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.

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.

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%.

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.

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.

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.

The effect of maximum bite force on alveolar bone morphology.

OBJECTIVES: To investigate to what extent maximum bite force contributes to alveolar bone morphology parameters, i.e. alveolar thickness, shape and arch width. DESIGN: An observational cross-sectional survey. SETTING AND SAMPLE POPULATION: One hundred and fifty one 12- to 14-year-old students from a secondary school in Hatyai City, Songkhla Province, Thailand. MATERIAL AND METHODS: Height, weight and maximum bite force of each subject were recorded. Alveolar bone morphology parameters were measured from study models. RESULTS: Maximum bite force moderately correlated with alveolar thickness and shape (r = 0.31-0.44, p < 0.001), but weakly correlated with arch width (r = 0.03-0.05, p > 0.05). After adjusting for gender and body mass index (BMI), the maximum bite force significantly determined alveolar thickness and shape (p < 0.001), accounting for 10-20% of the variations. Boys were associated with larger posterior arch width (p < 0.01), where BMI was not associated with alveolar bone morphology parameters (p > 0.01) after Bonferroni correction for multiple testing. CONCLUSION: Maximum bite force had a selective influence on alveolar thickness and shape, but not on arch width.

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.

Environmental factors and incidence of dengue fever and dengue haemorrhagic fever in an urban area, Southern Thailand.

Using the enumeration district (ED) block level this study looked at the incidence of dengue fever and dengue haemorrhagic fever (DF/DHF) within the Songkhla municipality in Thailand. Each of the 146 blocks in this area were considered as study units and surveyed for their environmental characteristics. A total of 287 cases of DH/DHF occurring in the year 1998 were selected for this study and the location of their homes mapped. Clustering analysis showed point clustering of the homes (P<0.0001) which was probably due to high density habitation, without any actual prevalence of case clustering. There was no evidence of clustering of the ED blocks with an incidence of DF/DHF (P=0.32). DF/DHF incidence for each block was strongly associated with the percentages of shop-houses, brick-made houses and houses with poor garbage disposal (all P<0.01). DF/DHF control should be emphasized for the areas which have a predominance of these housing types.

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.

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.

Oral manifestations of HIV infection in relation to clinical and CD4 immunological status in northern and southern Thai patients.

OBJECTIVES: To assess prevalence and variations in the oral manifestations of HIV in HIV-infected subjects in southern Thailand (a new HIV epidemic) and northern Thailand (a mature epidemic), and the association with age, sex, risk behaviours, CD4 count and medication used. SUBJECTS AND METHODS: A total of 102 and 135 HIV-infected individuals were enrolled in northern and southern hospitals, respectively. Oral and haematological examination was performed after sociodemographic interview of the patients. Clinical history was retrieved from patients' medical records. RESULTS: Oral candidiasis (OC, 55%), oral hairy leucoplakia (OHL, 21%) and HIV-associated-periodontal disease (14%) were among the most common oral lesions in southern Thailand. OHL (38%), OC (25%), HIV-associated-periodontal disease (15%) were the three most common lesions in the north. A significant association was found between any oral lesion, OC, particularly the pseudomembranous type (PC), and CD4 < 200 cells mm(-3) at both sites. A negative relationship was found between systemic antifungal treatment and OC including PC and erythematous candidiasis (EC) in the southern data. OHL showed a positive relationship with male sex and a negative relationship with antiretroviral treatment in the northern site. Younger age and being a current smoker were positively associated with oral lesions in the southern group. CONCLUSION: OC, particularly PC, could be useful as a marker for immunosuppression, particularly where CD4 count cannot be determined routinely. Antifungal treatment is of benefit in the subjects who cannot afford highly active antiretroviral therapy (HAART).

A radiotherapy technique to improve dose homogeneity around bone prostheses.

Purpose. Following limb conserving surgery for bone or soft tissue sarcoma, patients may require post-operative radiotherapy to minimise the risk of local recurrence. In such circumstances the metal prosthesis reduces the dose in its shadow by approximately 10% when using opposed fields. We describe a technique to boost the underdosed area to overcome this problem.Patients or subjects. Seven sequential patients presenting between 1995 and 2001 had their treatment individualised because they had metal prosthesis in the treatment volume.Methods. To improve the target dose homogeneity we used a custom-made keyhole cutout to boost the area in the shadow of the prosthesis. The degree of attenuation caused by the metal prosthesis was estimated and a boost dose calculated. Exit thermoluminescent dosimetry (TLD) was used to confirm the estimates made.Results and discussion. Variation between patients was seen, demonstrating the need for exit TLD to individualise the treatment plan. The use of a boost field provides a method to overcome under-dosage in the shadow of a metal prosthesis. It improves dose homogeneity throughout the target volume and ensures adequate dose intensity around the prosthesis, the site most at risk of local recurrence.

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.

Misdiagnosis in vertebral osteomyelitis: problems and factors.

One hundred and one cases diagnosed with vertebral osteomyelitis were evaluated for misdiagnosis and both factors and outcomes of misdiagnosis were assessed. There were 67 patients with tuberculous spondylitis and 34 patients with pyogenic vertebral osteomyelitis. Misdiagnosis occurred in 33.7 per cent of the cases. The average delayed diagnosis time was 2.6 months (range, 0.2 to 12). Age between 60 to 70 years was the most frequent group for misdiagnosis, while the most frequent area of misdiagnosis was the lumbar spine. Metastatic carcinoma, spinal stenosis, herniated nucleus palposus and back strain were common initial misdiagnoses. The factors, age group, absence of fever and positive straight leg raising test (SLRT) were associated with misdiagnosis in univariate analysis and multivariate analysis (odds ratio 3.40 (95%CI:1.07-11.94), 3.47 (95%CI:1.20-10.05), and 24.47 (95%CI:2.18-274.28), respectively) Misdiagnosis was statistically significantly associated with the result of treatment. This paper emphasizes that the elderly age group, absence of fever and positive SLRT are the independent factors which increase the risk of misdiagnosis of vertebral osteomyelitis.

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.

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.

The indigenous fisherman divers of Thailand: diving-related mortality and morbidity.

The Urak Lawoi are indigenous fishermen on Thailand's west coast. The population includes an estimated 400 divers who dive using surface-supplied compressed air. In a cross-sectional survey conducted among the 6 major communities of Urak Lawoi, questionnaire-based interviews were administered to active divers, ex-divers, and families or colleagues of divers who had died in the previous 5 years. Six deaths resulting from diving-related accidents were identified, indicating a diving-related mortality rate of approximately 300 per 100,000 person-years, while in the same 5-year period 11 divers had been disabled owing to diving-related events, indicating a diving-related disabling event rate of approximately 550 per 100,000 person-years. Among 342 active divers interviewed, one third reported having suffered from decompression illness, although based on reported current symptoms over 50% were classified as suffering from recurring non-disabling decompression illness. Physical examination conducted on a subset of 98 active divers revealed the presence of spinal injury (clonus, raised muscle tone, and heightened reflexes) and of joint damage (pain in one or more joint, crepitus, or restricted movement) in 24 and 30% respectively. Improved primary prevention and medical treatment are needed to reduce mortality and morbidity among this population.