Browsing by Author "Ruangsomboon O."
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Item Metadata only Association between cardiopulmonary resuscitation audit results with in-situ simulation and in-hospital cardiac arrest outcomes and key performance indicators(2023-12-01) Ruangsomboon O.; Surabenjawongse U.; Jantataeme P.; Chawaruechai T.; Wangtawesap K.; Chakorn T.; Mahidol UniversityIntroduction: In-situ simulation (ISS) is a method to evaluate the performance of hospital units in performing cardiopulmonary resuscitation (CPR). It is conducted by placing a high-fidelity mannequin at hospital units with simulated scenarios and having each unit’s performance evaluated. However, little is known about its impact on actual patient outcomes. Therefore, we aimed to evaluate the association between the ISS results and actual outcomes of patients with in-hospital cardiac arrest (IHCA). Methods: This retrospective study was conducted by reviewing Siriraj Hospital’s CPR ISS results in association with the data of IHCA patients between January 2012 and January 2019. Actual outcomes were determined by patients’ outcomes (sustained return of spontaneous circulation (ROSC) and survival to hospital discharge) and arrest performance indicators (time-to-first-epinephrine and time-to-defibrillation). These outcomes were investigated for association with the ISS scores in multilevel regression models with hospital units as clusters. Results: There were 2146 cardiac arrests included with sustained ROSC rate of 65.3% and survival to hospital discharge rate of 12.9%. Higher ISS scores were significantly associated with improved sustained ROSC rate (adjusted odds ratio 1.32 (95%CI 1.04, 1.67); p = 0.01) and a decrease in time-to-defibrillation (-0.42 (95%CI -0.73, -0.11); p = 0.009). Although higher scores were also associated with better survival to hospital discharge and a decrease in time-to-first-epinephrine, most models for these outcomes failed to reach statistical significance. Conclusion: CPR ISS results were associated with some important patient outcomes and arrest performance indicators. Therefore, it may be an appropriate performance evaluation method that can guide the direction of improvement.Item Metadata only Changes in Primary Care Health Services During the COVID-19 Pandemic: A Longitudinal Analysis of Data From Ontario(2024-08-01) Ruangsomboon O.; Zhong A.; Kopp A.; Elston B.; Eldridge K.; Lee S.; Plenert E.; Pinto A.D.; Glazier R.H.; Kiran T.; Ruangsomboon O.; Mahidol UniversityThe COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.Item Metadata only Characteristics and factors associated with mortality in palliative patients visiting the Emergency Department of a large tertiary hospital in Thailand(2022-12-01) Monsomboon A.; Chongwatcharasatit T.; Chanthong P.; Chakorn T.; Prapruetkit N.; Surabenjawong U.; Limsuwat C.; Chaisirin W.; Ruangsomboon O.; Mahidol UniversityBackground: The characteristics and outcomes of palliative patients who visited the Emergency Department (ED) in Thailand, a country in which no standard palliative care system existed, have not been comprehensively studied. We aimed to report the characteristics of ED palliative patients and investigate factors associated with mortality. Methods: A prospective observational study was conducted at Siriraj Hospital, Bangkok, Thailand, between March 2019 and February 2021 by means of interviewing palliative patients and/or their caregivers and medical record review. Palliative patients with either incurable cancer or other end-stage chronic diseases were included. Results: A total of 182 patients were enrolled. Their mean age was 73 years, 61.5% were female, and 53.8% had incurable cancer. Of these, 20.3% had previously visited the palliative clinic. Approximately 60% had advanced directives, 4.9% had a living will, and 27.5% had plans on their preferred place of death. The most common chief complaint was dyspnea (43.4%), and the main reason for ED visits was ‘cannot control symptoms’ (80%). At the ED, 17% of the patients had been seen by the palliative care team, and 23.1% died. Although 51% were admitted, 48.9% could not survive to discharge. Cancer, having received morphine, a palliative performance scale > 30, and ED palliative consultation were independently associated with hospital mortality. Conclusion: The recognition and utilization of palliative care were largely inadequate, especially for non-cancer patients. An improvement and promotion in the palliative care system from the ED through home care are mandatory to improve the quality of life of palliative patients.Item Metadata only Clinical and radiological outcomes of robotic-assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials(2023-01-01) Ruangsomboon P.; Ruangsomboon O.; Pornrattanamaneewong C.; Narkbunnam R.; Chareancholvanich K.; Mahidol UniversityBackground and purpose — Robotic-assisted total knee arthroplasty (RATKA) is an alternative surgical treatment method to conventional total knee arthroplasty (COTKA) that may deliver better surgical accuracy. However, its impact on patient outcomes is uncertain. The aim of this systematic review of randomized controlled trials (RCTs) is to evaluate whether RATKA could improve functional and radiological outcomes compared with COTKA in adult patients with primary osteoarthritis of the knee. Methods — We searched Ovid MEDLINE, EMBASE, Scopus, and the Cochrane Library to identify published RCTs comparing RATKA with COTKA. 