Volume 8 (2014): Issue 6 (December 2014)

Background: Compensatory articulation disorders (CAD) are the most common speech defects in patients with a cleft. Early prevention programs are needed to avoid CAD.

Objectives: To examine articulation disorders, patterns, and related speech outcomes in children with a cleft palate with or without lip defects.

Methods: Articulation test record forms and clinical records of 42 children were accessed retrospectively to provide the data of speech outcomes related to cleft palate. Double data entries and incorrect completion type errors were corrected.

Results: Prevalence of articulatory defects was 88% (functional articulation disorders, 12%; compensatory articulation disorders, 10%; functional articulation disorders and CAD, 67%), resonance disorder was 50%, and voice abnormalities was 19%. Abnormal backing of oral consonants, particularly glottal substitution was the most common pattern of CAD (40%), follow by velar substitution (36%), and nasal consonant for oral pressure consonant (21%). There was high incidence of functional articulation disorder in patients with a cleft (76%). Younger children (≤7 years old) had more articulation defects than older children (>7 years old) (mean difference = 3.308, P = 0.002, 95% confident interval 1.683-6.971). Levene’s test for equal variance found that resonance disorder seems unaffected by the number of articulation errors (mean difference = 0.253, P = 0.897, 95% confident interval -3.736-4.241).

Conclusion: CAD, particularly abnormal backing of oral consonants and hypernasality were the most common speech defects in children with cleft. Refinement and revision of timing for referring for early speech intervention should be reconsidered.

Background: Reports on characteristics of pediatric diabetes in children from Southeast Asian countries are limited.

Objectives: To describe the clinical characteristics, prevalence, glycemic control, and current treatment regimens of diabetes in Thai children.

Materials and Methods: Data from 132 patients seen at our pediatric diabetes clinic at Chulalongkorn University during 2001−2013 were retrospectively reviewed.

Results: We found an increasing number of patients newly-diagnosed with type 1- (T1DM) or type 2- diabetes mellitus (T2DM). The overall proportion of T1DM was 69.7%, T2DM 23.4%, and other types 6.9%. Children with T1DM were younger at diagnosis, had higher initial glucose and glycated hemoglobin A_1c (HbA_1c), a lower body mass index z-score, lower C-peptide and insulin levels, and were more likely to have classic diabetes symptoms and ketoacidosis, compared with children with T2DM. Mixed diabetes phenotypes were found in about 12%−14% of these children. Glutamic acid decarboxylase and islet antigen-2 autoantibodies were found in 70% and 54% of T1DM patients, respectively, and not in T2DM patients. HbA_1c in T1DM was 9.6 ± 2.2% total hemoglobin, and in T2DM was 7.9 ± 2.6%. There were no differences in HbA_1c levels between different insulin regimens in the T1DM group.

Conclusion: The number of children with T1DM or T2DM has been increasing and there are overlapping phenotypes in a significant proportion of these children. Correct diagnosis requires clinical evaluation and monitoring of the clinical course. Further research is needed to determine the risk factors for the poor glycemic control found in children with T1DM.

Background: Infective endocarditis (IE) is an important cause of child morbidity and mortality, but the current burden of the disease in Thai children is unknown.

Objectives: To determine the current burden of IE in Thai children.

Patients and Methods: The records of all children aged <15 years admitted to Khon Kaen University Hospital from 1992 to 2011 were reviewed.

Results: Of 69,822 admissions, 56 patients fulfilled the modified Duke criteria for definite IE giving a rate of 0.8 cases per 1,000 admissions. Age at diagnosis was 7.9 ± 3.8 years (range, 8 days to 14.8 years). There was congenital heart disease in 38 (68%) patients, rheumatic heart disease (RHD) in 10 (18%), and no previous heart disease in 8 (14%). RHD was a less frequent underlying disease during the latter half (2002-2011) of the period studied (1/34 vs. 9/22, P < 0.001). Blood cultures were positive for pathogens in 34 (61%) patients with 11 cases of Streptococcus viridians and 8 cases of Staphylococcus aureus infections. Vegetations on echocardiography were present in 46 (82%) patients. For 8 embolic events, patients with large vegetations had a higher rate (4/6) than patients with small and no vegetations (4/50) (P < 0.003). In-hospital mortality was 11%. Eight patients with S. aureus infection had a higher mortality (5/8) than 26 patients (1/26) infected with other pathogens (P < 0.001).

