The impact of environmental cleaning protocol featuring PX-UV in reducing the incidence of multidrug-resistant gram-negative healthcare-associated infection and colonization in intensive care units in Thailand

In this quasi-experimental study, implementing PX-UV to the standard environmental cleaning protocol was associated with a reduction in the overall incidence of multidrug-resistant (MDR) gram-negative organisms (P = .01) and MDR Acinetobacter baumannii (P = .001) in intervention intensive care units. However, the intervention did not reduce patient length of stay and 30-day mortality.

CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases

OBJECTIVES

Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths.

METHODS

CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus.

RESULTS

Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343-3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1-88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis.

CONCLUSIONS

Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings.

CLINICAL RELEVANCE STATEMENT

This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases.

KEY POINTS

• Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings

OBJECTIVES

The study aimed to evaluate scoring systems for predicting complicated appendicitis in adults diagnosed with acute appendicitis on computed tomography.

METHODS

Three hundred twenty-five consecutive adult patients (mean age 51.9 ± 19.6 years, 212 women) diagnosed with acute appendicitis on computed tomography were retrospectively included. Clinical and imaging findings were compared between patients with and without complicated appendicitis, and independent associations were identified. As C-reactive protein was not available for most patients, 5 out of 8 scoring systems were modified. They, and a newly proposed system, were compared via area under the receiver operating characteristics (ROC) curve (AUC), Additionally, the latter was internally validated. Pairwise comparison was performed, and diagnostic performance of these scoring systems was obtained.

RESULTS

One hundred twenty-seven patients (36.8%) had complicated appendicitis. Significant independent associations were found between complicated appendicitis and duration of symptoms > 12 h, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air (p values < 0.001 to 0.037; AUCs of 0.824-0.829). AUCs of 9 scoring systems ranged from 0.692 to 0.831. Of these, modified Atema, Kim HY, and proposed scores had similarly high and non-significantly different AUCs (0.793-0.831) on pairwise comparison. Their sensitivities, specificities, and accuracies were 73.0-90.6%, 48.5-70.6%, and 64.3-72.3%, respectively. Internal validity test demonstrated high AUCs (0.826-0.844) with one of the proposed scores using odds ratio having 100% sensitivity and 100% negative predictive value.

CONCLUSIONS

Few scoring systems, including proposed ones, had high AUCs, sensitivity, and reasonable specificities, which could potentially aid in safely selecting adult patients with acute appendicitis for nonoperative management.

CRITICAL RELEVANCE STATEMENT

The study suggests few scoring systems for predicting complicated appendicitis with high AUCs and reasonable sensitivities, potentially aiding in selecting patients for nonoperative management.

KEY POINTS

• The study evaluated existing and proposed new scoring systems to predict complicated appendicitis in adults with acute appendicitis on computed tomography. • Several factors were found to be significantly associated with complicated appendicitis, including duration of symptoms, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air. • The modified Atema, Kim HY, and newly proposed scoring systems performed well, potentially aiding in nonoperative management selection.

Small bowel transmural necrosis secondary to acute mesenteric ischemia and strangulated obstruction: CT findings of 49 patients

Rationale and objectives

Transmural bowel necrosis (TBN) is an uncommon surgical emergency that represents an endpoint of occlusive acute mesenteric ischemia (AMI), nonocclusive AMI and small bowel obstruction (SBO). According to limited evidence, each etiology of TBN might demonstrate a different CT finding. This investigation aimed to 1) identify overall CT findings of TBN, and 2) compare CT findings of TBN in each etiology.

Materials and methods

Forty-nine consecutive adults (mean age, 64.6 years; 26 men) with occlusive AMI, nonocclusive AMI or SBO, and pathologically proven TBN were enrolled. All had a CT scan within 24 h before surgery. Clinical information was compiled from medical records. CT examinations were re-reviewed by two radiologists with disagreements resolved by the third radiologist. Data were analyzed and compared.

Results

Transmural bowel necrosis were secondary to arterial AMI, venous AMI, combined arterial and venous AMI, nonocclusive AMI, and SBO in 6, 5, 2, 10, and 26 patients, respectively. The CT findings were ascites (93.9%), abnormal wall enhancement (91.8%), bowel dilatation (89.8%), mesenteric fat stranding (89.8%), abnormal wall thickness (71.5%), pneumatosis (46.9%) and intrinsic hyperattenuation of bowel walls (22.5%). Portovenous gas, mesenteric venous gas, and pneumoperitoneum were present in 4 patients (8.2%). Bowel wall thickness was the only CT findings that showed a statistically significant difference among the 5 etiologies of TBN (P = 0.046).

