Laparoscopic versus open hepatectomy for large hepatocellular carcinoma: a single center propensity-score-matching comparative analysis of perioperative outcomes and long-term survival.

BACKGROUND: Although the benefits of laparoscopic hepatectomy (LH) for hepatocellular carcinoma (HCC) in most circumstances are evident, the benefits for large HCC are contentious. This study aimed to compare the perioperative outcomes and survival after LH versus open hepatectomy (OH) in large HCC patients. METHODS: An analysis of prospectively maintained database included 215 hepatectomies for large HCC (diameter ≥ 5 cm). The operative and survival outcomes were compared between the LH group (n = 109) and the OH group (n = 106). Propensity score matching (PSM) 1:1 included 70 patients in each group. The entire cohort multivariable analyses were performed to identify the factors associated with surgical complications and suboptimal recurrence-free survival (RFS). RESULTS: After PSM, baseline characteristics and the extent of liver resection were similar in both groups. The LH group had a shorter hospital stay than the OH group (7 vs 9.5 days, p = 0.001). The R0 resection rate, complication rate, overall survival, and RFS were similar between the groups. The multivariate analyses revealed two independent factors predicting surgical complication (major resection; p < 0.001 and large volume blood loss; p = 0.042), and 3 independent factors predicting suboptimal RFS including R1 resection (p = 0.011), multifocal HCC (p = 0.005), and microvascular invasion (p = 0.001). LH was not associated with surgical complication and suboptimal RFS. CONCLUSION: Our study highlights the benefits of LH by improving the perioperative outcomes, without long-term survival inferiority in selected large HCC patients compared with conventional OH. LH can be an attractive option for large HCC treatment.

Ivermectin Accelerates Circulating Nonstructural Protein 1 (NS1) Clearance in Adult Dengue Patients: A Combined Phase 2/3 Randomized Double-blinded Placebo Controlled Trial.

BACKGROUND: Dengue is the most significant mosquito-borne viral disease; there are no specific therapeutics. The antiparasitic drug ivermectin efficiently inhibits the replication of all 4 dengue virus serotypes in vitro. METHODS: We conducted 2 consecutive randomized, double-blind, placebo-controlled trials in adult dengue patients to evaluate safety and virological and clinical efficacies of ivermectin. After a phase 2 trial with 2 or 3 days of 1 daily dose of 400 µg/kg ivermectin, we continued with a phase 3, placebo-controlled trial with 3 days of 400 µg/kg ivermectin. RESULTS: The phase 2 trial showed a trend in reduction of plasma nonstructural protein 1 (NS1) clearance time in the 3-day ivermectin group compared with placebo. Combining phase 2 and 3 trials, 203 patients were included in the intention to treat analysis (100 and 103 patients receiving ivermectin and placebo, respectively). Dengue hemorrhagic fever occurred in 24 (24.0%) of ivermectin-treated patients and 32 (31.1%) patients receiving placebo (P = .260). The median (95% confidence interval [CI]) clearance time of NS1 antigenemia was shorter in the ivermectin group (71.5 [95% CI 59.9-84.0] hours vs 95.8 [95% CI 83.9-120.0] hours, P = .014). At discharge, 72.0% and 47.6% of patients in the ivermectin and placebo groups, respectively had undetectable plasma NS1 (P = .001). There were no differences in the viremia clearance time and incidence of adverse events between the 2 groups. CONCLUSIONS: A 3-day 1 daily dose of 400 µg/kg oral ivermectin was safe and accelerated NS1 antigenemia clearance in dengue patients. However, clinical efficacy of ivermectin was not observed at this dosage regimen.

Cut-off values for positive bronchodilator response in healthy Thai preschool children using forced oscillation technique.

