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.

Transferability of the early-stage ovarian malignancy (EOM) score: an external validation study that includes advanced-stage and metastatic ovarian cancer.

PURPOSE: To validate the diagnostic performance of the Early-stage Ovarian Malignancy (EOM) score in an external dataset that includes advanced-stage and metastatic ovarian cancer. METHODS: The data from two cross-sectional cohorts were used in the statistical analysis. The development dataset of the EOM score was collected in Phrapokklao Hospital between September 2013 and December 2017. The validation dataset was collected in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018. The internal and external performance of the EOM score was evaluated in terms of discrimination via area under the receiver-operating characteristic curve (AuROC) and calibration. RESULTS: There were 270 and 479 patients included in the development and validation datasets, respectively. The prevalence of ovarian malignancy was 20.0% (54/270) in the development set and 30.3% (145/479) in the validation set. The EOM score had excellent discriminative ability in both the development and validation sets (AuROC 88.0 (95% CI 82.6, 93.9) and 88.0 (95% CI 84.3, 91.4), respectively). The EOM score also showed good calibration in both datasets. CONCLUSIONS: The EOM score had consistent diagnostic performance in the external validation data. It is recommended for use as a triage tool in patient referrals instead of the RMI in settings where experienced sonographers are not available.

Acute kidney injury risk prediction score for critically-ill surgical patients.

BACKGROUND: There has been a global increase in the incidence of acute kidney injury (AKI), including among critically-ill surgical patients. AKI prediction score provides an opportunity for early detection of patients who are at risk of AKI; however, most of the AKI prediction scores were derived from cardiothoracic surgery. Therefore, we aimed to develop an AKI prediction score for major non-cardiothoracic surgery patients who were admitted to the intensive care unit (ICU). METHODS: The data of critically-ill patients from non-cardiothoracic operations in the Thai Surgical Intensive Care Unit (THAI-SICU) study were used to develop an AKI prediction score. Independent prognostic factors from regression analysis were included as predictors in the model. The outcome of interest was AKI within 7 days after the ICU admission. The AKI diagnosis was made according to the Kidney Disease Improving Global Outcomes (KDIGO)-2012 serum creatinine criteria. Diagnostic function of the model was determined by area under the Receiver Operating Curve (AuROC). Risk scores were categorized into four risk probability levels: low (0-2.5), moderate (3.0-8.5), high (9.0-11.5), and very high (12.0-16.5) risk. Risk of AKI was presented as likelihood ratios of positive (LH+). RESULTS: A total of 3474 critically-ill surgical patients were included in the model; 333 (9.6%) developed AKI. Using multivariable logistic regression analysis, older age, high Sequential Organ Failure Assessment (SOFA) non-renal score, emergency surgery, large volume of perioperative blood loss, less urine output, and sepsis were identified as independent predictors for AKI. Then AKI prediction score was created from these predictors. The summation of the score was 16.5 and had a discriminative ability for predicting AKI at AuROC = 0.839 (95% CI 0.825-0.852). LH+ for AKI were: low risk = 0.117 (0.063-0.200); moderate risk = 0.927 (0.745-1.148); high risk = 5.190 (3.881-6.910); and very high risk = 9.892 (6.230-15.695), respectively. CONCLUSIONS: The function of AKI prediction score to predict AKI among critically ill patients who underwent non-cardiothoracic surgery was good. It can aid in early recognition of critically-ill surgical patients who are at risk from ICU admission. The scores could guide decision making for aggressive strategies to prevent AKI during the perioperative period or at ICU admission. TRIAL REGISTRATION: TCTR20190408004, registered on April 4, 2019.

Development of a clinical diagnostic tool to differentiate multiple myeloma from bone metastasis in patients with destructive bone lesions (MM-BM DDx).

