Ward characteristics associated with delayed defibrillator and doctor presence in cardiopulmonary resuscitation simulated survey.

Objective: To survey the times to critical actions (defibrillator and doctor presence, initiation of chest compression) of in-hospital simulated cardiopulmonary resuscitation (CPR). Methods: A 1-year retrospective simulated audit 2009 in a 2,400-bed university hospital in Thailand. Results: A total of 57 adult wards (around a third of all wards in the hospital), including intensive care units, critical wards, procedural units, general wards and out-patient units were audited. Overall, the median time of initiation of chest compression and defibrillator presence among CPR teams were 1.27 (0.35-7.19) and 1.16 (0.00-26.00) minutes, respectively. The median time of the first doctor presence was 3.45 (0.00-15.15) minutes. However, there were significant differences in time to defibrillator and doctor presence among wards. The longer time of these critical managements were recorded in non-monitored areas (general wards and out-patient units) (p = 0.004 and 0.007, respectively). Conclusion: In our CPR simulated survey, delayed initiation of critical managements commonly occurred in non-monitored areas. Better management should be concerned for favorable outcomes.

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 children has not been reported. Objective: To determine the effect of montelukast (Singulairâ) 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 was significantly higher in montelukast group compared to those of placebo group (p<0.05). After 6 weeks of treatment, mean (+ SEM) PC was 20 in the placebo group (5.7 + 1.41 mg/ml) which was lower than in montelukast group (6.8 + 1.74 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.

Accuracy of cranial and mandible morphological traits for sex determination in Thais.

Objective: To evaluate the accuracy of sexual dimorphism in the cranium and mandible of Thais using Krogman’s cranioscopy and the modified Krogman’s cranioscopy traits by grading and measurement. Methods: Data were from 101 dry adult skulls (66 males and 35 females) residing in central Thailand. Results: Sex determination using Krogman’s cranioscopy by an inexperienced person had a very high accuracy of 95.5% for males, 82.9% for females respectively and 91.1% overall. According to modified Krogman’s cranioscopy traits by grading, males had larger supraorbital tours, a rougher glabella region and more external occipital protuberance than females. Regarding modified Krogman’s cranioscopy trait by measurement, males had a wider base and a higher mastoid process, with longer and wider occipital condyles than females. Both later methods were also useful in the sexing of fragmented skulls. Conclusion: The cranioscopy study based on 14 traits according to Krogman’s cranioscopy is the best method for sex determination of individual unknown skulls. The modified Krogman’s cranioscopy trait by grading and by measurement is simplified and can very well predict the sexing of fragmented skulls.

Clinical and echocardiographic parameters and score for the left atrial thrombus formation prediction in the patients with mitral stenosis.

BACKGROUND: Rheumatic mitral stenosis is one of the important health problems, especially in Thailand. Thromboembolic complications from this disease remain the major problem in these patients. These complications are usually related to the left atrial thrombus formation. OBJECTIVE: To determine the parameters that can predict the presence of left atrial thrombus in these patients. MATERIAL AND METHOD: Two hundred and sixty Thai patients with mitral stenosis from Siriraj Hospital were prospectively recruited in the study. The baseline clinical characteristics of these patients which were related to thrombus formation were properly collected. All patients underwent the transthoracic and transesophageal echocardiography with the standard technique to detect the mitral valve area, mitral valve score, left atrial size, LV ejection fraction, right ventricular systolic pressure, spontaneous echo contrast (SEC) and associated valvular lesions. Transesophageal echocardiography was used as the gold standard for evaluation of left atrial thrombus. These parameters were analyzed to demonstrate association with the presence of left atrial thrombus by univariate and multiple logistic regression analysis. Equation with score for prediction of left atrial thrombus was also purposed. RESULTS: There were 77 men and 183 women in the present study. Left atrial thrombus was detected in 26% and previous thromboembolic complications occurred in 16.5%. Atrial fibrillation presented in 52.5%. From univariate analysis, atrial fibrillation (81.2% vs. 42.9%, p < 0.001), male sex (37.7% vs 25.6%, p < 0.050), left atrial enlargement by electrocardiogram (45.5% vs 15.4%, p < 0.001), left atrial diameter (7.26 vs 6.97 cm, p < 0.030), left atrial volume (132. 7 vs. 113.5 cm2, p < 0.001), EFby Teich method (58.9 vs 62.5%, p < 0.011), EF by MOD-bp (60.7 vs. 64.6%, p < 0.005), tricuspid regurgitation (46.4% vs. 28.8%, p < 0.008), mitral regurgitation (10.1 vs. 3.1%, p < 0.022), and RVSP (57.0 vs. 49.7 mmHg, p < 0.005) can predict the presence of left atrial thrombus formation with statistical significance. Using multiple logistic regression model, only atrial fibrillation (OR 5.95, 95% CI 1.21-29.3, p < 0.02) and RVSP (OR 1.02, 95%CI 1.01-1.04, p < 0.04) were independent predictors. The authors proposed score for predicting probability of left atrial thrombus formation that equal to -3.61 + 1.79 AF + 0.03 RVSP with AUC of 0.764. The best cut-off point for this score was -1.49, which gave a sensitivity of 91%, specificity of 56%, PPV of 48%, and NPV of 90%. CONCLUSION: Prevalence of thromboembolic complications and thrombus formation is high in patients with mitral stenosis in Thailand. From the present study, the predictors for left atrial thrombus formation in the patients with mitral stenosis were atrial fibrillation and RVSP The model for predicting left trial thrombus formation was also proposed with high sensitivity and NPV.