BACKGROUND: Forced oscillation technique (FOT) requires minimal patient cooperation and is particularly useful in young children. Bronchodilator test is a valuable tool for wheezy and asthmatic patients. The cut-off value for bronchodilator response by FOT in healthy Thai children has not been reported. OBJECTIVE: To determine the cut-off values for positive bronchodilator response in healthy Thai preschool children using pseudorandom FOT. METHODS: FOT was used to measure respiratory function at baseline and after 400 mcg MDI salbutamol in healthy Thai children aged 3-6 years. Respiratory resistance (Rrs) and reactance (Xrs) at 6, 8, and 10 Hz were collected. Pre- and post-bronchodilator tests were compared using paired t-test. Absolute and percent changes after bronchodilator were calculated and their cut-off values were defined as mean ± 1.96 SD. Correlation between each of those and baseline data was analyzed using Pearson's correlation coefficient. RESULTS: Of the 150 enrolled children, FOT measurement at baseline and after bronchodilator was successfully completed in 111 children (51 boys). The mean ± standard deviation age, height, and arm span was 5.2 ± 1.1 years, 109.3 ± 8.7 cm, and 107.2 ± 9.1 cm, respectively. No correlation was observed between any absolute or percent changes in bronchodilator response and gender, age, height, or arm span. The cut-off values established for bronchodilator response by percent change were, as follows: Rrs6: -23%, Rrs8: -20%, Rrs10: -20%, Xrs6: 36%, Xrs8: 60%, and Xrs10: 43%. CONCLUSIONS: The cut-off values identified in this study will be useful for evaluating bronchodilator response by FOT in wheezy and asthmatic young children.

A Comparison of Pediatric Weight Estimation Methods for Emergency Resuscitation.

OBJECTIVES: Obtaining accurate pediatric weight is necessary during emergency resuscitation. Although several weight estimation methods exist, the most precise method has not been conclusively determined. This study aimed to evaluate the validity, reliability, and practicality of these tools. METHODS: A prospective observational study was conducted in healthy Thai children aged 6 months to 12 years. Correlations between estimated and actual weights were tested. Validity was assessed by mean bias (estimated weight minus actual weight) and accuracy (10% error). Practicality was evaluated by time usage and data derived from user questionnaires. RESULTS: Four hundred thirty participants with mean age of 6.7 years and mean weight of 26 kg were enrolled. A strong correlation between estimated weight and actual weight in all methods was demonstrated. Parental estimation was the most accurate tool in all age groups, with the lowest overall mean error (ME) of -0.83 kg and the highest accuracy of 88.7%. The Broselow tape was the second most accurate tool in ages younger than 1 year and 1-to-5-year age groups (ME = 0.23 and 0.50 kg; accuracy = 55.3% and 54.1%, respectively). The Mercy method was the second most accurate tool in the 6-to-10-year and 11-to-12-year age groups (ME = -2.47 and -2.77; accuracy = 54.6% and 67.9%, respectively). The Broselow tape had the highest score for practicality of use. CONCLUSIONS: Parental estimation was the most accurate method in every age group. The next best alternative is the Broselow tape in children aged 5 years or younger and the Mercy method in children aged older than 5 years.

Surveillance of Otitis Media With Effusion in Thai Children With Cleft Palate: Cumulative Incidence and Outcome of the Management.

OBJECTIVE: To study the incidence and outcome of management of otitis media with effusion in Thai children with cleft palate. DESIGN: Retrospective cohort study in the tertiary care center. PATIENTS: Ninety-five children with cleft palate were referred for ear evaluation, from June 1997 to January 2015. Fifteen children (15.8%) had associated craniofacial syndromic anomalies. MAIN OUTCOME MEASURES: Cumulative incidence of otitis media with effusion, rate of ventilation tube insertion, duration of indwelling tubes, hearing outcome, and complications of ventilation tubes. RESULTS: Ear examinations were done every 8 to 12 weeks throughout the study. Cumulative incidence of otitis media with effusion was 53.7% in children within 12 months of age and 81.1% within 24 months of age. At the end of the study, all of the patients had at least 1 episode of otitis media with effusion. Eighty-eight children (92.6%) had palatoplasty, and there was no significant difference in the incidence of otitis media before and after palatoplasty. The mean hearing level at recruitment was 40.8 ±18.4 dB. Ventilation tube insertion was done in 76 patients (80%). The median time for indwelling tubes was 11.7 months. Rate of ventilation tube insertion was 0.5/year. The mean hearing level at last follow-up was 23.5 ± 14 dB. Otorrhea through tube was found in 24 cases (31.6%). CONCLUSION: Otitis media with effusion was common in Thai children with cleft palate. Surveillance of middle ear effusion and ventilation tube insertion contributed to a favorable hearing outcome.