BACKGROUND: Most patients with destructive bone lesions undergo a comprehensive diagnostic procedure to ensure that proper treatment decisions are pursued. For patients with multiple myeloma, this can lead to delays in diagnosis and treatment initiation. This study was conducted to develop a diagnostic rule that could serve as a tool for early identification of multiple myeloma and promote timely referral of patients to haematologists. METHODS: The clinical prediction rule was developed using a retrospective case-series of patients with multiple myeloma (MM) and those with bone metastasis (BM) at Chiang Mai University Hospital from 2012 to 2015. Multivariable fractional polynomial logistic regression was used to derive a diagnostic model to differentiate between MM and BM patients (MM-BM DDx). RESULTS: A total of 586 patients (136 MM patients and 450 BM patients) were included. Serum creatinine, serum globulin, and serum alkaline phosphatase were identified as significant indicators for the differentiation of MM and BM patients. The MM-BM DDx model showed excellent discriminative ability [AuROC of 0.90 (95%CI 0.86 to 0.93)] and good calibration. CONCLUSIONS: This MM-BM DDx model could potentially allow for early myeloma diagnosis and improvement of overall prognosis. A prospective validation study is needed to confirm the accuracy of the MM-BM DDx model prior to its application in clinical practice.

Clinical Predictors Influencing the Length of Stay in Emergency Department Patients Presenting with Acute Heart Failure.

Background and objectives: Acute heart failure is a common problem encountered in the emergency department (ED). More than 80% of the patients with the condition subsequently require lengthy and repeated hospitalization. In a setting with limited in-patient capacity, the patient flow is often obstructed. Appropriate disposition decisions must be made by emergency physicians to deliver effective care and alleviate ED overcrowding. This study aimed to explore clinical predictors influencing the length of stay (LOS) in patients with acute heart failure who present to the ED. Materials and Methods: We conducted prognostic factor research with a retrospective cohort design. Medical records of patients with acute heart failure who presented to the ED of Ramathibodi Hospital from January to December 2015 were assessed for eligibility. Thirteen potential clinical predictors were selected as candidates for statistical modeling based on previous reports. Multivariable Poisson regression was used to estimate the difference in LOS between patients with and without potential predictors. Results: A total of 207 patients were included in the analysis. Most patients were male with a mean age of 74.2 ± 12.5 years. The median LOS was 54.6 h (Interquartile range 17.5, 149.3 h). From the multivariable analysis, four clinical characteristics were identified as independent predictors with an increase in LOS. These were patients with New York Heart Association (NYHA) functional class III/IV (+72.9 h, 95%Confidence interval (CI) 23.9, 121.8, p = 0.004), respiratory rate >24 per minute (+80.7 h, 95%CI 28.0, 133.3, p = 0.003), hemoglobin level <10 mg/dL (+60.4 h, 95%CI 8.6, 112.3, p = 0.022), and serum albumin <3.5 g/dL (+52.8 h, 95%CI 3.6, 102.0, p = 0.035). Conclusions: Poor NYHA functional class, tachypnea, anemia, and hypoalbuminemia are significant clinical predictors of patients with acute heart failure who required longer LOS.

Early-Stage Ovarian Malignancy Score versus Risk of Malignancy Indices: Accuracy and Clinical Utility for Preoperative Diagnosis of Women with Adnexal Masses.

Background and objectives: To compare the diagnostic accuracy and clinical utility of the Early-stage Ovarian Malignancy (EOM) score with the Risk of Malignancy Index (RMI) in the presurgical assessment of women presenting with adnexal masses. Materials and Methods: A secondary analysis was carried out in a retrospective cohort of women who presented with an adnexal mass and were scheduled for surgery at Phrapokklao Hospital between September 2013 and December 2017. The clinical characteristics, ultrasonographic features of the masses, and preoperative CA-125 levels were recorded. The EOM and the RMI score were calculated and compared in terms of accuracy and clinical utility. Decision curve analysis (DCA), which examined the net benefit (NB) of applying the EOM and the RMI in practice at a range of threshold probabilities, was presented. Results: In this study, data from 270 patients were analyzed. Fifty-four (20.0%) women in the sample had early-stage ovarian cancer. All four RMI versions demonstrated a lower sensitivity for the detection of patients with early-stage ovarian cancer compared to an EOM score ≥ 15. An EOM ≥ 15 resulted in a higher proportion of net true positive or NB than all versions of the RMIs from a threshold probability of 5% to 30%. Conclusions: It also showed a higher capability to reduce the number of inappropriate referrals than the RMIs at a threshold probability between 5% and 30%. The EOM score showed higher diagnostic sensitivity and has the potential to be clinically more useful than the RMIs to triage women who present with adnexal masses for referral to oncologic gynecologists. Further external validation is required to support our findings.

