Bone mineral density of lumbar spines and proximal femur in the normal northeastern Thai women.

OBJECTIVE: To determine reference data for age-matched bone mineral density (BMD) of normal northeastern Thai women. MATERIAL AND METHOD: 350 northeastern Thai women aged 20-70 years were prospectively studied. After interview, the subjects were examined for BMD of lumbar spines and proximal femur. Mean BMD of each group was determined for each skeletal site. Standard deviation (SD) of BMD in the peak group was calculated to determine BMD cutoff level for diagnosing osteoporosis. RESULT: Peak average BMD of lumbar spines was at 40-45 years, whereas peak BMD of proximal femur was at 35-40 years. Mean value of peak BMD of lumbar spines and proximal femur was 1.226 and 1.035 g/cm2, respectively. According to T-score less than -2.5 SD criteria, osteoporosis of lumbar spines and proximal femur was considered when measured BMD was below 0.889 and 0.785 g/cm2, respectively. CONCLUSION: Our study provided the BMD reference data for northeastern Thai women.

Comparison between the antimicrobial susceptibility of Burkholderia pseudomallei to trimethoprim-sulfamethoxazole by standard disk diffusion method and by minimal inhibitory concentration determination.

Melioidosis, an infection caused by Burkholderia pseudomallei, usually occurs in immunocompromised patients and requires prolonged antibiotic therapy. Previously, oral trimethoprim-sulfamethoxazole (TM/SM), an inexpensive and effective drug has been used as a maintenance therapy. The susceptibility of B. pseudomallei to TM/SM by the standard disk diffusion method is very low. However, some patients who were treated with TM/SM as a maintenance therapy despite the in vitro resistance showed good clinical responses. There were no data comparing the susceptibility of B. pseudomallei by the standard disk diffusion method with other quantitative susceptibility tests. The objective of this study was to determine the agreement between the antimicrobial susceptibility of B. pseudomallei to TM/SM by standard disk diffusion and minimal inhibitory concentration determination (MIC). We performed the susceptibility test of 144 strains of B. pseudomallei to TM/SM by both the standard disk diffusion and microbroth dilution MIC. The sensitivity results were 53.5 per cent and 84.0 per cent respectively. The agreement between the 2 tests was very poor (Kappa = 0.14; 95% CI = -0.01 to 0.29). The false resistant rate by the standard disk diffusion test was 67.9 per cent. Further in vitro susceptibility and clinical study are needed to define the interpretive criteria that correlate with clinical response.

Bone mineral density of lumbar spine and proximal femur in normal Thai women.

OBJECTIVE: To find the reference data for age-specific normal bone mineral density in a Thai female population. STUDY DESIGN: Cross-sectional, Descriptive study. MATERIAL AND METHOD: 1773 Thai women aged between 11-80 years were recruited, using multistage cluster sampling and stratifying from six represented provinces in the country, each strata was randomly selected. After recruiting, the women were interviewed by well-trained personnel using structured questionnaires. Bone mineral density of the lumbar spine 1-4 and nondominant hip were measured by Dual Energy Photon Absorptiometer. The scientists, X-rays technician were trained and standardized inter and intra observers variation. Quality control of examination was measured periodically. Every BMD outcome was re-examined by a specialist. RESULTS: The peak bone mineral density of both spines and hips was between the age of 30 to 34 years old. Mean Value for spine and femoral neck was 0.957 and 0.814 g/cm2 respectively. The BMD of spine and hip was significantly decreased after the age of 35 and the loss was accelerated at age 50. Osteoporosis for spine and femoral neck is considered when BMD are below 0.682 and 0.569 g/cm2 respectively. CONCLUSION: The results are important data for public health policy, by maximizing bone mass during skeletal growth before menopause and minimizing bone loss throughout life as well as for detection of important risk factors.

Survival of children with AIDS: experience in a university hospital in northeast Thailand.

The survival experience of pediatric AIDS patients from three points: birth, age at first symptom and age at AIDS diagnosis (by the WHO definition) was studied. We had 90 subjects, 46 males and 44 females. They were under 15 years of age and were diagnosed as having perinatally-acquired pediatric AIDS. The children came to Srinagarind Hospital between January, 1989 and December, 1997. They were followed-up until April 30, 1998. Patients who did not come to the hospital were traced by confidential mail. The two most common first symptoms were chronic diarrhea (36.7%) and persistent lower respiratory tract infection (34.4%). The median age at the first symptom was four months (95% CI = 3 to 5 months) and the median age at diagnosis was 13 months (95% CI = 11 to 15 months). Thirty-nine cases received antiretroviral treatment, either AZT, ddI or both. Forty-five cases died, 18 cases lived to the end of the study, 27 could not be followed-up. A survival curve was calculated according to the Kaplan and Meier method using SPSS version 6.0. The 1- and 2-year survival rates from the time of the first symptom were 75.3 per cent (95% CI = 65.8% to 84.7%) and 60.3 per cent (95% CI = 49.0% to 71.6%). The corresponding survival rates from AIDS diagnosis were 59.7 per cent (95% CI = 48.4% to 71.1%) and 42.8% (95% CI = 30.3% to 55.3%), respectively.

