Ramathibodi Hospital Research Articles

Radiation Dose in Coronary Angiogram: A Comparison of Radial and Femoral Approach

Background: Many clinical trials have demonstrated the benefit of trans-radial access (TRA) over trans-femoral access (TFA) in reducing mortality and bleeding events, but there is some concern about radiation exposure with radial access. Objective: To assess the difference in radiation exposure between radial and femoral approach as measured by dose-area product (DAP) and fluoroscopy time. Methods: This cross-sectional study was performed in patients aged 15 years and above who underwent invasive percutaneous coronary angiography at Ramathibodi Hospital between December 2019 and December 2020. Exclusion criteria included previous coronary artery bypass graft, unstable hemodynamic status during procedure, and changing the access site or using access sites other than femoral or radial arteries. Demographic data of patients was collected through medical records. DAP and fluoroscopy time of patients with radial and femoral approach were evaluated. Results: Of 427 patients (49.4% male wtih mean age of 65.7 years), 245 (57.4%) patients underwent TFA. There was no significant difference in the median DAP between the radial and femoral approach (radial 1838 mGy.cm2 vs femoral 1690.7 mGy.cm2, P = .31). However, the fluoroscopy time was significantly higher in radial approach group (radial 4.6 min vs femoral 3.3 min, P < .001). Conclusions: The radiation exposure was not significantly different between trans-radial and trans-femoral coronary angiography.

Prevalence and Associated Factors of Sarcopenia in Preretirement Aged With Chronic Nonspecific Low Back Pain

Background: Sarcopenia stands as a prominent health concern, exhibiting a notable correlation with chronic lower back pain among the elderly population, with an observed upward trajectory of both conditions within the preretirement age group. Objective: To examine the prevalence of sarcopenia among individuals in the preretirement age group experiencing chronic nonspecific low back pain, and identify any associated factors. Methods: This descriptive cross-sectional study included 164 participants, aged 50 to 59 years, from the Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University. Patient data encompassing demographics, physical activity (International Physical Activity Questionnaires, IPAQ), and quality of life (European Quality of Life 5-Dimension 5-Level, EQ-5D-5L) were collected. Sarcopenia criteria, following the Consensus of the Asian Working Group of Sarcopenia (AWGS) 2014, were evaluated through bioelectrical impedance analysis, handgrip dynamometry, and/or the 6-meter walk test. Participants with chronic low back pain underwent assessments of pain severity and functionality. Results: Of 164 participants (mean [SD] age, 55.1 [2.6] years; mean [SD] body mass index, 24.7 [4.3] kg/m2), IPAQ responses indicated a range from low to moderate activity levels. The health-related quality of life score (median [range]) from EQ-5D-5L assessments stood at 0.94 [0.34 - 1.00]. Sarcopenia was detected in 10 out of 58 subjects (17.2%) with chronic low back pain, and in 6 out of 106 normal subjects (5.7%). Conclusions: The prevalence of sarcopenia among individuals within the preretirement age group experiencing chronic low back pain was notably high when compared to non chronic low back pain cases, without associated factors.

Heterotopically-placed right ventricle-to-pulmonary artery conduit does not negatively affect outcomes

ObjectivesSince the introduction of surgical implantation of conduit for right ventricle-to-pulmonary artery pathway reconstruction, there has been a number of studies on possible factors which might potentially affect conduit longevity, as well as patient’s reintervention-free and overall survival. Still, no definite consensual agreement could be made thus far. We aimed to compare conduit longevity, reintervention-free survival, and overall survival between patients with congenital heart diseases indicated for operations involving right ventricle-to-pulmonary artery pathway reconstruction whose conduits were placed heterotopically to those with orthotopically placed ones.Materials and methodsWe retrospectively collected data from electronic medical records of Ramathibodi hospital from 1st January 2005 to 31st December 2022. Patients with congenital heart diseases whose operations involved reconstruction of right ventricle-to-pulmonary artery continuity were included. Patients whose medical record data were significantly missing were excluded. Demographic data, operative, and postoperative details were collected and reviewed.ResultsThere were 67 patients included in our study, with 25 receiving orthotopic and the other 42 receiving heterotopic conduit implantation. Conduit dysfunction-free, reintervention-free, and overall survival were not statistically different between both groups. There was 1 early and no late death up to the end date of our study.ConclusionsConduits placed on a heterotopic position did not result in worse longevity, reintervention-free survival, as well as overall survival when compared to conduits placed on an orthotopic position. This suggested that the less technically demanding heterotopic conduit placement could be recommended as an operation of choice for right ventricular outflow tract reconstruction.

