Alan Geater

Synchronized Electrical Stimulation in Treating Pharyngeal Dysphagia

Objective/Hypothesis The objectives were to test the hypothesis that synchronous contraction of the thyrohyoid muscle by electrical stimulation during swallowing would improve dysphagia resulting from reduced laryngeal elevation and to evaluate the effectiveness of the synchronous electrical stimulator.

Risk factors for postcesarean surgical site infection.

Objective To determine postcesarean complications and identify independent risk factors for surgical site infection. Methods We studied a cohort of 969 women delivered by cesarean between May and August 1997. Infections were determined by examinations during ward rounds, reviews of laboratory results, and follow-up for 30 days after discharge. Risk factors were identified by multiple logistic regression. Results Surgical complications were rare. There were febrile morbidity and infection complications in 16.2% and 12.4% of subjects, respectively. Eighty-five subjects had 95 surgical site infections (9.8%), and seven risk factors were independently associated with infection. Risk factors included preoperative remote infection (adjusted odd ratio [OR] 16.5, 95% confidence interval [CI] 2.1, 128.3); chorioamnionitis (OR 10.6, 95% CI 2.1, 54.2); maternal preoperative condition (OR 5.3 for those with severe systemic disease [American Society of Anesthesiologists score ≥3], 95% CI 1.2, 24.0); preeclampsia (OR 2.3, 95% CI 1.1, 4.9); higher body mass index (OR 2.0 for every five-unit increment, 95% CI 1.3, 3.0); nulliparity (OR 1.8, 95% CI 1.1, 3.2); and increased surgical blood loss (OR 1.3 for every 100-mL increment, 95% CI 1.1, 1.5). Conclusion Host susceptibility and existing infections were important predictors of surgical site infection after cesarean delivery. Further intervention should target this high-risk group to reduce the clinical effect of surgical site infection.

The effect of heavy maternal workload on fetal growth retardation and preterm delivery. A study among southern Thai women.

Heavy maternal workloads are considered to be hazardous to the fetus. The effects of physical activity during pregnancy on low birth weight (LBW), small for gestational age (SGA), and prematurity were assessed from a sample of 1797 women in a follow-up study at the antenatal clinic of two hospitals in southern Thailand. The women were interviewed twice, at 17 and 32 gestational weeks. Outcome data were obtained from medical records and the newborn gestational age determined using Dubowitzs score. The risk of SGA was elevated for women working > 50 hours/week, squatting in work, commuting > 1 hour/day, and having high psychological job demands; the risk of preterm delivery was increased with obstetrical complications. Women who worked long hours and had demanding work conditions had an elevated risk of giving birth to SGA infants but not of preterm delivery.

Outcome of Dengue Hemorrhagic Fever-Caused Acute Kidney Injury in Thai Children

OBJECTIVES To examine the outcome of acute kidney injury (AKI) in children with dengue hemorrhagic fever (DHF), the cause(s) of AKI, and the risk of AKI and fatality. STUDY DESIGN The medical records of patients age <15 years during 1989 to 2007 were reviewed. DHF-caused AKI and patients with DHF with no AKI were matched 1:2 by age. RESULTS DHF-caused AKI was clinically estimated to be 0.9% (25/2893) of admissions, with a high mortality rate of 64.0%. Risk factors of AKI were DHF grade IV and obesity (odds ratio, 16.9; 95% CI, 4.2 to 68.5, and odds ratio, 6.3; 95% CI, 1.4 to 28.8, respectively). Respiratory failure, hepatic failure, and massive bleeding were complications found in 80.0%, 96.0%, and 84.0% of cases with AKI, respectively. Fatality was more likely in cases with DHF grade IV, oliguric AKI, respiratory failure, or prolongation of prothrombin or activated partial thromboplastin time more than twice that of reference specimens. Among the survivors, none had chronic kidney disease, and serum creatinine levels returned to normal in 32 (1 to 48) days. CONCLUSIONS Patients with DHF and AKI had a high mortality rate, although those who survived had a full return to normal function within 1 month. DHF grade IV and obesity were the major risk factors of AKI.

Differential diagnosis of Chikungunya, dengue viral infection and other acute febrile illnesses in children.

