Ambient air pollution as a time-varying covariate in the survival probability of childhood cancer patients in the upper Northern Thailand.

The objective of this study is to determine the possible association between exposure to air pollution and the risk of death from cancer during childhood in upper northern Thailand. Data were collected on children aged 0-15 years old diagnosed with cancer between January 2003 and December 2018 from the Chiang Mai Cancer Registry. Survival rates were determined by using Kaplan-Meier curves. Cox proportional hazard models were used to investigate associations of potential risk factors with the time-varying air pollution level on the risk of death. Of the 540 children with hematologic cancer, 199 died from any cause (overall mortality rate = 5.3 per 100 Person-Years of Follow-Up (PYFU); 95%CI = 4.6-6.0). Those aged less than one year old (adjusted hazard ratio [aHR] = 2.07; 95%CI = 1.25-3.45) or ten years old or more (aHR = 1.41; 95%CI = 1.04-1.91) at the time of diagnosis had a higher risk of death than those aged one to ten years old. Those diagnosed between 2003 and 2013 had an increased risk of death (aHR = 1.65; 95%CI = 1.13-2.42). Of the 499 children with solid tumors, 214 died from any cause (5.9 per 100 PYFU; 95%CI = 5.1-6.7). Only the cancer stage remained in the final model, with the metastatic cancer stage (HR = 2.26; 95%CI = 1.60-3.21) and the regional cancer stage (HR = 1.53; 95%CI = 1.07-2.19) both associated with an increased risk of death. No association was found between air pollution exposure and all-cause mortality for either type of cancer. A larger-scale analytical study might uncover such relationships.

A 9-year retrospective cohort study of the monitoring and screening of childhood developmental delay in Thailand.

BACKGROUND: Developmental delay in early childhood can have negative long-term cognitive and psychiatric sequelae, along with poor academic achievement, so early screening and surveillance are paramount. The aim of this study is to evaluate the impact of screening and surveillance on child developmental delay using the Developmental Surveillance and Promotion Manual (DSPM) and the Thai Early Developmental Assessment for Intervention (TEDA4I) for Thai children aged 0-5 years old. METHODS: Data were obtained from the routine developmental screening for specific disorders at ages 9, 18, 30, 42 and 60 months conducted using DSPM and TEDA4I from 2013 to 2021. Descriptive statistics were used to analyse the data, and the results are visualised graphically herein. RESULTS: Only 56% of the children were screened for child developmental delay using DSPM. The proportion of children screened increased from <1% in 2013 to 90% in 2021. Suspected developmental delay prevalence increased significantly from 3.91% in 2013-2015 to 10.00% in 2016-2018 and 26.48% in 2019-2021. Moreover, of the children with suspected developmental delay who received developmental stimulation within a month, only 87.9% returned for follow-up visits when they were evaluated again using TEDA4I to ascertain any abnormalities and specific areas of deficit. The overall proportion of children diagnosed with developmental delay was 1.29%. During the pandemic, the proportion of screening tests for child developmental delay at routine vaccination visits and follow-ups decreased but was still at least 80% in each region. CONCLUSIONS: Since 1%-3% of children have suspected developmental delay, early detection is key to treating it as soon as possible. We anticipate that our findings will raise awareness in parents and caregivers about childhood developmental delay and lead to the implementation of early intervention and follow-up at the rural level in Thailand.

Factors Associated with Suspected Developmental Delay in Thai Children Born with Low Birth Weight or Asphyxia.