Optimizing the Yield of Abnormal Preoperative Chest Radiographs in Elective Non-cardiothoracic Surgery: Development of a Risk Prediction Score and External Validation.

Guideline recommendations for preoperative chest radiographs vary to the extent that individual patient benefit is unclear. We developed and validated a prediction score for abnormal preoperative chest radiographs in adult patients undergoing elective non-cardiothoracic surgery. Our prospective observational study recruited 703 adult patients who underwent elective non-cardiothoracic surgery at Ramathibodi Hospital. We developed a risk prediction score for abnormal preoperative chest radiographs with external validation using data from 411 patients recruited from Thammasat University Hospital. The discriminative performance was assessed by receiver operating curve analysis. In addition, we assessed the contribution of abnormal chest radiographs to perioperative management. Abnormal preoperative chest radiographs were found in 19.5% of the 703 patients. Age, pulmonary disease, cardiac disease, and diabetes were significant factors. The model showed good performance with a C-statistics of 0.739 (95% CI, 0.691-0.786). We classified patients into four groups based on risk scores. The posttest probabilities in the intermediate-, intermediate-high-, and high-risk groups were 33.2%, 59.8%, and 75.7%, respectively. The model fitted well with the external validation data with a C statistic of 0.731 (95% CI, 0.674-0.789). One (0.4%) abnormal chest radiograph from the low-risk group and three (2.4%) abnormal chest radiographs from the intermediate-to-high-risk group had a major impact on perioperative management. Four predictors including age, pulmonary disease, cardiac disease, and diabetes were associated with abnormal preoperative chest radiographs. Our risk score demonstrated good performance and may help identify patients at higher risk of chest abnormalities.

Use of Near-InfraRed Spectroscopy (NIRS) during Vascular Occlusion Test (VOT) for predicting an increase in oxygen consumption after fluid challenge in circulatory shock patients

Background: The goal of fluid challenge (FC) is to increase cardiac output (CO) and oxygen delivery (DO2) (known as fluid responders) to correct tissue hypoxia. To optimize fluid administration, fluid challenge (FC) during dependence of oxygen consumption on oxygen delivery (VO2/DO2 dependency) would correct tissue hypoxia confirmed by an increase of oxygen consumption (VO2) and oxygen delivery (DO2) after FC (known as VO2 responders) and get more benefit from a reduction in tissue hypoxia. Markers of anaerobic metabolisms, such as blood lactate concentration or the ratio of venous-arterial CO2 tension difference (P(cv-a)CO2) over arterial-to-venous oxygen content difference (C(a-cv)O2), can predict VO2 responders but still have several limitations. Therefore, near-infrared spectroscopy (NIRS) has been developed to evaluate tissue perfusion, presented as tissue oxygen saturation (StO2), at the bedside. Combining StO2 with the vascular occlusive test (VOT) and introducing a short period of forearm ischemia is a non-invasive technique to examine microvascular alterations at the bedside. However, a study validating the ability of these variables to predict VO2 response has not been conducted. Methods: We plan to conduct a single-center prospective study on circulatory failure patients. The cardiac index (CI), oxygen delivery (DO2), oxygen consumption (VO2), arterial lactate, central venous oxygen saturation (ScvO2), ratio of venous-arterial carbon dioxide tension to arterial-to-central venous oxygen content difference (P(cv-a)CO2/ C(a-cv)O2), and tissue oxygen saturation measured by near-infrared spectroscopy (NIRS) probe during vascular occlusion test variables (NIRS-VOT variables) will be collected before and after the fluid challenge. Hypothesis: We hypothesize that markers of reactive hyperemia by NIRs will predict an increase in VO2 after FC in patients with circulatory shock. Ethics: The study protocol has been approved by the ethics committee of the faculty of medicine, Ramathibodi Hospital, Mahidol University (COA. MURA2022/80).

Long-term clinical outcomes of stereotactic radiotherapy for bilateral vestibular schwannomas in neurofibromatosis type 2 patients.