Background: Clinical manifestations of chikungunya (CHIK) are similar to those of dengue. It would be useful to be able to identify clinical manifestations that could reliably help to differentiate CHIK from dengue and other acute febrile illnesses during a CHIK outbreak in a dengue-endemic area. Methods: A prospective cohort study was conducted between April and July 2009 in children aged 1 month to 15 years who lived in a CHIK outbreak area in southern Thailand and who had fever <7 days with arthralgia/arthritis, myalgia or rash. CHIK was confirmed by real-time polymerase chain reaction or the indirect immunofluorescence test. Results: Fifty patients were suspected of having CHIK, of whom 32 were confirmed, 1 had coinfection with dengue viral infection (DVI), 10 had dengue alone and 7 had an acute febrile illness. The specificity and positive predictive value of fever and arthralgia together to diagnose CHIK were 47.1% and 74.2%, and the corresponding values of the standard clinical triad (fever, arthralgia, rash) were 70.6% and 83.3%, respectively. Fever ⩽2 days, skin rash during fever and white blood cell count ≥ 5000 cells/mm3 were independently and significantly associated with CHIK in comparison with DVI and acute febrile illnesses, with relative risk ratios (95% confidence intervals) of 10.4 (0.9–116) and 13.7 (1.3–145), 13.8 (1.2–164) and 14.8 (1.6–168), and 18.3 (1.7–194) and 1.8 (0.1–20.6), respectively. Conclusions: During a CHIK outbreak in a DVI-endemic area, overdiagnosis of CHIK was common. Skin rash during fever and white blood cell count ≥ 5000 cells/mm3 or specific antigen testing (if available) can be helpful in differentiating CHIK from DVI.

The influence of the rural health security schemes on health utilization and household impoverishment in rural China: data from a household survey of western and central China

BackgroundThe New Rural Cooperative Medical Scheme (NRCMS, voluntary health insurance) and the Medical Financial Assistance (MFA, financial relief program) were established in 2003 for rural China. The aim of this study was to document their coverage, assess their effectiveness on access to in-patient care and protection against financial catastrophe and household impoverishment due to health spending, and identify the factors predicting impoverishment with and without these schemes.MethodsA cross-sectional household survey was conducted in 2008 in Hebei and Shaanxi provinces and the Inner Mongolia Autonomous Region using a multi-stage sampling technique. Information on personal demographic characteristics, chronic illness status, health care use, household expenditure, and household health spending were collected by interview.ResultsNRCMS covered 90.8% of the studied individuals and among the designated poor, 7.6% had their premiums paid by MFA. Of those referred for hospitalization in the year prior to the interview, 34.3% failed to comply, mostly (80.2%) owing to financial constraints. There was no significant difference in the unmet need for admission between the insured with NRCMS and the uninsured. Before reimbursement, the incidence of catastrophic health payment (household health spending more than 40% of households capacity to pay) and medical impoverishment (household per capita income falling below the poverty line due to medical expense) was 14.3% and 8.2%, respectively. NRCMS prevented 9.9% of the households from financial catastrophe and 7.7% from impoverishment, whereas MFA kept just one household from impoverishment and had no effect on financial catastrophe. Household per capita expenditure and household chronic disease proportion (proportion of members of a household with chronic illness) were the most important determinants of the unmet need for admission, risk of being impoverished and the chance of not being saved from impoverishment.ConclusionThe coverage of NRCMS among the rural population was high but not adequate to improve access to in-patient care and protect against financial catastrophe and household impoverishment due to health payment, especially for the poor and the chronically ill. Furthermore, MFA played almost no such role; therefore, the current schemes need to be improved.

Exhaled breath condensate cytokine level as a diagnostic tool for obstructive sleep apnea syndrome

BACKGROUND Relationships between exhaled breath condensate (EBC) and serum cytokines and apnea-hypopnea index (AHI) in patients with excessive daytime sleepiness and loud snoring were evaluated for their potential to predict the severity of obstructive sleep apnea syndrome (OSAS). METHODS Non-smoking patients with suspected OSAS who had undergone polysomnography (PSG) were selected until 22 non-OSAS, and 22 mild, 22 moderate and 24 severe OSAS cases based on AHI were achieved. Ten healthy smokers served as a smoker control group. Interleukin-6 (IL-6), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-alpha), and 8-isoprostane were measured in EBC and serum on the morning after PSG and related to OSAS severity using linear discriminant analysis (LDA) and logistic regression (LR). RESULTS Biomarker levels, in both EBC and serum, differed significantly across the four groups. Classification by LDA using IL-10 in EBC showed the highest agreement with AHI classification (kappa=0.88). LR distinguished moderate and severe OSAS from mild OSAS and non-OSAS perfectly using IL-6 in EBC and almost perfectly using IL-10 in EBC (area under the ROC curve=0.997). The levels of biomarkers among smokers overlapped with mild to severe OSAS patients. CONCLUSIONS Among non-smoker OSAS suspects, EBC IL-6 and IL-10 have potential to predict severity of OSAS.

