Jiraporn Khorana

Clinical prediction rules for failed nonoperative reduction of intussusception

Purpose The nonoperative reduction of intussusception in children can be performed safely if there are no contraindications. Many risk factors associated with failed reduction were defined. The aim of this study was to develop a scoring system for predicting the failure of nonoperative reduction using various determinants. Patients and methods The data were collected from Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012. Inclusion criteria consisted of patients with intussusception aged 0–15 years with no contraindications for nonoperative reduction. The clinical prediction rules were developed using significant risk factors from the multivariable analysis. Results A total of 170 patients with intussusception were included in the study. In the final analysis model, 154 patients were used for identifying the significant risk factors of failure of reduction. Ten factors clustering by the age of 3 years were identified and used for developing the clinical prediction rules, and the factors were as follows: body weight <12 kg (relative risk [RR] =1.48, P=0.004), duration of symptoms >48 hours (RR =1.26, P<0.001), vomiting (RR =1.63, P<0.001), rectal bleeding (RR =1.50, P<0.001), abdominal distension (RR =1.60, P=0.003), temperature >37.8°C (RR =1.51, P<0.001), palpable mass (RR =1.26, P<0.001), location of mass (left over right side RR =1.48, P<0.001), ultrasound showed poor prognostic signs (RR =1.35, P<0.001), and the method of reduction (hydrostatic over pneumatic, RR =1.34, P=0.023). Prediction scores ranged from 0 to 16. A high-risk group (scores 12–16) predicted a greater chance of reduction failure (likelihood ratio of positive [LR+] =18.22, P<0.001). A low-risk group (score 0–11) predicted a lower chance of reduction failure (LR+ =0.79, P<0.001). The performance of the scoring model was 80.68% (area under the receiver operating characteristic curve). Conclusion This scoring guideline was used to predict the results of nonoperative reduction and forecast the prognosis of the failed reduction. The usefulness of these prediction scores is for informing the parents before the reduction. This scoring system can be used as a guide to promote the possible referral of the cases to tertiary centers with facilities for nonoperative reduction if possible.

Adenovirus infection: A potential risk for developing intussusception in pediatric patients

The pathogenesis of intussusception without obvious anatomical leading points remains unclear. The objective of this study was to determine a feasibility of association between certain gastroenteritis viruses and intussusception. This was a prospective cohort study. Forty intussusception cases and 136 acute gastroenteritis controls with comparable age and gender were separately consecutively enrolled and relevant clinical data of both groups were recorded. The clinical specimens collected from all patients were screened for adenovirus, rotavirus, norovirus, and astrovirus by PCR and RT‐PCR using specific primers. The genomes of detected viruses were characterized further to identify their genotypes by nucleotide sequencing. In 40 intussusception cases, adenovirus, rotavirus, and norovirus were detected in 12 (30.0%), 2 (5.0%), and 2 (5.0%), respectively while astrovirus was undetectable. In contrast, 136 acute gastroenteritis patients, adenovirus, rotavirus, and norovirus were detected in 11 (8.1%), 24 (17.7%), and 24 (17.7%) patients, respectively and again astrovirus was undetectable. The detection of adenovirus in intussusception patients was significantly higher than those in the control group (P < 0.001) with an odd ratio of 4.87 (95%CI: 1.95, 12.16). Interestingly, molecular analysis of adenovirus genome demonstrated that all of adenovirus detected in intussusception patients belonged to adenovirus C. This could be a potential risk factor or pathogenesis for developing intussusception in the cases of those without apparent anatomical leading points. J. Med. Virol. 88:1930–1935, 2016.