The evidence for treating patients with neurofibromatosis 2-related vestibular schwannoma (VS-NF2) using hypofractionated stereotactic radiation therapy (HSRT) is limited. This study aimed to investigate clinical outcomes in patients with VS-NF2 treated with Robotic HSRT. We retrospectively analyzed 25 NF2 patients with 48 VSs who were treated using Robotic HSRT at Ramathibodi Hospital from January 2009 to January 2020. Median follow-up was 98 months (range, 24-155 months). Median tumor volume was 2.3 cm3 (range, 0.4-28.3 cm3). Median prescribed dose was 18Gy (range, 18-25Gy) in three fractions (range, 3-5). The 5- and 10-year local control rates were 87% and 80%, respectively. The 5- and 10-year hearing preservation rates were 59% and 35%, respectively. Three patients developed new symptoms associated with transient volume expansion after treatment: hydrocephalus in one, facial weakness in one, and ataxia in one. No patient developed worsening of trigeminal nerve function. No histologically confirmed of radiation induced malignancy was reported in the study. Robotic HSRT demonstrated excellent long-term tumor control with a low non-auditory complication rate in patients with VS-NF2. However, preservation of hearing remains a major concern.

Higher milk consumption is associated with a lower risk of diabetes mellitus: A case-control study.

Studies have determined that people with genetically defined lactase non-persistence have lower dairy intake that may lead to an increase risk of various non-communicable diseases. Furthermore, lactase non-persistence itself has been associated with insulin resistance. However, data on lactase non-persistence status and dairy intake in developing countries are sparse. We therefore aimed to define 1) the prevalence of lactase non-persistence among individuals with diabetes and non-diabetes in Thai population and 2) the links between lactase non-persistence, milk consumption, and risk of diabetes mellitus. We conducted a case-control study from participants of the National Health Examination Survey. DNA was isolated from the blood for LCT -13910C>T (rs4988235) polymorphism and processed using the Bio-rad c1000 touch thermal cycler and MALDI-TOF Mass Spectrometry MassARRAY Typer v4.0 (Agena Bioscience, San Diego, CA, USA) at the Center for Medical Genomics, Faculty of Medicine Ramathibodi Hospital. Cases were participants with previously diagnosed diabetes mellitus or fasting plasma glucose ≥126 mg/dL (n = 1,756) vs. the controls (n = 2,380). We included 4,136 participants, 62% female, and 98.8% were > 30 years old. Homozygous CC genotype (i.e., lactase non-persistence) was noted in 98.6% and only 1.4% carried heterozygous CT. Most (76%) consumed milk <1 portion/month. Participants with either CC or CT genotype had comparable milk consumption and the risk of diabetes mellitus. Males, older adults, and lower education had a lower chance of consuming milk at least one portion per month. Besides various baseline variables, we found that higher milk consumption was associated with a lower DM risk (P = .01). The prevalence of lactase non-persistence in Thai population is very high. A significant difference in milk consumption frequency in relation to the lactase non-persistence status was not found. However, higher milk consumption is associated with a lower risk of diabetes mellitus.

Twenty-Four-Hour Intraocular Pressure in Chronic Primary Angle-Closure Disease.

Primary angle closure and primary angle closure glaucoma may exhibit normal intraocular pressure. Twenty-four-hour intraocular pressure fluctuation is highest in primary angle closure glaucoma. The degree of peripheral anterior synechiae was associated with a 24-hour intraocular pressure pattern in primary angle-closure disease without laser iridotomy. The purpose of this study was to study 24-hour intraocular pressure (IOP) patterns in eyes with chronic primary angle-closure disease and evaluate associations between peripheral anterior synechiae (PAS) and 24-hour IOP pattern. In this prospective cohort study, 59 eyes of 35 Asian patients with chronic primary angle-closure disease underwent complete ocular examinations at Ramathibodi Hospital, Mahidol University. Twenty-four-hour IOP records were obtained using Goldmann applanation tonometry at 2-hour intervals. Peak, mean, and trough 24-hour IOP values and 24-hour IOP fluctuation (difference between peak and trough values) were compared among groups. None of the participants received any treatment before complete data collection. Even univariable analysis demonstrated a significant difference in peak, mean, and trough IOP and 24-hour IOP fluctuation between the 3 groups; the magnitude of trough IOP was not higher than 21mmHg in all groups. In multivariable analysis, PAC and PACG eyes showed significantly higher peak IOP ( P =0.020 and 0.006, respectively) and 24-hour IOP fluctuation ( P =0.048 and 0.001, respectively) compared with PACS eyes. In comparison between combined PACS and PAC eyes versus PACG eyes, PACG eyes revealed significantly higher 24-hour IOP fluctuation. The degree of PAS was associated with peak and mean IOP values and with 24-hour IOP fluctuation in PAC and PACG eyes. Twenty-four-hour IOP fluctuation was highest in PACG eyes. Although PAC and PACG eyes showed higher peak IOP and 24-hour IOP fluctuation values, compared with PACS eyes, trough IOP in PAC and PACG eyes were mostly below 21mmHg. In addition, the degree of PAS was associated with a 24-hour IOP pattern in either PAC or PACG eyes.