Evaluation of a practical method to assess antiretroviral adherence in HIV-infected Thai children.

The objective of this study was to evaluate a practical method to assess adherence to antiretroviral therapy by observing virological and immunological responses. We conducted a 12-month longitudinal cohort study of 162 HIV-infected Thai children. Adherence was assessed using 5 methods (self reporting calendar, records of missed doses, pill counts, physician assessment, and an interview questionnaire). CD4 count, percentage and viral load were performed at baseline and at 12 months. Mean adherence rates at 2, 6, and 12 months were 98, 100, and 99% by the calendar method; 98, 100, and 100% by recording missed doses; 96, 96, and 92% by pill count; and 90, 94, and 97% by physician assessment. Poor agreement (kappa < or = 0.1) was found among the methods. There was a statistically significant difference (p = 0.05) in virological response between participants with > or = 95% adherence (0.8 log10) and those with < 95% adherence (0.2 log10) when pill counts were used to assess adherence. In conclusion, despite poor agreement among these tools, a pill count appeared to be the only practical, validated method to differentiate the virological outcome between those who were fully and partially adhere to the treatment regimen.

Sex determination in Thai skulls by using craniometry: Multiple logistic regression analysis.

Objective: To evaluate sexual dimorphism in the cranium and mandible of Thais by using Jorgensenûs craniometry and to develop a statistical model to determine sex from craniometrical measurements and indices. Methods: One hundred and one Thai skulls (66 males and 35 females) which ranged in age from 18 to 86 years were studied. Results: According to craniometry, the skull of a male is larger and higher than that of a female. Considering each individual measurement, although 26 of 30 measurements and 5 of 14 indices showed a statistically significant difference between males and females, they had some overlaps. To predict gender more accurately, a multiple logistic regression model based on 4 skull measurements (mm) i.e., nasion-basion length (M5), maximum breadth of the cranium (M8), facial length (M40), and bizygomatic breadth of the face (M45) was developed as follows: In (odds) = Z = -52.5312 + 0.27 M5 - 0.1867 M8 + 0.1268 M40 + 0.319 M45 The probability of being males (P) is then ez/(1+ez). Using a cut off point for P of 0.5, this logistic model could correctly predict 82.9% (95% CI: 66.4%, 93.4%) of females and 92.1% (95% CI: 82.4%, 97.4%) of males respectively with the overall accuracy of 88.8% (95% CI: 80.8%, 94.3%). Conclusion: Jorgensenûs craniometry of the cranium and mandible can be used to determine gender among Thais via a multiple logistic regression model on M5, M8, M40 and M45.

Leptin level in Thai children and adolescents: Relation to BMI and sexes.