Prediction of Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke: The Symptomatic Intracranial Hemorrhage Score.

BACKGROUND: Symptomatic intracranial hemorrhage (sICH) is common after intravenous thrombolysis in acute ischemic strokes (AISs). Available predictive scoring systems were derived mostly in the Western countries. METHODS: Retrospective data in 1 provincial and 4 regional hospitals in the northern part of Thailand were reviewed. Patients with AIS, to whom recombinant tissue plasminogen activator (rt-PA) had been prescribed, were classified into 3 groups: no intracranial hemorrhage (no ICH), asymptomatic intracranial hemorrhage (asICH) and sICH. Coefficients under the multilevel ordinal logistic model were transformed into item scores and sum scores. Measures of discrimination, calibration, and internal validation were analyzed. RESULTS: Among 1172 patients, there were 78.8% with no ICH (n = 923), 13.1% with asICH (n = 154), and 8.1% with sICH (n = 95). The final model was named "SICH score" and included 6 variables: valvular heart diseases, use of aspirin, systolic blood pressure prior to thrombolysis that is 140 mmHg or higher, National Institutes of Health Stroke Scale scores higher than 10 and 20, a platelet count lower than 250,000 cell/mm3, and use of intravenous antihypertensive drugs during thrombolysis, with an Area under Receiver Operating Characteristic of .75 (95% confidence interval, .71-.80). CONCLUSION: The SICH score could be an assisting tool to predict an individual risk of sICH after intravenous thrombolysis for AIS in Thai patients.

The prognostic utility of GRACE risk score in predictive cardiovascular event rate in STEMI patients with successful fibrinolysis and delay intervention in non PCI-capable hospital: a retrospective cohort study.

BACKGROUND: Fibrinolytic therapy is the main reperfusion therapy for most STEMI patients in several countries. Current practice guidelines recommended routine early pharmacoinvasive (within 3-24 h after successful fibrinolysis, however it cannot be performed in timely fashion due to limitation of PCI-capable hospitals. This study aimed to evaluate the prognostic utility of the GRACE score in patients receiving delayed intervention after successful fibrinolysis in non PCI-capable hospital. METHODS: We retrospectively analysed the data from the Maharaj Nakorn Chiang Mai Hospital acute ST-elevation myocardial infarction (STEMI) registry during the period 2007-2012. The STEMI patients who had successfully fibrionolysis in non PCI-capable hospital and received delayed PCI (during 24 h to 14 days after successful fibrinolytic therapy) at Maharaj Nakorn Chiang Mai hospital were included. The primary end point for this analysis was the composite outcomes, which included all-cause mortality, re-hospitalization with acute coronary syndrome (ACS), re-hospitalization with heart failure (HF) and stroke at 1 and 6-month. RESULTS: A total of 152 patients were included. 88 patients and 64 patients were in low GRACE group (GRACE risk score ≤ 125) and intermediate to high GRACE group (GRACE risk score above 126), respectively. The median time from fibrinolysis to coronary intervention in low GRACE group was 8.5 days (interquartile range, 4.6-10.9) and 7.9 days (interquartile range,3.2,12.0) in intermediate to high GRACE group (p = 0.482). At 1 month, the composite cardiovascular outcome at 1 month occurred in 2 patients (2.3 %) in low GRACE group and 10 patients (15.6 %) in intermediate to high GRACE group (P = 0.003). During 6 months, the composite cardiovascular outcomes occurred in 6 patients (6.8 %) in low GRACE group and 12 patients (18.7 %) in intermediate to high GRACE group (P = 0.024). The cumulative of composite cardiovascular outcome was significant higher in intermediate to high GRACE group than in low GRACE group (Hazard ratio: 2.97, 95 % CI 1.11-7.90; p = 0.030). CONCLUSION: The long delay pharmacoinvasive strategy in intermediate to high GRACE score after successful fibrinolysis in non PCI-capable facilities were associated with worse cardiovascular outcomes than the patients with low GRACE score at 1 and 6 months. GRACE risk score may be helpful and guided the clinicians in non PCI-capable center in early transferred to early intervention in STEMI patients after fibrinolytic therapy.