Dose–response relationship between treatment delay of smear-positive tuberculosis patients and intra-household transmission: a cross-sectional study

In order to document the effect of treatment delay on tuberculosis (TB) latent infection among the household contacts of TB patients, a cross-sectional TB infection prevalence survey was conducted among household contacts in Yunnan Province, southern China. In total, 1360 household contacts of 393 smear-positive pulmonary TB patients were enrolled, together with 308 household contacts of 90 non-TB patients. Using the contacts of non-TB patients as the baseline of TB infection, there was a dose-response relationship between household infection and delay of TB treatment (TB infection prevalence 9.7, 7.8, 19.9, 25.7 and 26.9% for non-TB case, TB case with delay < or =30 d, 30-60 d, 60-90 d and >90 d, respectively). Older age, TB index patient with lung cavitation, and sleeping in the same bedroom with a TB patient were all associated with an increased risk of being tuberculin-skin-test positive. In conclusion, 30 d delay in treatment seems to be the turning point at which a significant increase in risk for TB infection occurs. Apart from conventional indicators, magnitude of treatment delay should be considered as a performance indicator for TB control programmes in high-TB-burden countries. Measures for the detection of early cases should be intensified.

Are long working hours and shiftwork risk factors for subfecundity? A study among couples from southern Thailand.

OBJECTIVE: To estimate the effect of long working hours and shift work on time to pregnancy. METHODS: Cross sectional samples with retrospective data collection from two 700 bed hospitals at secondary to tertiary care level in Hatyai district, Songkhla Province, Thailand. The study was conducted from March 1995 to November 1995 among 1496 pregnant women attending the antenatal clinics. Subfecundity was defined as time to pregnancy longer than 7.8, 9.5, or 12 months (time to pregnancy was calculated from the date at which the couples started having sexual relations without any contraception until last menstrual date). RESULTS: The descriptive analyses were restricted to 1201 planned pregnancies and the analytical part to 907 working women. Separate analyses on primigravid women were also done. Logistic regressions adjusted for age, education, body mass index, menstrual regularity, obstetric and medical history, coital frequency, and potential exposure to reproductive toxic agents, showed an odds ratio (OR) associated with female exposure to long working hours of 2.3 (95% confidence interval (95% CI) 1.0 to 5.1) in primigravid and 1.6 (1.0 to 2.7) in all pregnant women. Male exposure to long working hours and shiftwork showed no association with subfecundity. The OR of subfecundity was highest when both partners worked > 70 hours a week irrespective of the cut off point used (OR 4.1 (95% CI 1.3 to 13.4) in primigravid women; OR 2.0 (95% CI 1.1 to 3.8) in all pregnant women). CONCLUSIONS: Long working hours is a risk factor for subfecundity especially for women. Shiftwork was not associated with subfecundity in this study.

Predictors for the risk of hookworm infection: experience from endemic villages in southern Thailand

To assess the role of defaecation pattern in predicting the level of risk for hookworm infection in southern Thailand, 4 villages in different geographical settings in endemic areas were studied. Close observation and stool examinations for hookworm were carried out. The first village was used for exploring the risk factors for hookworm infection. The resultant statistical model was then tested using the other 3 villages. Only 23-40% of the sample regularly defaecated in a latrine. The pattern of defaecation did not differ between the sexes, but was associated with age and site of residence. In the first village, the following variables were not statistically significant: sex, age, level of past education, household income, having neighbouring houses within 20 m, latrine availability, site of defaecation. The only statistically significant protective factor was shoe wearing, which showed an exposure-outcome severity relationship. Similar results were obtained in the other 3 villages. These results refute the protective effect of latrine use on the individual user, who may still get infection from the faeces of other community members. Promotion of shoe-wearing, which provides individual protection, should be an important supplementary strategy for hookworm control programmes in such areas.