Hospitals In Southern Thailand Research Articles

Clinical outcomes of 3-year experience of targeted temperature management in patients with out-of-hospital cardiac arrest at Songklanagarind Hospital in Southern Thailand: an analysis of the MICU-TTM registry.

BackgroundOut-of-hospital cardiac arrest (OHCA) is one of the leading causes of intensive care unit admission, which results in high hospital mortality. Targeted temperature management (TTM) was introduced several years ago and is considered to improve neurological and mortality outcomes. This management process was implemented in our hospital in 2012, which was expected to improve the standard of care in OHCA patients.PurposeWe aimed to report the clinical and mortality outcomes after TTM was introduced to our hospital in 2012.Patients and methodsAn analysis of data from the Medical Intensive Care Unit-TTM registry between 2012 and 2015 was performed. After successful cardiopulmonary resuscitation, TTM was applied to all OHCA patients regardless of causes if there was no contraindication. The Cerebral Performance Category scale score and other clinical outcomes were recorded and analyzed.ResultsOut of 23 patients, 87% were male and the mean age was 54.5±18.1 years. The causes of OHCA from cardiac etiology comprised 52.2%. The most common initial cardiac rhythm was ventricular fibrillation (47.8%). The survival rate to hospital discharge was 47.8% (11/23), but neurological outcomes were in a persistent vegetative state (8/11, 72.7%). The group with poor neurological outcomes had a significantly higher Acute Physiologic Assessment and Chronic Health Evaluation II score than the group with good neurological outcomes (22.9±4.2 vs 16.0±3.6, P=0.01). In the multivariate analysis, initial shockable rhythm was associated with survival at hospital discharge (odds ratio 10.1, 95% confidence interval 1.1–94.3, P=0.04).ConclusionTTM in OHCA patients gave better mortality benefits compared to our previous records, despite poor neurological outcomes. Ventilator-associated pneumonia was the major complication of TTM. Therefore, TTM should be considered in OHCA patients, especially in shockable rhythms, after return of spontaneous circulation.

A study of cutaneous manifestations among febrile neutropenic patients: A five-year retrospective review in a single tertiary university hospital in Southern Thailand

A study of cutaneous manifestations among febrile neutropenic patients: A five-year retrospective review in a single tertiary university hospital in Southern Thailand

Development of a web-based epidemiological surveillance system with health system response for improving maternal and newborn health: Field-testing in Thailand.

Surveillance systems are yet to be integrated with health information systems for improving the health of pregnant mothers and their newborns, particularly in developing countries. This study aimed to develop a web-based epidemiological surveillance system for maternal and newborn health with integration of action-oriented responses and automatic data analysis with results presentations and to assess the system acceptance by nurses and doctors involved in various hospitals in southern Thailand. Freeware software and scripting languages were used. The system can be run on different platforms, and it is accessible via various electronic devices. Automatic data analysis with results presentations in the forms of graphs, tables and maps was part of the system. A multi-level security system was incorporated into the program. Most doctors and nurses involved in the study felt the system was easy to use and useful. This system can be integrated into country routine reporting system for monitoring maternal and newborn health and survival.

Assessment of multimedia-supported intervention in Muslim diabetic patients treated with insulin

