Reliability and validity study of the Thai adaptation of the Copenhagen Burnout Inventory-Student Survey (CBI-SS) among preclinical medical students at the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand

Burnout syndrome is a syndrome of emotional exhaustion, professional efficacy and cynicism. A significant proportion of medical students reported having burnout syndrome during their training in medical education. Several tools including the Copenhagen Burnout Inventory-Student Survey (CBI-SS) are considered to be a valid measurement of burnout syndrome in medical students. This study aimed to translate, culturally adapt, and validate the CBI-SS for assessing burnout syndrome among preclinical medical students in Thailand. This study was conducted during February to March 2019 at the Faculty of Medicine Siriraj Hospital, Mahidol University (Bangkok, Thailand), which is Thailand’s largest and oldest medical school, and Thailand’s largest national tertiary referral center. After receiving formal permission to do so from the copyright owner, the original English language version of the CBI-SS was translated to Thai language using an internationally recommended and accepted forward-backward translation protocol. The Thai version of the CBI-SS (Thai CBI-SS) comprises 25 items, including 6 items for personal burnout, 7 items for study-related burnout, 6 items for colleague-related burnout, and 6 items for teacher-related burnout. Standardized Cronbach’s alpha coefficient was calculated to evaluate internal consistency reliability, and correlation coefficient was computed to determine test-retest reliability. A total of 414 preclinical medical students participated in this study. Due to sub-optimal factor weights (<0.50), items 6, 10 and 17 were excluded. The Cronbach’s alpha coefficients of the 22-item Thai CBI-SS for personal, study-related, colleague-related, and teacher-related burnout were 0.898, 0.896, 0.910 and 0.900 respectively. The correlation coefficients for test-retest reliability after three weeks were 0.820, 0.870, 0.821, and 0.787 for personal, study-related, colleague-related, and teacher-related burnout, respectively. Maximum likelihood analysis with oblimin rotation indicated four main components, and confirmatory factor analysis revealed good fit indices of the Thai CBI-SS. Confirmatory factor analysis showed good fit indices of CBI-SS domains (χ2/df = 2.39; CFI = 0.957; GFI = 0.909; RMSEA = 0.058; TLI = 0.949; and NFI = 0.928). The convergent validity analysis using the Average Variance Extracted (AVE) and the Composite Reliability (CR) was adequate for all dimensions (personal: AVE = 0.626, CR = 0.893; study-related: AVE = 0.601, CR = 0.899; colleague-related: AVE = 0.677, CR = 0.913; teacher-related: AVE = 0.606, CR = 0.900). The HTMT values for all variables are in the range from 0.315 to 0.833, confirming the discriminant validity. The Thai CBI-SS was found to be a valid and reliable tool for evaluating burnout syndrome in preclinical medical students in Thailand.

Happiness of Preclinical Students: Evaluating Factors Influencing Happiness of Preclinical Students

This study aimed to determine factors influencing happiness in preclinical students especially in aspects of teaching and learning, students’ motivation, study habits, and academic achievement. This study was a questionnaire-based cross-sectional study. The questionnaire was validated and approved for clarity, readability, rational analysis, and comprehensiveness by the experts. Questionnaires were sent to all second and/or third-year medical students of the 2018 (328) and 2019 (329) classes, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand. Cronbach’s alpha values were 0.886. The data were analyzed by the Statistical Package for Social Science version 18. From open-ended questions, the top 5 ranking factors increasing students’ happiness were teaching of instructors, content satisfaction, content understanding, free time, and handouts. Factors that had positive influences/associations with happiness of preclinical students were happiness in learning subjects taught in a particular year; satisfaction of content, study outcomes, materials, handouts, teaching motivating desire to learn, and applicability of content to medical profession; high motivation to study medicine, expected score, and the percentage of achievement of study targets; less amount of time spent on recorded-e-lecture study and internet for non-academic use; and low stress. Happiness of preclinical students was influenced by satisfaction in teaching and learning, their attitude, study habits, and academic achievement. Further studies on determining students’ happiness after improvement of teaching and learning environments, augmenting activities that enhance students’ motivation, and promoting good study habits among medical students, are required to prove whether enhancement of these factors could effectively increase students' happiness.