2 reviewers inde-pendently screened eligible studies, reviewed the full texts, assessed risk of bias using the Risk of Bias 2.0 tool, and extracted data. Outcomes were patient-reported outcomes, range of motion, and mechanical alignment (MA) deviation and outliers, and complications. Results — We included 12 RCTs involving 2,200 patients. RATKA probably results in little to no effect on patient-reported outcomes (mean difference (MD) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of –0.35 (95% confidence interval [CI] –0.78 to 0.07) and range of motion (MD –0.73°; CI –7.5° to 6.0°) compared with COTKA. However, RATKA likely results in a lower degree of MA outliers (risk ratio 0.43; CI 0.27 to 0.67) and less deviation from neutral MA (MD –0.94°; CI –1.1° to –0.73°). There were no differences in revision rate or major adverse effects associated with RATKA. Conclusion — Although RATKA likely results in higher radiologic accuracy than COTKA, this may not be clinically meaningful. Also, there is probably no clinically important difference in clinical outcomes between RATKA and COTKA, while it is as yet inconclusive regarding the revision and complication rates due to insufficient evidence.Item Metadata only Clinical factors associated with adverse clinical outcomes in elderly versus non-elderly COVID-19 emergency patients: a multi-center observational study(2023-12-01) Puchongmart C.; Boonmee P.; Jirathanavichai S.; Phanprasert N.; Thirawattanasoot N.; Dorongthom T.; Monsomboon A.; Praphruetkit N.; Ruangsomboon O.; Mahidol UniversityBackground: The COVID-19 pandemic has caused over 6 million deaths worldwide. The elderly accounted for a large proportion of patients with their mortality rate largely higher than the non-elderly. However, limited studies have explored clinical factors associated with poor clinical outcomes in this important population. Therefore, this study aimed to determine factors independently associated with adverse clinical outcomes among COVID-19 elderly patients. Methods: We conducted a multicenter observational study at five emergency departments (EDs) in Thailand. Patients over 18 years old diagnosed with COVID-19 between January and December 2021 were included. We classified patients into elderly (age ≥ 65 years) and non-elderly (age < 65 years). The primary clinical outcome was in-hospital mortality. The secondary outcomes were endotracheal intubation and intensive care unit admission. We identified independent factors associating with these outcomes both in the whole population and separately by age group using multivariate logistic regression models. Results: A total of 978 patients were included, 519 (53.1%) were elderly and 459 (46.9%) were non-elderly, and 254 (26%) died at hospital discharge. The mortality rate was significantly higher in the elderly group (39.1% versus 14.3%, p<0.001)). In the elderly, age (adjusted odds ratio (aOR) 1.13; 95% confidence interval (CI) 1.1—1.2; p<0.001), male sex (aOR 3.64; 95%CI 1.5–8.8; p=0.004), do-not-resuscitate (DNR) status (aOR 12.46; 95%CI 3.8–40.7; p<0.001), diastolic blood pressure (aOR 0.96; 95%CI 0.9–1.0; p=0.002), body temperature (aOR 1.74; 95%CI 1.0–2.9; p=0.036), and Glasgow Coma Scale (GCS) score (aOR 0.71; 95%CI 0.5–1.0; p=0.026) were independent baseline and physiologic factors associated with in-hospital mortality. Only DNR status and GCS score were associated with in-hospital mortality in both the elderly and non-elderly, as well as the overall population. Lower total bilirubin was independently associated with in-hospital mortality in the elderly (aOR 0.34; 95%CI 0.1–0.9; p=0.035), while a higher level was associated with the outcome in the non-elderly. C-reactive protein (CRP) was the only laboratory factor independently associated with all three study outcomes in the elderly (aOR for in-hospital mortality 1.01; 95%CI 1.0–1.0; p=0.006). Conclusion: Important clinical factors associated with in-hospital mortality in elderly COVID-19 patients were age, sex, DNR status, diastolic blood pressure, body temperature, GCS score, total bilirubin, and CRP. These parameters may aid in triage and ED disposition decision-making in this very important patient population during times of limited resources during the COVID-19 pandemic.Item Metadata only Clinical factors associated with in-hospital mortality in elderly versus non-elderly pneumonia patients in the emergency department(2023-12-01) Chongthanadon B.; Thirawattanasoot N.; Ruangsomboon O.; Mahidol UniversityBackground: Pneumonia is a respiratory infection with an increasing incidence with age. However, limited evidence has identified factors associated with its outcome among different age groups, especially in the elderly and in the emergency department (ED) setting. We aimed to identify clinical factors associated with in-hospital mortality in elderly versus non-elderly pneumonia patients in the ED. Methods: A retrospective observational study was conducted at the ED of Siriraj Hospital, Thailand. Patients aged at least 18 years old diagnosed with non-COVID pneumonia between June 1, 2021, and May 31, 2022, were included. They were categorized into the elderly (age ≥ 65 years) and non-elderly (age < 65 years) groups. The primary outcome was in-hospital mortality. We employed multivariate logistic regression models to identify independent factors associated with the