This study aimed to evaluate the effect on diabetic care of an educational DVD in Jawi, the primary spoken language of Muslims in the study area, and pharmacist intervention among Muslim patients with diabetes treated with insulin. Type 2 diabetes Muslim patients on insulin treatment and poor glycemic control (N = 143) in one hospital in southern Thailand were recruited to participate in a 6-month-period pre- and post-intervention study. For the intervention, the pharmacist provided the patients with education using a DVD and then asked them to show how to use insulin injection. Afterward, the pharmacist would correct the techniques for patients individually. At 6 months after intervention, significant reductions in glycated hemoglobin (HbA1c) (8.31 ± 1.40 to 7.19 ± 1.15 %, P < 0.001), fasting blood glucose (FBG) (195.06 ± 86.14 to 115.81 ± 11.48 mg/dL, P < 0.001), systolic blood pressure (130.62 to 126.57 mmHg, P = 0.004), triglycerides (183.36 ± 90.48 to 182.31 ± 90.68 mg/dL, P < 0.001), and total cholesterol (199.57 ± 68.77 to 194.97 ± 64.77 mg/dL, P = 0.006) were detected in patients who received the intervention. Increased low-density lipoprotein cholesterol (LDL-C) level (P = 0.028) but no significant change in high-density lipoprotein cholesterol (HDL-C) were found (P = 0.900). Moreover, medication adherence, diabetes knowledge, and skill in using insulin injection improved at the end of the study (P < 0.001). In conclusion, the combination of language-specific educational DVD and pharmacist intervention appears to improve the short-term outcomes of diabetes care in Muslim patients on correctional insulin therapy.

Lived experience of caring for dying patients in emergency room.

Dying often occurs in hospitals and frequently in emergency rooms. Understanding caring for critical and dying patients is necessary for quality nursing. This study described the meaning of nurses' lived experience of caring for critical and dying patients in the emergency rooms. This study was conducted in three emergency rooms of tertiary hospitals in southern Thailand. Twelve nurses met the inclusion criteria: nurses working in emergency room for at least 2 years, and experienced caring for critical and dying patients in an emergency department. Data were collected using in-depth individual interviews. Data transcription and analysis used van Manen's hermeneutic phenomenological approach. Trustworthiness was established following Lincoln and Guba's criteria. Experiences of caring for critical and dying patients revealed four thematic categories: defying death; no time for palliative care; lacking support for family; and privacy for peaceful deaths. These thematic categories reflected van Manen's four lived worlds of body, time, relations and space. The study described the meaning of the experience of caring for critical and dying patients while supporting the development of nursing knowledge for palliative and end-of-life care in emergent settings. Findings of the study influence nursing policies toward enhancing education of nurses regarding palliative and end-of-life care in emergency settings. These findings can also influence the value of caring-healing environments for critical and dying patients and their families. Policies can focus on practice and education of families particularly about end-of-life care for critical and dying patients.

Using an evidence-based care bundle to improve initial emergency nursing management of patients with severe traumatic brain injury.

To test the feasibility of an evidence-based care bundle in a Thai emergency department. The specific objective of this study was to examine the impact of the implementation of the care bundle on the initial emergency nursing management of patients with severe traumatic brain injury. A care bundle approach is one strategy used to improve the consistency, quality and safety of emergency care for different patients groups, however, has not been tested in patients with severe traumatic brain injury. A pretest/post-test design was used. The study intervention was an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury. Nonparticipant observations were conducted between October 2012-June 2013 at an emergency department of a 640 bed regional hospital in Southern Thailand. The initial emergency nursing care was observed in 45 patients with severe traumatic brain injury: 20 patients in the pretest period and 25 patients in the post-test period. There were significant improvements in clinical care of patients with severe traumatic brain injury after implementation of the care bundle: (1) use of end-tidal carbon dioxide monitoring, (2) frequency of respiratory rate assessment, (3) frequency of pulse rate and blood pressure assessment, and (4) patient positioning. This study demonstrated that implementation of an evidence-based care bundle improved specific elements of emergency nurses' clinical management of patients with severe traumatic brain injury. The study suggests that a care bundle approach can be used as a strategy to improve emergency nursing care of patients with severe traumatic brain injury.