Conclusions

Most common CT findings of TBN were ascites, abnormal bowel wall enhancement, dilatation, and mesenteric fat stranding. Wall thickness differentiated five etiologies, being most thickened in venous AMI and normal in arterial AMI.

The role of procalcitonin and Clinical Pulmonary for Infection Score (CPIS) score to reduce inappropriate antibiotics use among moderate to severe coronavirus disease 2019 (COVID-19) pneumonia: A quasi-experimental multicenter study

In this quasi-experimental study, implementing a procalcitonin and Clinical Pulmonary Infection Score (CPIS) successfully reduced inappropriate antibiotic use among severely-to-critically ill COVID-19 patients, multidrug-resistant organisms, and invasive fungal infections during the intervention period in 2 medical centers. However, this strategy did not improve inappropriate antibiotic use among mildly-to-moderately ill COVID-19 patients.

Antibiotic prescribing behavior among physicians in Asia: a multinational survey

Objective

To evaluate antibiotic prescribing behavior (APB) among physicians with various specialties in five Asian countries.

Design

Survey of antibiotics prescribing behavior in three stages (initial, on-treatment, and de-escalation stages).

Methods

Participants included internists, infectious diseases (ID) specialists, hematologists, intensivists, and surgeons. Participants' characteristics, patterns of APB, and perceptions of antimicrobial stewardship were collected. A multivariate analysis was conducted to evaluate factors associated with appropriate APB.

Results

There were 367 participants. The survey response rate was 82.5% (367/445). For the initial stage, different specialties had different choices for empiric treatment. For the on-treatment stage, if the patient does not respond to empiric treatment, most respondents will step up to broader-spectrum antibiotics (273/367: 74.39%). For the de-escalation stage, the rate of de-escalation was 10%-60% depending on the specialty. Most respondents would de-escalate antibiotics based on guidelines (250/367: 68.12%). De-escalation was mostly reported by ID specialists (66/106: 62.26%). Respondents who reported that they performed laboratory investigations prior to empirical antibiotic prescriptions (aOR = 2.83) were associated with appropriate use, while respondents who reported ID consultation were associated with appropriate antibiotic management for infections not responding to empiric treatment (aOR = 40.87); adherence with national guidelines (aOR = 2.57) was associated with reported successful carbapenem de-escalation.

Conclusion

This study highlights the variation in practices and gaps in appropriate APB on three stages of antibiotic prescription among different specialties. Education on appropriate investigation, partnership with ID specialist, and availability and adherence with national guidelines are critical to help guide appropriate APB among different specialties.

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults

OBJECTIVES

Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery.

METHODS

A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated.

RESULTS

Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47-100%, and 54-100%, which increased to 53-100%, and 60-100%, respectively, when considering only radiologists' reinterpretations.

CONCLUSIONS

In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

Strategies to limit invasive fungal infection in a coronavirus disease 2019 (COVID-19) intensive care unit: The role of infection prevention for renovation and construction in resource-limited settings

Hospital construction and renovation activities are the main cause of healthcare-associated fungal outbreaks. Infection control risk assessments (ICRAs) for renovation and construction decrease the risk of healthcare-associated fungal outbreaks, but they are typically not performed in developing countries. We reviewed an outbreak investigation to limit the construction-related fungal infections in a COVID-19 ICU in a resource-limited setting.

The feasibility of procalcitonin and CPIS score to reduce inappropriate antibiotics use among severe-critically ill COVID-19 pneumonia patients: A pilot study

Antibiotics have been extensively used in COVID-19 patients without a clear indication. We conducted a study to evaluate the feasibility of procalcitonin along with the "Clinical Pulmonary for Infection Score" (CPIS) as a strategy to reduce inappropriate antibiotic use. Using procalcitonin and CPIS score (PCT-CPIS) successfully reduced inappropriate antibiotics use among severe-critically ill COVID-19 pneumonia patients (45% vs 100%; P < .01). Compared to "non PCT-CPIS" group, "PCT-CPIS" group was associated with a reduction in the incidence of multidrug-resistant organisms and invasive fungal infections (18.3% vs 36.7%; P = .03), shorter antibiotic duration (2 days vs 7 days; P < .01) and length of hospital stay (10 days vs 16 days; P < .01).

Predictive ability of CT findings in the differentiation of complicated and uncomplicated appendicitis: a retrospective investigation of 201 patients undergone appendectomy at initial admission

BACKGROUND

Paradigm shift toward nonoperative management (NOM) of adult appendicitis has made computed tomography (CT) more important than ever, particularly in differentiating complicated from uncomplicated disease. Complete surgical and pathological data of appendicitis in a place where appendectomy at initial admission is a standard of care would allow retrospective review of preoperative CT for performance and predictive ability in identifying those that may benefit from NOM in the future.

