-1935, 2016. © 2016 Wiley Periodicals, Inc.

The outcomes of a frenulotomy on breastfeeding infants followed up for 3 months at Thammasat University Hospital.

PURPOSE: To study the effects of frenulotomy on nipple pain, latch and the success in exclusive breastfeeding (EBF) at 3-month follow-up. METHODS: A prospective cross-sectional study of 328 mother-infant pairs with both tongue-tie and breastfeeding problems was performed. Nipple pain and latch were evaluated using numeric rating scale and LATCH score, respectively, and compared between pre and post-operatively at 24 h and 1 week. The success rate of EBF was assessed at 3 months after frenulotomy. RESULTS: Nipple pain score were significantly decreased (median difference = 3 and 4, P < 0.001) and LATCH score were significantly increased (mean difference = 1.92 and 2.13, P < 0.001) at 24 h and 1 week post-operatively. At 3 months, a success rate of EBF was 66.67 %. Multivariable analysis clustering by maternal age of 18 years was performed. Factors that were significantly (P < 0.05) associated with the success were: girls, age at surgery ≤24 h, higher number of children in family, low birth weight, tongue-tie severity, nipple grading, LATCH score ≥8 and nipple sensation at 1 week after surgery. CONCLUSION: Frenulotomy could significantly reduce nipple pain and increase LATCH score in tongue-tied infants with breastfeeding difficulty. Several factors are positively associated with the success of EBF. Tongue-tie severity, LATCH score and nipple sensation were the factors that can be modified by frenulotomy.

Thai health care provider knowledge of neonatal male circumcision in reducing transmission of HIV and other STIs.

BACKGROUND: Male circumcision (MC) reduces the risk of female-to-male transmission of HIV and other sexually transmitted infections (STIs). MC has not been practiced as a disease prevention measure in Thailand probably because of low recognition of its benefits among stakeholders. Neonatal male circumcision (NMC) is simpler, safer and cheaper than adult MC. This study aimed to assess Thai health care provider knowledge of benefits implementing NMC in Thailand. METHODS: Multi-stage sampling identified 16 government hospitals to represent various hospital sizes and regions of the country. Researchers administered a fixed choice questionnaire, developed by the research team based on a previous study, to physician administrators, practicing physicians, and nurses whose jobs involved NMC clinical procedures or oversight. The participants reviewed printed educational materials on the benefits of NMC during questionnaire completion. Data were analyzed using descriptive statistics, chi square tests, odds ratios, and logistic regression. RESULTS: One hundred thirty-three individuals participated in this quantitative study. Only 38% of the participants agreed that NMC reduced the risk of sexual transmission of HIV while 65% indicated that they knew that NMC prevented STIs. Most participants recognized the benefits of NMC on hygiene (96%) as well as cancer prevention (74%). Major concerns raised were potential trauma to the child, child rights and safety of NMC. After reviewing written information about the benefits of NMC, 59% of the participants agreed that NMC should be offered in their hospital. Physicians and nurses who had previous experience with circumcising patients of all ages were more reluctant to have NMC performed in their hospital. CONCLUSIONS: A clear policy advocating NMC, thorough preparation of health facilities, and staff training are needed before NMC could be used in Thailand as prevention strategy for HIV and other STIs.

Executive dysfunction as a possible mediator for the association between excessive screen time and problematic behaviors in preschoolers.