Ventricular pacing dependency after transcatheter aortic valve replacement: a prospective cohort.

Atrioventricular conduction disturbance occurs in a significant number of patients undergoing transcatheter aortic valve replacement (TAVR). However, not all cases are ventricular pacing-dependent. Thus, we aimed to study the incidence, predictors, and outcomes of new ventricular pacing dependency (VpDep) after TAVR. We prospectively analyzed 130 consecutive transfemoral TAVR cases performed in Ramathibodi Hospital between 2015 and 2020. Three patients with prior ventricular pacing-dependent on cardiac implantable electronic devices (CIEDs) were excluded. The endpoints were VpDep at 1 month and all-cause mortality at the follow-up period end in 2021. The effects of variables on VpDep and all-cause mortality were evaluated using multivariate binary logistic regression and Cox regression analyses, respectively. First-degree atrioventricular block (AVB) was considered severe when the PR interval was >300 ms. Of the 127 patients [mean age, 81.8 years; 62.2% females; 67.7% balloon-expandable (BE) device], 7 patients (5.5%) had CIEDs implanted before TAVR that were not ventricular pacing-dependent. TAVR was successfully performed in 126 (99.2%) patients. Periprocedural stroke, cardiac tamponade, and major bleeding occurred in 2 (1.6%), 4 (3.1%), and 4 (3.1%) patients, respectively. The VpDep incidence at 1 month was 7.9% (n=10) among all patients and 34.5% among those with CIEDs (n=29). VpDep was more likely to occur in patients with pre-existing right bundle branch block (RBBB) [odds ratio (OR), 21.38; 95% confidence interval (CI): 3.28-139.33; P=0.001] and severe 1st degree or Mobitz I AVB (OR, 14.79; 95% CI: 1.65-132.74; P=0.016). After a mean follow-up of 25.8 months [standard deviation (SD), 21.2 months], death from any cause occurred in 18 patients (14.2%). However, VpDep was not associated with an increased mortality. In this real-world cohort, pre-existing conduction abnormalities were significantly associated with a higher risk of VpDep. Mortality was similar between patients with and without VpDep.

Validity and reliability of the Thai version of the Utrecht Gender Dysphoria Scale-Gender Spectrum (UGDS-GS) in Thai youths and young adults with gender dysphoria

BackgroundMany people who are gender variant have undiagnosed gender dysphoria, resulting in delayed receipt of gender-affirming support and prolonged distress in living with their gender-non-conforming sex. The Utrecht Gender Dysphoria...

Comparing Explainable Machine Learning Approaches With Traditional Statistical Methods for Evaluating Stroke Risk Models: Retrospective Cohort Study.