Enema reduction of intussusception: the success rate of hydrostatic and pneumatic reduction

Purpose Intussusception is a common surgical emergency in infants and children. The incidence of intussusception is from one to four per 2,000 infants and children. If there is no peritonitis, perforation sign on abdominal radiographic studies, and nonresponsive shock, nonoperative reduction by pneumatic or hydrostatic enema can be performed. The purpose of this study was to compare the success rates of both the methods. Methods Two institutional retrospective cohort studies were performed. All intussusception patients (ICD-10 code K56.1) who had visited Chiang Mai University Hospital and Siriraj Hospital from January 2006 to December 2012 were included in the study. The data were obtained by chart reviews and electronic databases, which included demographic data, symptoms, signs, and investigations. The patients were grouped according to the method of reduction followed into pneumatic reduction and hydrostatic reduction groups with the outcome being the success of the reduction technique. Results One hundred and seventy episodes of intussusception occurring in the patients of Chiang Mai University Hospital and Siriraj Hospital were included in this study. The success rate of pneumatic reduction was 61% and that of hydrostatic reduction was 44% (P=0.036). Multivariable analysis and adjusting of the factors by propensity scores were performed; the success rate of pneumatic reduction was 1.48 times more than that of hydrostatic reduction (P=0.036, 95% confidence interval [CI] =1.03–2.13). Conclusion Both pneumatic and hydrostatic reduction can be performed safely according to the experience of the radiologist or pediatric surgeon and hospital setting. This study showed that pneumatic reduction had a higher success rate than hydrostatic reduction.

Perception, concern and acceptability of neonatal male circumcision among postpartum mothers in Thailand.

Introduction: Three randomized controlled trials involving over 11,000 men have demonstrated that male circumcision reduces female to male transmission of HIV. It is recommended by the World Health Organization as part of a HIV prevention program. Adult male circumcision is associated with significant complications while neonatal male circumcision (NMC) has few risks and may be a preferred prevention strategy. Internationally, NMC is seldom performed except as a religious ritual. So, introducing NMC in Thailand needs to determine its acceptability among mothers. Therefore a study was conducted among postpartum Thai mothers to determine their perceptions of, concerns about and acceptability of NMC. Methods: A survey was conducted of 593 postpartum mothers from 16 hospitals in 4 provinces in Thailand. Data were analyzed using descriptive statistics, univariate analysis and binary logistic regression. Results: 70 % of the participants reported that they knew or have heard about MC. Safety and pain were the major concerns of the mothers towards NMC. One-third would chose to have their infants circumcised after receiving the information about NMC, an additional third were undecided and 34.5% would not allow their sons to undergo NMC. Mothers (44.0 %) were the most influential person when it comes to the decision on NMC followed by fathers (37.9 %). In a multiple regression, having 9 years or greater of formal education (OR 1.64; 95% CI 1.01-2.66), having a circumcised husband (OR 2.88; 95% CI 1.11-7.50), and knowing of at least one circumcised child (OR 1.97; 95% CI 1.22-3.18) were independent predictors of acceptability to NMC among postpartum mothers. Conclusions: The results suggest that NMC may be culturally neutral with evidence that even modest educational efforts can impact mothers’ decisions in favor of NMC. However, this study and a previous study suggest that both parents and health professionals need to be educated about the benefits of NMC.

Prognostic indicators for failed nonsurgical reduction of intussusception.

Purpose To identify the risk factors for failure of nonsurgical reduction of intussusception. Methods Data from intussusception patients who were treated with nonsurgical reduction in Chiang Mai University Hospital and Siriraj Hospital between January 2006 and December 2012 were collected. Patients aged 0–15 years and without contraindications (peritonitis, abdominal X-ray signs of perforation, and/or hemodynamic instability) were included for nonsurgical reduction. The success and failure groups were divided according to the results of the reduction. Prognostic indicators for failed reduction were identified by using generalized linear model for exponential risk regression. The risk ratio (RR) was used to report each factor. Results One hundred and ninety cases of intussusception were enrolled. Twenty cases were excluded due to contraindications. A total of 170 cases of intussusception were included for the final analysis. The significant risk factors for reduction failure clustered by an age of 3 years were weight <12 kg (RR =1.48, P=0.004), symptom duration >3 days (RR =1.26, P<0.001), vomiting (RR =1.63, P<0.001), rectal bleeding (RR =1.50, P<0.001), abdominal distension (RR =1.60, P=0.003), temperature >37.8°C (RR =1.51, P<0.001), palpable abdominal mass (RR =1.26, P<0.001), location of mass (left over right side) (RR =1.48, P<0.001), poor prognostic signs on ultrasound scans (RR =1.35, P<0.001), and method of reduction (hydrostatic over pneumatic) (RR =1.34, P=0.023). The prediction ability of this model was 82.21% as assessed from the area under the receiver operating characteristic curve. Conclusion The identified prognostic factors for the nonsurgical reduction failure may help to predict the reduction outcome and provide information to the parents.