Conclusion: The changing epidemiology of pediatric IE was toward fewer children with RHD. Mortality among children with IE was higher in those with S. aureus infection.

Background: Domestic violence is seen in all communities.

Objectives: To determine the risk factors that facilitate emergence of domestic violence.

Methods: A qualitative study where in-depth interviews were used. A total of 30 women who stated they had been experiencing violence from their partner for at least a year made up the study sample. The common opinions in the interviews were grouped and coded according to the themes created for “descriptive analysis”. Excerpts from the statements that best emphasized/defined the women’s opinions and experiences were used in the study report.

Results: The factors stated by the women as facilitating the emergence of domestic violence in our study were: the man being older, the woman being in a marriage that she did not want, was forced into, or that her family did not want, a lack of support by the woman’s family, the man’s family not wanting the woman, the man seeing violence as a societal right, and a lack of mutual love, respect, or trust in the marriage/relationship.

Conclusions: To decrease the emergence of domestic violence in the Turkish family system where traditional female-male roles are present: the woman and man within the marriage/relationship should have similar sociodemographic attributes (age, education, employment), the decision for marriage/relationship should be with the woman’s own free will, educational and awareness increasing programs to ensure societal change should be arranged, and the quality and quantity of social institutions should be brought to a level where the support systems for women can be strengthened.

Background: Anesthesia for cesarean delivery in parturients diagnosed with placenta previa remains controversial.

Objectives: To investigate factors correlated with choice of anesthesia in these parturients and their outcomes.

Methods: Retrospective analysis of patients with placenta previa and cesarean delivery at King Chulalongkorn Memorial Hospital. Peri operative anesthetic and complication data were collected using a structured collection form. Univariate analysis and multivariate logistic regression were used. P < 0.05 was considered significant.

Results: Among 50,237 deliveries from July 1, 2005 to June 30, 2011, there were 562 cesarean sections in diagnosed cases of placenta previa. Cesarean deliveries (479) were performed under spinal anesthesia (81%), epidural anesthesia (1.8%), and if the effects spinal anesthesia dissipated, general anesthesia (2.3%). Among 46 cases of cesarean hysterectomy, 27 patients (58.7%) received regional anesthesia. However, 6 of 10 patients with planned cesarean hysterectomy underwent general anesthesia, while 1 of 4 of a group with regional anesthesia needed conversion to general anesthesia. There was no serious anesthesia-related complication. Factors related to general anesthesia were: a higher American Society of Anesthesiologists (ASA) physical status OR 2.7 (95% CI 1.7-4.3) P < 0.001; presentation with bleeding OR 1.8(95% CI 1.0-3.1) P = 0.033; anterior site of placenta OR 1.8 (95% CI 1.1-3.2) P = 0.025; heart rate >125 bpm OR 5.6 (95% CI 1.5-214) P = 0.01; and pack red cell transfusion OR 3.4 (95% CI 2.0-5.7) P < 0.001.

Conclusions: Most parturients received regional anesthesia. Neuroaxial anesthesia and general anesthesia are safe.

Background: Oral lichen planus (OLP) is a chronic immune-mediated inflammatory disease that usually causes oral mucosal damage. OLP has been considered to be a potentially malignant disorder associated with an increased risk for oral cancer. Trefoil factors (TFFs) are mainly synthesized by mucin-producing epithelial cells. Expression of TFFs in oral epithelia is thought to be an essential factor in protection against oral mucosal damage. However, very little is known about the connection between tissue damage of oral mucosa in OLP patients and expression of TFFs.

Objectives: To determine levels of TFF expression in oral mucosa from patients with OLP.