Clinical indicators for recurrent cardiovascular events in acute coronary syndrome patients treated with statins under routine practice in Thailand: an observational study.

BACKGROUND: Acute coronary syndrome (ACS) patients are at very high cardiovascular risk and tend to have recurrent cardiovascular events. The clinical indicators for subsequent cardiovascular events are limited and need further investigation. This study aimed to explore clinical indicators that were associated with recurrent cardiovascular events following index hospitalization. METHODS: The data of patients hospitalized with ACS at a tertiary care hospital in northern Thailand between January 2009 and December 2012 were retrospectively reviewed from medical charts and the electronic hospital database. The patients were classified into three groups based on the frequency of recurrent cardiovascular events (nonfatal ACS, nonfatal stroke, or all-cause death) they suffered: no recurrent events (0), single recurrent event (1), and multiple recurrent events (≥2). Ordinal logistic regression was performed to explore the clinical indicators for recurrent cardiovascular events. RESULTS: A total of 405 patients were included; 60 % were male; the average age was 64.9 ± 11.5 years; 40 % underwent coronary revascularization during admission. Overall, 359 (88.6 %) had no recurrent events, 36 (8.9 %) had a single recurrent event, and 10 (2.5 %) had multiple recurrent events. The significant clinical indicators associated with recurrent cardiovascular events were achieving an LDL-C goal of < 70 mg/dL (Adjusted OR = 0.43; 95 % CI = 0.27-0.69, p-value < 0.001), undergoing revascularization during admission (Adjusted OR = 0.44; 95 % CI = 0.24-0.81, p-value = 0.009), being male (Adjusted OR = 1.85; 95 % CI = 1.29-2.66, p-value = 0.001), and decrease estimated glomerular filtration rate (Adjusted OR = 2.46; 95 % CI = 2.21-2.75, p-value < 0.001). CONCLUSION: The routine clinical practice indicators assessed in ACS patients that were associated with recurrent cardiovascular events were that achieving the LDL-C goal and revascularization are protective factors, while being male and having decreased estimated glomerular filtration rate are risk factors for recurrent cardiovascular events. These clinical indicators should be used for routinely monitoring patients to prevent recurrent cardiovascular events in ACS patients.

Recurrence of Endometrioma Following Conservative Ovarian Endometrioma Cystectomy: Laparoscopy versus Laparotomy.