RESULTS

The study included 201 CT scans of consecutive adult patients who presented for appendectomy at initial admission with pathologically confirmed acute appendicitis. Complicated appendicitis referred to gangrene or perforation on pathological or operative findings. The overall CT sensitivity, specificity and accuracy for differentiation of complicated from uncomplicated appendicitis were 87.2%, 75.7% and 81.1%, respectively. The most sensitive CT findings of complicated appendicitis were mucosal enhancement defect (83.2%; 95% CI 74.1-90.0) and moderate-to-severe periappendiceal fat stranding (96.8%; 95% CI 91.1-99.3), both independently predictive of complicated appendicitis with adjusted odds ratios (ORs) of 4.62 (95% CI 1.86-11.51) and 4.41 (95% CI 1.06-18.29), respectively. Phlegmon, fluid collection, extraluminal appendicolith, periappendiceal air and small bowel dilatation had specificity of 98.1-100%. Intraluminal appendicoliths were found more frequently in complicated appendicitis (52.6% vs. 22.6%) but not predictive for this diagnosis. Independent clinical predictors of complicated appendicitis were lack of pain migration (OR 2.06), neutrophilia ≥ 82% (OR (2.87) and symptoms ≥ 24 h (OR 5.84).

CONCLUSIONS

CT findings were highly accurate in differentiating complicated from uncomplicated appendicitis among patients undergone appendectomy at initial admission.

Clinical risk scoring for predicting non-alcoholic fatty liver disease in metabolic syndrome patients (NAFLD-MS score)

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) can progress from simple steatosis to hepatocellular carcinoma. None of tools have been developed specifically for high-risk patients. This study aimed to develop a simple risk scoring to predict NAFLD in patients with metabolic syndrome (MetS).

METHODS

A total of 509 patients with MetS were recruited. All were diagnosed by clinicians with ultrasonography-confirmed whether they were patients with NAFLD. Patients were randomly divided into derivation (n=400) and validation (n=109) cohort. To develop the risk score, clinical risk indicators measured at the time of recruitment were built by logistic regression. Regression coefficients were transformed into item scores and added up to a total score. A risk scoring scheme was developed from clinical predictors: BMI ≥25, AST/ALT ≥1, ALT ≥40, type 2 diabetes mellitus and central obesity. The scoring scheme was applied in validation cohort to test the performance.

RESULTS

The scheme explained, by area under the receiver operating characteristic curve (AuROC), 76.8% of being NAFLD with good calibration (Hosmer-Lemeshow χ² =4.35; P=.629). The positive likelihood ratio of NAFLD in patients with low risk (scores below 3) and high risk (scores 5 and over) were 2.32 (95% CI: 1.90-2.82) and 7.77 (95% CI: 2.47-24.47) respectively. When applied in validation cohort, the score showed good performance with AuROC 76.7%, and illustrated 84%, and 100% certainty in low- and high-risk groups respectively.

CONCLUSIONS

A simple and non-invasive scoring scheme of five predictors provides good prediction indices for NAFLD in MetS patients. This scheme may help clinicians in order to take further appropriate action.

Cost-effectiveness analysis of ultrasonography screening for nonalcoholic fatty liver disease in metabolic syndrome patients

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) can be diagnosed early by noninvasive ultrasonography; however, the cost-effectiveness of ultrasonography screening with intensive weight reduction program in metabolic syndrome patients is not clear. This study aims to estimate economic and clinical outcomes of ultrasonography in Thailand.

METHODS

Cost-effectiveness analysis used decision tree and Markov models to estimate lifetime costs and health benefits from societal perspective, based on a cohort of 509 metabolic syndrome patients in Thailand. Data were obtained from published literatures and Thai database. Results were reported as incremental cost-effectiveness ratios (ICERs) in 2014 US dollars (USD) per quality-adjusted life year (QALY) gained with discount rate of 3%. Sensitivity analyses were performed to assess the influence of parameter uncertainty on the results.

RESULTS

The ICER of ultrasonography screening of 50-year-old metabolic syndrome patients with intensive weight reduction program was 958 USD/QALY gained when compared with no screening. The probability of being cost-effective was 67% using willingness-to-pay threshold in Thailand (4848 USD/QALY gained). Screening before 45 years was cost saving while screening at 45 to 64 years was cost-effective.

CONCLUSIONS

For patients with metabolic syndromes, ultrasonography screening for NAFLD with intensive weight reduction program is a cost-effective program in Thailand. Study can be used as part of evidence-informed decision making.

TRANSLATIONAL IMPACTS

Findings could contribute to changes of NAFLD diagnosis practice in settings where economic evidence is used as part of decision-making process. Furthermore, study design, model structure, and input parameters could also be used for future research addressing similar questions.

