A prospective observational study to investigate the relationship between local anesthetic infiltration pain before spinal anesthesia and acute and chronic postsurgical pain in women undergoing elective cesarean delivery

BACKGROUND

Cesarean delivery is one of the most common procedures performed worldwide. We conducted this prospective cohort study to evaluate the association between local anesthetic infiltration (LAI) pain prior to spinal anesthesia and pain and morphine consumption within 24 h after cesarean delivery (primary outcomes). A secondary objective was to assess the association between LAI pain and pain at one month postoperatively.

METHODS

Recruitment of 216 eligible women scheduled for elective cesarean delivery. Local infiltration before spinal anesthesia was performed using a 24-gauge needle and 3 mL 2% plain lidocaine. All subjects received 2.2 mL 0.5% hyperbaric bupivacaine with 200 µg morphine for spinal anesthesia. A 0-10 verbal numerical rating scale was used to assess LAI pain severity, and subsequent pain at 24 h, 1, 3 and 12 months.

RESULTS

We found a moderate correlation between LAI pain intensity and severity of acute pain at rest (rho=0.56, P <0.001) and with movement (rho=0.58, P <0.001) and a weak correlation with morphine consumption (rho=0.17, P=0.01) within 24 h postoperatively. We also found a positive correlation between LAI pain and the severity of persistent wound pain at rest (rho=0.30, P <0.001) and with movement (rho=0.52, P <0.001) at 1 month. The incidence of wound pain at 1, 3 and 12 months postoperatively was 37.1%, 7.0% and 1.4%, respectively.

CONCLUSIONS

Pain from LAI prior to spinal anesthesia is significantly associated with subsequent postoperative pain both acutely and at one month in women scheduled for elective cesarean delivery under spinal anesthesia.

Reducing secondhand smoke exposure at home in rural areas, Thailand: a cluster randomised controlled trial

BACKGROUND: Secondhand smoke (SHS) exposure cause of morbidity and mortality, especially in non-smokers and children. This study tested the effectiveness of an intervention for reducing exposure to SHS in homes by creating smoke-free environment where 1 to 5-year old infants reside.METHODS: A cluster randomised controlled trial was conducted in a rural geographic area of Thailand, with 47 villages assigned to either an intervention or a comparison group. The intervention consisted of self-education and infographic material, together with 45 text messages delivered via short message service. The control group received the self-education after the intervention at 3 months. The primary outcome was assessed by parent´s self-reported in exposure to SHS in home. Multiple logistic regression was used to test the effect of the intervention.RESULTS: The effects of the intervention increased the likelihood of a reducing exposure to SHS at home by 1.8-fold (95%CI 1.04 to 3.11). The average number of days of SHS exposure at home (7 days) also decreased by -1.25-fold (95%CI -1.85 to -0.66) in the intervention group.CONCLUSION: The effectiveness of the intervention in reducing SHS exposure at home by a creating a smoke-free environment was observed to be statistically significant.

Effect of Global Fund financial support for patients with multidrug-resistant tuberculosis

SETTING: The Global Fund provides financial support for patients with multidrug-resistant tuberculosis (MDR-TB), patients' families and hospitals providing services for these patients in Thailand, but the impact of this support has not been evaluated.OBJECTIVE: To assess the impact of Global Fund financial support on drug adherence, out-of-pocket (OOP) payments, sputum culture conversion and the perception of the usefulness of this support.DESIGN: A retrospective cohort study was conducted in eight provincial hospitals with and without financial support in four regions of Thailand. MDR-TB patients aged ≥15 years registered in 2015-2016 who received treatment at these hospitals for at least 6 months were included.RESULTS: There was no significant difference in drug adherence rates. The OOP payments during treatment were significantly lower in patients who received financial support (P < 0.001). Although the supported group had higher positive culture rates at the beginning of treatment, sputum converted at a faster rate than for the unsupported group (P = 0.034). More than 80% of both groups perceived financial support as being useful, leading to faster diagnosis and improving follow-up compliance.CONCLUSION: Financial support for MDR-TB patients has a positive impact on treatment and should be continued.

Fully vs. partially integrated services for TB-HIV in Myanmar: a health services review and a cohort study

<sec id="st1"> <title>SETTING</title> In Myanmar, integrated services for tuberculosis (TB) and human immunodeficiency virus (HIV) are operated either fully (as one single unit) or partially (each vertical programme provides both services). </sec> <sec id="st2"> <title>OBJECTIVE</title> To review the fully and partially integrated services for TB-HIV and to assess their TB treatment outcomes. </sec> <sec id="st3"> <title>METHODS</title> We analysed the compiled service database and conducted a cohort study on newly registered TB-HIV patients in 12 townships in Myanmar. </sec> <sec id="st4"> <title>RESULTS</title> No significant association between region/state and types of integration was detected. Townships with partially integrated services had a significantly larger population size, higher proportion of urban population as well as higher TB and TB-HIV case notification rates; however, the cartridge-based Xpert^® MTB/RIF assay was used less frequently than in townships with fully integrated services. Treatment completion rate and unfavourable outcomes were not significantly different between the two models, although fully integrated services reported a higher cure rate. </sec> <sec id="st5"> <title>CONCLUSIONS</title> These mixed results suggest that during expansion of fully integrated services, the progress of treatment outcomes should be monitored carefully. </sec>.

Additional active tuberculosis cases detected and costs incurred by a second household contact investigation

In routine contact investigation in Myanmar, basic health staff conduct home visits and symptom screening among household contacts before investigation. We supplemented this with follow-up telephone calls by programme nurses inviting all contacts to be screened. The staff identified 376 contacts, 4 with symptoms, 3 of whom presented, including 1 with tuberculosis (TB). Due to the second intervention, 264 of the remaining 373 contacts received screening and 17 additional cases were detected. The additional cost incurred by the second intervention was 4.3 times higher than that of the conventional method, but TB yield was increased by a factor of 17.