Long-term outcome following regenerative periodontal treatment of intrabony defects.

This study aimed to evaluate the long-term outcome of the regenerative periodontal therapy of an intrabony defect in terms of tooth survival and clinical attachment level (CAL) stability. The association between failure and patient as well as tooth variables was assessed. Treatment records of the patients who received regenerative surgery and re-evaluation at 1-year post-surgery were screened. Patient and tooth variables, defect characteristics, and types of treatments were collected. Periodontal parameters were retrieved before regenerative surgery (baseline), 1-year post-surgery, and every visits of supportive periodontal treatment (SPT) until failure, including tooth loss or CAL loss ≥2 mm was found. In this study, treatment records from 89 patients were included. These patients continued SPT from 0.5-11.16 years. Of these patients, 92.1 % survived from tooth loss, while 61.8 % survived from CAL loss ≥2 mm compared to 1-year post-surgery. At the sites with residual pocket depth <5 mm, patients attending SPT >80 % had a significantly less percentage of teeth with CAL loss ≥2 mm compared to 1-year post-surgery than those attending SPT <80 %. However, at the sites with residual pocket depth ≥5 mm, no significant difference in the percentage of teeth with CAL loss ≥2 mm was found between patients attending SPT >80 % or <80 %. Smoking, patient's compliance, and residual pocket depth after regenerative surgery were significantly associated with tooth loss. However, these factors were not significantly associated with CAL loss compared to baseline or 1-year post-surgery.

Microparticles provide a novel biomarker to predict severe clinical outcomes of dengue virus infection.

UNLABELLED: Shedding of microparticles (MPs) is a consequence of apoptotic cell death and cellular activation. Low levels of circulating MPs in blood help maintain homeostasis, whereas increased MP generation is linked to many pathological conditions. Herein, we investigated the role of MPs in dengue virus (DENV) infection. Infection of various susceptible cells by DENV led to apoptotic death and MP release. These MPs harbored a viral envelope protein and a nonstructural protein 1 (NS1) on their surfaces. Ex vivo analysis of clinical specimens from patients with infections of different degrees of severity at multiple time points revealed that MPs generated from erythrocytes and platelets are two major MP populations in the circulation of DENV-infected patients. Elevated levels of red blood cell-derived MPs (RMPs) directly correlated with DENV disease severity, whereas a significant decrease in platelet-derived MPs was associated with a bleeding tendency. Removal by mononuclear cells of complement-opsonized NS1-anti-NS1 immune complexes bound to erythrocytes via complement receptor type 1 triggered MP shedding in vitro, a process that could explain the increased levels of RMPs in severe dengue. These findings point to the multiple roles of MPs in dengue pathogenesis. They offer a potential novel biomarker candidate capable of differentiating dengue fever from the more serious dengue hemorrhagic fever. IMPORTANCE: Dengue is the most important mosquito-transmitted viral disease in the world. No vaccines or specific treatments are available. Rapid diagnosis and immediate treatment are the keys to achieve a positive outcome. Dengue virus (DENV) infection, like some other medical conditions, changes the level and composition of microparticles (MPs), tiny bag-like structures which are normally present at low levels in the blood of healthy individuals. This study investigated how MPs in culture and patients' blood are changed in response to DENV infection. Infection of cells led to programmed cell death and MP release. In patients' blood, the majority of MPs originated from red blood cells and platelets. Decreased platelet-derived MPs were associated with a bleeding tendency, while increased levels of red blood cell-derived MPs (RMPs) correlated with more severe disease. Importantly, the level of RMPs during the early acute phase could serve as a biomarker to identify patients with potentially severe disease who require immediate care.

Clinical effect of locally delivered gel containing green tea extract as an adjunct to non-surgical periodontal treatment.