Ovarian Teratoma with Predominant Hemangiomatous Component in Early Childhood

BACKGROUND Ovarian teratoma with predominant hemangiomatous component in pediatric patients is very rare and its presentation may mimic that of malignancy. CASE A 2-year-old girl presented with proptosis of the right eye. A right ovarian mass was detected on the physical examination. The right orbital lesion was consistent with venolymphatic-type vascular malformation on magnetic resonance imaging. The abdominal computed tomographic scan revealed a solid ovarian mass that raised a suspicion for malignancy. A 5.5-cm right ovarian solid hemorrhagic mass was resected. Microscopically, the mass was almost exclusively composed of variable-sized blood vessels, with few microscopic mature teratomatous foci. SUMMARY AND CONCLUSION Hemangiomatous lesion of the ovary may have a presentation mimicking a malignant neoplasm, and may be associated with multiple vascular lesions.

Natural Course of Fetal Axillary Lymphangioma Based on Prenatal Ultrasound Studies

This series and literature review aimed to prenatally characterize the nature of axillary lymphangioma. A total of 30 cases, including our 5 cases, were analyzed. Insights gained from this review are as follows: Septate and nonseptate cysts seem to be different entities. The nonseptate type tends to be small and transient but more highly associated with aneuploidies. Septate cysts are very rarely associated with other abnormalities and hydrops fetalis, unlike cystic hygroma colli, but are more progressive with gestational age and associated with adverse outcomes. The cases with high flow have a higher risk of intralesional hemorrhage. Prenatal diagnosis is important for the route of timely delivery and possibly prenatal interventions. Shoulder dystocia is common and should always be taken into account for decisions on the route of delivery.

Physicians’ and nurses’ thoughts and concerns about introducing neonatal male circumcision in Thailand: a qualitative study

BackgroundNeonatal male circumcision (NMC) is an alternative approach to adult male circumcision for HIV prevention. Recent studies found that NMC was rarely performed in Thailand and that most Thai health professionals did not recognize that NMC could reduce the risk of HIV infection and would not want NMC services in their hospitals. This study explored the thoughts and concerns of Thai government health staff regarding the introduction of NMC in government health facilities as a public health measure.MethodsIn-depth interviews with physicians, nurses and physician administrators from four different levels of government hospitals in four provinces representing 4 regions of Thailand were conducted after provision of education regarding the benefits and risks of NMC. Interviews were audio recorded and analyzed using Atlas.ti software to develop themes.ResultsSix themes emerged from the data of 42 respondents: understanding of the benefits of NMC; risks of NMC; need for a pilot project; need for staff training and hospital readiness; need for parental/family education; and need for public awareness educational campaign. Major concerns included possible medical complications of NMC, infringement of child rights, and lack of understanding from staff and parents. The respondents emphasized the need for a clear policy, proper training of staff, financial and equipment support, and piloting NMC rollout before this measure could be fully implemented.ConclusionsThai health professionals who took part in this study expressed several concerns if NMC had to be performed in their health care facilities. There is significant preparation that needs to be done before NMC can be introduced in the country.

Intussusception in Premature Baby: Unusual Cause of Bowel Obstruction and Perforation

Intussusception in a premature baby is a rare condition. We report a male preterm infant, who developed abdominal distension and abdominal wall erythema. He was operated with suspicion of NEC but an ileo-ileal intussusception and intestinal perforation were encountered at operation.