OBJECTIVE: To investigate the recurrence rate and disease-free interval between laparoscopy versus laparotomy for the conservative surgery of endometrioma. MATERIAL AND METHOD: A retrospective cohort study was conducted. The medical records of reproductive women who underwent conservative ovarian cystectomy surgery (laparoscopy or laparotomy) for endometrioma at Thammasat University Hospital were retrieved. The patients were followed through 24 months to evaluate the recurrence of endometrioma. Propensity scoring was used to adjust for confounding by indication and confounding by contraindication. Model for competing time to event was used in analysis. RESULTS: One hundred and twenty-eight and 114 patients were enrolled in laparoscopy and laparotomy groups, respectively. Mean age and body weight in laparotomy group were statistically higher than those in the other group were. Mean height and body mass index were, however not statistically different in either groups. In addition, the stage of disease and bilaterality in both groups were comparable. Diameter ofendometrioma in laparotomy group was significantly larger than that in laparoscopy group (7.0 ± 2.5 vs. 6.2 ± 1.8 cm, respectively; p = 0.004). After adjusting for propensity scoring, the endometrioma recurrence rate was significantly higher in laparoscopy group as compared to laparotomy group (27.3% vs. 14.9%, respectively; p = 0.02). However, the cumulative rate of pregnancy after surgery was not statistically different (4.7% vs. 4.4%, respectively; p = 1.0). CONCLUSION: The present study has demonstrated that the surgical technique has a strong impact on the recurrence or disease-free interval. Laparoscopy might not eradicate the disease pathology as effectively as open laparotomy in some situations, such as in cases with complexity of disease.

Diurnal variation of serum chondroitin sulfate WF6 and hyaluronic acid in the healthy, traumatic knee and the osteoarthritic knee.

OBJECTIVE: An understanding of diurnal change is one of the important milestones for either biomarker validation or therapeutic level monitoring. The present study determines the most suitable period during the day for serum chondroitin sulfate WF6 (CS-WF6) and hyaluronic acid (HA) collection, and identifies the possible factors which affect the estimated putative half-life of serum CS-WF6 and hyaluronic acid (HA). MATERIAL AND METHOD: Forty-nine volunteers were enrolled in the present study, 22 healthy, 14 with anterior cruciate ligament (ACL) injury, and 13 volunteers with osteoarthritis (OA). Blood sample collection was carried out every four hours starting at 18.00 hours for 24 hours, with additional samples taken at 07:00 and 08:00 hours. Serum CS-WF6, HA levels were determined by an ELISA-based assay. RESULTS: The serum CS-WF6 level was significantly different between the normal and both pathological conditions. The serum HA level was significantly different in every condition. There was no diurnal pattern of serum CS-WF6 and HA during the 24 hour period. An estimated putative half-life of serum CS-WF6 and HA was 4.32 ± 2.63 and 4.10 ± 2.34, respectively. The maximum CS-WF6, creatinine clearance (CrCl) level and body mass index (BMI) were not related to the changes of the WF6 half-life. The higher maximum HA and CrCl level related to the longer half-life of serum HA level, p = 0.008 and p = 0.001, respectively. CONCLUSION: There was no diurnal pattern of serum CS-WF6 and HA due to the present study approach. Two hours after awakening in official time would be the suitable for serum CS-WF6. Two hours after awakening and after meals were suitable times for serum HA collection.

Prognostic factors for small cell neuroendocrine carcinoma of the uterine cervix: an institutional experience.

OBJECTIVE: This study aimed to determine the clinicopathologic characteristics that affected the survival in patients with small cell neuroendocrine carcinoma of the uterine cervix (SNEC). MATERIALS AND METHODS: All patients with SNEC treated at Chiang Mai University Hospital between January 1995 and October 2011 were retrospectively reviewed with histologic confirmation of SNEC diagnosis. The prognostic predictors for survival were assessed using competing risk regression analysis concerning the probabilities of competing events. RESULTS: One hundred thirty histologically confirmed patients with SNEC met the study criteria. The median overall survival and median cancer-specific survival (CSS) for entire group were 47.8 and 58.1 months, respectively. Five-year CSS for patients with early-stage disease was 62.6% and for patients with advanced-stage disease was 18.1% (P < 0.001). Among the patients with surgically treated early-stage disease, those with adjuvant chemotherapy had a better 5-year survival rate than those with surgery alone, those with adjuvant radiotherapy, and those with adjuvant chemoradiation therapy (P = 0.041). In multivariable analyses, decreased survival in patients with early-stage disease was associated with age older than 60 years at diagnosis (hazards ratio [HR], 4.9; P = 0.007) and deep stromal invasion (HR, 2.9; P = 0.011). Among the patients with advanced-stage disease, decreased survival was associated with age at diagnosis (older than 60 years: HR, 9.9; P < 0.001 and younger than 45 years: HR, 3.4; P = 0.035) and International Federation of Gynecology and Obstetrics stage IV (HR, 7.4; P = 0.024). CONCLUSIONS: International Federation of Gynecology and Obstetrics stage, age at diagnosis, and deep stromal invasion were important prognostic factors for CSS in patients with SNEC. Adjuvant chemotherapy may provide survival benefits in surgically treated patients with early-stage SNEC.