Intestinal capillariasis in the 21st century: clinical presentations and role of endoscopy and imaging

Background

Intestinal capillariasis is one of the common causes of malabsorption in the East. Reports emphasizing the roles of clinical, endoscopic and radiologic findings of intestinal capillariasis are limited.

Methods

Retrospective review of medical records of 26 patients diagnosed with intestinal capillariasis at Siriraj Hospital, Bangkok, Thailand between 2001- 2013.

Results

Clinical manifestations were chronic watery diarrhea (93%), chronic abdominal pain (70%), significant weight loss (92%), hypoalbuminemia (100%; 85% lower than 2.0 g/dL), and anemia (50%). The median duration of symptoms was 5.5 months (1-60 months). Parasites were found in stool in 15 patients (57%). In patients whose stool tests were initially negative, parasites were discovered in tissue biopsy from endoscopy in 1 from 10 esophagogastroduodenoscopies (EGD), 0 from 7 colonoscopies, 3 from 5 push enteroscopies, and 3 from 5 balloon-assisted enteroscopies (BAE). Endoscopic findings included scalloping appearance, mucosal cracking, and redness of mucosa. These endoscopic findings affected mostly at jejunum and proximal ileum. They were similar to celiac disease except duodenal involvement which is uncommon in capillariasis. Three patients underwent video capsule endoscopy (VCE) and typical abnormal findings were observed in all patients. Small bowel barium study showed fold thickening, fold effacement, and increased luminal fluid in 80% of patients, mainly seen at distal jejunum and ileum. CT findings were long segment wall thickening, enhanced wall, and fold effacement. Treatment with either albendazole or ivermectin cured all patients with most responding within 2 months.

Conclusions

In endemic area, intestinal capillariasis should be considered if patients develop chronic watery diarrhea accompanied by significant weight loss and severe hypoalbuminemia. Stool examination had quite low sensitivities in making diagnosis in our study. Deep enteroscopy with biopsy guided by imaging or VCE may improve diagnostic yield. Empirical therapy may also be justifiable due to the very good response rate and less side effects.

Correlation between the severity of hepatitis B cirrhosis and CT volumetry-based hepatic segmental anatomic changes

OBJECTIVE

To study the correlation between the changes of hepatic segmental volumes and the severity of hepatitis B cirrhosis, classified by Child-Pugh score.

MATERIAL AND METHOD

The study cohort comprised viral hepatitis B cirrhotic patients with different severity (Child-Pugh score grade A to C) and control subjects who underwent hepatic computed tomographic (CT) scan between February 2006 and May 2012. The volumes of total liver (TLV), right lobe (RV), left medial segment (LMV), left lateral segment (LLV), and caudate lobe (CV) were measured and compared between the control group and Child-Pugh A, B, and C groups.

RESULTS

Among 120 hepatitis B cirrhotic subjects, there were 85 males (70.8%) with the mean age of 59.2 years (range 36-86 years). Sixty-two subjects were Child-Pugh A, 39 were Child-Pugh B, and 19 were Child-Pugh C. Among 62 control subjects, there were 28 males (45.2%) with the mean age of54.5 years (range 19-82 years). The TLVand R Vwere significantly decreased in Child-Pugh B and C subjects when compared with control subjects. LMV was significantly decreased in Child-Pugh A and continually decreased along with the severity of the disease. LLV was significantly increased in Child-Pugh A and B, but relative in Child-Pugh C subjects. CV was not significantly different in these four groups.

CONCLUSION

Hepatitis B cirrhotic patients had progressive hepatic atrophy, initially by left medial segment, followed by right lobe and the whole liver Hypertrophy of left lateral segment was evident in early cirrhosis but not significantly shown in severe cirrhosis. Hypertrophy of caudate lobe was not evident in any degrees of hepatitis B cirrhosis.

The CT appearances for differentiating of peripheral, mass-forming cholangiocarcinoma and liver meatastases from colorectal adenocarcinoma

OBJECTIVE

To evaluate the computed tomographic (CT) appearances for differentiating of primary hepatic adenocarcinoma (peripheral, mass-forming cholangiocarcinoma) and secondary hepatic adenocarcinoma (liver metastases from colorectal carcinoma).

MATERIAL AND METHOD

Between January 2004 and December 2010, 45 patients with peripheral, mass-forming cholangiocarcinoma (Group 1) and 45 patients with liver metastases from colorectal adenocarcinoma (Group 2) who underwent abdominal CT scan at the authors' institution were included in the present retrospective study. Two experienced, abdominal radiologists blinded to the participants 'clinical histories and pathological results, separately reviewed the CT findings of each participant (number of liver mass(es), size, margin, internal calcification, hepatic capsule retraction, vascular invasion, peripheral bile duct dilatation, proximal bile duct enhancement, extrahepatic spreading, nearby lymphadenopathy and nearby organ invasion) and gave the presumed diagnosis of each individual case. Any discrepancies were solved by a consensus review. Finally, the authors conducted a stratified analysis of the patients in both groups based on their CT appearances.