Association between Intraoperative and Post-Anesthetic Care Unit Respiratory Events among 12,641 Children in Southern Thailand

Aims: The association between intraoperative respiratory events (IRE) and post-anesthetic care unit respiratory events (PARE) in children as well as the risk factors for PARE have not been described. The objectives of this study were to describe the association between IRE and PARE and to identify the risk factors of PARE in children at a tertiary care hospital in southern Thailand. Methodology: A historical cohort study based on the surveillance anesthetic database and chart review of children who received surgery at Songklanagarind Hospital during January 2005 to December 2011 was conducted. Demographic, surgery and anesthesia-related data were Original Research Article Oofuvong et al.; BJMMR, 6(11): 1101-1112, 2015; Article no.BJMMR.2015.288 1102 collected. The association between IRE and PARE and other potential risk factors were analyzed using cross tabulation. Multivariate logistic regression was employed to identify independent predictors for PARE, indicated by adjusted odds ratios (aOR) and their 95% confidence intervals (CI). Results: Overall, perioperative respiratory event (PRE) occurred in 531 out of 14153 children (315 IRE, 348 PARE). The association between PARE and IRE was strong, with adjusted odds ratios ranging from 3.1 (laryngospasm) to 18.5 (desaturation). Anesthesia-related risk factors for PARE were ASA classification 3 (aOR=3.1, 95%CI=1.9-5.0), jet ventilation (aOR=3.4, 95%CI=1.6-7.1), intubation with succinylcholine vs non-depolarizing muscle relaxant (aOR=1.9, 95%CI=1.4-2.5), use of intraoperative morphine vs fentanyl (aOR=2.4, 95%CI=1.7-3.3) and duration of anesthesia ≥ 3 hours (aOR=3.2, 95%CI=2.1-4.9). Conclusion: The magnitude of association between IRE and PARE was high. Increased vigilance and close monitoring by anesthesia personnel in high risk children and high risk surgery may prevent IRE and therefore also PARE, so that overall PRE can be reduced. Preventable risk factors for PARE such as using succinylcholine and morphine can be managed under discretion of the anesthesiologist.

Acute respiratory failure and active bleeding are the important fatality predictive factors for severe dengue viral infection.

ObjectiveTo determine the outcome of severe dengue viral infection (DVI) and the main dengue fatality risk factors.Study designThe medical records of patients aged <15 years admitted to Songklanagarind Hospital in southern Thailand during 1989–2011 were reviewed. Patients who had dengue hemorrhagic fever (DHF) grades III–IV, organ failure (cardiovascular, respiratory, liver, renal or hematologic), impaired consciousness, or aspartate aminotransferase more than 1,000 units/L, were classified as having severe DVI. To determine the fatality risk factors of severe DVI, the classification trees were constructed based on manual recursive partitioning.ResultsOf the 238 children with severe DVI, 30 (12.6%) died. Compared to the non-fatal DVI cases, the fatal cases had higher rates of DHF grade IV (96.7% vs 24.5%), repeated shock (93.3% vs 27.9%), acute respiratory failure (ARF) (100% vs 6.7%), acute liver failure (ALF) (96.6% vs 6.3%), acute kidney injury (AKI) (79.3% vs 4.5%), and active bleeding requiring blood transfusion (93.3% vs 5.4%), all p<0.01. The combined risk factors of ARF and active bleeding considered together predicted fatal outcome with sensitivity, specificity, and negative and positive predictive values of 0.93 (0.78–0.99), 0.97 (0.93–0.99), 0.99 (0.97–1.00), and 0.82 (0.65–0.93), respectively. The likelihood ratios for a fatal outcome in the patients who had and did not have this risk combination were 32.4 (14.6–71.7) and 0.07 (0.02–0.26), respectively.ConclusionSevere DVI patients who have ARF and active bleeding are at a high risk of death, while patients without these things together should survive.

Impact of antibiotic exposure on occurrence of nosocomial carbapenem-resistant Acinetobacter baumannii infection: a case control study.