Incidence of and risk factors for cardiovascular complications after thoracic surgery for noncancerous lesions.

OBJECTIVE: The purpose of this study was to determine the incidence of and risk factors for cardiovascular complications after thoracic surgery for noncancerous lesions. DESIGN: Retrospective cohort study. SETTING: A tertiary medical center. PARTICIPANTS: All consecutive patients undergoing either thoracotomy or thoracoscopy for noncancerous lesions between 2005 and 2011 were included. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were the incidence and types of cardiovascular complications such as cardiac arrhythmias, cardiac arrest, heart failure, and myocardial ischemia during hospitalization. A total of 719 patients were recruited, 60% of whom had infections. The incidence of cardiovascular complications after thoracic surgery was 6.7% (48 of 719), of which cardiac arrhythmia was the most common (25 of 48, 52%). The multivariate risk regression analysis showed that age>55 years (risk ratio [RR]=4.0; 95% confidence interval [CI]=2.1-7.5; p<0.01), diabetes mellitus (RR=3.0; 95% CI=1.7-5.3; p<0.01), coronary artery disease (RR=4.8; 95% CI=2.3-10.2; p<0.01), duration of surgery>180 minutes (RR=2.6; 95% CI=1.3-5.1; p<0.01), intraoperative hypotension (RR=2.6; 95% CI=1.6-4.3; p<0.01), and positive fluid balance>2,000 mL (RR=2.5; 95% CI=1.4-4.5; p<0.01) were independent risk factors for cardiovascular complications. CONCLUSIONS: Knowledge of risk factors could help surgical teams to identify high risk patients and adjust modifiable risk factors including optimization of medical conditions, correction of intraoperative hypotension, and appropriate blood and fluid administration in order to reduce perioperative morbidity and mortality.

Recurrence and death from breast cancer after complete treatments: an experience from hospitals in Northern Thailand.

OBJECTIVE: To describe the pattern of disease progression and to describe locoregional recurrence, distant recurrence, and death rates in breast cancer patients after complete treatment. MATERIAL AND METHOD: Medical records of women diagnosed with breast cancer at two university affiliated tertiary care hospitals in the Northern Thailand that had complete treatments between 2006 and 2010 were traced. Extracted key information included patient clinical profiles and documented recurrence of cancer The causes of death were verified from breast cancer case registration database, death certificates through The Ministry of Internal Affairs'civil registration, by direct telephone contact, or by distributed prepaid postcards. RESULTS: Medical records of 829 women diagnosed with breast cancer without prior evidence ofdistant metastasis, and had complete recommended treatment were included. Six hundred thirty seven women had not experienced any events up to the end of the follow-up (76.8%). The first occurring events were focused and categorized into three distinct types, locoregional recurrence (n = 83, median follow-up time = 34.2 months), distant recurrence (n = 78, median follow-up time = 35.4 months), and death without any evidences of locoregional or distant recurrences (n = 12, median follow-up time = 36.7 months). Distant recurrence after locoregional recurrence was reported (n = 33). There were 109 patient who had died (breast cancer related death) up to the end of the follow-up (13.2%). The three types of consecutively occurring deaths were death after locoregional recurrence without any distant recurrences (n = 15), death after distant recurrence with locoregional recurrence (n = 21), and death after documenited distant recurrence without any locoregional recurrences (n = 61). CONCLUSION: The trend was that the rate of the first occurring locoregional recurrence was slightly higher than that of distant recurrence, The death rate in patients without any recurrences was much lower than in those experiencing prior recurrences. The rates of disease progression from local recurrence to distant recurrence and to death were approximately 5 to 7 times faster in patients who had experienced earlierprogressions.