outcome in each age group. Results: We enrolled 735 patients, 515 elderly and 222 non-elderly. There was no difference in in-hospital mortality rate between the two groups (39.0% in the elderly and 32.9% in the non-elderly; p = 0.116). In the elderly cohort, independent factors associated with in-hospital mortality were do-not-resuscitate (DNR) status (adjusted odds ratio (aOR) 12.89; 95% confidence interval (CI) 7.19–23.1; p < 0.001), Glasgow Coma Scale (GCS) score (aOR 0.91; 95%CI 0.85–0.96; p = 0.002), hemoglobin level (aOR 0.9; 95%CI 0.82–0.98; p = 0.012) and the type of initial oxygen support (p = 0.05). Among non-elderly patients, independent factors were DNR status (aOR 6.81; 95%CI 3.18–14.59; p < 0.001), GCS score (aOR 0.89; 95%CI 0.8–0.99; p = 0.025), platelet level (aOR 1; 95%CI 1–1; p = 0.038), Charlson Comorbidity Index (CCI) (aOR 1.12; 95%CI 0.99–1.28; p = 0.078), and the type of initial oxygen support p = 0.079). Conclusion: In pneumonia patients presenting to the ED, DNR status, lower GCS score, and more invasive initial oxygen supplementation were independently associated with in-hospital mortality in both elderly and non-elderly groups. However, lower hemoglobin level was only associated with in-hospital mortality in the elderly, while higher CCI and lower platelet count were independent factors only in the non-elderly. These findings emphasize the importance of age-specific considerations for the disease, and these factors are potential prognostic markers that may be used in clinical practice to improve patient outcomes.Item Metadata only Clinical, functional, and radiological outcomes of robotic assisted versus conventional total hip arthroplasty: a systematic review and meta-analysis of randomized controlled trials(2024-12-01) Ruangsomboon P.; Ruangsomboon O.; Osman K.; Pincus D.; Mundi R.; Tomescu S.; Ravi B.; Chaudhry H.; Ruangsomboon P.; Mahidol UniversityThis systematic review of randomized controlled trials (RCTs) aims to compare important clinical, functional, and radiological outcomes between robotic-assisted total hip arthroplasty (RATHA) and conventional total hip arthroplasty (COTHA) in patients with hip osteoarthritis. We identified published RCTs comparing RATHA with COTHA in Ovid MEDLINE, EMBASE, Scopus, and Cochrane Library. Two reviewers independently performed study screening, risk of bias assessment and data extraction. Main outcomes were major complications, revision, patient-reported outcome measures (PROMs), and radiological outcomes. We included 8 RCTs involving 1014 patients and 977 hips. There was no difference in major complication rate (Relative Risk (RR) 0.78; 95% Confidence Interval (CI) 0.22 to 2.74), revision rate (RR 1.33; 95%CI 0.08 to 22.74), and PROMs (standardized mean difference 0.01; 95%CI − 0.27 to 0.30) between RATHA and COTHA. RATHA resulted in little to no effects on femoral stem alignment (mean difference (MD) − 0.57 degree; 95%CI − 1.16 to 0.03) but yielded overall lower leg length discrepancy (MD − 4.04 mm; 95%CI − 7.08 to − 1.0) compared to COTHA. Most combined estimates had low certainty of evidence mainly due to risk of bias, inconsistency, and imprecision. Based on the current evidence, there is no important difference in clinical and functional outcomes between RATHA and COTHA. The trivial higher radiological accuracy was also unlikely to be clinically meaningful. Regardless, more robust evidence is needed to improve the quality and strength of the current evidence. PROSPERO registration: the protocol was registered in the PROSPERO database (CRD42023453294). All methods were carried out in accordance with relevant guidelines and regulations.Item Metadata only Cost-effectiveness of robotic-assisted versus conventionatotal knee arthroplasty: an analysis from a middle income country(2025-01-01) Ruangsomboon P.; Ruangsomboon O.; Isaranuwatchai W.; Zywiel M.G.; Naimark D.M.J.; Ruangsomboon P.; Mahidol UniversityBackground and purpose — Robotic-assisted total knee arthroplasty (RATKA) can enhance surgical precision. In middle-income countries (MICs), constrained fiscal space and the double burden of rising demand for high-cost technologies and competing public-health priorities—unlike high-income countries with broader fiscal headroom and low-income countries with limited adoption of expensive innovations—make adoption decisions for RATKA particularly challenging. We aimed to evaluate the cost-effective-ness analysis (using a cost-utility framework) of RATKA vs conventional TKA (COTKA) from a societal perspective in Thailand as a MIC. Methods — A discrete event simulation model was employed to compare the cost-effectiveness of unilateral RATKA with COTKA over 4.5 years from a societal perspective, using patient-level data from January 2018 to June 2022 from an arthroplasty center in Thailand. Patients were propensity matched to balance comorbidities. Base case analysis assumed 1 robot performs 434 TKA cases per year with an anticipated lifespan of 12.5 years. We considered direct medical, non-medical, and indirect costs, alongside quality-adjusted life years (QALYs) gained from a societal perspective. We calculated incremental net monetary benefits (INMB) and cost-effectiveness ratios (ICERs) as the main outcome measures. Sensitivity analyses and 10 scenario analyses were performed exploring various possible settings. Threshold analyses determined combinations where RATKA could be cost-effective with positive INMB under the Thai cost-effectiveness threshold of US$4,888 per QALY gained. Results — The base case analysis involved 157 COTKA and 1570 RATKA matched cases with a mean age of 69 (standard deviation 8 years). The lifetime average outcomes per patient were: COTKA—US$5,031.9 and 9.07 QALYs; RATKA—US$5,666.9 and 9.16 QALYs. The incremental (RATKA–COTKA) differences were +US$633.6 (95% credible intervals [CrI] ~592–675) and +0.085 QALYs (CrI ~0.04–0.13), yielding an ICER of US$7,436.6/QALY. RATKA was not cost-effective compared with COTKA, with an INMB of –216.9 US$/patient. The probability of RATKA being cost-effective at the Thai cost-effectiveness threshold was 44.3%. For RATKA to be economically attractive, 1 robot must operate on at least 640 TKA cases/year over 12.5 years. 