Progress and challenges in improving maternal health in the Tibet Autonomous Region, China

Background

The maternal mortality ratio (MMR) of the Tibet Autonomous Region (hereinafter “Tibet”) is still five times higher than the national average. This study aims to identify the successes and pitfalls of the health system that might be related to the high mortality rate based on the WHO health system building blocks, focusing on human resources for health and health infrastructure and the impact on maternal health and outcomes.

Methods

Sources of information include China’s central government and Tibet’s local government policies and regulations, health statistical yearbooks, maternal and child health routine reporting system, and English and Chinese online research articles. Joinpoint analysis was applied for MMR and maternal health service trends, and correlation test was used to test the relationship between maternal health services and outcomes.

Results

Between 2000 and 2015, public health spending in Tibet increased 67-fold, the hospital delivery rate increased 70.1%, and the MMR dropped from 466.9 to 100.1 per 100,000 live births. However, the total number of health workers, qualified medical doctors, and registered nurses per 1,000 people were 4.4, 1.4, and 1.0, respectively, much lower than the national average (5.8, 1.8, and 2.4). In Tibet, there were 80 basic and 16 comprehensive emergency obstetric care (EOC) centers. On average, there were 12 basic and 2.5 comprehensive EOC centers per 500,000 of the population. Though it met the WHO’s recommendation, it might remain inadequate in the low population density of the area like Tibet.

Conclusion

The shortage of health professionals and EOC centers and health information in predominantly remote rural areas with a scattered population still needs to be rectified.

Rural Health Care Workers and Local Residents Health Status in Yulong County of Yunnan Province China and Hat Yai City of Songkhla Mansion Thailand

INTRODUCTION

To compare health status between Hat Yai city of Songkhla Province in Thailand and Yulong county of Yunnan province in China about rural health care workers and local residents, analyzing of both differences, learning from the advanced experience and practice of Thailand, adjusting policy, especially for the implementation of measures to improve the lack of human resources construction of Yulong County rural health, promote the level of rural health service of Lijiang.

METHODS

A qualitative study consisting of focus group discussions and individual in-depth interviews were conducted in Rural Health Care Workers and Local Residents Health Status in Yulong County of Yunnan Province China and Hat Yai City of Songkhla Mansion Thailand from.

RESULTS

Compared to 41(100%) bachelor's degree of medical staffs in Hat Yai, this accounted only 94 (42%) bachelor's degree of medical staffs in Yulong county hospital, and 31 (12%)in townships hospitals. For medical workers in Hat Yai, they have at least one time on-job training per year, but for Yulong county, only 144 (29%)of the medical personnel participated in the training per year. Health expenditures of Yulong county was mainly borne by the local government, and medical insurance coverage rate is 217,107 (99%). Insurance average awareness of Hat Yai is 4449 (66.4%), Yulong County is 62,501 (28.5%), P<0.001, there are statistically significant differences between two cities.

CONCLUSIONS

Thailand has good experience in training, well-paid, motivating and retaining talent for rural health human resources; multi-pronged, mechanism innovation, establish and perfect the system of human resources for health, is the essential way to solve the problem.

A randomized controlled trial of cluster audit and feedback on the quality of dental sealant for rural schoolchildren

THE OBJECTIVE

To examine whether audit and feedback could improve the quality of the application of dental sealant in rural Thai school children.

RESEARCH DESIGN

A single blind, cluster randomized controlled trial was conducted.

CLINICAL SETTING

Hospital-based and school-based school sealant applied by dental nurses in Southern province of Thailand.

PARTICIPANTS

Dental nurses and school children who received dental sealant were involved.

INTERVENTION

The intervention consisted of confidential feedback of data and tailor-made problem-solving workshops.

MAIN OUTCOME MEASURES

Sealant quality was measured by sealant retention and caries on sealed surfaces at six-month after sealing. The teeth examinations were done among different groups of children prior and after the intervention.

RESULTS

After the intervention, the sealant retention rate increased dramatically in the intervention group, whereas in the control group the rate was similar to that found at baseline. The rate of caries after the intervention was stable in the intervention group and increased slightly in the control group. At the beginning of the study, the adjusted odds ratio of complete sealant retention between the intervention and control group was 0.47 which increased to 1.99 at the end of the study. However, no effect on caries on sealed surfaces was observed.

CONCLUSIONS

The intensive focus on actual problems during the audit and feedback improved the dental nurses' performance and the quality of the dental service, although it had no statistical impact on the incidence of caries.

Financial burden on the families of patients with hepatitis B virus-related liver diseases and the role of public health insurance in Yunnan province of China

OBJECTIVE

To investigate the financial burden of patients who had various stages of hepatitis B virus-related diseases and the level of alleviation from financial burden by health insurance schemes in Yunnan province of China.

STUDY DESIGN

A cross-sectional survey.

METHODS

Patients' information was consecutively recorded at the First Affiliated Hospital of Kunming Medical University, from December 2012 to June 2013. Consecutive cases of hepatitis B virus (HBV) (520), compensated cirrhosis (91), decompensated cirrhosis (198) and hepatocellular carcinoma (HCC) (131) were recruited from the outpatient and inpatient departments. The total direct costs, hospital charge, outpatient costs, hospitalization fees being reimbursed and household catastrophic health expenditure were estimated for each disease group.

RESULTS

The average annual direct costs for each disease group were 19,496 RMB for HBV, 28,466 RMB in compensated cirrhosis, 46,061 RMB for decompensated cirrhosis, and 33,044 RMB for HCC patients. Catastrophic health expenditure occurred in all four groups. Health insurance reimbursement released the financial burden incurred by medical expenses of patients under a high level of household economic status. Public health insurance schemes helped the patients to various extents.

CONCLUSIONS

Among these patient groups, direct costs represent a significant economic burden. Health expenditure and financing systems must be considered to prevent the increase of household catastrophe, particularly among the poor.