OBJECTIVES: The aim of the study was to identify factors associated with a risk of suspected developmental delay (SDD) in high-risk children in Thailand. METHODS: We used data on children enrolled for developmental delay (DD) screening across Thailand collected by the Rajanagarindra Institute of Child Development, Department of Mental Health, Ministry of Public Health, Thailand. Children who were under 5 years of age with a birth weight of fewer than 2500 g and/or birth asphyxia in Thailand with high risk of DD were assessed using the Developmental Assessment for Intervention Manual (DAIM) between August 2013 and November 2019 (N = 14,314). RESULTS: The high-risk children who had a gestational age at birth of < 37 weeks (adjusted odds ratio = 1.54; 95% confidence interval = 1.39-1.70) and/or had a birth weight < 2500 g (1.22; 1.02-1.45), or had mothers who were not government officers (1.46; 1.11-1.93), had a low education level (1.36; 1.19-1.55), had a poor nutritional status (1.34; 1.09-1.65), and/or who were living in a high-altitude area (1.59; 1.32-1.91) were at a higher risk of SDD. CONCLUSIONS FOR PRACTICE: Children with a low birth weight and/or asphyxia during birth had a high risk of DD. SDD monitoring of children by community health workers and/or by developing outreach strategies, especially in underserved regions, should be considered. In addition, developing policies and guidelines, and intervention for high-risk children ought to be conducted to reduce the subsequent problems caused by the late detection of DD.

A comparative study of transgender women accessing HIV testing via face-to-face and telemedicine services in Chiang Mai, Thailand during the COVID-19 pandemic and their risk of being HIV-positive.

BACKGROUND: Due to the restricted availability of health services in Thailand, there are still some transgender women (TGW) who do not have access to HIV counseling and testing. Telehealth, which is accessible to individuals who are reluctant to undergo face-to-face interviewing, played an especially important role during the COVID-19 epidemic. The objectives of this study are to compare the characteristics, pattern of accessing HIV testing, and the HIV-positive rates of TGW between the face-to-face and telemedicine services. METHODS: We conducted a cross-sectional study to compare the access to HIV testing and the HIV-positive rates among TGW via face-to-face service and telemedicine services and examined the influence of potential associated factors on the risk of being HIV-positive. RESULTS: Of the 637 TGW participants, 26 (4.1%) were HIV-positive. Accessing the telemedicine service increased in the third and fourth COVID-19 waves (28.1% in the first and second vs. 71.9% in the third and fourth). There was no difference in the risk of being HIV-positive between the types of service. Having sex work experience (adjusted odds ratio (aOR) = 5.92; 95% confidence interval (CI): 1.57-22.30) and either never having been or tested more than 1 year ago were independently significantly associated with a higher risk of being HIV-positive (aOR = 4.05; 95% CI: 1.11-14.77). CONCLUSION: The telemedicine service became more popular among TGW during the COVID-19 pandemic and was not related to a higher risk of being HIV-positive. Moreover, it proved to be an effective alternative channel to access HIV testing, especially for intravenous drug users. Sex work experience and irregular HIV testing are key risk factors for HIV infection in TGW seeking either the telemedicine or face-to-face service.

Prediction of survival and analysis of prognostic factors for hepatocellular carcinoma: a 20-year of imaging diagnosis in Upper Northern Thailand.

BACKGROUND: To evaluate survival rates of hepatocellular carcinoma (HCC), the Chiang Mai Cancer Registry provided characteristics data of 6276 HCC patients diagnosed between 1998-2020 based on evolution of imaging diagnosis. Evolution can be separated into four cohorts, namely, cohort 1 (1990-2005) when we had ultrasound (US) and single-phase computed tomography (CT), cohort 2 (2006-2009) when one multi-phase CT and one magnetic resonance imaging (MRI) were added, cohort 3 (2010-2015) when MRI with LI-RADS was added, and finally, cohort 4 (2016-2020) when two upgraded MRIs with LI-RADS were added. METHODS: Cox proportional hazard models were used to determine the relation between death and risk factors including methods of imagining diagnosis, gender, age of diagnosis, tumor stages, history of smoking and alcohol-use, while Kaplan-Meier curves were used to calculate survival rates. RESULTS: The median age of diagnosis was 57.0 years (IQR: 50.0-65.0) and the median survival time was 5.8 months (IQR: 1.9-26.8) during the follow-up period. In the univariable analysis, all factors were all associated with a higher risk of death in HCC patients except age of diagnosis. In a multivariable analysis, elderly age at diagnosis, regional and metastatic stages and advanced methods of imagining diagnosis during cohorts 2 and 3 were independently associated with the risk of death in HCC patients. The survival rate of patients diagnosed during cohort 4 was significantly higher than the other cohorts. CONCLUSION: As a significantly increasing survival rate of HCC patients in cohort 4, advanced methods of diagnostic imaging can be a part of the recommendation to diagnose HCC.