3 scenarios found RATKA to be cost-effective: (i) maximal robot utilization (850 cases/year); (ii) lowest capital costs (611,060 US$/robot) with high efficacy for RATKA (hazard ratio [HR] 0.6); and (iii) extreme efficacy of RATKA in reducing complications (HR 0.024). Conclusion — In the context of MIC, a broad adoption of RATKA is not economically attractive as treatment of endstage knee osteoarthritis patients compared with COTKA.Item Metadata only Cost-effectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy for medial compartment knee osteoarthritis in young patients: a Canadian public payer perspective(2025-12-01) Ruangsomboon P.; Ruangsomboon O.; Tam D.; Ravi B.; Ekhtiari S.; Pincus D.; Tomescu S.; Ruangsomboon P.; Mahidol UniversityBackground: In medial compartment osteoarthritis (OA) of the knee in young patients who fail conservative treatment, clinical equipoise exists between three surgical strategies: (1) total knee arthroplasty (TKA), (2) unicompartmental knee arthroplasty (UKA), and (3) medial opening wedge high tibial osteotomy (HTO). This study evaluated the cost-effectiveness of three surgical strategies, using a probabilistic Markov model from the Ontario public payer perspective in Canada. Methods: A probabilistic Markov model was developed to perform a cost-utility analysis comparing TKA, UKA, and HTO. The base case simulated a 45-year-old Canadian cohort with unilateral medial knee OA over a lifetime horizon. Outcomes included quality-adjusted life months (QALMs), discounted lifetime costs (1.5% annually), incremental cost-effectiveness ratios (ICERs), and net monetary benefit (NMB), reported in 2023 Canadian dollars (CAD, $). A willingness to pay (WTP) threshold of $4,166.67/QALM was applied. Model uncertainty was assessed via 3,000 iterations of probabilistic sensitivity analysis. Scenario analyses using sex-specific mortality rates were also conducted. Results: Mean costs were $9,157 (TKA), $9,238 (HTO), and $9,419 (UKA). UKA produced the highest QALMs (290.53), followed by TKA (277.02) and HTO (270.88). HTO was absolutely dominated, as it was both more costly and less effective than TKA. Among undominated strategies, UKA yielded an ICER of $19.46/QALM compared to TKA. UKA also had the highest NMB ($1,201,112), outperforming TKA ($1,145,110) and HTO ($1,119,411). UKA was the most cost-effective option in 55.27% of probabilistic simulations, followed by TKA (23.83%) and HTO (20.90%). Scenario analyses with sex-specific mortality showed similar trends. Conclusions: UKA is the most cost-effective surgical strategy from a public payer perspective for young patients with medial knee OA. At a WTP of $4,166.67/QALM, UKA balances long-term durability and economic value better than TKA or HTO. Level of evidence: Level III, Model-based economic evaluation.Item Metadata only Cost-effectiveness of treatment strategies for non-displaced osteoporotic femoral neck fractures in older adults in Ontario, Canada(2026-05-01) Ruangsomboon P.; Huang Y.Q.; Ruangsomboon O.; Tam D.; Zywiel M.; Ravi B.; Naimark D.M.J.; Ruangsomboon P.; Mahidol UniversityAims: This economic evaluation study assessed the cost-effectiveness of six treatment strategies for non-displaced osteoporotic femoral neck fractures (NDFNFs) in older adults using a Markov cohort model from the Ontario, Canada, public payer perspective. Methods: A probabilistic Markov chain Monte Carlo decision analysis model was developed to compare six strategies: 1) cemented femoral fixation total hip arthroplasty (THA; hybrid, cemented femoral component/uncemented cup - 'cemented THA'); 2) cementless THA; 3) cemented hip hemiarthroplasty (HHA); 4) cementless HHA; 5) internal fixation (IF); and 6) conservative treatment. The base case cohort consisted of Canadian patients presenting with a NDFNF aged 65 years, modelled with a lifetime horizon. Outcomes included quality-adjusted life-months (QALMs), lifetime costs (discounted at 1.5% annually), net monetary benefits (NMBs), and incremental cost-effectiveness ratios (ICERs). All costs are presented in Canadian dollars (CAD, $). The cost-effectiveness threshold (λ) was $4,166.67 per QALM. The primary outcome measure was expected NMBs, and the preferred strategy was the one with the highest expected NMBs over the lifetime horizon. Results: The estimated mean costs were $6,054 (IF), $11,995 (cemented THA), $11,011 (cemented HHA), $11,854 (cementless HHA), $15,405 (cementless THA), and $7,617 (conservative treatment). Cemented THA yielded the highest QALMs (192.7). Cemented THA had the highest NMB ($790,784). Cementless THA, cementless HHA, and conservative treatment were absolutely dominated while cemented HHA was extendedly dominated. After excluding dominated strategies, the ICER for cemented THA compared with IF was $127.5 per QALM, indicating that cemented THA is cost-effective relative to IF. At a λ of $4,166.67 per QALM, cemented THA was the most cost-effective strategy in 48.7% of simulations, followed by cemented HHA (31.2%) and IF (17.9%). Conclusion: Cemented femoral fixation THA is the most preferred strategy (highest expected NMB at λ) for NDFNFs in 65-year-old patients. When evaluated against a λ of $4,166.67 per QALM, cemented THA outperforms cementless THA, HHA, IF, and conservative treatment.Item Metadata only Evaluating the impact of surgery sequence on infection rates in hip or knee arthroplasty: does sequence matter?