Carbapenem-resistant Acinetobacter baumannii (CRAB) infection is one of the most important healthcare associated diseases worldwide. Although antibiotic use is recognized as a risk factor for CRAB infection, the impact of antibiotic class and length of use on CRAB infection is still unclear. A case-control study was conducted in adult intensive care units and general wards of Songklanagarind Hospital, a tertiary-care hospital in southern Thailand, to investigate the effect of different antibiotic exposure and the duration of use on the risk of developing CRAB infection. Cases were defined as patients with carbapenem-susceptible A. baumannii (CSAB) or CRAB infection. Controls were randomly selected from patients and matched 1:1 with cases using ward and date of admission. Multinomial logistic regression was used to compute relative risk ratios (RRR) and 95% confidence intervals (CI) for CRAB infection. Of 197 cases with A. baumannii infection, there were 139 with CRAB infection and 58 with CSAB infection. Compared to the control group, use of fluoroquinolones, broad-spectrum cephalosporins and carbapenems for more than three days increased the risk of CRAB infection with RRR (95% CI) of 81.2 (38.1-862.7), 31.3 (9.9-98.7) and 112.1 (7.1-1770.6), respectively. The RRR (95% CI) for one to three day treatment of fluoroquinolones, broad-spectrum cephalosporins and carbapenems were 5.4 (0.8-38.7), 6.2 (0.1-353.2) and 63.3 (15.6-256.9), respectively. Long-term use of certain antibiotics and even short term use of carbapenems increased the risk of CRAB infection. In this setting, use of these antibiotics, especially carbapenems, should be limited to reduce CRAB infection.

Effects of a Brief Intervention for Substance Use on Tobacco Smoking and Family Relationship Functioning in Schizophrenia and Related Psychoses: A Randomised Controlled Trial

Surveys indicate that substance use is prevalent in populations with schizophrenia. Family members may be able to support brief interventions (BI).We conducted a randomised controlled trial with 6-month follow-up among adult patients with schizophrenia and related psychoses who were referred to two hospitals in southern Thailand. Patients with psychosis were screened using the Alcohol Smoking and Substance Involvement Screening Test (ASSIST). 169 participants (all at moderate substance risk on the ASSIST) were randomised to receive simple advice (the clinics' treatment-as-usual, TAU condition), or single-session brief intervention (BI), or a single-session BI with family support (BI-FS).Given observed substance use, the primary outcome was the ASSIST tobacco smoking involvement score (SIS). Secondary outcomes were cigarettes smoked per day, change motivation (Taking Steps from the Stages of Change and Treatment Eagerness Scale), and DSM-IV Axis V Global Assessment of Relational Functioning (GARF).At follow-up, BI-FS participants reported a lower SIS (mean difference, −2.82, 95% confidence interval [CI] −4.84 to −0.81; Glass' effect size [Δ]=0.57, 95% CI 0.19 to 0.95), smoked fewer cigarettes per day (mean difference −3.10, 95% CI −5.45 to −0.74; Δ=0.56, 95% CI 0.18 to 0.94), had greater change motivation (mean difference 3.05, 95% CI 0.54 to 5.57; Δ=0.41, 95% CI 0.03 to 0.79) and GARF (mean difference 6.75, 95% CI 1.57 to 11.93; Δ=0.54, 95% CI 0.16 to 0.92). The BI-FS group also had better relational functioning in comparison to those receiving BI only (mean difference 5.44, 95% CI 0.20 to 10.67; Δ=0.46, 95% CI 0.08 to 0.84).In schizophrenia and related psychoses, a brief intervention supported by a family member reduces smoking involvement, cigarette smoking intensity, and increases change motivation and relational functioning.

INTERNALISED STIGMA IN YOUNG PEOPLE AT HIGH RISK OF DEVELOPING PSYCHOSIS: FINDINGS FROM A COGNITIVE THERAPY TRIAL

To develop a scale to measure the burden of care for caregivers of patients with dementia and explore its factor structure.The initial draft of the Thai dementia patients’ caregiver burden (Thai-DCAB) scale was developed based on literature review, in-depth interviews and expert opinions. The drafted scale was administered to 203 caregivers of dementia patients treated at two large public hospitals in southern Thailand. An exploratory factor analysis using maximum likelihood extraction with varimax rotation was conducted. The reliability of the scale was assessed using Cronbach's alpha.The Thai-DCAB scale consisted of 18 questions. Three factors were obtained, covering psychological, physical and financial burdens of the caregivers in taking care of dementia patients. These three factors accounted for 67% of the variance. The Cronbach's alpha coefficient was 0.95.The Thai-DCAB scale has high internal consistency and captures key theoretical constructs of the perceived burden among caregivers of patients with chronic and deteriorating dementia and in accordance with the social and cultural contexts and the way of life of the Thai people.