Methods: Tissue samples were collected from 35 patients with normal oral mucosa (controls) and 35 patients with OLP. An immunohistochemical method was used to determine the expression of the 3 TFFs (TFF1, 2, and 3) in mucosal tissues of the oral cavity.

Results:TFF2 and TFF3 expression in oral epithelia were significantly decreased in OLP patients (Mann- Whitney U test; P = 0.006, and P = 0.002, respectively). There were no significant differences in TFF1 expression between OLP patients and control subjects.

Conclusion: The present study demonstrated reduced expression of TFF2 and TFF3 in oral epithelia of OLP patients. These outcomes support our previous observations that chronic inflammation may play a major role in downregulation of TFF expression, which may be associated with oral mucosal damage in OLP patients.

Background: Attitude is recognized as a key determinant of health-related behaviors, including calcium intake for prevention of osteoporosis. Most existing instruments that measure attitudes towards calcium consumption are not appropriate for use in the Thai population because they focus on attitudes towards the consumption of dairy products, which are not a common source of calcium for Thais.

Objectives: To develop and validate an instrument for measuring attitudes towards calcium consumption among Thai adults.

Methods: An initial attitudinal scale (25 items) was developed and administered to 250 Thais (age ≥20 years) living in Khon Kaen, the largest province in the northeast Thailand, to assess its dimensions using exploratory factor analysis. Three factors were identified. The scale was reduced to 15 items and administered to 733 subjects to validate the identified factor structure and optimize the length of the scale.

Results: A three-factor model (10 items) was validated and interpreted as (1) a negative effect of calcium consumption on the body (4 items, reliability = 0.90), (2) the health benefits of calcium consumption for the body (3 items, reliability = 0.78), and (3) the need to take calcium on a regular basis (3 items, reliability = 0.86). The model fitted the data well (relative χ² = 1.43, adjusted goodness-of-fit index = 0.98, confirmatory fit index = 0.997, root mean square error of approximation = 0.024).

Conclusion: The developed scale is a reliable and useful instrument for measuring attitudes towards calcium consumption. Further research is needed to validate the scale in different populations.

Background: Deep vein thrombosis (DVT) is a silent killer in hospitalized patients. Its prevalence in Thai population may be different from Western countries.

Objective: To evaluate recognized risk factors for DVT in high-risk Thai patients according to the American College of Chest Physicians (ACCP).

Methods: Hospitalized patients were prospectively enrolled at the Department of Medicine, Khon Kean Hospital. The study period was January 2010 to March 2011. Inclusion criteria were patients who were admitted with either (1) heart or respiratory failure or (2) one of the following conditions: cancer, sepsis, acute stroke, or inflammatory bowel disease. The admission length was at least four days. Patients were excluded if the hospitalization was because of venous thromboembolism or if there was a requirement for heparin therapy.

Results: One hundred patients met the study criteria during the study. Of those, 5 patients (5%) had evidence of DVT by ultrasonography. None of these patients had pulmonary embolisms by computed tomographic angiography. In the multiple logistic regression analysis, only acute stroke was significantly associated with DVT. The adjusted odds ratio (OR) was 19.72; (95% confidence interval (CI) 1.37, 284.37). DVT was the only significant factor associated with death during admission with adjusted OR of 30.76 (95% CI: 2.02, 469.03).

Conclusions: The prevalence of DVT in hospitalized high-risk patients by ACCP criteria was low. Admission because of acute stroke may increase the risk of DVT and having DVT may result in high mortality.

Background: Radical nephrectomy is the treatment of choice for large renal cell carcinoma (RCC).

Objectives: To describe the complications after radical nephrectomy for suspected or proven RCC and analyze the risk factors.

Materials and methods: We retrospectively reviewed medical records from 110 patients who underwent radical nephrectomy for RCC in our institution between January 2007 and December 2013. The clinicopathological data of all patients were recorded and complications were graded using modified Clavien classification. Univariate and multivariate analysis was made of the predictive factors for complications.