RESULTS

Ninety participants were 35 (38.9%) female, 55 (61.1%) male, age range from 43 to 88 years (mean 63.4 years, SD = 10.7). There were 28.9% vs. 48.9% female with the mean age (SD) of 61.5 (9.4) vs. 65.4 (11.6) years in Group 1 and 2, respectively. The mean size (SD) were 7.4 (3.7) cm vs. 4.0 (2.1) cm, in Group 1 and 2, respectively (p < 0.001). The presence of hepatic capsule retraction, vascular invasion, peripheral bile duct dilatation, proximal bile duct enhancement, extrahepatic spreading, nearby lymphadenopathy, and nearby organ invasion were significantly higher in Group 1 than Group 2 (p < 0.001). In contrary, the presence of multiple lesions with separated locations, and smooth margin were significantly suggested of Group 2 (p < 0.001 and p = 0.007, respectively). By logistic regression analysis, peripheral bile duct dilatation, extrahepatic spreading, and proximal bile duct enhancement were the sole predictors of peripheral, mass-forming cholangiocarcinoma. The interobserver agreement for the presumed diagnosis of liver mass was good (kappa = 0.76).

CONCLUSION

The presence of peripheral bile duct dilatation, extrahepatic spreading, and proximal bile duct enhancement were highly suggestive of peripheral, mass-forming cholangiocarcinoma.

Detection of recurrent colorectal cancer by 18F-FDG PET/CT comparison with contrast enhanced CT scan

OBJECTIVE

To evaluate diagnostic performance of 18F-FDG PET/CT in assessment of recurrence colorectal cancer after treatment in Siriraj Hospital.

MATERIAL AND METHOD

The authors retrospectively studied 48 treated colorectal cancer patients with suspected recurrence who underwent 18F-FDG PET/CT and contrast-enhanced CT (CECT). Clinical information, image follow-up for at least one year, and pathological reports of the patients were reviewed for gold standard

RESULTS

Recurrent or metastatic disease was found in 36 of 48 patients. Calculated sensitivity, specificity and accuracy of 18F-FDG PET/CT were 94.4%, 66.7%, and 87.5%. 18F-FDG PET/CT can reduce false positive results of CECT in six patients, thus specificity of 18F-FDG PET/CT was statistically significantly better than that of CECT. Using lesion-based analysis with 65 recurrent sites and 26 non-recurrent lesion, 18F-FDG PET/CT showed better sensitivity 87.7%, specificity 61.5%, and accuracy 80.2 than CECT without statistical significance.

CONCLUSION

18F-FDG PET/CT overall showed higher sensitivity, specificity, and accuracy than CECT.

Comparison of pasteurized whole milk, UHT whole milk, water, and diluted iodine contrast as computed tomographic enteric contrasts

OBJECTIVE

To compare four computed tomographic (CT) enteric contrasts (pasteurized whole milk, UHT whole milk, water, and diluted iodine contrast) in various aspects, including gastrointestinal (GI) distension, mural visualization, GI landmark distinction, taste, patients 'satisfaction, adverse effects, and prices.

MATERIAL AND METHOD

Sixty patients scheduled for whole abdominal CT at the present institution were randomized to receive 1,000 ml of pasteurized whole milk (n = 15), UHT whole milk (n = 15), water (n = 15) and diluted iodine contrast (n = 15) as CT enteric contrasts. Two radiologists separately assessed the GI distension (using a 4-point scale: poor, partial, good, and full), mural visualization (using a 3-point scale: poor, partial, and good), GI landmark distinction at esophagogastric (EG) junction, ampulla of Vater, and pancreatic head-duodenal loop (using a 3-point scale: poor, partial, and good). The participants graded the taste of received enteric contrasts and their satisfaction using a 4-point scale (unacceptable, unpleasant, acceptable, and pleasant). Adverse effects were evaluated by GI associated symptoms (nausea, vomiting, abdominal cramping/discomfort, and diarrhea).

RESULTS

Pasteurized whole milk was superior to other agents in GI distension and tended to be better than other agents in mural visualization and GI landmark distinction. No difference in taste and patients' satisfaction was noted between pasteurized whole milk and other agents. Gallbladder collapse was inevitable in participants with pasteurized and UHT whole milk consumption, due to 4%fat content in whole milk. GI adverse effects were more common in whole milk group than other agents. The prices of pasteurized whole milk, UHT whole milk, water and diluted iodine contrast were about 42, 40, 14, and 36 Baht, respectively.