Objective: The prevalence of obesity is rapidly increasing worldwide, including Thai children. Serum leptin is demonstrated largely that it increased in the dynamic phase in childhood –onset obesity. To our knowledge, there was no data of leptin measurement in this age group of our population. Methods: Therefore, we measured serum leptin by an immunoradiometric assay in sample from 208 obese and non-obese healthy children aged 2-18 years old. Its relationship to body mass index (BMI), ages and sexes were analyzed. Results: The mean serum leptin concentration in obese children was 35.06 + 17.31 ng/ml compared with 14.70 + 8.93 ng/ml in the non - obese children (p < 0.001). The obese female had significant higher level than in obese male group (43.26 + 16.82 vs. 30.34 + 15.85 ng/ml; p < 0.001), but they were not different in the non - obese group. The results showed that serum leptin correlated with BMI (r = 0.71; p < 0.001) and with % weight for height (%wt for ht) (r = 0.60, p < 0.001), respectively. Leptin levels in both sexes compared to age were also demonstrated. We did not find leptin deficiency or leptin resistance in all obese cases. Conclusion: In summary, leptin level in Thai children were increased according to BMI, % wt for ht and sexes as demonstrated in other ethnic groups. However, there is neither leptin deficiency nor leptin resistance demonstrated in this study.

Thailand diabetes registry project: current status of dyslipidemia in Thai diabetic patients.

OBJECTIVE: To determine the prevalence of dyslipidemia in adult Thai type 2 diabetes who attended diabetes clinics in university and tertiary-care hospitals. MATERIAL AND METHOD: A cross-sectional, multi-center, hospital-based diabetes registry was conducted in 11 diabetic clinics in tertiary medical centers in Bangkok and major provinces between April and December 2003. A group of 9419 diabetic patients were registered. Individual Demographic data including education and socioeconomic status were collected. The results of the physical examination for complications, history screening and laboratory results were recorded. The prevalence of the various complications of diabetes was analyzed and the percentage achievement of metabolic control calculated. RESULTS: Of the 9419 diabetic patients registered 8769 had complete demographic and plasma lipid data. Mean age was 59.5 +/- 13.3 years. The percentage of male patients was 33.9%. In the present study, there were 8464 type 2 diabetes and 383 type I diabetes. History of coronary artery disease and cerebrovascular disease were present in 8.1 and 4.2 percent ofthepatients, respectively. More than 80% of the patients had dyslipidemia. The patients with CVD had higher proportion of achieving the LDL target (< 100 mg/dl, 43 vs. 34%). More than half of the patients (55%) were taking lipid lowering medications, but one-third (30%) did not despite havingfulfilled indications. The patients covered by government supported health plan were less likely to received lipid-lowering medication than the patients covered by private health plans (OR 0.65, 95% CI 0.57-0.75). The two most commonly used lipid-lowering agents were HMG CoA reductase inhibitors (76%) and fibrates (19%), both agents were used in combination in 5% ofthe patients. Only 40.1% ofthe patients on lipid-lowering medications reached the target LDL goal (<100 mg/dl). CONCLUSION: Elevated LDL cholesterol was the most common lipid abnormality in the present study. Although 55% of the patients were taking lipid lowering agents, another 42% of the patients needed the medication. More than half of the patients treated needed more intensive lipid lowering in order to achieve the LDL goal. If the authors wish to follow the current (2005) American Diabetes Association recommendations, we would have to treat up to 97% of diabetic patients with lipid lowering

Thailand diabetes registry project: prevalence and risk factors of stroke in thai diabetic patients.

OBJECTIVE: To determine the prevalence of stroke and its risk factors in Thai diabetic patients who attended the diabetes clinics of university and tertiary-care hospitals. MATERIAL AND METHOD: A cross-sectional, multi-center hospital-based diabetes registry was carried out at diabetes clinics of 11 university and tertiary-care hospitals. Demographic data, clinical characteristics, common drugs used and laboratory parameters were analyzed for prevalence and risk factors associated with stroke. RESULTS: The prevalence of stroke in the patients studied was 3.5%. Most of the patients were type 2 diabetes and had ischemic stroke. One of the risk factors associated with stroke was age greater than 60 years, and the risk appeared to be highest if the patients' age was greater than 70 years (adjust OR = 3.29, p = 0.012). Other risk factors included male sex, systolic blood pressure of > or =140 mmHg, use of oral hypoglycemic agents, lipid lowering agents and aspirin. There was no association between stroke and duration of diabetes, occupation, educational level, BMI, smoking, alcohol drinking, diastolic blood pressure, use of antihypertensive drugs or insulin, glycemic control, lipid profiles and kidney function. CONCLUSION: Ischemic stroke was common among Thai patients with diabetes especially in the elderly. The present result emphasizes the relationship between level of systolic blood pressure and the occurrence of stroke. Optimal blood pressure control should be underscored in caring for diabetic patients.