Experiences of Being Bullied and the Quality of Life of Transgender Women in Chiang Mai Province, Thailand.

Purpose: The objective of this study is to identify factors associated with depression and the quality of life of Thai transgender women (TGW) from Chiang Mai province, Thailand, who have experienced being bullied. Methods: We conducted the study on TGW ≥18 years of age in Chiang Mai province, Thailand, from May to November 2020. Data were collected using self-reporting questionnaires at the MPlus Chiang Mai foundation. Binary logistic regression analysis was used to examine the association between potential factors associated with depression and quality of life. Results: Of the 205 TGW individuals who participated in this study with a median age of 24 years, most were students (43.3%), and the most common type of bullying was verbal (30.9%). The prevalence of depression among the TGW participants was 30.1%, although most of the participants had a good overall quality of life (53.4%). The impacts of being physically bullied at primary or secondary school and experiencing cyberbullying at primary school were associated with a higher risk of depression. The impacts of being cyberbullied within the previous 6 months and physically bullied at primary or secondary school were associated with a fair quality of life. Conclusion: Our results show that many TGW had experienced bullying in their childhood and within the previous 6 months. Screening for experiences of having been bullied and psychological problems might be advantageous for the wellbeing of TGW, while counseling programs or psychotherapy should be provided for those who have experienced bullying to mitigate depression and improve their quality of life.

Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study.

BACKGROUND: Although discriminatory experiences of transgender people seeking healthcare services have been well-documented in several studies, differentiating those experiences based on gender identity/expression and related factors has been limited. The aim of this study was to compare the characteristics, experiences, attitude, and expectation toward accessing healthcare service and healthcare providers of transgender women and transgender men in Thailand. METHODS: A cross-sectional study was conducted from October 2017 to March 2018. The data were collected from transgender women and transgender men aged ≥ 18 years old who lived in Thailand using online platform via different websites and Facebook pages of local transgender group. Binary logistic regression was used to identify the factors related to the study outcomes. RESULTS: Of 186 transgender people who responded to the questionnaire and were eligible for the study, 73.7% (95% confidence interval [CI] = 66.7-79.8) were transgender women and 26.3% (95% CI = 20.2-33.3) were transgender men. Transgender women were more likely to seek general healthcare from non-traditional healthcare services (crude odds ratio [cOR] = 4.28; 95% CI = 1.55-11.81; P = 0.005), buy hormone treatment from non-traditional healthcare services (cOR = 3.89; 95% CI = 1.18-12.83; P = 0.026), and receive healthcare counseling from non-traditional healthcare providers (cOR = 5.16; 95% CI = 1.42-18.75; P = 0.013) than transgender men. According to the results of applying a multivariable model, transgender respondents who did not know that gender-affirming healthcare services existed in Thailand were more unwilling to receive counseling from gender-affirming healthcare providers than those who did (adjusted odds ratio = 3.70; 95% CI = 1.11-12.36; P = 0.033). CONCLUSIONS: The findings from this cross-sectional study indicate that transgender women are more likely than transgender men to receive general healthcare and hormone treatment from non-traditional healthcare services and buy hormone treatment without a physician's supervision. We also found approximately 15% of transgender individuals who did not receive gender-affirming counseling services. Continuing to improve access to care for the transgender community, increasing public relations channels may encourage transgender people to access more healthcare services.