An evaluation of two small group learning strategies among third-year medical students at the Faculty of Medicine, Siriraj Hospital, Mahidol University

Small group learning (SGL) is a discussion-based teaching strategy that can improve critical thinking, analytical skills, problem-solving, and interpersonal skills. This study aimed to evaluate student satisfaction in two SGL models among third-year medical students enrolled in a blood and lymphoid systems II course at the Faculty of Medicine Siriraj Hospital, Mahidol University in Bangkok, Thailand. A total of 318 students were divided into 12 groups, and each group had one facilitator. All included students and groups were exposed to both the central summary (CS) model and the individual facilitator summary (IFS) model (both SGLs). A questionnaire was developed to evaluate student rating of learning activities, perceived benefit, timing, workload, and satisfaction. Medical students rated the IFS model superior to the CS model for four of five parameters [confidence in performing and interpreting a laboratory test (83.6% vs. 78.8%), guidance for self-learning (52% vs. 39.5%), increased understanding of a disease (87.7% vs. 72.1%), and application of knowledge (77.4% vs. 70.2%), respectively]. Moreover, the IFS model was rated as having more suitable timing and workload and better satisfaction than the CS model. The results of this study suggest a strong preference for the IFS model over the CS model among medical students.

PRRT2 Gene Analysis of Paroxysmal Kinesigenic Dyskinesia (PKD) in Thai Children

Objective: To examine the frequency of the proline-rich transmembrane protein-2 (PRRT2) gene mutation in Thai patients with paroxysmal kinesigenic dyskinesia (PKD). Material and Methods: A retrospective study of children aged 0-18 years with a diagnosis of PKD at Siriraj Hospital. The genetic analyses of the PRRT2 gene were done by bidirectional Sanger sequencing.Results: Twelve patients with PKD were included. The known PRRT2 mutation, c.649dupC (p.Arg217Profs*8), was identified in three of the patients (25.0%), one of the nine sporadic cases (11.1%) and two of the three familial cases (66.6%), all from different families. PKD had a complete response to carbamazepine treatment regardless of PRRT2 mutation status. Conclusion: Our study provided the new details of the clinical phenotypes and PRRT2 gene analysis findings for Thai PKD. PRRT2 mutations were identified in our Thai PKD patients with increased detection rates in the familial PKD cases. The c.649dupC (p.Arg217Profs*8) was also found to be a hot-spot mutation in our Thai PKD patients. Furthermore, this study demonstrates the importance of PRRT2 gene analysis in order to properly diagnose and treat these patients.

Speech Outcome Analysis after Primary Cleft Palate Repair: Interim Siriraj Hospital Audit

Objective: To evaluate the speech outcomes after primary cleft palate repair in a single tertiary medical institution of Thailand.Materials and Methods: A prospective cohort study was performed. Patients who had cleft palate with/without cleft lip and underwent primary cleft palate repair were included. Speech assessment was performed using the Pittsburgh weighted speech score (PWSS) by a speech-language pathologist.Results: Forty patients (21 males and 19 females) who underwent primary cleft palate repair at Siriraj Hospital were included. The median age at the time of speech evaluation was 7 years. The median age at primary cleft palate surgery was 12 months. The predominant cleft palate type was Veau 3 (47.5%). Oronasal fistula occurred 40%. Two-flap palatoplasty and intravelar veloplasty were the most common procedures. Median PWSS was 7, in which the competence velopharyngeal mechanism was found 5%, borderline competence 10%, borderline incompetence 32.5%, and incompetence velopharyngeal mechanism 52.5%. Among the velopharyngeal incompetence group, articulation disorder was the most common disorder with median score of 3. Besides, the median scores for hypo/hyper-nasality, nasal emission, phonation, and facial grimace disorder were 1, 2, 0 and 0, respectively. There was no statistically significant association between velopharyngeal incompetence and cleft types, age at primary surgery, type of operation, the width of cleft palate and prevalence of postoperative oronasal fistula or otitis media effusion.Conclusion: Velopharyngeal incompetence has been commonly identified after cleft palate repair in our institute. The articulation disorder is the most common characteristic.

Ganciclovir Treatment in Symptomatic Congenital CMV Infection at Siriraj Hospital: 11 Year-Review (2008 to 2019)

Background: Congenital cytomegalovirus (CMV) infection is the most common non-genetic cause of permanent sensorineural hearing loss in infants and children. A 6-month course of intravenous ganciclovir or valganciclovir is recommended for treatment of patients with moderate to severe symptomatic congenital CMV disease. Hearing status improvement has been reported in those that received treatment within the first month of life. In Thailand, there has been no data of antiviral treatment in symptomatic congenital CMV patients. Objective: To determine the incidence of symptomatic congenital CMV infection in the past 11 years and to evaluate the hearing, neurological, and developmental outcomes of the antiviral treatment and factors associated with hearing outcomes. Materials and Methods: A retrospective observational study was performed at Siriraj Hospital, between January 2008 and December 2019. The medical records of the patients diagnosed of symptomatic congenital CMV infection (ICD10-P351) were reviewed. Results: The incidence of symptomatic congenital CMV infection was 0 to 1.01 case per 1,000 livebirths. Of the 52 patients, 18 received 6-week course of ganciclovir and five continued with oral valganciclovir for three to six months. Developmental delayed was found in 69.2% (36). No difference in hearing outcomes at 6 and 12 months of age between the patients who did or did not receive treatment. Among 24 (46.1%) children who underwent hearing test at two to three years of age, the birth characteristics, as well as antiviral treatment (attributable risk 0.007, 95% CI –0.4 to 0.4, p=0.973), had no difference in hearing outcome. Long-term disability was diagnosed in the lower proportion among the patients receiving antiviral treatment (attributable risk –0.3, 95% CI –0.5 to –0.1, p=0.030). Conclusion: Symptomatic congenital CMV infection resulted in poor hearing and developmental outcomes. Antiviral treatment reduced risk of disability but did not improve hearing outcomes. The results underscore the need for early diagnosis and initiation of antiviral treatment in infants with symptomatic congenital CMV. Keywords: Congenital infection; CMV; Hearing loss; Ganciclovir; Valganciclovir; Disability