Thailand diabetes registry project: glycemic control in Thai type 2 diabetes and its relation to hypoglycemic agent usage.

OBJECTIVE: To determine the pattern of hyperglycemic agent usage in Thai type 2 diabetics (T2 DM) who attended the diabetes clinic in university and tertiary-care hospitals. The achievement oftarget glycemic control by various modalities of treatment was also analyzed. MATERIAL AND METHOD: A cross-sectional, hospital-based diabetes registry of 8913 type 2 diabetic patients in 11 tertiary care hospitals and medical schools was carried out from April to December 2003. Demographic data, usage of hypoglycemic agents and level of glycemic control were collected to determine the pattern ofuse, associated factors, and achievement of glycemic control. RESULTS: Overall, 2342 (26.3%) of T2 DM achieved HbA1C less than 7%. The percentage of patients treated with metformin was 70.8%, sulfonylureas (SU) was 68.7% and insulin was 25.3%. Only 7.0% of patients received alpha-Glucosidase Inhibitor (AGI), 5.7% received ThaiZoliDinediones (TZD), 1.1% received repaglinide, and 3.2% was on diet control alone. Target glycemic control was achieved in 57.6%, 37.1%, 52%, 16.7%, 62.5%, 52% and 16.9% of patients who were on diet control only, monotherapy with SQU, metformin, TZD, AGI, repaglinide and insulin,respectively. Sulfonylureas were the most commonly used drug for monotherapy. Metformin with sulfonylurea was the most common combination therapy and was used in 39.5% of patients. More than 60% of the patients treated with metformin monotherapy had body mass index (BMI) of more than 25 kg/m2, as compare to less than half of patient treated with other monotherapy agent. Mean +/- SD duration of diabetes in thepatients treated with metformin alone was 5.9 +/- 5.5 years, less than that in the SU-treated patients (8.3 +/- 7.1 years) and also in the insulin-treated patients (14.8 +/- 9.0 years). TDZ were commonly prescribed in combination with sulfonylureas and metformin in subjects with relatively longer duration of diabetes. CONCLUSION: Better treatment strategies for glucose control ofdiabetic patients on medical treatments should be encouraged to improve glycemic control and reduce long term complications.

Satisfaction of nurses and packing personnel with feeding bag compared to normal saline bottle among enteral feeding patients.

Objective: To assess the satisfaction of nurses and packing personnel with the use of a feeding bag compared to a normal saline bottle for patients needing enteral feeding. Methods: Ninety-three nurses in eleven wards who had been using both feeding bags and normal saline bottles and eight packing personnel who had been preparing food in these two containers were recruited. They were asked to give a satisfaction score (0-100) for both the feeding bag and the normal saline bottle. Results: Nurses were happier with the use of feeding bags than with normal saline bottles in 10 out of 11 aspects (p-value < 0.001): type of container, appropriateness of the container, preparation steps, duration of preparation, correct amount of food, convenience in feeding, flow of food, duration of feeding, food storage and patient’s complications. The only unsatisfactory aspect was reheating due to the loss of the patient’s name tag after soaking the feeding bag in warm water. Conversely, the packing personnel were more satisfied with the use of the traditional normal saline bottle in most aspects, except for the correct amount of food and food transportation. In terms of cost for each patient per day, using the normal saline bottle was a little more expensive than using the feeding bag (44.33 vs. 41.67 baht). Conclusion: For patients needing enteral feeding, the feeding bag should be considered for use, instead of the conventional normal saline bottle. However, more preparation skills and space are needed.

How the dose of iodine-131 should be determined in the treatment of graves’ and toxic nodular hyperthyroidism.