Risk Factors Associated with Loss to Follow-up Among Transgender Women Receiving HIV Pre-exposure Prophylaxis in Chiang Mai province, Thailand.

Although HIV pre-exposure prophylaxis (PrEP) is free in Thailand, many transgender women discontinue taking it after initiation. We determined the loss to follow-up (LTFU) rate of transgender women who initiated PrEP at the Mplus Foundation, Chiang Mai, Thailand, and identified associated risk factors using Cox proportional hazard models. Of 235 participants who initiated PrEP, 59 (55%) out of 108 remaining participants had reactive syphilis. The LTFU rate at 6 months was 38% (95% confidence interval [CI]: 29-48%). Multivariable analysis indicates that LTFU is independently associated with age ≥ 26 years old (adjusted hazard ratio [aHR] = 2.09; 95% CI: 1.06-4.14) and reactive syphilis (aHR = 1.98; 95% CI:1.01-3.88). Delayed appointment scheduling by the PrEP providers and the syphilis clinic was associated with transgender women having reactive syphilis, and the lockdown policy during the COVID-19 pandemic might have influenced them to discontinue PrEP and their subsequent LTFU.

Discrimination against and Associated Stigma Experienced by Transgender Women with Intersectional Identities in Thailand.

Although Thailand is overtly open to diversity and promotes equality, discrimination of minorities based on gender, ethnicity, and/or certain occupations is unfortunately still prevalent. Society either obstructs their inclusion or accepts them but only under certain conditions. The objective of this study is to examine the discrimination of TGWs with intersectional identities within Thai society. A total of 19 TGW participants were recruited and underwent in-depth thematic interviews about their experiences of discrimination. Rechecking of the extracted information from the interview transcripts and the subsequent encoding process were conducted using the NVivo program. The results show that the median age was 30 years old, and the majority of the individuals with intersectional identities were ethnic minority TGWs (47%). The in-depth interviews were divided into four main themes, including discrimination at an educational institution, discrimination in the workplace, discrimination in daily life, and discrimination at a healthcare facility. Our findings reflect problems associated with multiple sources of discrimination aimed at transgender women with an intersectional identity in Thailand in every aspect, including harsh speech or physical abuse; occupational, social, and legal inequality; and healthcare provision disparity. Raising awareness about gender diversity and intersectionality, as well as enforcing anti-bullying legislation and anti-discrimination laws, should be continually pursued in order to protect the rights and improve the quality of life of transgender individuals with an intersectional identity.

The Optimal Cut-Off Point for Thai Diagnostic Autism Scale and Probability Prediction of Autism Spectrum Disorder Diagnosis in Suspected Children.

The Thai Diagnostic Autism Scale (TDAS) was developed to diagnose autism spectrum disorder (ASD) under the context and characteristics of the Thai population. Although the tool has an excellent agreement, the interpretation of diagnostic results needs to rely on the optimal cut-off point to maximize efficiency and clarity. This study aims to find an optimal cut-off point for TDAS in the diagnosis of ASD and to compare its agreement with the DSM-5 ASD criteria. This study was conducted on 156 children aged 12-48 months old who were suspected of having ASD and had enrolled from hospitals in the four regions of Thailand in 2017-2018. The optimal cut-off point for TDAS was considered by using receiver operating characteristic (ROC) curves according to the DSM-5 ASD criteria. The areas under the curve (AUCs) for TDAS and ADOS-2 were also compared. Multivariable logistic regression was performed to create a predictive model for the probability of ASD. The AUC of TDAS was significantly higher than that of ADOS-2 (0.8748 vs. 0.7993; p = 0.033). The optimal cut-off point for TDAS was ≥20 points (accuracy = 82.05%, sensitivity = 82.86%, and specificity = 80.93%). Our findings show that TDAS with a cut-off point can yield higher diagnostic accuracy than ADOS-2 and TDAS domain. Diagnosis by using this cut-off point could be useful in practical assessments.