Results: Fifty postoperative complications occurred in 34 patients (31%) within 30 days, including 11% transfusion related complications. There were 22% minor complications (6% grade 1, 16% grade 2) and 9% major complication (5% grade 3, 2% grade 4, and 2% grade 5). The most common complications were transfusion-related, re-laparotomy because of bleeding, and prolong ileus. In univariate analysis, pathological T-stage (P = 0.001), American Society of Anesthesiologists (ASA) score (P = 0.007), tumor size (P = 0.01), and tumor diameter >4 cm (P = 0.03) were significant predicting factors. Major Charlson comorbidity index (CCI >2) was the only significant factor for major complications (P = 0.04). In multivariate analysis, ASA score was a significant independent predictor for overall complications (odds ratio 4.83, P = 0.01).

Conclusions: ASA score was a significant predictive factor for overall postoperative complications. Comorbidities was also a predictor for major complications in radical nephrectomy. Preoperative risk stratification for complications should be considered during decision-making and for proper counseling of patients.

Background: Neonatal sepsis is a cause of mortality and long-term morbidity worldwide.

Objectives: To describe longitudinal trends in the cumulative incidence of early- and late-onset sepsis (EOS and LOS), mortality, and causative organisms in a Thai Hospital before and after construction of a new neonatal intensive care unit (NICU).

Methods: Review of NICU admissions with blood cultures positive for bacteria or fungi for the periods 1995 to 2002 (preconstruction) and 2004 to 2010 (postconstruction). Sepsis was categorized into EOS (within first 3 days of life) and LOS (after first 3 days of life).

Results: Of 5,570 admissions, 241 (4.3%) neonates with 276 episodes of sepsis were identified. There was no difference in the rate of sepsis overall (P = 0.90), LOS (P = 0.30), or sepsis-related mortality (P = 0.61) over the two periods, but the rate of EOS increased significantly from 0.34% to 0.81% (P = 0.04). Rates of Klebsiella species and Escherichia coli sepsis increased from 13.6% to 25.6% (P = 0.01) and from 5.3% to 12.2% (P = 0.04), respectively, while rates of Staphylococcus aureus sepsis decreased from 12.9% to 4.3% (P < 0.007). Sepsisrelated mortality was 1.8%.

Conclusions: Although direct causality cannot be proven, the rate of EOS and the pattern of causative organisms changed following construction of the new NICU. Building a new unit does not necessarily result in a reduction in the rate of sepsis. This data may provide a baseline for implementing evidence-based infection control strategies to prevent/reduce sepsis and improve neonatal care.

Background: Helminth infections continue to pose serious health problems in Thailand. The infections of greatest concern are opisthorchiasis and hookworm.

Objectives: We evaluated the prevalence of these infections. The Thai Ministry of Health established a national health plan in 1995 to coordinate health plans for the provincial public health sectors.

Methods: A national survey based on probability sampling, interviews, and stool examinations was conducted in 2009 to gather prevalence information of the helminth infections.

Results: We found an overall prevalence of helminthiasis among 15,555 Thai people of 18.1%. The highest prevalence was found in the northeastern regions of Thailand. By comparison with previous surveys conducted over the past 5 decades, the prevalence rates have decreased. However, pockets of high infection remain, particularly in the north and northeast of Thailand.

Conclusions: Targeted intervention by means of educational programs and public health intervention, and continuing surveillance are indicated.

Background: Across the Asia-Pacific, men who have sex with men (MSM) constitute a growing proportion of those infected with and at risk for HIV/AIDS, but frequently lack access to treatment-related resources because of stigma and discrimination.

Objective: To identify challenges that a community-based organization (CBO) and its corresponding HIV clinic in Bangkok, Thailand, face in order to facilitate access to HIV-related care and treatment services by HIV-positive MSM.

Methods: Data were collected through focus group discussions, semi-structured interviews, and surveys of staff members and volunteers working at the support facilities from April through May 2011.

Results: A total of 21 staff and volunteers working at the support facilities participated. Participants reported various barriers to use of HIV-related services by MSM including fear of stigmatization because of their infection status, limited clinic/hospital hours, and misunderstanding of risks.