(2024-01-01) Ruangsomboon P.; Ruangsomboon O.; Tomescu S.; Rahman C.; Pincus D.; Ravi B.; Ruangsomboon P.; Mahidol UniversityPurpose: The potential influence of surgical sequence of elective hip-and-knee reconstructive surgery in relation to an infection-related procedure on postoperative infection rates is not clearly understood. Therefore, we aimed to examine the impact of surgical sequence on the incidence of postoperative infections within one-year and the longest available follow-up period in patients undergoing hip-and-knee reconstructive surgery. Methods: A case-control study with propensity matching was utilized to examine elective surgeries conducted at Sunnybrook Holland Orthopaedic & Arthritic centre, Toronto, Canada between 2015 and 2018. We determined and categorized them based on their operating room (OR) sequence in relation to an infected case; the cases were those performed right after (post-infection cohort), and the controls were those performed before an infection-related procedure in the same OR (pre-infection cohort). We employed survival analysis to compare the infection incidence within one year and at the longest available follow-up among the propensity-matched cohort. Results: A total of 13,651 cases were identified during the four year period. We successfully matched 153 cases (21 post-infection and 132 pre-infection) using propensity scores. Demographic and clinical characteristics were balanced through matching. Kaplan-Meier survival analysis showed no significant difference in infection-free survival within one year and at a median follow-up of 2.2 years [interquartile range 0.9-5.0] between surgeries conducted before and after infected cases (both log-rank p-values = 0.4). The hazard ratios for infection within one year and the longest follow-up period were both 0.37 [95%Confidence Interval 0.03–4.09, p = 0.418], as no more events occurred after one year. Conclusion: The sequence of surgical procedures, whether or not an elective arthroplasty or lower limb reconstructive procedure occurs before or after an infection-related case in the same OR, does not significantly affect postoperative infection rates. This finding supports the efficacy of the current infection control measures and suggests a reconsideration of surgical scheduling standards.Item Metadata only Impact of low body mass index on reoperation risk and complications after joint arthroplasty: a cohort study(2025-01-01) Ruangsomboon P.; Ruangsomboon O.; Al-Obaedi O.; Lameire D.L.; Pincus D.; Lex J.R.; Tomescu S.; Ravi B.; Ruangsomboon P.; Mahidol UniversityPurpose: The risks associated with low body mass index (BMI) in arthroplasty patients are underexplored. While outcomes of patients with elevated BMI are well-documented, low BMI patients may also face unique challenges, including malnutrition, osteopenia, and increased surgical risks and postoperative complications. To evaluate the impact of low BMI on reoperation risk and other complications compared with normal BMI among patients undergoing total hip or knee arthroplasty. Methods: This retrospective cohort study analyzed electronic health records of patients with BMI < 25 kg/m² who underwent hip or knee arthroplasty at Sunnybrook Holland Orthopaedic & Arthritic centre, Toronto, Canada between April 2, 2012, and April 6, 2023. Patients were stratified into low BMI (< 20 kg/m²) and normal BMI (20–24.9 kg/m²) groups, with their outcomes followed until November 2024. The main exposure was BMI categorized as low or normal. Other covariates controlled for were relevant demographics and comorbidities. The primary outcome was the risk of reoperation. The secondary outcome was composite complications (persistent pain, wound issues, and radiographic abnormalities). Survival analysis was performed with probabilities visualized with Kaplan-Meier curves. Multivariate Cox proportional hazards models were employed adjusting for potential confounders. Results: Among 1,162 included patients (mean [standard deviation] age, 68.8 [11.1] years; 70.1% women), 182 (15.7%) had low BMI and 980 (84.3%) had normal BMI. Kaplan-Meier curves demonstrated significantly higher risks of reoperation and composite complications in patients with low BMI compared to those with normal BMI (both p < 0.001). After adjusting for other covariates, low BMI was independently associated with increased risks of reoperation (adjusted Hazard Ratio (aHR), 5.8; 95% confidence interval (CI), 2.8–12.1; p < 0.001) and composite complications (aHR, 7.5; 95% CI, 3.9–14.5; p < 0.001). Conclusions: In this large cohort of arthroplasty patients, BMI < 20 kg/m² was associated with elevated risks