UNLABELLED: Green tea catechins had an in vitro antibacterial effect against periodontopathic bacteria and were able to inhibit destruction of the periodontal tissue. In this study, we aimed to evaluate the effect of locally delivered gel containing green tea extract as an adjunct to non-surgical periodontal treatment. Forty-eight subjects who had teeth with probing pocket depth of 5-10 mm were randomly allocated into the test or control group. Probing pocket depth, clinical attachment level, gingival index (GI), bleeding on probing (BOP) and full mouth plaque score were measured at baseline. Subjects received oral hygiene instruction, single episode of scaling and root planing and subgingival application of the green tea gel (test group) or the placebo gel (control group). The gel was repeatedly applied at 1 and 2 weeks later. The parameters were recorded again at the 1st, 3rd and 6th month after the last gel application. The results showed that all parameters were improved in both groups compared to baseline. The test group exhibited significantly higher reduction in BOP at the 3rd month (p = 0.003) and significantly lower GI at the 1st month (p < 0.001) and 3rd month (p < 0.001) when compared with the control group. Thus, green tea gel could provide a superior benefit in reducing bleeding on probing and gingival inflammation when used as an adjunct to non-surgical periodontal treatment. ( TRIAL REGISTRATION: MU-IRB 2008/153.0511, ClinicalTrials.gov NCT00918060).

Predictors of Prolonged Length of Stay in General Surgical Intensive Care Unit.

Objective: The aims of this study were to explore the incidence, clinical factors, severity scores and outcome associated with prolonged length of intensive care unit (ICU) stay >3 days. Material and Method: This study was a prospective observational study on the noncardiac surgical patients who were admitted to surgical intensive care unit in a tertiary university hospital. The cardiothoracic, neurosurgical and traumatic surgical patients or the patients who died within the first 3 days of ICU admission were excluded. Patient demographic data, preoperative predictors and severity scores (APACHE II, APACHE III, SOFA, SAPS II and MODS scores) at day 1 and day 3 of ICU admission were recorded. Results: A total of 948 patients were observed. The incidence of prolonged ICU stay was 20.1%. Patients with prolonged ICU stay had significantly higher ventilator hours (p<0.001) and ICU length of stay (p<0.001). On the multivariable analysis model of preoperative variables, the significant predictors of prolonged ICU stay were preoperative serum albumin less than 2.6 mg/dL (p = 0.023), preoperative hematocrit less than 34% (p = 0.035), emergency surgery (p = 0.003), having surgical complications (p = 0.017), having anesthetic complications (p = 0.017), admission for respiratory support with or without unstable hemodynamic (p<0.001), and sepsis on ICU admission (p = 0.003). Regarding the multivariable analysis of severity scoring system, the significant severity predictors were found only the preoperative ASA class IV (p<0.001) and emergency ASA status (p<0.001). Conclusion: About one-fifth of the study patients had prolonged ICU stay (>3 days). Low preoperative serum albumin (<2.6 mg/dL), low preoperative hematocrit (<34%), ASA physical status class IV, underwent emergency surgery, having anesthetic complications, surgical complications, sepsis on ICU admission, having respiratory support with or without unstable hemodynamic were significantly associated with prolonged ICU stay.

DIFFERENCES IN MORTALITY BY EDUCATION LEVEL AMONG PATIENTS IN DIABETIC REGISTRY FOR THAILAND.

This study was conducted in order to determine the impact of education on mortality due cardiovascular, infectious and renal disease, and cancer among Thai diabetics using data from the Thailand diabetes registry cohort prospected and conducted between April 2003 and February 2006. The study population consisted of 9,370 registered diabetic patients attending ten diabetes clinics at tertiary medical centers in Bangkok and major provinces. The population was classified by education level: those who had not yet attained a bachelor's degree classified as having "lower education" (7,684: 82%) and those with a bachelor's degree or higher classified as having "higher education" (1,686:18%). The overall mortality rate among those in the higher education group was lower than those in the lower education group (8.9 vs 20.5 per 1,000 patient-years, respectively) with a hazard ratio (HR) of 0.43 (0.31-0.61). The higher education group also had lower mortality rates due to infectious disease [HR 0.10 (0.02-0.41)], renal disease [HR 0.24 (0.06-0.99)] and cardiovascular disease [HR 0.42 (0.22-0.80)]. There was no difference in cancer mortality between the two groups [HR 1.25 (0.74-2.11)].

Stroke awareness and factors influencing hospital arrival time: a prospective observational study.