Study of tuberculosis and AIDS stigma as barriers to tuberculosis treatment adherence using validated stigma scales

BACKGROUND

Adherence to tuberculosis (TB) treatment is important for TB control. The effect of stigma on adherence has not been well quantified.

OBJECTIVE

To identify the effects of TB and acquired immune-deficiency syndrome (AIDS) stigma on missed doses during TB treatment.

DESIGN

Validated TB and AIDS stigma scales assessing perceived and experienced/felt stigma were administered in a prospective cohort of 459 TB patients at TB treatment initiation and after 2 months. Repeated measures and multivariable models estimated the effects of stigma on the rate of missed doses.

RESULTS

Fifty-six per cent of patients missed no doses, and associations between stigma and missed doses were minimal. Heterogeneity of effects was observed, how- ever, with higher experienced and felt TB stigma increasing missed doses among women (adjusted RR 1.22, 95%CI 1.10-1.34) and human immunodeficiency virus (HIV) co-infected patients (aRR 1.39, 95%CI 1.13-1.72). Experienced and felt AIDS stigma also increased missed doses among HIV co-infected patients (aRR 1.43, 95%CI 1.31-1.56).

CONCLUSION

Stigma has a minimal effect in this population with good adherence. Among women and HIV co-infected patients, however, experienced and felt stigma, and not perceived stigma, increased the rate of missed doses. Further research is needed to determine if stigma or coping interventions among these subgroups would improve adherence.

Tuberculosis and AIDS stigma among patients who delay seeking care for tuberculosis symptoms

BACKGROUND

Delay in presentation to a health facility is an important concern for tuberculosis (TB) control. The effect of stigma on delay in seeking care for TB symptoms is not well studied, especially in the context of the human immunodeficiency virus (HIV) co-epidemic.

OBJECTIVE

To estimate the association of TB and acquired immune-deficiency syndrome (AIDS) stigma on delay in seeking care for TB symptoms.

METHODS

For 480 newly diagnosed patients with TB, time from first TB symptom to the first visit to a qualified provider was calculated. Stigma scales were administered to each patient to obtain a stigma score.

RESULTS

Among men, those with higher TB stigma had a small increase in delay times, while women had a small decrease in delay. Among patients presenting with hemoptysis, higher TB stigma was associated with a small increase in delay, while among patients presenting with fever or extra-pulmonary symptoms only, higher TB and AIDS stigma resulted in shorter delay times.

CONCLUSION

In a population with a relatively short median delay (26 days), the impact of TB and AIDS stigma translates into a minimal change in delay time. This suggests that stigma does not have a clinically relevant effect on TB patient delay in southern Thailand.

Effect of village income and household income on sanitation facilities, hygiene behaviours and child undernutrition during rapid economic growth in a rural cross-border area, Yunnan, China

BACKGROUND

The study aimed to examine the effects of village income and household income on child nutrition status through basic sanitation and hygiene behaviours.

METHODS

A survey was conducted in a rural cross-border area of Yunnan, China. Data on village income in 2002-2006 and household income in 2002-2007 were obtained from an official report and a household survey respectively. Anthropometric measurement of the children aged 6 months to 5 years (n = 1801) was used to determine their nutrition status. Child caretakers were interviewed about household sanitation facilities and their hygiene behaviours using a structured questionnaire.

RESULTS

Households with incomes below the national poverty line decreased from 22% in 2002 to less than 8% in 2007. The coverage of safe drinking water and water-sealed latrines gradually increased, but was still inadequate. The prevalence of stunting and underweight in children was 37% and 17.5% respectively. Village income had a greater positive effect than household income on exclusive breastfeeding, drinking boiled water, handwashing with soap, as well as reducing the prevalence of stunting. Village income at one lag year had the greatest effect on the availability of basic sanitation compared with other lag years, while household income had a small but significant effect through all lag years.

CONCLUSIONS

Rapid economic growth is not always followed by improved child nutrition status. Village income has a greater effect than household income on sanitation facilities, hygiene behaviours of caretakers and child nutrition status.

Loss of sealant retention and subsequent caries development

OBJECTIVES

To assess the transition process of sealant retention and to determine the effect of sealant loss on subsequent caries. RISK DESIGN: A follow-up study from the day sealants was applied by dental nurses, every six months over a period of 30 months.

SETTING

Mobile dental clinics at primary schools in Songkhla, Thailand.

PARTICIPANTS

206 first grade primary school children, with 383 first permanent molars.

OUTCOME MEASURES

Intermediate outcomes were: three categories of sealant retention: full retention, partial retention and missing sealant. The final outcome was whether occlusal caries was present or not.

RESULTS

The percentages of occlusal surfaces of first permanent molars which were at risk (caries free) at time points 6, 12, 18, 24 and 30 months which became carious during the subsequent six months were 2.4, 8.00, 7.4, 5.4 and 6.1 respectively. Caries incidence was highest in the first year after sealing. Odds ratio of conversion from non-caries to caries between partial retention and missing sealant was 3.07 and between full retention and missing sealant, 0.27.

CONCLUSION

Under high caries risk and low retention rate settings, partial retention posed a high risk of caries, suggesting an urgent need to improve sealant performance.

Late HIV diagnosis and delay in CD4 count measurement among HIV-infected patients in Southern Thailand

The objectives of this study were to evaluate timeliness of HIV testing and of getting CD4 count measured and their associated factors in Southern Thailand. Between July 2004 and February 2005, consenting HIV-positive patients from seven public hospitals in Songkhla province, Southern Thailand were interviewed. Outcomes were late HIV diagnosis (having HIV-related symptoms at the time of first positive test) and the time between HIV diagnosis and first CD4 count being measured. Of 402 study patients, 55% were late HIV-diagnosed. Factors independently associated with late HIV diagnosis were age above 30 years, male and being unemployed with respective odd ratios (95% CI) of 3.10 (1.90-5.07), 7.95 (4.52-13.99), and 2.14 (1.22-3.76). Only 34% and 47% received CD4 assessment within 6 and 12 months of HIV diagnosis, respectively. Median of first-known CD4 count was 73 (IQR 16-169) and 22 (IQR 9-85) cells/microl among asymptomatic and symptomatic HIV-diagnosed patients, respectively. Common predictors for shortened delay of CD4 count measured among symptomatic and asymptomatic HIV-diagnosed patients were: infection through sexual contact (HR=1.61; 95%CI 1.12-2.33) and receiving posttest counseling (HR 1.71; 95%CI 1.15-2.52). Among the asymptomatic, those aged >25-30 years had significantly shortened delay (HR=2.18; 95%CI 1.50-3.18) compared with the younger age group as did those aged >30 years (HR=1.94; 95%CI 1.32-2.85). Such age effect on the delay was absent in the symptomatic group. Attempts to diagnose HIV at an earlier stage and timely CD4 count measured are needed.