Direct Oral Anticoagulants (DOACs)-Based Versus Warfarin-Based Antithrombotic Regimens in Patients with Atrial Fibrillation Underwent Successful Coronary Stenting at Siriraj Hospital

Objective: To investigate the 1-year bleeding outcome between direct oral anticoagulants (DOACs)-based regimens and warfarin-based regimens in real-world practice in Thai patients with atrial fibrillation (AF) and significant coronary artery disease (CAD). Materials and Methods: The present study was a retrospective study. The authors reviewed the electronic medical charts of patients treated at the Siriraj Hospital between January 1, 2012 and October 31, 2019. The inclusion criteria were patients with AF and significant CAD that underwent percutaneous coronary intervention (PCI) with a stent and were prescribed or planned to prescribe anticoagulants after the PCI. The primary end point was the International Society on Thrombosis and Hemostasis (ISTH) bleeding during a 1-year follow-up period after successful coronary stenting. The trial assessed for the difference in the bleeding outcome and composite efficacy end point of myocardial infarction, ischemic stroke, and systemic embolism between patients that received warfarin-based regimen and those that received DOACs-based regimen. Results: The prevalence of patients that received additional oral anticoagulation was 5.1% (679/13,306 patients). One hundred seventy patients met the study inclusion and exclusion criteria. The incidence of the primary end point was 9.0% in the warfarin-based regimen compared with 8.1% in the DOACs-based regimen (p=1.000). The incidence of the composite efficacy end point was 8.3% in the warfarin-based regimen compared with 0% in the DOACs-based regimen (p=0.124). Conclusion: In patients with AF and significant CAD that underwent PCI, the use of a DOACs-based regimen had no statistically significant difference in bleeding outcome but associated with lower ischemic endpoint. However, due to the limited study sample size, the study had insufficient power to declare the results statistically significant. Keywords: Coronary artery disease; Atrial fibrillation; DOAC; Warfarin

Complete Genome Sequence of Neisseria gonorrhoeae Multilocus Sequence Type ST7363 Isolated from Thailand

A Neisseria gonorrhoeae multilocus sequence type (MLST) ST7363 strain was isolated from a patient at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, in 2010 and completely sequenced. This strain is susceptible to ceftriaxone and cefixime. A complete circular chromosome and circular plasmids were assembled from combined Oxford Nanopore Technologies (ONT) and Illumina sequencing.

Modified del Nido versus blood cardioplegia in congenital cardiac surgery

Background Lactated Ringer-based del Nido cardioplegia has been reported to be safe for acquired cardiac surgery. The original Plasma-Lyte-based solution has been proved for congenital cardiac surgery but its modification has not been adequately examined. We compared the clinical outcomes of congenital cardiac surgery using lactated Ringer-based del Nido cardioplegia versus cold blood cardioplegia. Methods Between September 2018 and November 2020, 116 consecutive patients with congenital heart disease undergoing operations with cardioplegic arrest performed by a single surgeon at Faculty of Medicine Siriraj hospital; 66 with modified del Nido solution and 50 with institutional's blood cardioplegia. The patient risk profiles, operative details, mortality rates, care durations, inotrope use, blood transfusion and complications were compared. Results Preoperative characteristics were similar between groups, including median age (2.5 vs. 3.1 years; p = 0.49), size, and gender. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score of 3 to 5 was more prevalent in the del Nido group (24.2% vs. 10%; p = 0.049). There were 4 deaths in the modified del Nido group (risk category score of 4) but none in the cold blood group (p = 0.13). There was no significant difference in median intubation duration, length of intensive care unit stay, and vasoactive medications immediately and 24 h after the operation. The del Nido group required 70 to 100 ml less blood transfusion (p = 0.04). All complications were similar between the two groups. Conclusions Clinical outcomes of lactated Ringer-based del Nido cardioplegia were comparable to those of blood cardioplegia in congenital cardiac surgery.