Conclusions: In response to these barriers, CBOs implemented solutions ranging from outreach activities to organization of a men’s health clinic targeting MSM.

Background: Male-to-female sex reassignment surgery (MTF-SRS) is a treatment for gender identity disorders (GID) wherein the penis is removed and an epithelialized neovagina is created in the retroprostatic or rectovesical space. This is a space between the double layers of Denonvilliers’ fascia that contains motor, sensory, and autonomic nerves to the pelvic organs. Injury to these nerves may lead to anorectal dysfunction. However, there has been no objective study of anorectal physiologic changes after SRS.

Objectives: To compare anorectal physiological parameters, before and after, male-to-female sex reassignment surgery (SRS) and to evaluate the effects of SRS on anorectal physiology.

Methods: In 10 patients with MTF GID who underwent SRS at King Chulalongkorn Memorial Hospital, anorectal manometry was performed using a water perfused catheter (Mui Scientific, Ontario, Canada) and a state-of-the-art anorectal manometry system (Medtronic, Minneapolis, MN, USA) at the Gastrointestinal Motility Research Unit at 2 weeks before and 3 months after the SRS. Data were analyzed using PolygramNet software. Anal sphincter pressures (mmHg) with volume used to elicit rectal sensation (mL).

Results: There was no significant change in the resting anal sphincter pressure, anal sphincter squeezing pressure, sustained squeezing pressure, and duration of squeeze, rectal sensation, and threshold of the desire to defecate affected by SRS. Cough reflex and rectoanal inhibitory reflex were normal both before and after SRS in all patient participants.

Conclusions: Sex reassignment surgery seems to produce no effect on clinical anorectal functions. This was proven by absence of clinically significant changes in anorectal manometry.

Background: The effectiveness of medical treatment depends on proper drug dosing. The most accurate measurement of a child’s weight is by weighing the child on a scale, and can be done for stable children. However, an emergency, or other conditions may preclude normal weighing. The child’s weight must then be estimated quickly for treatment including drug dosages, equipment sizes, ventilator volume settings, and cardioversiondefibrillation.

Objectives: To assess the accuracy of the Broselow tape in the weight estimation of Thai children.

Methods: Retrospective analysis reviewing the hospital-based data of 4746 Thai children aged less than 15 years. Demographic data, measured weight (MW), and height were collected. The subjects were divided into nine color-coded groups according to the Broselow tape color range and the actual weight plotted according to their groups. Comparison between Broselow tape-predicted weight (TW), height and MW was explored.

Results: A total of 3869 children met the inclusion criteria, of whom 2121 (54.8%) were male. The overall agreement between actual weight and predicted weight was 62.1% (range 36.4-90.5 depending on color-code). The mean difference between TW and MW was -3.56% (95% CI -3.964 to -3.150) with SD 12.91%, P < 0.001. TW was within a 10% error for 58% of children.

Conclusions: The accuracy of the Broselow tape in the weight estimation of Thai children decreases with increasing height. The Broselow tape underestimates Thai children’s weight.

Background: Melanoma is a highly malignant skin cancer. Acral lentiginous melanoma (ALM) is most common among Asians. The prevalence of ALM among melanoma cases in Cambodian is not known.

Objective: To describe the prevalence of ALM among cases of melanoma and the stage of disease at presentation to the health facilities and health providers.

Method: Electronic clinical records were obtained from Children’s Surgical Centre (CSC) database between January 2002 and April 2014. Types and stages melanoma at presentation were documented.

Result: A total of 10 out of 26 melanoma patients had ALM. Their average age at diagnosis was 65.3 years. Most primary lesions were located on the plantar or lateral surfaces of the foot. Most histopathological descriptions were consistent with ALM. Seventy percent had lymph node metastases.

Conclusion: A high proportion of ALM was found associated with trauma as a potential risk factor. Most frequency presented at a late stage of disease. Providers must be made aware of the disease and render appropriate management early for good outcome.