The effect of geographical distance on TB patient delays in a mountainous province of China

SETTING

One hundred and twenty-nine counties in Yunnan, a mountainous province in China.

OBJECTIVE

To document the relationship between patient delays and distance to local county tuberculosis (TB) centres.

DESIGN

A computerised medical record-based study of a cohort of 10356 new smear-positive TB cases in 2005.

RESULTS

The median total delay was 71 days (interquartile range [IQR] 38-128), with a median long patient delay of 60 days (IQR 28-111) and a relatively short median health care system delay of 4 days (IQR 2-13). Older age (>40 years), being an agriculturer and poor economic status were significantly associated with longer patient delays. Risk of delay increased with increasing geographical distance, with a greater effect on relatively shorter patient delays. Using the first quartile of distance as the reference group, hazard ratios for subsequent quartiles were 0.61 (0.57-0.65), 0.30 (0.28-0.33) and 0.15 (0.14-0.17) for short patient delays (<or=60 days), and 1.04 (0.94-1.17), 0.69 (0.63-0.77) and 0.43 (0.39-0.47) for long patient delays (>60 days).

CONCLUSION

Patients living in remote areas need support to overcome the barrier posed by geographical distance, which has a greater effect in the initial phases of the disease.

Under- and over-consumption intermittent TB treatment among rural TB patients in south-west China

OBJECTIVE

To assess adherence to intermittent directly observed treatment (DOT) during the 2-month intensive phase of tuberculosis (TB) treatment in south-west rural China.

DESIGN

A cross-sectional study was conducted in Simao Prefecture, Yunnan Province, China. One hundred and thirty new TB patients registered under DOTS and treated during the 2-month intensive phase and their observers were separately interviewed at their homes using structured questionnaires. Numbers of packs of TB drugs were checked on the spot.

RESULTS

Of 130 visits, the same percentage (3.1%) of patients and their observers reported missing > or =2 consecutive weeks of treatment (prevalence-adjusted kappa = 0.94). The percentages who missed > or =20% of the packs, as reported by patients and observers, were 3.8 and 2.3, respectively (prevalence-adjusted kappa = 0.969). According to the pill count, nine patients (7%) had missed > or =20% of the packs, 10 had over-consumed TB drugs and two had lost respectively five and six packs. Eight of the 10 who had over-consumed had done so due to confusion in the days of the month, and two because they wanted a quicker recovery.

CONCLUSIONS

Intermittent regimens in China need to be more carefully monitored to avoid over-consumption of anti-tuberculosis drugs in addition to non-adherence due to under-consumption.

Root surface and coronal caries in adults with type 2 diabetes mellitus

OBJECTIVES

To determine the effect of type 2 diabetes mellitus (DM) on coronal and root surface caries and to investigate some factors suspected of being related to or interacting with DM, that may be associated with coronal and root surface caries.

METHODS

A stratified cross-sectional study was conducted in 105 type 2 diabetic patients and 103 non-diabetic subjects of the same age and gender. Coronal and root surface caries, exposed root surfaces, periodontal status, stimulated salivary functions, oral hygiene status, oral health behaviors, and counts of mutans streptococci and lactobacilli were measured.

RESULTS

Type 2 diabetic patients compared with non-diabetic subjects had a higher prevalence of root surface caries (40.0% versus 18.5%; P = 0.001), a higher number of decayed/filled root surfaces (1.2 +/- 0.2 versus 0.5 +/- 0.1; P < 0.01) and a higher percentage of generalized periodontitis (98.1% versus 87.4%; P < 0.01); but the prevalence and decayed/filled surface of coronal caries was not significantly different (83.8% versus 72.8% and 8.0 +/- 9.4 versus 6.3 +/- 7.5 respectively). The factors associated with root surface caries included type 2 DM, a low saliva buffer capacity, more missing teeth, and existing coronal caries; whereas wearing removable dentures, more missing teeth, a high number of lactobacilli, and a low saliva buffer capacity were associated with coronal caries.

CONCLUSION

Type 2 DM is a significant risk factor for root surface, but not for coronal caries. Periodontal disease should be treated early in type 2 diabetic subjects to reduce the risk of subsequent root surface caries.

The microbiological profiles of saliva, supragingival and subgingival plaque and dental caries in adults with and without type 2 diabetes mellitus

INTRODUCTION

The relationships between suspected bacteria in saliva, yeasts in oral rinse, and supragingival and subgingival plaque versus root surface and coronal caries in adults with type 2 diabetes mellitus and a non-diabetic group were explored.

METHODS

One-hundred and five patients with type 2 diabetes and 103 non-diabetic subjects were recruited; their periodontal status, plaque index and magnitude of root surface and coronal caries were assessed. Saliva and an oral rinse were cultured for mutans streptococci, lactobacilli and yeasts. Toothbrush samples of supragingival plaque and curette samples of subgingival plaque were assessed for 17 bacterial species using the checkerboard DNA-DNA hybridization method.