of reoperation and composite complications. These findings emphasize the importance of tailored preoperative optimization and vigilant postoperative care for this high-risk population. Level of evidence: Level III.Item Metadata only Implementation of machine learning in emergency departments: A systematic review(2026-01-01) Hosseini B.; Patel A.; Landes M.; Vaillancourt S.; Mamdani M.; Maruthananth K.; Matharu N.; Pathan Z.; Sivapragasam K.; Ruangsomboon O.; Skidmore B.; Pinto A.D.; Hosseini B.; Mahidol UniversityObjectives: This systematic review aims to evaluate studies that implemented and evaluated machine learning models in emergency department settings, focusing on their clinical and operational impact. Methods: A comprehensive search was conducted across multiple databases from inception to January 2024. Studies were eligible if they assessed the implementation of machine learning models in emergency departments, with a particular focus on clinical and operational impact. Results: A total of 84 studies met the inclusion criteria. Gradient boosting and neural networks were the most frequently used models. Mortality prediction models achieved AUC values ranging from 0.618 to 0.978, with key predictors including age, sex, race, vital signs, and comorbidities. Disposition prediction models showed AUC values of 0.675–0.96, often incorporating age, sex, vital signs, triage data, and past medical history. Length of stay prediction studies identified demographic data, triage level, chief complaints, and comorbidities as significant predictors, with gradient boosting models yielding the highest predictive accuracy. Machine learning-based treatment decision models showed promise in sepsis detection and cardiovascular triage. Wait time prediction models using gradient boosting decreased patient wait times by 18%–26%. Emergency department cost prediction studies were limited, with logistic regression models achieving AUCs of 0.71–0.76 for identifying high-cost patients. Conclusion: Machine learning is widely used in emergency department research, but issues with generalizability and workflow integration limit its clinical use. Future work should improve data quality, representation, and ongoing model validation to enhance real-world utility.Item Metadata only Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand(2022-12-01) Pansiritanachot W.; Ruangsomboon O.; Limsuwat C.; Chakorn T.; Mahidol UniversityBackground: There is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI). Methods: This single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined. Results: A total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55–4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10–3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37–0.80 and aHR 0.57, 0.33–0.96, respectively). Etomidate dosage was not associated with mortality in our study. Conclusion: In septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.Item Metadata only International medical learners and their adjustment after returning to their countries of origin: a qualitative study(2024-12-01) Wongprom I.; Ruangsomboon O.; Huang J.; Ghavam-Rassoul A.; Wongprom I.; Mahidol UniversityIntroduction: International medical trainees, including residents and fellows, must cope with many challenges, such as differences in cultural hierarchical systems, languages, and acceptance. Nonetheless, the need for adjustment perpetuates even after training is completed abroad. When some international trainees return to their countries of origin, they continue to face adjustment challenges due to reverse culture shock. Others must make many further readjustments. This study presents an exploration of the adjustment and coping strategies of international medical learners after returning to their countries of origin upon completion of their programs. Method: This study employed a qualitative approach grounded in interpretivism and utilised inductive thematic analysis following Braun and Clarke’s method. Semi-structured, in-depth individual interviews were employed to explore the participants’ coping strategies. Participants included international medical learners who were (1) international medical graduates who had already returned to their countries of origin, (2) non-Canadian citizens or nonpermanent residents by the start of the programs, and (3) previously enrolled in a residency or fellowship training programme at the University of Toronto, Ontario, Canada. Results: Seventeen participants were included. Three main themes and seven subthemes were created from the analysis and are represented by the Ice Skater Landing Model. According to this model, there are three main forces in coping processes upon returning home: driving, stabilising, and situational forces. The sum and interaction of these forces impact the readjustment process. Conclusion: International medical learners who have trained abroad and returned to their countries of origin often struggle with readjustment. An equilibrium between the driving and stabilising forces is crucial for a smooth transition. The findings of this study can help stakeholders better understand coping processes. As healthy coping processes are related to job satisfaction and retention, efforts to support and shorten repatriation adjustment are worthwhile.Item Metadata only Methodological standards in the design and reporting of pilot and feasibility studies in emergency