Stroke has multiple modifiable and nonmodifiable risk factors and represents a leading cause of death globally. Understanding the complex interplay of stroke risk factors is thus not only a scientific necessity but a critical step toward improving global health outcomes. We aim to assess the performance of explainable machine learning models in predicting stroke risk factors using real-world cohort data by comparing explainable machine learning models with conventional statistical methods. This retrospective cohort included high-risk patients from Ramathibodi Hospital in Thailand between January 2010 and December 2020. We compared the performance and explainability of logistic regression (LR), Cox proportional hazard, Bayesian network (BN), tree-augmented Naïve Bayes (TAN), extreme gradient boosting (XGBoost), and explainable boosting machine (EBM) models. We used multiple imputation by chained equations for missing data and discretized continuous variables as needed. Models were evaluated using C-statistics and F1-scores. Out of 275,247 high-risk patients, 9659 (3.5%) experienced a stroke. XGBoost demonstrated the highest performance with a C-statistic of 0.89 and an F1-score of 0.80 followed by EBM and TAN with C-statistics of 0.87 and 0.83, respectively; LR and BN had similar C-statistics of 0.80. Significant factors associated with stroke included atrial fibrillation (AF), hypertension (HT), antiplatelets, HDL, and age. AF, HT, and antihypertensive medication were common significant factors across most models, with AF being the strongest factor in LR, XGBoost, BN, and TAN models. Our study developed stroke prediction models to identify crucial predictive factors such as AF, HT, or systolic blood pressure or antihypertensive medication, anticoagulant medication, HDL, age, and statin use in high-risk patients. The explainable XGBoost was the best model in predicting stroke risk, followed by EBM.

Effect of mini-course training in communication and teamwork on non-technical skills score in emergency residents: a prospective experimental study

BackgroundNon-technical skill (NTS) teaching is a recent development in medical education that should be applied in medical education, especially in medical specialties that involve critically ill patients, resuscitation, and management, to promote patient safety and improve quality of care. Our study aimed to compare the effects of mini-course training in NTS versus usual practice among emergency residents.MethodsIn this prospective (non-randomized) experimental study, emergency residents in the 2021–2022 academic year at Ramathibodi Hospital, a tertiary care university hospital, were included as participants. They were categorized into groups depending on whether they underwent a two-hour mini-course training on NTS (intervention group) or usual practice (control group). Each participant was assigned a mean NTS score obtained by averaging their scores on communication and teamwork skills given by two independent staff. The outcome was the NTS score before and after intervention at 2 weeks and 16 weeks.ResultsA total of 41 emergency residents were enrolled, with 31 participants in the intervention group and 10 in the control group. The primary outcome, mean total NTS score after 2 weeks and 16 weeks, was shown to be significantly better in intervention groups than control groups (25.85 ± 2.06 vs. 22.30 ± 2.23; P < 0.01, 28.29 ± 2.20 vs. 23.85 ± 2.33; P < 0.01) although the mean total NTS score did not differ between the groups in pre-intervention period. In addition, each week the NTS score of each group increased 0.15 points (95% CI: 0.01–0.28, P = 0.03), although the intervention group showed greater increases than the control (0.24 points) after adjustment for time (95% CI: 0.08–0.39, P < 0.01).ConclusionEmergency residents who took an NTS mini-course showed improved mean NTS scores in communication and teamwork skills versus controls 2 weeks and 16 weeks after the training. Attention should be paid to implementing NTS in the curricula for training emergency residents.Trial registrationThis trial was retrospectively registered in the Thai Clinical Trial Registry on 29/11/2022. The TCTR identification number is TCTR20221129006.

Effect of Continuation-Maintenance Electroconvulsive Therapy on Hospitalization: A Retrospective Mirror-Image Study.

To examine the effect of continuation-maintenance electroconvulsive therapy (ECT) on psychiatric hospitalization in Thai patients. This retrospective mirror-image study reviewed medical records of Thai patients who received continuation-maintenance ECT at Ramathibodi Hospital, Bangkok, between September 2013 and December 2022. The initiation of continuation-maintenance ECT served as the index event, establishing pre-initiation and post-initiation periods. The primary outcome measured the differences in admissions and admission days before and after continuation-maintenance ECT. Forty-seven patients were included in the study, with diagnoses of schizophrenia (38.3%), schizoaffective disorder (21.3%), and bipolar disorder (19.1%) being the most common. The mean (standard deviation; SD) age was 44.6 (12.2) years. The total duration that patients received continuation-maintenance ECT was 53 ± 38.2 months. Following the initiation of ECT, there was a significant reduction in the median (interquartile range) number of hospitalizations for all patients (2 [2] versus 1 [2], p < 0.001), as well as for the psychotic disorder group (2 [2] versus 1 [2.75], p = 0.006) and the mood disorder group (2 [2] versus 1 [2], p = 0.02). Moreover, there was a significant reduction in the median (interquartile range) length of admission days for all patients after the initiation of continuation-maintenance ECT (66 [69] versus 20 [53], p < 0.001). Specifically, the psychotic disorder group (64.5 [74] versus 15.5 [62], p = 0.02) and mood disorder group (74 [57] versus 20 [54], p = 0.008) demonstrated statistically significant decreases in admission days. Continuation-maintenance ECT may be an effective treatment option for reducing hospitalizations and admission days in patients with various psychiatric diagnoses. However, the study also highlights the need to carefully consider the potential adverse effects of ECT in clinical decision-making.