CONCLUSION

Pasteurized whole milk is an attractive oral contrast agent, providing good GI distension, mural visualization, and GI landmark discrimination. Apart from gallbladder collapse, increase of GI adverse symptoms was another major drawback of whole milk when used as CT oral contrast, especially in Thai people.

Abdominal CT findings to distinguish between tuberculous peritonitis and peritoneal carcinomatosis

OBJECTIVE

Determine useful CT findings for differentiation between tuberculous peritonitis and peritoneal carcinomatosis.

MATERIAL AND METHOD

Abdominal CT scans in 27 clinically or pathologically proven cases of tuberculous peritonitis and 53 pathologically proven cases of peritoneal carcinomatosis were retrospectively reviewed. CT findings were assessed for ascites, abnormalities of peritoneum, omentum, and mesentery, abdominal lymphadenopathy, and other associated findings in abdomen, bone, and lung bases. Statistical differences of CT findings between two diseases were analyzed using Chi-square or Fisher's exact test.

RESULTS

Fibrin in ascites was found in 5/26 patients with tuberculous peritonitis but none in peritoneal carcinomatosis (p < 0.05). Smooth and uniform peritoneal thickening was more frequently seen in tuberculous peritonitis (p < 0.001), but irregular peritoneal thickening and peritoneal nodules were more frequently seen in peritoneal carcinomatosis (p < 0.001). Type of omental abnormalities showed significantly differed between two diseases (p < 0.001). Smudge type was more commonly found in tuberculous peritonitis, while nodular and cake types were more commonly detected in peritoneal carcinomatosis. Lymph nodes size < 1 cm and location of lymph nodes at peripancreatic region were more frequently identified in tuberculous peritonitis, whereas lymph nodes size > or = 1 cm and contour abnormality of the liver or the spleen were more frequently visualized in peritoneal carcinomatosis (p < 0.05).

CONCLUSION

Although some CT findings were overlapped, the present study addressed some useful CT findings for differentiation between tuberculous peritonitis and peritoneal carcinomatosis.

Renal vascular variants in living related renal donors: evaluation with CT angiography

BACKGROUND

Renal vascular variants may complicate the surgical techniques of living related renal transplantation. Renal computed tomographic (CT) angiography is now well accepted for preoperative renal vascular mapping in living related renal donors.

OBJECTIVE

To study the prevalence of renal vascular variants in living related renal donors using CT angiography.

MATERIAL AND METHOD

Preoperative renal CT angiography of 65 consecutive living related renal donors were retrospectively reviewed by two abdominal radiologists on a 3-D workstation. The number and branching patterns of bilateral renal arteries and veins, as well as the presence of renal arterial and venous variants were described.

RESULTS

Supernumerary renal arteries and early branching were present in 18.5% and 12.8% respectively on the right kidneys and 27.7% and 22.4% respectively on the left kidneys. The prevalence of precaval right renal artery was 4.6%. Supernumerary renal veins were present in 35.4% and 1.5% on the right and left kidneys, respectively. Late confluences of left renal veins were identified in 1.5% of left kidneys. Other venous anomalies included 1.5% duplicated inferior vena cava (IVC), 1.5% circumaortic left renal vein, 1.5% retroaortic left renal vein, 1.5% outsized left gonadal veins drained into the left renal vein, and 6.2% right gonadal vein drained into the right renal vein.

CONCLUSION

Renal vascular anatomical variants were common. The surgeons and the radiologists should be aware of these variants to prevent postoperative complications.

Diffuse type autoimmune pancreatitis: the first case report in Thailand

BACKGROUND

Autoimmune pancreatitis (AIP) is a recently-recognized form of pancreatitis mimicking pancreatic cancer (PaC) but treatable with corticosteroid. There is one report of focal-type AIP in Thailand. Here we presented the first case report of diffuse-type AIP.

CASE REPORT

A 76-year-old man presented with 10-day obstructive jaundice. Computed tomography (CT) showed obstructive jaundice from diffusely swollen pancreas, which had a characteristic capsule-like rim non-enhancement pattern of AIP. Serum immunoglobulin G4 (IgG4) was elevated of 468 mg/dL. Endoscopic ultrasound-guided fine needle aspiration demonstrated no PaC. Prednisolone 40 mg/day was started. Jaundice disappeared in 2 weeks and follow-up CT demonstrated normalization of swollen pancreas.

CONCLUSION

Diffuse-type AIP does exist in Thailand. Recognition of this condition is critical to avoid misdiagnosis of PaC or unnecessary surgery.

CT appearances of post-radiation livers in patients with unresectable cholangiocarcinoma

OBJECTIVE

To characterize the computed tomographic (CT) findings of post-radiation livers and the interval changes in patients with unresectable cholangiocarcinoma.