Diagnostic Abilities of Three-dimensional Anterior Segment Optical Coherence Tomography in Detecting Angle Closure.

PRCIS: 3D-angle parameters and cutoff values for detecting angle closure were proposed. The 3D parameters demonstrated excellent diagnostic performance. Certain horizontal 2D parameters (i.e.,TISA-750, AOD-750, and AOD-500) can attain similar performance to their high-performing 3D counterparts. PURPOSE: To investigate the diagnostic performance of single horizontal 2-dimensional (2D) versus 3-dimensional (3D) angle parameters from swept-source anterior segment optical coherence tomography (CASIA2) in detecting angle closure. METHODS: The cross-sectional study included 118 phakic subjects (59 open-angle, 59 closed-angle). Angle opening distance (AOD), angle recess area (ARA), trabecular-iris space area (TISA) at 250, 500, and 750 µm from scleral spur were measured in 360° radial-scan images. The 3D information of each measurement was analyzed in two patterns: (1) average 3D parameter - the averaged value from 360-degree angle values, and (2) estimate 3D parameter - the estimation of surface area of circumferential angle inlet (using AOD) or circumferential angle volume (using ARA and TISA). The areas under receiver operating curve (AUCs) of eighteen 3D parameters were compared with 2D horizontal parameters. RESULTS: Among 3D parameters, AOD-500 estimate 3D gave the highest AUC (AUC 0.950, cut-off 6.09 mm2), followed by AOD-750 estimate 3D (AUC 0.948, cut-off 8.26 mm2). 3D parameters significantly increased the AUC of ARA-250 and TISA-250 (all P<0.02) compared to the 2D parameters. No significant improvement in AUC was demonstrated for AOD-250 and all parameters at 500 and 750 µm. No significant difference in AUC was found among the six maximum AUC parameters which were AOD-750 horizontal 2D, AOD-500 estimate 3D, TISA-750 horizontal 2D, AOD-500 horizontal 2D, AOD-750 estimate 3D and TISA-750 average 3D. CONCLUSIONS: The 3D-angle parameters had high performance in detecting angle closure. However, comparing a horizontal measurement to 3D parameters, the AUC improvement was mostly insignificant.

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.

Optimal volume for the draw-and-return methods to enhance activated partial thromboplastin time ratio accuracy in hemodialysis patients with central venous catheters.

Background: Significant errors of activated partial thromboplastin time (aPTT) ratio were frequently observed in blood sampling from central venous dialysis catheter (CVC) of hemodialysis (HD) patients. Following the draw-and-return methods, initial blood withdrawal from the catheter before sampling can reduce the error, but the optimal withdrawal volume remains undetermined. Aim: The objective of this study is to determine the optimal blood withdrawal volume for the draw-and-return methods to improve aPTT ratio accuracy in hemodialysis patients with CVC. Methods: A prospective study was conducted in patients receiving HD via CVC. Four blood samples were collected from each patient, involving a peripheral venipuncture and three draw-and-return samples (10 ml, 20 ml and 25 ml groups). The aPTT ratio of a peripheral sample was used as a reference to determine the aPTT ratio accuracy for each draw-and-return group. Subsequently, the agreement was illustrated using modified Bland-Altman plot. Results: A total of 1,000 samples were obtained from 250 patients. The patients had a mean age of 59.6 ± 15.4 years, with 17.2% using citrate as the CVC's locking agent. The adjusted accuracies of the aPTT ratio varied significantly among the three withdrawal volumes (p-value <0.001). The 25 ml group demonstrated the highest accuracy (43.2%; 95%CI, 38.0-48.4), followed by the 20 ml group (30.0%; 95%CI, 24.9-35.2), and the 10 ml group (18.0%; 95%CI, 12.8-23.2). Additionally, using citrate as a locking agent provided more than 80.0% aPTT ratio accuracy, whereas heparin demonstrated inferior accuracy even in the 25 ml withdrawal group. Conclusion: The optimal blood withdraw volume for the draw-and-return methods concluded at 20 ml for citrate locked-CVC and 25 ml for heparin which significantly improved aPTT ratio accuracies. Applying citrate as a locking agent provides clear benefits for aPTT ratio monitoring, while peripheral venipuncture is recommended in cases of heparin-locked CVC.