RESULTS

Type 2 diabetes patients had significantly more severe periodontitis, a higher plaque index and a higher prevalence and magnitude of root surface caries than non-diabetic subjects. Significantly more diabetic subjects had higher levels of Treponema denticola, Prevotella nigrescens, Streptococcus sanguinis, Streptococcus oralis and Streptococcus intermedius in their supragingival plaque than non-diabetic subjects. No significant difference was found for the organisms in saliva, oral rinse and subgingival plaque between the two groups. After adjustment for diabetic status, root surface caries was associated with an increased count of mutans streptococci, lactobacilli and yeasts in saliva and of Streptococcus mutans in supragingival plaque samples. Coronal caries was only associated with lactobacilli and yeasts in saliva.

CONCLUSION

The number of cariogenic organisms in saliva and oral rinse estimated by culture demonstrated a stronger association with both root surface and coronal caries compared to those 17 species assessed with the checkerboard method in supragingival and subgingival plaque.

Environmental factors and incidence of dengue fever and dengue haemorrhagic fever in an urban area, Southern Thailand

Using the enumeration district (ED) block level this study looked at the incidence of dengue fever and dengue haemorrhagic fever (DF/DHF) within the Songkhla municipality in Thailand. Each of the 146 blocks in this area were considered as study units and surveyed for their environmental characteristics. A total of 287 cases of DH/DHF occurring in the year 1998 were selected for this study and the location of their homes mapped. Clustering analysis showed point clustering of the homes (P<0.0001) which was probably due to high density habitation, without any actual prevalence of case clustering. There was no evidence of clustering of the ED blocks with an incidence of DF/DHF (P=0.32). DF/DHF incidence for each block was strongly associated with the percentages of shop-houses, brick-made houses and houses with poor garbage disposal (all P<0.01). DF/DHF control should be emphasized for the areas which have a predominance of these housing types.

Relationship between atopic dermatitis and wheeze in the first year of life: analysis of a prospective cohort of Thai children

BACKGROUND

Patients with atopic dermatitis show increased risk of concomitant respiratory symptoms such as wheeze and cough. However, limited data is available on respiratory symptoms in atopic dermatitis patients when the disease is in remission.

OBJECTIVE

The aim of this study was to investigate the relationship between atopic dermatitis and wheeze during periods of active disease and remission of atopic dermatitis.

METHODS

The study formed part of the Prospective Cohort Study of Thai Children (PCTC) involving children born during the period October 2000 to September 2002. The principal caregiver in each family was identified and interviewed about socioeconomic factors, paternal health, and exposure to tobacco smoke. Data on wheeze and atopic dermatitis were collected from questionnaires administered at 6 and 12 months after birth.

RESULTS

Of the 4245 live births included in the PCTC cohort, 4021 (94.7%) participated in the follow-up survey at age 6 months and 12 months. The prevalence of wheeze and eczema were 13.8% and 7.4%, respectively. There was also a significant association between current atopic dermatitis and wheeze in the same period (P < .01). However, no significant association was observed between previous atopic dermatitis and wheeze when atopic dermatitis was in remission.

CONCLUSION

There is a significant increase in the risk of wheeze in infants with current atopic dermatitis but not in those in whom the disease is in remission.

Social impact of tuberculosis in southern Thailand: views from patients, care providers and the community

BACKGROUND

There is growing recognition that attention to social and behavioral factors in tuberculosis (TB) control needs to complement biomedical emphasis on better drugs, vaccines and new diagnostic tools.

METHODS

Using qualitative methods, we conducted 10 focus groups and seven individual interviews to explore how TB is perceived or experienced in southern Thailand. Participants included male and female patients with TB, patients with AIDS, TB care providers, family members of patients with TB, religious leaders (Buddhist and Muslim), and unaffected community members.

RESULTS

Responses informed two conceptual frameworks on stigma and social support. The first model dichotomized the meaning of TB into 'good' and 'bad' factors related to social support and stigma, respectively. The second model identified three themes--disease severity, religion, and knowledge of TB--linked to either stigma, social support, or both.

CONCLUSION

Social support as a facilitator and stigma as a barrier are diametrically opposed concepts that need to inform TB care and treatment. Interventions to reduce stigma and promote social support at the patient, household, community, and health care system levels should be part of future efforts in the control of TB in Thailand.

Impact of surgeon-specific feedback on surgical site infection rates in Thailand

Data on surgeon-specific feedback on surgical site infection (SSI) rates are not currently available in Thailand. The authors conducted a before and after study among patients undergoing surgery in seven Thai hospitals to examine whether a feedback system to surgeons could reduce SSI rates. After a six-month surveillance period, surgeons were provided with their own SSI rates and standardized infection ratios (SIRs). The criteria of the National Nosocomial Infection Surveillance (NNIS) system were used to determine SSI rates, and the SSI rates were compared with the NNIS report in terms of the SIR. To compare the SIR before and after intervention, the SIR ratio was calculated and logistic regression analysis was used to estimate the relative impact of surgeon-specific feedback, adjusting for patient sex, patient age, degree of wound contamination, American Society of Anesthesiologists' score, duration of operation, type of operation, use and duration of antibiotic prophylaxis, and length of pre-operative stay. After confidential feedback to surgeons for six months, SSI rates and the SIR remained unchanged. The SSI rate in the pre-intervention period was 1.7 infections/100 operations and the corresponding SIR was 0.8 [95% confidence intervals (CI)=0.6-0.9]. In the post-intervention period, the SSI rate was 1.8 infections/100 operations, with a corresponding SIR of 0.8 (95%CI=0.7-0.9). The SIR ratio was 1.0. The relative risk of SSI after surgeon-specific feedback suggested that this intervention had no effect (adjusted relative risk=1.02, 95%CI=0.77-1.35). Feedback to surgeons on their SSI rates did not reduce the rates of such infections in Thailand.

Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform

SETTING

Seven public hospitals in a southern province of Thailand.

OBJECTIVES

To measure delays in tuberculosis (TB) diagnosis and to examine the factors associated with these delays, with special focus on the effect of drug store utilisation and health insurance coverage on patient delay.