Detection of Electroencephalographic Abnormalities and Its Associated Factors among Children with Autism Spectrum Disorder in Thailand.

Epilepsy often causes more severe behavioral problems in children with autism spectrum disorder (ASD) and is strongly associated with poor cognitive functioning. Interestingly, individuals with ASD without a history of epilepsy can have abnormal electroencephalographic (EEG) activity. The aim of this study was to examine associations between EEG abnormalities and the ASD severity in children. The children with ASD who enrolled at the Rajanagarindra Institute of Child Development, Thailand were included in this study. The severity of ASD was measured by interviewing their parents with the Thai autism treatment evaluation checklist. The short sensory profile checklist was used for screening the abnormality of children in each domain. Ordinal logistic regression analysis was used to examine associations between factors potentially linked to EEG abnormalities. Most of the study participants were boys (87.5%) and the median age was 5 years. Among the 128 children, 69.5% showed EEG abnormalities (41.4% slow-wave and 28.1% epileptiform-discharge). The results show that a larger number of symptoms and increased severity of ASD were independently associated with a higher risk of EEG abnormalities. Our results emphasize the need for guidelines on the presence of EEG abnormalities in children with ASD for the early detection of epilepsy and improving treatment outcomes.

Automatic Driver Drowsiness Detection Using Artificial Neural Network Based on Visual Facial Descriptors: Pilot Study.

Purpose: Driving while drowsy is a major cause of traffic accidents globally. Recent technologies for detection and alarm within automobiles for this condition are limited by their reliability, practicality, cost, and lack of clinical validation. In this study, we developed an early drowsiness detection algorithm and device based on the "gold standard brain biophysiological signal" and facial expression digital data. Methods: The data were obtained from 10 participants. Artificial neural networks (ANN) were adopted as the model. Composite features of facial descriptors (ie, eye aspect ratio (EAR), mouth aspect ratio (MAR), face length (FL), and face width balance (FWB)) extracted from two-second video frames were investigated. Results: The ANN combined with the EAR and MAR features had the most sensitivity (70.12%) while the ANN combined with the EAR, MAR, and FL features had the most accuracy and specificity (60.76% and 58.71%, respectively). In addition, by applying the discrete Fourier transform (DFT) to the composite features, the ANN combined with the EAR and MAR features again had the highest sensitivity (72.25%), while the ANN combined with the EAR, MAR, and FL features had the highest accuracy and specificity (60.40% and 54.10%, respectively). Conclusion: The ANN with DFT combined with the EAR, MAR, and FL offered the best performance. Our direct driver sleepiness detection system developed from the integration of biophysiological information and internal validation provides a valuable algorithm, specifically toward alertness level.

Impact of Residential Concentration of PM2.5 Analyzed as Time-Varying Covariate on the Survival Rate of Lung Cancer Patients: A 15-Year Hospital-Based Study in Upper Northern Thailand.

Air pollutants, especially particulate matter (PM) ≤ 2.5 µm (PM2.5) and PM ≤ 10 µm (PM10), are a major concern in upper northern Thailand. Data from a retrospective cohort comprising 9820 lung cancer patients diagnosed from 2003 to 2018 were obtained from the Chiang Mai Cancer Registry, and used to evaluate mortality and survival rates. Cox proportional hazard models were used to identify the association between the risk of death and risk factors including gender, age, cancer stage, smoking history, alcohol-use history, calendar year of enrollment, and time-updated PM2.5, PM10, NO2 and O3 concentrations. The mortality rate was 68.2 per 100 persons per year of follow-up. In a multivariate analysis, gender, age, cancer stage, calendar year of enrollment, and time-varying residential concentration of PM2.5 were independently associated with the risk of death. The lower the annually averaged PM2.5 and PM10 concentrations, the higher the survival probability of the patient. As PM2.5 and PM10 were factors associated with a higher risk of death, lung cancer patients who are inhabitant in the area should reduce their exposure to high concentrations of PM2.5 and PM10 to increase survival rates.