Multi-vessel coronary artery grafting: analyzing the minimally invasive approach and its safety.

Introduction: At our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG). Methods: From August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics. Results: After matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p < 0.001) and fewer distal anastomoses (2.7 ± 0.8 vs. 3.2 ± 0.9, p < 0.001). There were no significant differences in hospital stay, intensive care unit stay, postoperative complications, and 30-day mortality. The MICS group had less drain output (MICS 350 ml [250-500], MS 450 ml [300-550]; p = 0.013). Kaplan-Meier analysis revealed no significant differences in postoperative MACCE (major adverse cardiac or cerebrovascular events)-free and survival rates between the groups (MACCE-free rate p = 0.945, survival rate p = 0.374). Conclusion: With proper patient selection, MICS-OPCAB can provide good short to mid-term results, similar to those of conventional OPCAB.

Assessing the benefits of anaortic off-pump coronary artery bypass grafting.

Introduction: The procedure called the "aorta no-touch" (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke. Methods: From April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics. Results: In both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35-1.86, p = 0.624). Conclusion: The present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.

Safety and immunogenicity of locally produced trivalent inactivated influenza vaccine (Tri Fluvac) in healthy Thai adults aged 18-64 years in Nakhon Phanom: A Phase III double blinded, three-arm, randomized, controlled trial.

BACKGROUND: Domestic influenza vaccine production facilitates a sustainable supply for mitigating seasonal influenza and improves national health security by providing infrastructure and experience for pandemic vaccine production, if needed. METHODS: A Phase III, double blind, randomized controlled trial was conducted from Sep 2019-Oct 2020 in healthy adults 18-64 years in Nakhon Phanom, Thailand. Randomization (3:3:1) compared study vaccine (Tri Fluvac), saline placebo, and an active comparator (licensed vaccine). Primary outcomes were superior efficacy compared to placebo based on RT-PCR-confirmed influenza virus infection within 12 months and non-inferiority compared to active comparator based on immunogenicity (HAI assay) at 28 days. Safety was also assessed. RESULTS: The trial enrolled 4,284 participants (Tri Fluvac = 1,836; placebo = 1,836; active comparator = 612). There were 29 RT-PCR positive influenza infections (10 Tri Fluvac, 5.5/1,000 PY; 19 placebo, 10.4/1,000PY; 0 comparator) for an absolute protective efficacy of 46.4 (95 % CI = -22.0-76.5) compared with placebo, but the power was 43.7 %. Seroconversion difference rates between Tri Fluvac and comparator at Day 28 were 1.74 (95 % CI: -2.77, 6.25), 2.22 (-2.40, 6.84), and -0.57 (-5.41, 4.27) for A(H1N1), A(H3N2), and B strains, respectively. Adverse and severe adverse events occurred in 175 (9.5 %) Tri Fluvac, 177 (10.8 %) placebo, and 66 (10.8 %) comparator arms (p-value = 0.437, Tri Fluvac vs. comparator) CONCLUSIONS: Tri Fluvac was well tolerated, and immunogenicity was non-inferior to the active comparator, meeting U.S. Food and Drug Administration (FDA) criteria for adult vaccine licensure. Few acute respiratory infections were reported during intense COVID-19 pandemic restrictions, resulting in insufficient power to evaluate clinical efficacy.