medicine literature: a systematic review(2024-11-11) Ruangsomboon O.; Lima J.P.; Eltorki M.; Worster A.; Ruangsomboon O.; Mahidol UniversityOBJECTIVE: Pilot and feasibility studies are intended to ensure that subsequent randomised controlled trials (RCTs) are feasible, economical and rigorous, especially in a challenging research environment such as emergency medicine (EM). We aimed to evaluate the methodological quality in conducting and reporting randomised pilot and feasibility studies in the EM literature and propose recommendations to improve their quality. DESIGN: Methodological systematic review. DATA SOURCES AND ELIGIBILITY: We searched MEDLINE and Embase (2018-29 September 2023) for pilot or feasibility RCTs published as full texts in the five top-ranked and other first-quartile EM journals according to Scimago. DATA EXTRACTION AND ANALYSIS: We assessed their methodological features and reporting quality primarily based on the Consolidated Standards of Reporting Trials (CONSORT) extension. RESULTS: A total of 24 randomised trials identified as pilot (n=13), feasibility (n=3) or both (n=8) were included. At least one feasibility outcome was assessed in 9 trials (feasibility trials), while 15 others only focused on treatment efficacy (efficacy trials). Only three (12.5%) studies progressed to the main trials. Among 12 feasibility trials, 55.6% reported their outcomes with uncertainty estimates, and 33.3% had clear progression criteria. Efficacy trials tended to draw clinical implications on their results. Studies from the five top-ranked journals had better methodological and reporting quality than those from other first-quartile journals. CONCLUSION: Main methodological concerns for pilot and feasibility studies in first-quartile EM literature include misconceptions, misuses and suboptimal design and reporting quality. These issues were more prominent in lower-ranked first-quartile journals. Our findings highlight the need for resources and training for researchers, journal editors and peer reviewers on the value, objectives and appropriate conduct of pilot and feasibility studies. The conceptual framework and standardised methodological components should be emphasised. EM journals should reinforce the reporting standards and support their publication. These actions can lead to more methodologically rigorous pilot and feasibility studies in EM. PROSPERO REGISTRATION NUMBER: CRD42023468437.Item Metadata only Parallel-group, randomised, controlled, non-inferiority trial of high-flow nasal cannula versus non-invasive ventilation for emergency patients with acute cardiogenic pulmonary oedema: study protocol(2022-07-01) Ruangsomboon O.; Praphruetkit N.; Monsomboon A.; Mahidol UniversityIntroduction High-flow nasal cannula (HFNC) is an innovative oxygen-delivering technique, which has been shown to effectively decrease the intubation risk in patients with hypoxaemic respiratory failure of various aetiologies compared with conventional oxygen therapy. Also, it has proved to be non-inferior to non-invasive positive pressure ventilation (NIPPV) in patients with hypoxaemic respiratory failure primarily due to pneumonia. Evidence on its benefits compared with NIPPV, which is the standard of care for patients with acute cardiogenic pulmonary oedema (ACPE) with hypoxaemic respiratory distress, is limited. Therefore, we planned this study to investigate the effects of HFNC compared with NIPPV for emergency patients with ACPE. Methods and analysis In this single-centred, non-blinded, parallel-group, randomised, controlled, non-inferiority trial, we will randomly allocate 240 patients visiting the emergency department with ACPE in a 1:1 ratio to receive either HFNC or NIPPV for at least 4 hours using computer-generated mixed-block randomisation concealed by sealed opaque envelopes. The primary outcome is the intubation rate in 72 hours after randomisation. The main secondary outcomes are intolerance rate, mortality rate and treatment failure rate (a composite of intolerance, intubation and mortality). The outcome assessors and data analysts will be blinded to the intervention. These categorical outcomes will be analysed by calculating the risk ratio. Interim analyses evaluating the primary outcome will be performed after half of the expected sample size are recruited. Ethics and dissemination This study protocol has been approved by the Siriraj Institutional Review Board (study ID: Si 271/2021). It has been granted the Siriraj Research and Development Fund. All participants or their authorised third parties will provide written informed consent prior to trial inclusion. The study results will be published in a peer-reviewed international journal and presented at national and international scientific conferences. Trial registration number TCTR20210413001.Item Metadata only Performance of A-DROP, NEWS2, and REMS in predicting in-hospital mortality and mechanical ventilation in pneumonia patients in the emergency department: a retrospective cohort study(2024-12-01) Thirawattanasoot N.; Chongthanadon B.; Ruangsomboon O.; Thirawattanasoot N.; Mahidol UniversityBackground: Pneumonia is a potentially life-threatening respiratory tract infection. Many Early Warning Scores (EWS) were developed to detect patients with high risk for adverse clinical outcomes, but few have explored the utility of these EWS for pneumonia patients in the Emergency Department (ED) setting. We