DESIGN

A total of 202 newly diagnosed smear-positive and smear-negative pulmonary TB patients were interviewed using a structured questionnaire.

RESULTS

The median patient, health system and total delay were 4.4, 2.8 and 9.4 weeks, respectively. Risk factors for patient delay were age 31-60 years, having mild illness, previous similar symptoms and first presenting to non-qualified providers. Health insurance was not associated with a shorter patient delay. Health system delay was significant longer for patients with health insurance and first presenting to low-level public health facility (i.e., community hospital, health centre, primary care unit or private clinic/hospital).

CONCLUSIONS

The public should be informed how to recognise TB symptoms to shorten patient delay. The Thai National Tuberculosis Control Programme needs to supervise the private health sector, including drug stores, for better TB control. Drug store personnel need to be trained to recognise and refer TB suspects. The capacity of low-level public health facilities and private doctors in TB diagnosis needs improvement. A proper referral system should be developed.

Clinical drug interactions in outpatients of a university hospital in Thailand

BACKGROUND

A clinical event is likely to occur in patients receiving a pair of drugs, that have the potential to cause an interaction. The occurrence of a clinical drug-drug interaction in outpatients of university hospitals in Thailand is unknown.

PURPOSE

To investigate the occurrence of a clinical event associated with drug-drug interactions in outpatients at a Thai university hospital.

METHODS

A case-control study was established. The case was a sample group, randomly selected from a 1-year sample of outpatient prescriptions containing 'significance-1' potential drug-drug interactions, whereas the control was from the same year but with no potential drug interactions. Medical records of the cases and the controls were reviewed for an adverse event (AE) using a newly developed review form. The odds ratio of occurrence of the AE between the cases and the controls was determined. The AE was assessed for its possibility of being caused from a drug-drug interaction.

RESULTS

The most common specific AE in both the cases and the controls was cough. An unplanned revisit to outpatient department or emergency room was found to be the most common general AE. The odds ratio of the occurrence of an AE in the cases, compared with the controls, was 1.495 (95% CI: 0.917-2.438). The possibility that the AEs resulted from drug interactions in the case group was nine 'probable' patients and 15 'possible' patients, whereas that in the control group was eight 'possible' patients. The most common interacting drug pair was isoniazid-rifampin with an increase in serum hepatic enzymes as the corresponding AE.

CONCLUSIONS

Despite outpatients receiving drug pairs with a high potential for adverse interactions, the rate of occurrence of clinical drug interaction events was low.

Pharmacoepidemiologic study of potential drug interactions in outpatients of a university hospital in Thailand

BACKGROUND

Drug-drug interaction is a potential cause of adverse drug reactions. The incidence of such drug interactions in university hospitals in Thailand is unknown.

PURPOSE

To estimate the rate of potential drug-drug interactions in outpatients of a typical Thai university hospital, and to identify risk factors for such interactions in Thai patients.

METHODS

One-year outpatients' prescription data were retrieved from the hospital computer records. Potential drug interactions were identified using the existing drug-interaction database system. Potential interactions within a specific prescription and involving drugs prescribed 1-, 3- and 7-day earlier were searched for. Possible associations between occurrence of an interaction and a patient's age and gender and the number of items on the prescription were explored.

RESULTS

The overall rate of potential drug interactions was 27.9% with a maximal value of 57.8% at the Department of Psychiatry. The rate of the most potentially significant interactions was 2.6%, being the highest in the Department of Medicine (6.0%), with isoniazid vs. rifampin as the most common interacting combination. The rate increased with the patient's age and prescription size (P=0.000). The odd's ratio of having at least one potential drug interaction was 1.8 (64.2%) when age increased by 20 years (P=0.000) and 2.8 (165.7%) when another drug was added (P=0.000). The rate of potential drug interactions was the same for both genders. The rate of potential drug interactions detected across prescriptions was higher than within prescriptions and was dependent on the time interval between prescriptions.

CONCLUSIONS

Potential drug interactions were common in our sample of patients. The rate of such interactions increased with the number of drugs prescribed and the patient's age.

Deteriorated tuberculosis drugs and management system problems in lower southern Thailand

SETTINGS

Three institutes, 11 hospitals and 38 community hospitals in southern Thailand.

OBJECTIVES

To assess the quality of tuberculosis (TB) drugs used in TB treatment facilities in southern Thailand and their TB drug management systems.

DESIGN

Cross-sectional study utilising interviews, document review, inspection of drug storage, visual examination of TB drugs, and laboratory analysis of samples of isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA) and ethambutol (EMB).

RESULTS

No stock-out of TB drugs was found at any level. Thirteen (25%) hospitals/institutes removed coated EMB tablets from their foil packages for daily dose packing. Eleven (21%) hospitals/institutes bisected 400 mg coated EMB tablets before dispensing as a non-available 200 mg tablet. On the day of inspection grossly deteriorated EMB was observed in 44% of hospitals/institutes. All samples, except 14% of EMB, passed content assay tests. All INH and EMB samples passed the dissolution tests, but 62% of RMP samples and 26% of PZA samples failed.

CONCLUSIONS

Sub-standard deteriorated TB drugs are a serious problem for TB control. TB drugs examined in the study area were not managed properly. Education on TB drug packaging and storage, and non-destructive systems in TB drug distribution, storage, inventory control, quality assurance and supervision are essential interventions.

Integrated counseling and screening for tuberculosis and HIV among household contacts of tuberculosis patients in an endemic area of HIV infection: Chiang Rai, Thailand

SETTING

Combined hospital-based and home visit, Chiang Rai, Thailand.

OBJECTIVE

To describe the results of screening of tuberculosis (TB) and HIV infection among household contacts of TB patients in an area endemic for HIV.

DESIGN

Consecutive new smear-positive TB patients were interviewed and their household contacts were screened for TB including tuberculin skin test (TST), chest radiography, and sputum examination. Voluntary HIV testing and counseling was also performed.