Affecting burden and cost of care for the caregiver of dependent patients with advanced stage of cancer who had an arrangement for expected death at home.

e24000 Background: The terminal stage cancer patients suffer from disease and related therapeutic processes, lead to increasing need for caring from their caregivers. This affects the quality of life(QOL) of caregivers. Currently, there is no data on burden of caregivers who caring for cancer patients who are choose to die at their home. Objective: This study examined burden of caregivers, impact on QOL and satisfaction of caregivers for patients with terminal cancer, comparing in the group of patients who die at home versus at hospital, comparing in regular care group(RC) versus palliative care group(PC). Methods: The semi-qualitative-quantitative study enrolled caregivers of advance cancer patients who had PPS &lt; 60 at Ramathibodi Hospital from Dec 2021-Nov 2022. We assessed participants on 3-time-points (enrolment, 1, 2 months) for QOL and burden via telephone interviews, questionnaires by EQ5D5L and Zarit Burden. If the patients passed away, we interviewed caregivers in qualitative study. Analysis responses were recorded, transcribed and organized thematically analyzed. Analysis stratified on care with palliative care or not, and place of death. Results: We enrolled 108 participants, child (56%) and spouses (29%). They spent carring time average of 16.56 hr/day. 52 patients have passed away: home death(34) and hospital death(18). No significant difference in burden score and QOL between RC and PC. Burden score significantly increasing when time of death approach in both groups. However, significantly higher satisfaction score in caregivers of patients who died at home(P &lt; 0.001). In patient who died in hospital, early integrated palliative showed significantly higher satisfaction score(P = 0.046). Qualitative analysis revealed 3 primary themes, 1) caregiver burden is increasing and chronic stress condition until the death of their loves and still continue post their death 2) need more help in coping and nursing strategies, more early palliative care can relieve their distresses 3) opinion of the caregivers in group of hospital death, If they could turn back time, they would have promised to look after their lovers better in changing the pass away at their home. Conclusions: Caregivers for terminal cancer patients have a high burden. However, caregiver of patients who died at their home rather have more satisfaction. Early integrated palliative care improves satisfaction in caregiver of patients who died at hospital. [Table: see text]

Evaluation of transitions from early hypertension to hypertensive chronic kidney disease, coronary artery disease, stroke and mortality: a Thai real-world data cohort.

Systemic arterial hypertension (HT) is a major modifiable risk factor for cardiovascular disease (CVDs), associated with all-cause death (ACD). Understanding its progression from the early state to late complications should lead to more timely intensification of treatment. This study aimed to construct a real-world cohort profile of HT and to estimate transition probabilities from the uncomplicated state to any of these long-term complications; chronic kidney disease (CKD), coronary artery disease (CAD), stroke, and ACD. This real-world cohort study used routine clinical practice data for all adult patients diagnosed with HT in the Ramathibodi Hospital, Thailand from 2010 to 2022. A multi-state model was developed based on the following: state 1-uncomplicated HT, 2-CKD, 3-CAD, 4-stroke, and 5-ACD. Transition probabilities were estimated using Kaplan-Meier method. A total of 144,149 patients were initially classified as having uncomplicated HT. The transition probabilities (95% CI) from the initial state to CKD, CAD, stroke, and ACD at 10-years were 19.6% (19.3%, 20.0%), 18.2% (17.9%, 18.6%), 7.4% (7.1%, 7.6%), and 1.7% (1.5%, 1.8%), respectively. Once in the intermediate-states of CKD, CAD, and stroke, 10-year transition probabilities to death were 7.5% (6.8%, 8.4%), 9.0% (8.2%, 9.9%), and 10.8% (9.3%, 12.5%). In this 13-year cohort, CKD was observed as the most common complication, followed by CAD and stroke. Among these, stroke carried the highest risk of ACD, followed by CAD and CKD. These findings provide improved understanding of disease progression to guide appropriate prevention measures. Further investigations of prognostic factors and treatment effectiveness are warranted.