MATERIAL AND METHOD

Thirteen patients with unresectable cholangiocarcinoma who received concurrent chemoradiation with conformal radiotherapy technique (50 to 66 Gy, 2 Gy/fraction) were included in the present study. CT at pre-radiation and sequential follow-up at 1, 3, 6, 9 and 12 months were retrospectively reviewed by two abdominal radiologists to identify CT characteristics of post-radiation liver and the interval changes.

RESULTS

CT at pre-radiation and sequential follow-up at 1, 3, 6, 9 and 12 months were available in 92.3%, 100%, 76.9%, 53.8%, 30.8% and 23.1%, respectively. Post-radiation livers showed sharply-delineated, hypodense radiation areas, which were well related with the isodose line of 35 to 56 Gy (mean = 44.4 +/- 6.55 Gy). These radiation areas were mostly appreciated on portal venous phase at 1-month follow-up study in 12 of 13 (92.3%) patients and these were gradually less defined in subsequent studies. Progressive decrease size of radiation areas with persistent enhancement on delayed phase images were recognized. Progression of hepatic cortical irregularity was seen in four (30.8%) patients, as well as pulmonary fibrosis of lung bases.

CONCLUSION

Post-radiation liver in patients with unresectable cholangiocarcinoma showed a sharply-defined, hypodense radiation area, which was mostly appreciated in 1-month follow-up CT and was gradually less defined in subsequent studies with evidence of progressive atrophic change.

Efficacy of CT angiography for preoperative vascular mapping in adult to adult living related liver transplant donors

OBJECTIVE

To assess the utility of CT angiography (CTA) in preoperative mapping of hepatic vascular anatomy in adult-to-adult living related liver transplant (LRLT) donors.

MATERIAL AND METHOD

Over a 3-year period, 32 potential LRLTdonors underwent CTA with subsequent comparison studies [digital subtraction angiography (DSA) and/or transplantation] were included in this study. Their CTA reports were retrospectively correlated with available DSA and/or operative findings.

RESULTS

CTA correctly predicted right lobe arterial and portal venous anatomy in 32/32 (100%) donors. In 27 donors, hepatic venous anatomy on CT was compared with operative findings. The hepatic veins were well opacified in 23/27 (85.2%) donors. Of these, 15/16 (93.8%) significant (> or =5 mm) accessory right hepatic veins and 11/11 (100%) significant segment VIII vein draining to middle hepatic vein were detected.

CONCLUSION

CTA provided an excellent preoperative depiction of hepatic vascular anatomy in LRLT donors.

Intervention with an infection control bundle to reduce transmission of influenza-like illnesses in a thai preschool

BACKGROUND

Infection-control interventions are needed to minimize transmission of influenza-like illness (ILI) and other infections in settings where children are in close proximity.

SETTING

A 240-children Thai kindergarten.

METHODS

Three-year, quasi-experimental study was conducted to assess the association between the use of a bundle of 4 infection control interventions and the incidence of ILI, diarrheal illnesses, and hand-foot-mouth infections among preschool children. The numbers of incident infections were calculated for the preintervention year (period 1), the immediate postintervention year (period 2), and the sustained postintervention year (period 3).

RESULTS

The monthly incidence of ILI in period 1 (mean, 124 episodes per month) was 25.8 cases per 1,000 child-days; in period 2, it was 10.1 cases per 1,000 child-days (a reduction of 60.8%; P = .008); and in period 3, it was 8.2 cases per 1,000 child-days (a further reduction of 19%; P = .002). The monthly incidence of diarrheal illnesses in period 1 was 14 cases per 1,000 child-days; in period 2, it was 4 cases per 1,000 child-days (P = .01); and in period 3, it was 3 cases per 1,000 child-days (P = .007). The yearly incidence of hand-foot-mouth infection in period 1 was 10 cases per 1,000 child-days; in period 2, it was 1 case per 1,000 child-days (P = .01); and in period 3, it was 0.5 cases per 1,000 child-days per year (P = .007).

CONCLUSION

Use of the infection control intervention bundle was associated with reduced incidence of ILI at the Thai preschool.

Prospective, randomized comparison of castor oil and sodium phosphate preparation for barium enema

OBJECTIVE

To compare castor oil and sodium phosphate preparation (Swiff) in patients' satisfaction, efficacy for colon cleanness, side effects, and prices.

MATERIAL AND METHOD

One hundred patients referred for barium enema were randomized to receive castor oil (n = 50) and sodium phosphate preparation (n = 50). They graded their satisfaction using a 5-point scale (easy, acceptable, slightly difficult, extremely difficult, and unacceptable). The efficacy for colon cleanness was graded by two radiologists using a 5-point scale (excellent, easy for evaluation, acceptable, difficult for evaluation, and unacceptable). Side effects were evaluated by patients' vital signs, total number of bowel frequency, and 10 associated symptoms.