Latex sensitization and risk factors in female nurses in Thai governmental hospitals

Exposure to latex allergens in latex gloves can cause occupational health problems in nurses, yet latex gloves are still widely used in Thai hospitals. Therefore, we conducted a study to determine the prevalence of latex sensitization in nurses and identify risk factors associated with sensitization. A questionnaire, providing information on personal characteristics, ill-health, working conditions and symptoms related to latex product use, was administered to 363 female nurses working in two tertiary hospitals in southern Thailand. Latex sensitization was confirmed using a solid phase immunoassay to detect anti-latex IgE antibodies. Total glove protein levels were determined by using a modified Lowry method and latex aeroallergens by a competitive inhibition immunoassay. The overall prevalence of latex sensitization was 4.4%. Respiratory symptoms related to latex glove use were significantly associated with latex sensitization (OR = 5.5, 95% CI: 1.57-19). Total glove protein levels ranged 87.8-250.8 μg protein/dm(2). The prevalence of latex sensitization was higher (6.6% vs. 2.2%) in the hospital where gloves with higher protein levels (82-438 μg/g vs. 86-170 μg/g) were used. Furthermore, latex sensitization prevalence increased from 3% to 5% with increased average departmental aeroallergen concentrations. Latex sensitization prevalence in Thai nurses was higher than previously reported. Respiratory exposure seems to play an important role, in addition to dermal exposure. If latex gloves cannot be replaced by non-latex alternatives, replacement with gloves with lower protein content should be considered.

Multifaceted intervention to implement indicators of quality of care for severe pre-eclampsia/eclampsia

ObjectiveTo assess the acceptability of implementing indicators of quality of care for severe pre-eclampsia/eclampsia to health providers, and to evaluate the effect of a multifaceted intervention on adherence to these indicators. MethodsA multifaceted approach was used to implement indicators of quality of care for severe pre-eclampsia/eclampsia that were relevant to both district and referral hospitals. Healthcare providers at 9 hospitals in Southern Thailand rated the acceptability and priority of each indicator. In addition, medical records were reviewed before and after the intervention. ResultsMore than 90% of the indicators were considered to be acceptable by the 145 health providers who participated in the study. After the intervention, adherence to most indicators was significantly increased. However, adherence after the intervention was lower than 80% for one-third of the indicators at district hospitals, compared with less than 10% of the indicators at referral hospitals. Common barriers to indicator implementation were lack of resources and skills, difficulty in making early and accurate diagnoses, and management. ConclusionThe indicators for the quality of care for severe pre-eclampsia/eclampsia were acceptable. Adherence to the indicators increased through a multifaceted intervention; however, the adherence varied considerably depending on the hospital referral level.

Thai emergency nurses’ management of patients with severe traumatic brain injury: Comparison of knowledge and clinical management with best available evidence

In Thailand, the rate of TBI-related hospitalisation is increasing, however, little is known about the evidence-based management of severe TBI in the developing world. The aim of this study was to explore Thai emergency nurses' management of patients with severe TBI. An exploratory descriptive mixed method design was used to conduct this two stage study: survey methods were used to examine emergency nurses' knowledge regarding management of patients with severe TBI (Stage 1) and observational methods were used to examine emergency nurses' clinical management of patients with severe TBI (Stage 2). The study setting was the emergency department (ED) at a regional hospital in Southern Thailand. 34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were observed in 20 patients with severe TBI over 40 h. In this study there were five major areas identified for the improvement of care of patients with severe TBI: (i) end-tidal carbon dioxide (ETCO2) monitoring and targets; (ii) use of analgesia and sedation; (iii) patient positioning; (iv) frequency of nursing assessment; and (v) dose of Mannitol diuretic. There is variation in Thai nurses' knowledge and care practices for patients with severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge translation intervention that is ecologically valid, appropriate to the Thai healthcare context and acceptable to the multidisciplinary care team is needed.