BACKGROUND: Data concerning stroke awareness and factors associated with time of hospital arrival for acute stroke patients in Thailand are still lacking. OBJECTIVE: To assess stroke awareness and to identify factors influencing hospital arrival time after an acute stroke. MATERIAL AND METHOD: This is aprospective study comprising consecutive acute stroke patients admitted in Siriraj Hospital, Bangkok, Thailand between August 2010 and December 2011. Demographic data, stroke severity using the NIHSS, diagnosis and stroke awareness questionnaire were collected. RESULTS: Of 217 acute stroke patients, mean age was 66 ± 13.7 years. Mean stroke severity was 10 ± 7.6. Patients arrived at the Emergency Department within 4.5 hours (early hospital arrival: EHA) in 38.2% of the cases, 16.6% by ambulance. Only 34.6% of patients recognized that they were having stroke. Factors associated with EHA were 1) stroke awareness (OR 1.96, 95% CI 1.07-3.60, p = 0.030), 2) arrival by ambulance (OR 2.23, 95% CI 1.03-4.81, p = 0.042), and 3) NIHSS >15 (OR 2.26, 95% CI 1.17-4.35, p = 0.015). CONCLUSION: Only one-third of patients were aware of stroke symptoms. Only one in six patients used emergency transportation. Public educational campaign is needed to increase the community awareness of stroke warning symptoms and the urgent emergency medical services.

Utility of Adding SPECT/CT Imaging to Post-Therapeutic Radioiodine Whole-Body Scan in Patients with Differentiated Thyroid Cancer.

OBJECTIVE: To determine the usefulness of adding single-photon emission computed tomography/computed tomography (SPECT/CT) imaging to post-therapeutic radioiodine whole-body scan (RxWBS) in patients with differentiated thyroid cancer. MATERIAL AND METHOD: RxWBSs and SPECT/CT images of 93 consecutive patients were reviewed retrospectively by three experienced nuclear medicine physicians without knowledge of clinical data. RxWBSs were reviewed first followed by evaluation of RxWBS plus SPECT/CT imaging. Foci of increased radioiodine uptake were identified and localization was attempted. The findings obtained from RxWBS were compared with WBS plus SPECT/CT imaging to determine impact on lesion characterization, TNM staging, and management plan. RESULTS: Two hundred seventy seven lesions were identified by RxWBS alone. RxWBS plus SPECT/CT imaging detected eight additional pathologic lesions (4 in bones, two in neck, and one in lung and thyroid bed). RxWBS plus SPECT/CT studies reclassified 85 of 277 lesions (30.7%) detected by RxWBS. Most change occurred in neck region (57 lesions) followed by chest region (16 lesions). For impact on TNM staging, RxWBS plus SPECT/CT studies changed N stage of 21 patients (22.6%) and reclassified M stage of 10 patients (10.8%). These resulted in change of TNM stage group of 14 patients (15.1%) and changed management plan of 19 patients (20.4%). CONCLUSION: The addition of SPECT/CT imaging to RxWBS in patients with differentiated thyroid cancer improved disease localization and lesion characterization leading to more accurate N and M staging, which was mainly downstaged. SPECT/CT also had impact on plan of management in about one fifth of the patients. However, caution should be taken when interpreting lesion in lower chest and upper abdomen because misregistration of SPECT and CT images.

Reliability and validity of the Canadian neurological scale, Thai version.

BACKGROUND: The Canadian Neurological Scale (CNS) is one of the most reliable stroke severity assessment scales. There is a strong need for a simple and well validated stroke severity assessment scale among Thais. OBJECTIVE: To translate and perform a reliability and validity study of the Canadian Neurological Scale, Thai version (CNS-T). MATERIAL AND METHOD: Forward and backward translations of the original CNS version were independently performed. The final version of the CNS-T was prospectively tested for reliability and validity in acute ischemic stroke setting. Consecutive series of acute stroke patients were assessed by one of the six raters from three different types of healthcare providers: 2 stroke nurses, 2 internal medicine residents and 2 stroke fellows. Each patient was independently assessed twice at 3 weeks interval using video tape by all raters. Extent of infarction was measured by MRI lesion volume. Clinical outcome at 3 months was measured using modified Rankin Score (mRS). Correlation among the CNS-T and 3-mo mRS and MRI lesion volume were assessed. Inter and intra-observer reliabilities were evaluated. RESULTS: A total of 38 patients were enrolled. Median CNS-T was 8.5. Intra-observer reliability demonstrated a high agreement with an intraclass correlation (ICC) of 0.99, 0.97, 0.98, 0.96, 0.93 and 0.98 for 2 stroke fellows, 2 internal medicine residents and 2 stroke nurses respectively. Inter-observer reliability between the 6 raters was excellent: ICC 0.87 (95% CI; 0.81-0.92). The Spearman rank correlation coefficient was -0.55 (p = 0.001) between the initial CNS-T score versus initial MRI lesion volume and -0.61 (p < 0.001) between the initial CNS-T score versus 3-mo mRS. CONCLUSION: The CNS-T can be performed by trained nurses, internists and neurologists with an excellent reliability. The CNS-T is a valid and simple clinical tool for stroke severity assessment among Thais.