aimed to compare the prognostic utility of A-DROP, NEWS2, and REMS in predicting in-hospital mortality and the requirement for mechanical ventilation among ED patients with pneumonia. Methods: A retrospective study was conducted at the ED of Siriraj Hospital, Thailand. Adult patients diagnosed with non-COVID-19 pneumonia between June 1, 2021, and May 31, 2022, were included. We calculated and analyzed their EWS at ED arrival. The primary outcome was all-cause in-hospital mortality. The secondary outcome was mechanical ventilation. Results: We enrolled 735 patients; 272 (37%) died at hospital discharge, and 75 (10.2%) required mechanical ventilation. A-DROP had the highest discrimination capacity for in-hospital mortality (AUROC: 0.698, 95% CI 0.659–0.737) compared to NEWS2 (AUROC 0.657; 95%CI 0.617, 0.698) and REMS (AUROC 0.637; 95%CI 0.596, 0.678). A-DROP also had superior performances than NEWS2 and REMS in terms of calibration, overall model performance, and balanced diagnostic accuracy indices at its optimal cut point (A-DROP ≥ 2). No EWS could perform well in predicting mechanical ventilation. Conclusion: A-DROP had the highest prognostic utility for predicting in-hospital mortality in non-COVID-19 pneumonia patients in the ED compared to NEWS2 and REMS.Item Metadata only Physical Performance and Patient-Reported Outcomes Remain Stable at 5 Years After Total Knee Arthroplasty(2025-01-01) Ruangsomboon P.; Ruangsomboon O.; Anusitviwat C.; Ravi B.; Unnanuntana A.; Ruangsomboon P.; Mahidol UniversityPurpose: To evaluate changes in physical performance tests (PPTs) and patient-reported outcome measures (PROMs) at baseline, 1 year after total knee arthroplasty (TKA), and a minimum of 5 years after TKA. Methods: We enrolled patients who underwent TKA between 2013 and 2015 performed by a single arthroplasty surgeon at Siriraj Hospital, Mahidol University, Bangkok, Thailand. We evaluated PPTs and PROMs over a minimum 5-year follow-up period to assess changes over time, identified independent factors associated with PPT deterioration, and determined TKA survivorship. Results: The study included 126 participants with a mean age of 77.8 years. The average follow-up time was 7.4 ± 2.3 years. PPTs and PROMs changed significantly over time from baseline. However, the 2-minute walk test and timed up-and-go test results slightly declined after 1 year but did not attain minimal clinically important differences, and PROMs were maintained and showed no clinically significant changes after 1 year. Hospitalizations owing to complex medical conditions or trauma were independently associated with PPT deterioration. There was a 98.8% survivorship rate at 7.6 years. Conclusions: In an Asian population undergoing TKA, PPTs and PROMs are maintained within acceptable ranges for at least 5 years after primary TKA. Trauma or hospitalizations arising from complex medical conditions were found to be associated with functional decline. A combined evaluation of PPTs and PROMs is advocated for a comprehensive assessment of patients after TKA. Level of Evidence: Level III, cohort study.Item Metadata only Ratio of Oxygen Saturation to Inspired Oxygen, ROX Index, Modified ROX Index to Predict High Flow Cannula Success in COVID-19 Patients: Multicenter Validation Study(2023-01-01) Ruangsomboon O.; Jirathanavichai S.; Phanprasert N.; Puchongmart C.; Boonmee P.; Thirawattanasoot N.; Dorongthom T.; Monsomboon A.; Praphruetkit N.; Mahidol UniversityIntroduction: High-flow nasal cannula (HFNC) is a respiratory support measure for coronavirus 2019 (COVID-19) patients that has been increasingly used in the emergency department (ED). Although the respiratory rate oxygenation (ROX) index can predict HFNC success, its utility in emergency COVID-19 patients has not been well-established. Also, no studies have compared it to its simpler component, the oxygen saturation to fraction of inspired oxygen (SpO2/FiO2 [SF]) ratio, or its modified version incorporating heart rate. Therefore, we aimed to compare the utility of the SF ratio, the ROX index (SF ratio/respiratory rate), and the modified ROX index (ROX index/heart rate) in predicting HFNC success in emergency COVID-19 patients. Methods: We conducted this multicenter retrospective study at five EDs in Thailand between January–December 2021. Adult patients with COVID-19 treated with HFNC in the ED were included. The three study parameters were recorded at 0 and 2 hours. The primary outcome was HFNC success, defined as no requirement of mechanical ventilation at HFNC termination. Results: A total of 173 patients were recruited; 55 (31.8%) had successful treatment. The two-hour SF ratio yielded the highest discrimination capacity (AUROC 0.651, 95% CI 0.558-0.744), followed by two-hour ROX and modified ROX indices (AUROC 0.612 and 0.606, respectively). The two-hour SF ratio also had the best calibration and overall model performance. At its optimal cut-point of 128.19, it gave a balanced sensitivity (65.3%) and specificity (61.8%). The two-hour SF≥128.19 was also significantly and independently associated with HFNC failure (adjusted odds ratio 0.29, 95% CI 0.13-0.65; P=0.003). Conclusion: The SF ratio predicted HFNC success better than the ROX and modified ROX indices in ED patients with COVID-19. With its simplicity and efficiency, it may be the appropriate tool to guide management and ED disposition for COVID-19 patients receiving HFNC in the ED.