Development of a burden scale for caregivers of dementia patients

ObjectiveTo develop a scale to measure the burden of care for caregivers of patients with dementia and explore its factor structure. MethodsThe initial draft of the Thai dementia patients’ caregiver burden (Thai-DCAB) scale was developed based on literature review, in-depth interviews and expert opinions. The drafted scale was administered to 203 caregivers of dementia patients treated at two large public hospitals in southern Thailand. An exploratory factor analysis using maximum likelihood extraction with varimax rotation was conducted. The reliability of the scale was assessed using Cronbach's alpha. ResultsThe Thai-DCAB scale consisted of 18 questions. Three factors were obtained, covering psychological, physical and financial burdens of the caregivers in taking care of dementia patients. These three factors accounted for 67% of the variance. The Cronbach's alpha coefficient was 0.95. ConclusionThe Thai-DCAB scale has high internal consistency and captures key theoretical constructs of the perceived burden among caregivers of patients with chronic and deteriorating dementia and in accordance with the social and cultural contexts and the way of life of the Thai people.

The Trend of Vibrio parahaemolyticus Infections in Southern Thailand from 2006 to 2010

The bacterium, Vibrio parahaemolyticus was isolated from 776 patients at Hat Yai Hospital in Southern Thailand from 2006 to 2010. 51.3–73.6% of the isolates were tdh+ trh− and Group-specific PCR positive pandemic strains. A comparison of the number of V. parahaemolyticus isolates in this study and that from the same hospital in 2000–2005 indicates that this region of Thailandis endemic for V. parahaemolyticus.

The development of clinical nursing practice guideline for initial assessment in multiple injury patients admitted to trauma ward

Summary Background Missed diagnoses are very common in patients with multiple injuries. To help nurses identify missed injuries, this study aimed to develop and evaluate a clinical nursing practice guideline (CNPG) for the initial assessment of multiply injured patients admitted to the trauma ward in a provincial hospital in southern Thailand. Method The CNPG was developed using evidence-based knowledge of trauma assessment and the Advanced Trauma Life Support guideline. The CNPG was used by 18 nurses working in the trauma ward. They implemented the CNPG with 34 multiply injured patients. The outcome measures of the CNPG use were the nurses' self-reported compliance with the use of the CNPG, the nurses' satisfaction with using the CNPG, and the percentage of missed injuries detected as a result of the use of the CNPG. Results Most nurses (83.33%) reported complying with the CNPG and 72.2% of them indicated that their satisfaction with using the CNPG was at a high level. Missed injuries were discovered at a rate of 14.6% of the total injuries diagnosed in the injured patients within 24h of ward admission. Conclusion Further research needs to be conducted to establish if the CNPG could be more widely applied to improve the quality of care and increase the safety of those with multiple injuries.

Neonatal acute kidney injury in a tertiary center in a developing country

Acute kidney injury (AKI) is a common contributor to morbidity and mortality in newborns, with prevalences varying by population and hospital. A study of AKI in newborns in tertiary care centers in Thailand, a developing country with limited resources, has not been conducted yet. The aim of this study was to determine the prevalence of AKI in newborns in a tertiary care hospital in southern Thailand and to investigate the etiology, mortality and risk factors of mortality. The records of patients aged <30 days with high serum creatinine, admitted from 1984 to 2007, were retrospectively reviewed. Eighty-eight boys and 51 girls were enrolled; 61.4% were premature and 56.5% had a birth weight <2500 g. The prevalence of newborn AKI increased from 0.9 to 6.3% during the 24-year study period. Thirty-nine and 65% had renal failure within 2 and 7 days post-birth, respectively. Sepsis was the most common cause of AKI (30.9%) followed by hypovolemia (18.7%), kidney, ureter and bladder (KUB) anomalies (12.2%), congestive heart failure (12.2%) and birth asphyxia (11.5%). Indomethacin caused AKI in 24.4% with gestational age <32 weeks. Sepsis-induced AKI had the highest mortality rate (65.1%) with an overall mortality rate of 38.8% and nearly 14 times the risk of death compared to hypovolemia-induced AKI. The prevalence of newborn AKI in our Thai tertiary center over 24 years was 6.3% of admitted newborns. Sepsis was the most common cause of AKI and sepsis-induced AKI is the most common cause of death. Disease etiology was the only risk factor for mortality.