Despite the wide use of radioiodine treatment for hyperthyroidism, the best approach to radioiodine dose selection in the treatment remains controversial. The objective of our study was to evaluated factor affected treatment of hyperthyroidism with radioactive I-131, the result of radioactive iodine treatment in our department and the average number of radioiodine treatment. Material and Method: A database of 387 patients were retrospectively reviewed. The therapeutic activity administered was calculated by the equation Administered I-131 dose= 100 ตCi X Thyroid gland weight X 100 -------------------------------------------------------------------------------- % 24hr. I-131 uptake The thyroid gland weight was estimated by palpation. Results: The failure rates of I131 treatments of Graves’ disease in our study for first dose, second dose and third dose are 43.51%, 33.98% and 12%, respectively. The failure rates of I131 treatments of toxic nodular goiter in our study for first dose, second dose and third dose are 39.22%, 58.82% and 33.33%, respectively. The average number of treatments of Graves’ disease and Toxic nodular goiter were 1.45 and 1.58, respectively. There was not a significant between Graves’ disease and Toxic nodular goiter in the averge number treatments. The %24hr. I-131 uptake and gland weight were higher in the group of Graves’ disease patients who had hyperthyroidism in comparison with Graves’ disease patients who developed euthyroidism and hypothyroidism. The gland weight was higher in the group of toxic nodular patients who had hyperthyroidism in comparison with toxic nodular patients who developed euthyroidism. Discussion: The factors affecting the treatment of hyperthyroidism by the equation in this study are Thyroid gland weight and %24 hr. I-131 uptake. Large thyroid gland mass had a lower success rate from radioiodine treatment than small thyroid gland mass. The mean I-131 24 hours uptake of the patients with persistant hyperthyroid for Graves’ disease and Toxic nodular goiter is significantly higher than the mean percent uptake of I131 of the patients who developed euthyroid and hypothyroid. The description this finding may be from the administration I-131 dose is inversely proportional to the measured 24 hours radioiodine uptake.

A comparative study of the major allergenic components in house dust extracts between siriraj and commercially prepared extracts.

The quantity and concentration of major allergens in mite allergenic extracts are crucial for skin testing, which is the recommended standard method for the diagnosis of house dust mite allergic disease. The purposes of this study were 1) To compare the constituents of major mite allergens in 3 types of mite extracts, i.e., extracts from mite reared in-house (Dermatophagoides pteronyssinus and Dermatophagoides farinae), extracts from commercial mite products and commercial ready-made mite extracts. These in-house extracts were prepared either with or without the preservative, glycerine. The concentrations of the major constituents of group 1 and 2 allergens of the extracts were determined by a two-site monoclonal based ELISA. 2 ) Biological assays were also carried out to determine the relative potency of the extracts in 120 allergic patients by skin prick test. It was found that the mean concentrations of Der p1, Der f1 and group 2 mite allergens in extracts from mites reared in-house were 102, 195 and 94 ตg/ml, respectively, compared to 169, 238 and 91 ตg/ml, respectively in commercial mite extracts. The commercial with product had the lowest concentrations of mite allergens (1 ตg/ml). Comparison of mite extracts with and without glycerine preservative showed no significant difference in concentrations of major allergens. Reduction of allergens concentration from 10,000 to 1,000 PNU/ml also reduced the concentration of mite allergen proportionately. Siriraj mite extracts were stable for at least 1 year at 4 oC without any significant change in composition or concentration. In conclusion, mite reared in-house can be used as raw material for preparation of mite allergenic vaccine.

Rapid detection of iodine in iodised salt and iodised water essential in a program of iodine deficiency disorders control.

To determine and develop rapid on-site testing of iodine in salt and water samples and its use as field methods for monitoring and evaluation of the Iodine Deficiency Disorders (IDD) program. Methods: In order to monitor iodine in salt, the single bottle technique is recommended, utilizing SHMP (May & Baker), tapioca flour, KI and sodium azide. Secondly, to monitor iodine in water, the double bottle technique is employed and this utilizes 3N HCl as a substitute for SHMP to acidify flour, KI and sodium azide. Results: In salt, it is not positive until the colour starts to change from brown to black. In water, when it is positive reaching beyond an optimum level at 100-200 mg of iodine per litre, the colour starts to appear as faint blue and becomes darker blue as concentration of iodine increased. Discussion: Statistically, Spearman rank correlation co-efficient and the prediction method showed approximation of the two methods in estimation of iodine levels, indicating the interchangeability of the eyesight and it can be used in screening in place of the spectrophotometer. Conclusion: These techniques are cheap, simple and effective. This allows the monitoring kit to be beneficial and easy to use. These methods are ordinary and natural, and thus, in harmory with Thai culture and customs.