Awareness, perception and perpetration of cyberbullying by high school students and undergraduates in Thailand.

The modern online society requires everyone, especially children and young people, to learn how to use the Internet. Cyberbullying is one misuse that can be detrimental to the cyberbullied individuals' mental health and lifestyle, and it often ends up with the victim becoming depressed, fearful of society, and in the worst cases, suicidal ideation. The aim of this study is to investigate the awareness, perception, and perpetration of cyberbullying by high school students and undergraduates to find ways to prevent cyberbullying in the future. For this cross-sectional study, data were collected in 2020 from 14 schools throughout Thailand and 4 universities in Chiang Mai, Thailand, using two-stage sampling. Chi-squared tests were used to compare differences between the groups. Of the 2,683 high school students, girls perceived cyberbullying more than boys (81.6% vs. 75.4%; p <0.001), with those from the later academic years being more aware of cyberbullying (p = 0.033) and more likely to conduct cyberbullying behavior (p = 0.027). Of the 721 undergraduates, women were more aware of cyberbullying than men (92.1% vs. 82.7%; p <0.001). The most common cause of cyberbullying was aiming to tease the target (67.6% of high school students vs. 82.5% of undergraduates). The most commonly cyberbullying victimization was sending mocking or rebuking messages (29.6% of high school students and 39.6% of undergraduates). The most popular solutions for cyberbullying were to avoid leaving a trace on social media and be with friends who accept who you are. Our findings show that most of the cyberbullying perpetrators did not consider that their actions would have serious consequences and only carried out cyberbullying because of wanting to tease their victims. This is useful information for the cyberbullying solution center, teachers, and parents to recognize how to make the students realize the effects of cyberbullying on the victims.

Development and psychometric evaluation of a Thai Diagnostic Autism Scale for the early diagnosis of Autism Spectrum Disorder.

The Thai Diagnostic Autism Scale (TDAS) was developed for use as a diagnostic tool for the early diagnosis of Autism Spectrum Disorder (ASD) in Thai children aged 12-48 months old. TDAS consists of 23 items (13 and 17 items in the observational and interview sections, respectively) classified into seven domains (A1-A3 and B1-B4) according to the criteria in the Diagnostic and Statistical Manual of Mental Disorder, fifth edition (DSM-5). Children with a single score in the A1-A3 domains and at least two of the B1-B4 domains were classified with ASD. The item-objective congruence (IOC) index, confirmatory factor analysis, and Kappa coefficient were used to evaluate the content, constructs, and inter-rater validity levels between the evaluators and concurrent validity between TDAS and physicians' diagnoses, respectively. TDAS showed good overall content validity (IOC range 0.71-1.00), suitable construct validity (root-mean-squared errors of approximation of 0.076 and 0.067, comparative fit indexes of 0.902 and 0.858, and Tucker-Lewis indexes of 0.882 and 0.837 for the observation and interview sections, respectively), and excellent diagnostic agreement between TDAS and the evaluators (Kappa = 1.000) as well as between TDAS and the physicians' diagnoses (Kappa = 0.871). The sensitivity and specificity of TDAS were 100% and 82.4%, respectively. In conclusion, TDAS yielded a high level of content validity, concurrent validity, and inter-rater reliability for the early diagnosis of ASD in Thai children. A large-scale study using TDAS is needed to determine an appropriate cut-off point as well as its efficacy. LAY SUMMARY: The Thai Diagnostic Autism Scale was developed for use as a diagnostic tool for the early diagnosis of Autism Spectrum Disorder (ASD) among Thai children. It contains 23 items in seven domains for the screening via observations and interviews. The psychometric properties of this diagnostic tool provide its reliability and suitability for the early diagnosis of ASD. A large-scale study using it is needed to determine an appropriate cut-off point as well as its efficacy.