RESULTS

Of 499 pulmonary TB index cases, 197 (39.5%) were HIV-positive; 1200 household contacts were screened for TB and 890 (74.2%) agreed to HIV testing. The prevalence of TST induration > or = 10 mm and active TB among household contacts of HIV-positive pulmonary TB cases were 46.2% (225/487) and 2.9% (14/490), and among household contacts of HIV-negative TB cases were 62.1% (438/705) and 4.4% (31/710), respectively. Higher HIV prevalence was found among contacts of HIV-positive TB patients than among household contacts of HIV-negative TB index cases (52/376, 13.8% vs. 13/514, 2.5%) (P < 0.001). Spouses of HIV-positive TB cases had the highest HIV prevalence (36/74, 48.6%). Among the household contacts who were HIV-positive, 9.5% (7/74) had active TB.

CONCLUSION

Integrated counseling and screening for TB and HIV should be provided for household contacts of TB patients in an HIV endemic area.

Associated factors of tooth wear in southern Thailand

The purpose of this study was to evaluate the possible risk factors connected with tooth wear. Using the Tooth Wear Index (TWI) and the charting of pre-disposing factors tooth surface loss was recorded in 506 patients, of the Dental Hospital, Prince of Songkla University. We found that age, sex, number of tooth loss, frequency of alcohol, sour fruit and carbonate intake were significant risk factors. Regarding the tooth position, the first molar showed the greatest degree of wear, while the canine and premolar showed the least, respectively. The occlusal surface showed the greatest wear and the cervical, lingual and buccal surfaces showed the least, respectively.

Practice of directly observed treatment (DOT) for tuberculosis in southern Thailand: comparison between different types of DOT observers

SETTING

A government health system in southern Thailand where the directly observed treatment, short-course (DOTS) strategy has been implemented.

OBJECTIVE

To compare the practice of actual directly observed treatment (DOT) and the observer sustainability for different types of observer.

METHODS

During 1999-2000, 411 patients with new smear-positive pulmonary tuberculosis were followed up. The patients and/or their observers were interviewed about the presence of any person with the patient during drug intake and the practice of watching the patient swallowing the medicine (actual DOT). Data were recorded monthly and analysed by Cox and logistic regression models.

RESULTS

For health personnel (HP), community member (CM), and family member (FM) observers, the proportions who did not practise actual DOT were respectively 11%, 23%, and 35%, and the proportions who changed to no observer or self administration were respectively 11%, 1%, and 2%, during the first 9 months of treatment. Health personnel had the lowest risk of not practising actual DOT (odds ratio HP/FM 0.1, 95%CI 0.1-0.2; CM/FM 0.9, 95%CI 0.5-1.6) but the highest risk for change to self administration.

CONCLUSION

To increase the coverage of actual DOT, strategies are needed to maintain health personnel as the DOT observers and to promote actual DOT among family member observers.

Implementing the universal health coverage: which source of information is more reliable?

The implementation of universal health coverage needs accurate data on the distribution of health benefit coverage, particularly the uninsured. The national surveys and routine reports are two important sources of information ready for use. This study shows the validation of data from two sources. The data from national household surveys on the medical welfare, the health card and the social security schemes were validated with the routine report data of the Ministry of Public Health (MOPH) and the Social Security Office (SSO) by provinces. There were considerable differences between these data sets. The national survey data gave a 1.5 times higher estimate than the report data of the MOPH and the SSO. Financial implications of using inaccurate data to implement the universal health coverage could be huge, depending on the capitation rate.

High-risk childbirth practices in remote Nepal and their determinants

This study describes birth-related practices and their determinants among women in the Jumla district of Nepal. Data were derived from a household survey in 1996. Of 939 married women of reproductive age, 657 who had given birth to their last child during the previous five years were included in the analysis. Qualitative information was further obtained from traditional birth attendants (TBAs), mothers-in-law, community leaders and pregnant women. High-risk practices were common and related to local custom and lack of knowledge on the importance of cleanliness. Husband's level of education greater than fifth grade significantly reduced the high-risk practices in all stages of childbirth, independent of other socio-economic, biological and village variables.

Survey of knowledge and practice on oral contraceptive and emergency contraceptive pills of drugstore personnel in Hat Yai, Thailand

In Thailand, oral contraceptive (OC) and emergency contraceptive pill (ECP) are available as over-the-counter (OTC) drugs, and drugstores share 30% of services. While the rate of dispensing contraceptive pills has increased, the knowledge and awareness of ECP use is limited among users and providers. The objective of this study was to assess knowledge and practice of drugstore personnel on providing OC and ECP, in order to improve the quality of services. Drugstores located in Hat Yai District, Songkhla Province, Southern Thailand, were the accessible population. There were 109 drugstores, half of them owned by pharmacists. The population was stratified by owner (pharmacist or non-pharmacist) and randomly selected to obtain a sample size of 30 drugstores for each class. Two study methods, questionnaire interview and secret shopping, were used to measure knowledge, and practice, respectively. History-taking, drug-choosing, and advice-giving were the domains measured. The results demonstrated that knowledge on OC was fair, but that on ECP was poor. Pharmacists had better knowledge of proper history taking and ECP indication than non-pharmacists. OC and ECP provision were inappropriately practised in drugstores in the study area. A majority of drugstores were mainly owned by non-pharmacists. For OC practice, drug-choosing was good, but history-taking and advice-giving were poor in both groups. Although both groups dispensed ECP poorly, pharmacists dispensed significantly better than non-pharmacists. Among non-pharmacist staff, the average scores of OC advice-giving, and ECP dispensing, were statistically significantly better among those working in pharmacist-owned drugstores. Both knowledge and practice on OC and ECP should be improved in both types of drugstores in the study area.