Value of diffusion tensor imaging in differentiating high-grade from low-grade gliomas.

OBJECTIVE: To determine the usefulness of diffusion tensor imaging (DTI) in differentiating high-grade glioma (HGG) from low-grade glioma (LGG). MATERIAL AND METHOD: Patients with cerebral gliomas underwent conventional MRI and DTI before surgery. All proven pathologies were classified into two groups, i.e. LGG and HGG. The authors measured fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values in region of interest (ROI) including solid tumoral region, necrotic region, peritumoral edema, contralateral normal appearing white matter (NAWM) and normal corpus callosum as well as calculated ADC ratios. Pairwise comparisons were performed by using the t-test. The ROC curves of imaging parameters were employed to determine the best parameter for differentiating the two entities. RESULTS: Forty-three patients with cerebral gliomas, 17 with LGG and 26 with HGG, no statistical significant difference between LGG and HGG using mean FA values in each ROI. The ADC and minimal ADC values of solid tumoral region and peritumoral edema, the ADC and minimal ADC ratios of solid tumoral region are statistical significant to differentiate HGG from LGG, p < 0.05. The ratio ADC solid tumoral region to normal corpus callosum had highest predictive accuracy to differentiate the two entities with AUC of 0.74. CONCLUSION: The ADC value, minimal ADC value, and ADC ratios of solid tumoral region appeared to be useful for differentiating HGG from LGG.

Smoking and death in Thai diabetic patients: the Thailand Diabetic Registry cohort.

OBJECTIVE: To determine the impact of smoking and quit smoking on mortality rate. MATERIAL AND METHOD: This prospective cohort was a three-year follow-up of Thai Diabetes Registry project that registered 9,370 diabetic patients from 10 diabetic clinics in tertiary medical centers in Bangkok and major provinces between April 2003 and February 2006. RESULTS: The groups of 7,487 (80%), 1,315 (14%), and 568 (6%) patients were classified as non-smokers, ex-smokers, and current smokers. The crude death rate of ex-smokers (Hazard Ratio (HR) 1.52 (95% CI 1.19-1.95)) and current smokers (HR 1.55 (1.10-2.19)) were higher than death rate of non-smokers. After control for covariates, the HR comparing ex-smokers with non-smokers was not different (1.10 (0.81-1.50)), while the HR comparing current smokers with non-smokers remained statistical significant (1.74 (1.17-2.61)). CONCLUSION: Smoking increases mortality rate in diabetic patients by about 74%. Quitting smoking decreased mortality rate to the same rate as of diabetic non-smokers.

The relationship between creamatocrit and cumulative percentage of total milk volume: a cross-sectional study in mothers of very preterm infants in Bangkok, Thailand.