Nurses’ Caring Behaviors for Dying Patients in Southern Thailand

Background: Nowadays, the end-of-life care becomes an indicator of the quality of care in a hospital. However, current nursing standards and quality of care related to the end of life do not meet the desired expectations of both dying patients and their families. Therefore, caring behaviors of nurses need to be described. Purpose: The purpose of this descriptive research was to describe the level of nurses’ caring behaviors for dying patients in southern Thailand. Method: Proportionate stratified random sampling was used to select 360 registered nurses who had been working in general hospitals and regional/university hospitals in southern Thailand for at least one year. Instruments used in the study included the Demographic Data Questionnaire (DDQ) and the Nurse’s Caring Behavior for Dying Patients Questionnaire (NCBDQ). The questionnaires were content validated by three experts. The reliability of the NCBDQ was tested with 30 nurses yielding a Cronbach’s alpha coefficient of .97. The data were analyzed by using frequency, percentage, mean and standard deviation. Results: The level of nurses’ caring behaviors for dying patients was high (M = 2.12, SD = .43). The five dimensions of the nurses' caring behaviors including compassion, confidence, conscience, commitment and comportment were also at a high level. However, the competence dimension was at a moderate level (M = 1.82, SD = .51). Conclusion: The results of this study indicated that nurses perceived themselves as having a moderate level of competency in taking care of dying patients. Therefore, educational intervention on enhancing nurses’ competency for end of life care is recommended. In addition, factors relating to nurses’ caring behavior for dying patients should be further explored. Keywords: caring behaviors, dying patients, nurses, southern Thailand

Evaluation of the physicians' approach to the diagnosis and treatment of patients with antituberculosis drug‐induced hepatotoxicity

To describe the practices of physicians on the diagnosis and treatment of antituberculosis drug-induced hepatotoxicity (ATH), and to evaluate the concordance between these practices and the American Thoracic Society (ATS) 2006 guidelines. Information was reviewed on 670 new cases of tuberculosis patients aged not less than 15 years and registered at the outpatient clinics of a large hospital in southern Thailand during October 2006 to September 2009. The patient was identified as having ATH if: (1) he/she was diagnosed as transaminitis, hepatitis or hepatotoxicity from antituberculosis (anti-TB) drugs; (2) their treatment regimen was subsequently modified by their attending physicians; and (3) their liver enzyme decreased after withdrawal of the suspected anti-TB drugs. Compliance with the ATS guidelines was considered on diagnosis, initial management, selection of alternative regimens, and a reintroduction strategy. The prevalence of ATH was 6.7%. The proportion of patients diagnosed as ATH in accordance with the ATS 2006 guidelines was 73.8%. For the initial management, isoniazid, rifampicin and pyrazinamide were concurrently stopped in 55.0% of patients. While waiting for normalization of liver enzymes, 28 patients (70.0%) were treated with alternative regimens and 12 patients (30.0%) took no drug. Only 47.5% of the ATH patients received a regimen in accordance with ATS guidelines, including three less hepatotoxic drugs (ethambutol, ofloxacin and streptomycin). Of 34 patients who discontinued the treatment, anti-TB drugs were reintroduced sequentially in 30 patients (88.2%). Of these, only 23.4% were firstly rechallenged with rifampicin as suggested by the ATS guidelines. The practice of physicians on the diagnosis and management of ATH varied. The practices of physicians on the diagnosis and rechallenged method were in high compliance with the ATS guidelines. For the initial management and selection of alternative regimens, the physicians' compliance was not good.