Follow up of water use in a tin mining area affected with arsenic poisoning

Ron Phibun district in southern Thailand has been known as an endemic area for arsenic contamination. The government has been trying to improve the situation by encouraging the use of rainwater and piped water. This study aimed to document the change of water use and to identify factors associated with safe water use in 1997 compared to that in 1994. Home visits and face-to-face questionnaire interviews were undertaken. Information on water use for drinking, cooking, washing food and washing utensils in 1994 and 1997 was obtained. Among 3,849 households from which data could be obtained (estimated 79% of total households), the percentages of using safe water (including water from bottled rain water, piped and artesian well water) for drinking and cooking rose from 72.5 and 57.9 in 1994 to 93.6 and 80.9 in 1997, respectively. The percentages for washing foods and for washing utensils rose from 28.6 and 20.5 to 59.1 and 53.8, respectively. In 1997, percentage of households using piped water for drinking and cooking was still low (3.6 and 12.3) compared to those using piped water for washing food and utensils (39.1 and 43.6). Multivariate analysis shows that independent factors of the household predicting safe water use are: high arsenic area, near main road and having piped water installed. The influence of these factors (as judged by the level of odds ratio) operates more or less equally on water use for all purposes, except that installation of piped water has more influence on washing water than drinking and cooking water. We conclude that safe water supply in the area is still inadequate. Even if piped water is installed, it is often not used for drinking and cooking. The reasons for not using piped water for drinking and cooking need to be identified.

Infant death rates and animal-shed delivery in remote rural areas of Nepal

This article outlines a community-based retrospective study in a remote area of Nepal and describes local birth practices and their impact on infant mortality. Data collection was carried out in two steps, a household survey from September to October 1996 and a qualitative research phase. Data collected include socio-economic background, reproductive history, birth practices and child survival. Among 3007 live-born children, 660 (22%) died before their first birthday. In keeping with local customs, approximately half of the children were delivered in an animal shed and the other half in the home. Children born in an animal shed were at significantly higher risk of dying than were those born in the home even after adjusting for socio-economic status and biological variables. The association was stronger in the neonatal period (OR = 2.8, 95% CI 1.9-4.1) than during the post-neonatal period (OR= 1.3, 95% CI 1.02-1.6). The preparation of the delivery place was inadequate and thereby facilitated infection of both the newborn and the mother. Traditional norms and animal-shed delivery practices are common in the Jumla community. The reasons addressed for giving birth in the animal shed included (1) Household Deity's anger if delivery takes place in the home and (2) easy to clean the shed following the birth.

Community-based self-reported symptoms of antepartum morbidities; the health burden and care-seeking patterns of rural Bangladeshi women

In Bangladesh there is a dearth on information relating to complications during pregnancy. We followed up 1,019 pregnant women in rural Bangladesh sampled from all the 4 old administrative divisions of the country. Trained female interviewers visited households of the pregnant women at four-week intervals and interviewed them for their current pregnancy-related complications. Out of a total of 3,812 antepartum visits the percentage of reported symptoms of bleeding, fits and convulsions, excessive vomiting, fever >3 days, urinary problems, palpitations and symptomatic anemia were 0.3, 0.7, 1.4, 4.0, 26.8, 46.5 and 78.3 respectively. Morbidities were considered to cause a health burden if they imposed constraints in daily activities of the pregnant women and they were weighted according to intensity of the constraint. For each morbidity, the mean intensity of burden per episode and the population burden per 1,000 person months of observation of all the women were calculated. For common sustaining morbidities like symptomatic anemia and urinary problems the population burden was much heavier than that for more serious but rare morbidities like bleeding and convulsions. Among the visits in which the women had any symptoms, the percentages of care-seeking for less frequently reported morbidities such as fits and convulsions, bleeding, fever >3 days, excessive vomiting were about 74, 50, 34 and 33% respectively, whereas those for more commonly reported complications such as urinary problems, symptomatic anemia and palpitations were less than 20%. Care for these morbidities was mostly sought from untrained providers.

Biotypes of oral Candida albicans isolated from AIDS patients and HIV-free subjects in Thailand

This study was conducted to examine biotypes and antifungal susceptibility patterns of oral Candida albicans isolated from HIV-infected patients, HIV-free patients with candidiasis and healthy subjects. All isolates were biotyped using a typing system based on enzyme profiles, carbohydrate assimilation patterns and boric acid resistance. Thirty-eight biotypes were found amongst 218 oral C. albicans isolates. The major biotype found was A1S, which accounted for 32.6% of all isolates, and this biotype was the most common in all groups. There was a greater variety of biotypes of C. albicans in the HIV-infected group than in the other groups; however, there was no statistically significant difference between the groups. The minimum inhibitory concentrations (MICs) of a total of 118 isolates were determined for amphotericin B and for ketoconazole using the National Committee for Clinical Laboratory Standards (NCCLS) broth macrodilution method and the E-test. When the antifungal susceptibility patterns among the groups were compared, a statistically significant difference was found only with amphotericin B. The median MIC of amphotericin B in the HIV-infected group was higher than in the healthy group (P=0.013, NCCLS method; P=0.002, E-test). However, this difference in sensitivity was not restricted to any sub-type investigated. Our results showed that the biotype patterns of C. albicans isolates that colonize HIV-infected patients are similar to those of HIV-free subjects, and there is no relationship between antifungal susceptibility patterns and the biotypes.

Characteristics of repeat aborters in Vietnam

Two hundred and sixty married women seeking induced abortion service in Hanoi, Vietnam were interviewed to determine the magnitude of repeat induced abortion and explore selected characteristics of the repeat aborters. Seventy-one percent of the sample reported having had at least one previous induced abortion. After adjustment for age and number of living children, poor attitudes toward contraception, low use of modern contraceptives and failure of contraception were shown to be significantly associated with repeat induced abortion. Woman's age, number of living children, contraceptive knowledge and experience and desire for no more children were positively related to repeat induced abortion. Socio-demographic characteristics were not related to repeat induced abortion. Improvement of attitudes toward contraception, persuasion to use modern contraception and promotion of contraceptive effectiveness are recommended strategies to prevent repeat induced abortion.

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 > or =31, 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.