BACKGROUND: Human hindmilk contains higher concentrations of fat than foremilk and is more desirable for growth in preterm infants who can tolerate limited volumes of breastmilk. There is currently no clear demarcation between foremilk and hindmilk. This study characterized the change in breastmilk's fat content from the start to end of milk flow and defined this demarcation. METHODS: Mothers of infants born at ≤ 32 weeks gestational age and ≥ 14 days after childbirth in a University hospital in Bangkok, Thailand between July, 2011, and April, 2012 were included in this cross-sectional study. Breastmilk samples were sequentially collected from the start to end of milk flow in 5-mL aliquots using breast pumps. The fat content of each aliquot from each breast was determined through creamatocrit. The average creamatocrit of foremilk and hindmilk were compared in predefined foremilk to hindmilk ratios of 20:80, 25:75, 33:67, and 50:50. Creamatocrit of the first and last aliquots were compared for mothers who expressed low- (≤ 25-mL per breast) and high-volumes (> 25-mL per breast) of breastmilk. RESULTS: Of the 25 mothers enrolled, one was excluded due to unsuccessful creamatocrit measurement. The last aliquot of breastmilk had a significantly higher creamatocrit than the first from the same breast (median [interquartile range] of 12.7% [8.9%, 15.3%] vs. 5.6% [4.3%, 7.7%]; test statistic 1128, p < 0.001). Mean creamatocrit in hindmilk portions (9.23%, 9.35%, 9.81%, and 10.62%, respectively) was significantly higher than foremilk portions (6.28%, 6.33%, 6.72%, and 7.17%, respectively) at all predefined ratios. Creamatocrit increased by 1% for every 10% incremental increase in expressed breastmilk volume until the breast was emptied. Low-volume mothers had a significantly higher creamatocrit in the first aliquot compared with high-volume mothers (U = 437, p = 0.002). No significant difference in breastmilk volume was observed between mothers with and without breastfeeding experience. CONCLUSIONS: Fat content in breastmilk increased on an incremental basis. More fluid definitions of foremilk and hindmilk should be adopted. Mothers should prepare their breastmilk into aliquots based on the required feeding volume of their infant. Hindmilk aliquots can be prioritized over foremilk aliquots to ensure infants obtain optimal caloric intake.

Distinguishing SARS-CoV-2 Infection and Non-SARS-CoV-2 Viral Infections in Adult Patients through Clinical Score Tools.

This study aimed to determine distinguishing predictors and develop a clinical score to differentiate COVID-19 and common viral infections (influenza, respiratory syncytial virus (RSV), dengue, chikungunya (CKV), and zika (ZKV)). This retrospective study enrolled 549 adults (100 COVID-19, 100 dengue, 100 influenza, 100 RSV, 100 CKV, and 49 ZKV) during the period 2017−2020. CKV and ZKV infections had specific clinical features (i.e., arthralgia and rash); therefore, these diseases were excluded. Multiple binary logistic regression models were fitted to identify significant predictors, and two scores were developed differentiating influenza/RSV from COVID-19 (Flu-RSV/COVID) and dengue from COVID-19 (Dengue/COVID). The five independent predictors of influenza/RSV were age > 50 years, the presence of underlying disease, rhinorrhea, productive sputum, and lymphocyte count < 1000 cell/mm3. Likewise, the five independent predictors of dengue were headache, myalgia, no cough, platelet count < 150,000/mm3, and lymphocyte count < 1000 cell/mm3. The Flu-RSV/COVID score (cut-off value of 4) demonstrated 88% sensitivity and specificity for predicting influenza/RSV (AUROC = 0.94). The Dengue/COVID score (cut-off value of 4) achieved 91% sensitivity and 94% specificity for differentiating dengue and COVID-19 (AUROC = 0.98). The Flu-RSV/COVID and Dengue/COVID scores had a high discriminative ability for differentiating influenza/RSV or dengue infection and COVID-19. The further validation of these scores is needed to ensure their utility in clinical practice.

Incidence and risk factors of perioperative stroke in Siriraj Hospital.