Optional Method with Innovative Instrument for Ohvira Syndrome Treatment: Case Reports and Review of Literature

OHVIRA syndrome is a rare condition usually present during early puberty, after menarche. The main symptoms are caused by the obstruction of hemivagina and accumulation of blood, which cause the symptoms such as dysmenorrhea, chronic pelvic pain or pelvic mass. Transvaginal septectomy is the best way to treat of patient’s obstructive hemivagina. However, in young patients, the small vagina canal is a significant limitation, and it is challenging to explore the surgical field. Due to the uncommon condition at young ages and variation in coexisting anomalies, approach techniques and instruments are still under development. In this case series, we present 2 cases of OHVIRA syndrome who received surgical treatment at Ramathibodi Hospital, Mahidol University. Both cases used the same innovative vaginal retractor, designed and modified for the young patient with OHVIRA syndrome. After the procedure, patients showed no complications or recurrence up to 2 years of follow-up.

Spinal Extramedullary Arteriovenous Fistulas: A 15-Year Endovascular Treatment Experience in a Tertiary Care Hospital in Thailand.

Spinal arteriovenous shunts are rare diseases. Different classifications have been proposed, but the most widely used are those classified by locations. Different locations (i.e., intramedullary and extramedullary) have different treatment outcomes and different posttreatment angiographical results. Our study presents the 15-year endovascular treatment outcomes of patients who had spinal extramedullary arteriovenous fistulas (AVFs) at Ramathibodi Hospital, which is a tertiary care hospital in Thailand. A retrospective medical record and imaging review of all patients with spinal extramedullary AVFs, which were confirmed by a diagnostic spinal angiogram in our institute from January 2006 to December 2020, were performed. The angiographic complete obliteration rate in the first session of endovascular treatment, clinical outcomes of the patients, and complications of the procedures for all eligible patients were analyzed. Sixty-eight eligible patients were included in the study. The most common diagnosis was spinal dural AVF (45.6%). The most common presenting symptoms were weakness, numbness, and bowel-bladder involvement (70.6%, 67.6%, and 57.4%, respectively). Ninety-four percent had spinal cord edema in preoperative magnetic resonance imaging. All patients had pial venous reflux. Sixty-four patients (94.1%) received endovascular treatment as the first option. The complete obliteration rate in the first session of endovascular treatment was 75% and was high in all subgroups except for the perimedullary AVF group. The overall intraoperative complication of endovascular treatment was 9.4%. Follow-up imaging showed no residual AVF in 50 patients (87.7%). Most of the patients (57.4%) had improvement of neurological functions at 3- to 6-month follow-up. Treatment results of spinal extramedullary AVFs were good in terms of angiographic aspects and clinical outcomes. This may have resulted from the locations of the AVFs, which mostly did not involve the spinal cord arterial supply, with the exception of perimedullary AVFs. Although perimedullary AVF is difficult to treat, it can be cured by careful catherization and embolization.

Risk factors of cytomegalovirus infection after pediatric liver transplantation and effectiveness of preemptive therapy.

Cytomegalovirus (CMV) infection is the most common infection following pediatric liver transplantation (LT). Preemptive therapy (PET) is an approach to initiate antiviral treatment for asymptomatic early CMV viremia detected by surveillance testing. However, data on CMV infection after PET are scarce, and the optimal cut-off remains controversial. This study aimed to evaluate the incidence, risk factors, and consequences of CMV infection in pediatric LT using 2 different viral load (VL) cut-offs. We retrospectively reviewed patients aged 0-18 years who underwent LT at Ramathibodi Hospital between March 2001 and August 2020. Demographic data, CMV infection, CMV treatment, and consequences of CMV infection were collected. CMV viremia was monitored by a quantitative nucleic acid amplification test. Clinical outcomes were compared after starting antiviral therapy at a low (>400 but <2000IU/mL) and a high VL cut-off (≥2000IU/mL). A total of 126 patients were included. CMV infection was 71% (90/126), with an incidence rate of 5.5 per 1000 patient-day. Higher tacrolimus and prednisolone dosages were associated with CMV infection with an adjusted hazard ratio of 1.2 (95%CI 1.0-1.4, p=.02) and 2.4 (95%CI 1.9-3.4, p<.001), respectively. The consequences of CMV infection did not differ significantly for the low and high CMV VL cut-off groups. CMV infection in LT recipients is common and is associated with higher tacrolimus and corticosteroid dosage. Additionally, using the CMV VL cut-off at 2000IU/mL to initiate antiviral therapy is practical and effective in preventing CMV disease.