RESULTS

Both preparations revealed no difference in patients' satisfaction (p = 0.882) and efficacy of colon cleanness (p = 0.130). Sodium phosphate preparation was more expensive (79 vs. 10 Baht) and caused higher number of bowel frequency (p < 0.001).

CONCLUSION

With a cheaper price, castor oil was comparable with sodium phosphate preparation in patients' satisfaction and efficacy of colon cleanness.

Diffuse pachymeningitis due to Mycobacterium tuberculosis: a case report and review of the literature

Diffuse pachymeningitis is an uncommon presentation of tuberculous meningitis (TBM). We present a 78-year-old woman patient with a 1-year history of progressive headache and MRI of the brain compatible with diffuse pachymeningitis. Without strong evidence to support a diagnosis, she subsequently underwent dural biopsy which revealed caseous granulomatous inflammation and was positive for Mycobacterium tuberculosis complex by PCR. The dura tissue culture subsequently confirmed the diagnosis of TBM. Successful treatment with antituberculous drugs and corticosteroid was observed without complications. Literature review on characteristics, diagnoses and treatment of central nervous system tuberculosis was also performed.

Outbreak of varicella-zoster virus infection among Thai healthcare workers

OBJECTIVE

To evaluate the correlation between self-report of a prior history of chickenpox and results of varicella-zoster virus (VZV) immunoglobulin (Ig) G serologic test results in an outbreak of VZV infection among Thai healthcare workers (HCWs) and to conduct a cost-benefit analysis of establishing routine VZV immunization as part of an occupational health program on the basis of the outbreak data.

METHODS

All exposed patients received prophylaxis and the HCWs in our 3 intensive care units (ICUs) were prospectively evaluated. HCWs were assessed for disease history and serologic evidence of VZV IgG. A cost-benefit analysis was performed.

RESULTS

After 140 HCWs and 18 ICU patients were exposed to VZV, 10 HCWs (7%) with active VZV infection were relieved from work until skin lesions were crusted. Acyclovir (ACV) was prescribed to all 10 HCWs with active disease, and all 18 exposed patients received prophylaxis with ACV. Of 140 HCWs, 100 consented to longitudinal follow-up. Twenty-three (100%) of the HCWs who reported a history of chickenpox also had serologic test results that were positive for VZV IgG, compared with 30 (39%) of 77 HCWs who reported no prior history of chickenpox, yet had test results that were positive for VZV IgG. Reported history of chickenpox had a sensitivity of 43%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 61% with respect to VZV infection immunity. The total cost estimate for this outbreak investigation was $23,087.

CONCLUSIONS

An HCW's reported history of chickenpox was a reliable predictor of immunity; a report of no prior history of chickenpox was unreliable. Our cost-benefit analysis suggests that the costs of an occupational health program that included VZV surveillance and immunization for the next 323 HCWs would be approximately equal to the excess costs of $17,227 for the ACV therapy, HCW furloughs, and staff overtime associated with this outbreak.

Mycobacterium tuberculosis Associated Chylous Ascites in HIV-infected Patients: Case Report and Review of the Literature

Chylous ascites (CA) is a rare manifestation of tuberculosis. We report a case of CA due to tuberculosis in an HIV-infected patient and review the literature on CA in HIV disease. This patient was successfully treated with large volume abdominal paracentesis, antituberculous drugs, and parenteral medium chain triglycerides.

Computed tomography characteristics of Burkholderia pseudomallei liver abscess

We report 3 cases of Burkholderia pseudomallei liver abscesses that have a characteristic "honeycomb" appearance on computed tomography scans. Such a finding should prompt physicians to include B. pseudomallei infection in the differential diagnoses of liver abscesses and consider initiation of empirical therapy for melioidosis in high-risk patients from areas of endemicity.

Seroprevalence of Anti-H5 Antibody among Thai Health Care Workers after Exposure to Avian Influenza (H5N1) in a Tertiary Care Center

After the initial atypical presentation of a patient with avian influenza (H5N1) infection, paired acute-phase and convalescent-phase serum samples obtained from 25 health care workers (HCWs) who were exposed to the patient were compared with paired serum samples obtained from 24 HCWs who worked at different units in the same hospital and were not exposed to the patient. There was no serologic evidence of anti-H5 antibody reactivity or subclinical infection in either of the groups.

Atypical avian influenza (H5N1)

We report the first case of avian influenza in a patient with fever and diarrhea but no respiratory symptoms. Avian influenza should be included in the differential diagnosis for patients with predominantly gastrointestinal symptoms, particularly if they have a history of exposure to poultry.