BACKGROUND: Data concerning perioperative stroke incidence and risk factors are lacking in Thailand. OBJECTIVE: To study incidence and risk factors of perioperative stroke in Siriraj Hospital, Bangkok, Thailand. MATERIAL AND METHOD: The authors conducted a nested case-control study between July 2007 and June 2010. Consecutive perioperative stroke cases were compared with age-matched controls that had undergone surgery without having a stroke at a 1:4 ratio. Patients' characteristics, co-morbidities, clinical manifestation, stroke subtypes, duration, and types of surgery were collected. Multiple logistic regression analysis was performed to identify factors associated with a stroke during perioperative period. RESULTS: Sixty-six patients with perioperative stroke from 99,283 that underwent surgery were included. This resulted in an incidence of 66.5/100,000. Men comprised 65.2%. Mean age of stroke patients was 66.6-years-old. Age-match controls included 264 consecutive patients who underwent surgery without having a stroke. A multivariate analysis showed that male sex (adjusted OR 3.1, p = 0.003), surgical types: open heart surgery (adjusted OR 54.3, p < 0.0001), vascular surgery (adjusted OR 20.6, p < 0.0001) and endovascular procedure (adjusted OR 15.4, p < 0.0001), emergency surgery (adjusted OR 8.3, p < 0.0001), the presence of diabetes mellitus (adjusted OR 2.6, p = 0.018), chronic kidney disease (adjusted OR 2.6, p = 0.027), and coronary artery disease (adjusted OR 0.4, p = 0.039) were associated with perioperative stroke. CONCLUSION: Incidence of perioperative stroke was higher than a previous report. Male, type of surgery, emergency operation, diabetes mellitus, and chronic kidney disease were risk factors of perioperative stroke.

Prevalence and cumulative incidence of abnormal cervical cytology among HIV-infected Thai women: a 5.5-year retrospective cohort study.

BACKGROUND: Cervical cancer is one of the most common AIDS-related malignancies in Thailand. To prevent cervical cancer, The US Public Health Service and The Infectious Disease Society of America have recommended that all HIV-infected women should obtain 2 Pap smears 6 months apart after the initial HIV diagnosis and, if results of both are normal, should undergo annual cytological screening. However, there has been no evidence in supporting whether this guideline is appropriate in all settings - especially in areas where HIV-infected women are living in resource-constrained condition. METHODS: To determine the appropriate interval of Pap smear screenings for HIV-infected Thai women and risk factors for subsequent abnormal cervical cytology, we assessed the prevalence, cumulative incidence and associated factors of cervical cell abnormalities (atypical squamous cell of undetermined significance or higher grades, ASCUS+) among this group of patients. RESULTS: The prevalence of ASCUS+ was 15.4% at the first visit, and the cumulative incidence of ASCUS+ gradually increased to 37% in the first 3.5 years of follow-up appointments (first 7 times), and tended to plateau in the last 2 years. For multivariate correlation analysis, women with a CD4 count <350 cells/µL had a significant correlation with ASCUS+ (P = 0.043). There were no associations of subsequent ASCUS+ with age, pregnancy, contraceptive method, highly active anti-retroviral treatment, assumed duration of infection, or the CD4 count nadir level. CONCLUSION: There are high prevalence and cumulative incidence of ASCUS+ in HIV-infected Thai women. With a high lost-to-follow-up rate, an appropriate interval of Pap smear screening cannot be concluded from the present study. Nevertheless, the HIV-infected Thai women may require more than two normal semi-annual Pap smears before shifting to routinely annual cytologic screening.

The effect of montelukast on bronchial hyperreactivity and lung function in asthmatic children aged 6-13 years.

BACKGROUND: Cysteinyl leukotrienes have been shown to play an important role in the pathogenesis of asthma. The effect of the leukotriene receptor antagonist, montelukast, on bronchial hyperreactivity (BHR) as measured by the methacholine challenge test in school childre in has not been reported. OBJECTIVE: To determine the effect of montelukast (Singulair) on BHR measured by methacholine challenge and lung function tests in Thai asthmatic children aged 6-13 years. MATERIALS AND METHODS: This was a randomized double-blind, placebo-controlled, crossover study performed in 29 mild to moderate persistent asthmatic children aged 6-13 years. Each child received crossover treatment with 6 weeks of montelukast (5 mg/day) and 6 weeks of placebo separated by a two-week washout period. RESULTS: The improvement of FEV1 and FEV1/FVC after 6 weeks of treatment wa significantly higher in montelukast group compared to those of placebo group (p < 0.05) After 6 weeks of treatment, mean PC20 (+/- SEM in the placebo group (5.7 +/- 1.41 mg/ml) was lower than in montelukast group (6.8 +/- 1.7 mg/ml) but there was no significant difference (p = 0.79). CONCLUSION: Montelukast significantly improved FEV1 and FEV1/FVC but not BHR in mild to moderate persistent asthmatic children aged 6-13 years after the 6 weeks of treatment.