Deep vein thrombosis screening in pediatric orthopedic patients.

Deep vein thrombosis (DVT) is an important clinical condition that leads to subsequent morbidity and mortality in children, particularly those who involved operative procedures. The preoperative assessment for DVT in children may vary among different population risk factors and types of surgery. This study aimed to evaluate the screening methods for DVT in pediatric orthopedic patients. We performed a retrospective cohort study of orthopedic patients aged <18 years at Ramathibodi Hospital, Bangkok, Thailand, from 2015 to 2019. The inclusion criteria were children scheduled for orthopedic surgery; who performed a D-dimer test, Wells score, and Caprini score; and who underwent Doppler ultrasonography for DVT screening. The exclusion criteria were incomplete data or inconclusive ultrasonographic results. Age and results of the D-dimer test, Wells score, and Caprini score were collected from all patients. The outcome assessment was ultrasound-proven DVT. The screening abilities of each test were analyzed in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) for positive and negative tests, and area under the receiver operating characteristic curve (AUC). A total of 419 children were included in the study. Five (1.19%) patients were diagnosed with DVT. The mean age was 10.16 ± 4.83 years. D-dimer ≥500 ng/mL had a sensitivity of 100% (95% CI: 47.8%-100%), a specificity of 36.7% (95% CI: 32.1%-41.6%), a PPV of 1.9% (95% CI: 0.6%-4.3%), and an NPV of 100% (95% CI: 97.6%-100%). Wells score ≥3 demonstrated a sensitivity of 0% (95% CI: 0%-52.2%), a specificity of 99.3% (95% CI: 97.9%-99.9%), and an LR for a negative test of 1.00 (95% CI: 1.00-1.01). Caprini score ≥11 had a sensitivity of 0% (95% CI: 0%-52.2%) and a specificity of 99.8% (95% CI: 98.7%-100%). The parallel test included D-dimer ≥500 ng/mL, Wells score ≥3, or Caprini score ≥11 points, generating a sensitivity of 100% (95% CI: 47.8%-100%), a specificity of 36.7% (95% CI: 32.1%-41.6%), an LR for a positive test of 1.58 (95% CI: 1.47-1.70), and an AUC of 0.68 (95% CI: 0.66-0.71). The D-dimer test exhibited moderate ability in predicting the development of DVT among pediatric orthopedic patients requiring surgery. The Wells score and Caprini score had low performance in identifying hospitalized children at increased risk of DVT events.

Long-term follow-up outcomes of laser-treated port wine stain patients: A double-blinded retrospective study.

Port wine stains (PWS) can be effectively treated with lasers. However, complete clearance is rarely observed, and data from long-term studies are limited. The study aimed to evaluate the efficacy and complications of long-term laser treatment in patients with PWS. We performed a 25-year double-blinded retrospective chart review of patients diagnosed with PWS who underwent laser treatment at Ramathibodi Hospital, Thailand, between June 1995 and June 2021. The scores for improvement and color were independently evaluated by two dermatologists. A total of 129 patients were included. Most patients were male (70.54%). A total of 4141 laser treatment sessions were reviewed, with a median of 49 (interquartile range, 27-66) sessions per patient. A total of 1070 photographic records were reviewed. Overall, 53% of the patients achieved statistically significant (50%) improvement, after six treatment sessions. However, none of these patients achieved complete clearance. Due to the nonuniform treatments, we could not evaluate the efficacy of each laser type. However, this study illustrates the outcomes of a real-world setting in which various laser types were selected specifically for each patient to obtain the best result. Vascular lasers are a promising treatment for PWS. Although laser treatment is applicable to most patients, multiple treatment sessions are required to achieve excellent results.