Excessive screen time in children is a growing concern for parents and healthcare providers worldwide because it frequently leads to behavioral problems. Although executive dysfunction is proposed to be one of the contributing factors to maladaptive behaviors, little is known about the link between screen time and behaviors. This study aimed to identify whether executive dysfunction contributes to the negative behaviors of children exposed to excessive screen time. A cross-sectional study was conducted on preschool-aged children from public and private schools in Chiang Mai, Thailand. The parents/guardians of each child completed the questionnaires regarding clinical characteristics and screen time use, the Behavior Rating Inventory for Executive Function-Preschool (BRIEF-P), and the Strengths and Difficulties Questionnaire (SDQ). Children with more than one hour of media exposure per day were considered to have excessive screen time. Multivariable Gaussian regression was analyzed to compare the BRIEF-P and SDQ scores between the excessive and appropriate screen time groups. Causal mediation analysis was performed to examine the effects of total screen time on increasing behavioral problems with executive functioning as a mediator. A total of 1,126 preschoolers were included in the analyses. After controlling for age, sex, socioeconomic status, and maternal education, the excessive screen time group had significantly higher BRIEF-P global executive composite score than the appropriate screen time group (mean difference of global executive composite score = 1.49, 95% CI [0.12, 2.86], and p = 0.033). Concurrently, there were significant differences in externalizing behavior subscales and SDQ total difficulties scores between the excessive and appropriate screen time groups (mean difference of total difficulties score = 0.90, 95% CI [0.29, 1.50], and p = 0.004). A significant average causal mediation effect (ACME) of screen time on behavioral problems mediated through executive functioning was ß = 0.28, 95% CI [0.13-0.44], which was more than half of the total effect (54.9%, 95% CI [37.4-100%]). The current study suggests that the increase in behavioral issues in preschoolers might be partly explained by the direct effect of excessive screen time and the mediating effect of impaired executive functioning. Our results may raise concerns about the necessity to limit screen time and monitor for executive function deficits and behavioral problems in young children with high screen time.

Predictive factors for L-asparaginase hypersensitivity in pediatric acute lymphoblastic leukemia.

BACKGROUND: L-Asparaginase is a crucial component of acute lymphoblastic leukemia (ALL) treatment. However, hypersensitivity is a common adverse event. This study aimed to identify risk factors for L-asparaginase hypersensitivity in childhood ALL. METHODS: Children treated for ALL at Chiang Mai University Hospital, Thailand, between 2005 and 2020 were included. Demographic data, clinical characteristics, and factors related to L-asparaginase were retrospectively reviewed. RESULTS: L-Asparaginase hypersensitivity was observed in 24 of 216 children with ALL (11.1%). All patients received native L-asparaginase intramuscularly, and events occurred exclusively during the post-induction phase without concurrent corticosteroid use. Univariable analysis showed that relapsed ALL, higher accumulated doses, increased exposure days, and longer interval between drug administrations were potential risk factors. In multivariable logistic regression analysis, interruption of L-asparaginase administration for ≥ 52 weeks and exposure duration of ≥ 15 days were independent risk factors, with adjusted odds ratio of 16.481 (95% CI 3.248-83.617, p = 0.001) and 4.919 (95% CI 1.138-21.263, p = 0.033), respectively. CONCLUSIONS: Children with ALL who require re-exposure to L-asparaginase after 52-week interruption or who have received L-asparaginase for ≥ 15 exposure days are at risk of developing L-asparaginase hypersensitivity. Further management strategies in this setting should be evaluated.

Prognostic Factors for Functional Recovery at 1-Year Following Fragility Hip Fractures.

Background: The main objective of treating fragility hip fractures is to maximize the patients' ability to return to their basic activities of daily living (ADL) levels. This study explored prognostic factors associated with the ability to recover pre-fracture ADL levels at 1 year after fragility hip fractures. Methods: We retrospectively recruited patients admitted with fragility hip fractures between July 2016 and September 2018. Details of the following were extracted from electronic medical records: age, sex, body mass index; pre-fracture Charlson Comorbidity Index (CCI), Barthel index, and EuroQol-Visual Analog Scale (EQ-VAS) scores; pre-fracture ambulatory status; and fracture type and treatment. The primary endpoint was the ability to return to the pre-fracture ADL status at 1 year. Multivariable logistic regression analysis assessed the prognostic ability of predictors. Results: Of 405 patients, 284 (70.1%) managed to return to their pre-fracture ADL status. Multivariable logistic regression analysis demonstrated that the predictor with the most apparent effect size was pre-fracture EQ-VAS scores ≥ 65 (multivariable odds ratio [mOR], 12.90; p = 0.03). Other influential predictors were CCI scores < 5 (mOR, 1.96; p = 0.01) and surgical treatment for the hip fracture. Conclusions: Three prognostic factors can predict a hip fracture patient's ability to return to the pre-fracture ambulatory status at 1 year. They are the patient's CCI score, operative treatment for the hip fracture, and the pre-fracture EQ-VAS score. This information could be used to develop a clinical prediction model based on the prognostic factors.