Imipenem therapy for septicemic melioidosis in a child with penicillin and cephalosporin adverse reaction.

The recommended treatment for severe melioidosis is ceftazidime or a combination of ceftazidime and trimethoprim-sulfamethoxazole (TMP/SMX). Amoxicillin-clavulanate has been shown to be an effective alternative therapy. In patient who is allergic to penicillin and cephalosporin, imipenem an alternative drug may be used. We described a 10 year-old boy who was diagnosed as septicemic melioidosis and type 1 diabetes mellitus. He developed fever and rash while being given ceftazidime and TMP/SMX. The fever recurred when amoxicillin-clavulanate was administered orally. He was successfully treated with imipenem.

Screening for asymptomatic bacteriuria in pregnant women: urinalysis versus urine culture.

A diagnostic test study was conducted to evaluate the diagnostic performance of a simple urinalysis as a screening test for asymptomatic bacteriuria (ABU) in pregnant women. Seven hundred and seventy four asymptomatic pregnant women attending their first antenatal care at Srinagarind Hospital from June 1, 1994 to January 31, 1995 were studied. Simple urinalysis and urine culture were performed on all 774 subjects. The presence of > or = 5 WBC/HPF of centrifuged urine indicated a positive test. ABU was defined as the presence of > or = 10(5) colony forming units of single bacteria per milliliter of urine. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of simple urinalysis in detecting ABU, using urine culture as a gold standard were calculated. Simple urinalysis had a 18.4 per cent sensitivity, 97.2 per cent specificity, 45.7 per cent positive predictive value, 90.4 per cent negative predictive value and 88.4 per cent accuracy in detecting ABU. Because of its low sensitivity and the possible consequences of ABU, simple urinalysis should not be used as a screening test for ABU.

Loss to follow-up of patients with abnormal Pap smear: magnitude and reasons.

We studied the magnitude and reasons for loss to follow-up in cases of abnormal Pap smears. We studied 162 women whose Pap smear results were abnormal. The lost follow-up rate was 41.1 per cent (95% CI: 33.1 to 49.3). Reasons for not coming to receive treatment was mostly related to communication such as not receiving informed letters from the hospital (35.6%), not understanding the messages in the informed letters (10.2%), were informed from the hospital's letters that their results were normal (5.1%), and perceiving that the test result was not serious (13.6%). One third of them had traveling-related reasons. There were 25.4 per cent of patients who sought treatment at other hospitals and 8.5 per cent went to see a traditional healer for treatment. The results provide information to prevent such unnecessary loss after having a Pap smear screening test for cervical carcinoma.

Diabetic ketoacidosis and melioidosis in a child.

A case of 5 year old diabetic girl with melioidosis was reported. She presented with the symptoms and signs of intraabdominal infection, septicemia and diabetic ketoacidosis. Abdominal ultrasonography showed multiple splenic and liver abscesses, melioidosis was suspected. Hemoculture and pus culture yielded Burkholderia pseudomallei which was susceptible to ceftazidime and cotrimoxazole. Correction of fluid and electrolyte combined with insulin therapy and proper antibiotics resulted in a good outcome in this patient.

Doctors' statistical literacy: a survey at Srinagarind Hospital, Khon Kaen University.

Medical doctors need to keep abreast of new developments in medicine. This is often done by reading medical journals and carrying out research activities that require an understanding of statistical methods. This study was designed to assess the knowledge of statistics among doctors in Thailand. A pretested, self-administered questionnaire with nine multiple-choice questions on basic statistical issues was used. In a survey of university hospital staff, there were 365 doctors, including 156 specialists, 152 residents and 57 final year medical students (externs). The overall response rate was 40.0 per cent. The overall median number of correct answers was 4.0 (95% CI 3.0, 4.0). Specialists had a significantly higher median score, 4.0 than residents, and externs, 3.0's, (p = 0.02). Respondents who had previously attended statistical workshops had a significantly higher median score (5.0) than those who had not (3.0) (p < 0.01). These results indicate that doctors in our hospital have insufficient knowledge of the basic statistical concepts that are commonly used in medical journals. Continuing education in statistics for doctors during residency and post doctoral training must be given serious consideration.

Risk factors for neonatal Klebsiella septicemia in Srinagarind Hospital.

Three years' data were analysed to assess the risk factors for neonatal Klebsiella septicemia in Srinagarind Hospital. The incidence of Klebsiella septicemia was 4.1 per 1,000 livebirths or 5.2 per 100 discharged infants. Eighty-two per cent of infected cases were low birth weight infants and 67.7% were born prematurely. From multivariate analysis, the risk factors were endotracheal intubation (OR 31.57, 95% CI 289-343.82) and central venous catheterization (OR 16.99, 95% CI1.15-250.37). The overall mortality rate was 67.7%. Periodic review and continuous reinforcement of infection control policies in the neonatal unit are of paramount importance to decrease the incidence of nosocomial infection and successful control of outbreaks as well.

The prevalence of the indirect hemagglutination test for melioidosis in children in an endemic area.

The indirect hemaglutination test for melioidosis was studied in 295 children who live in the northeastern part of Thailand. Sixty-seven children (22.7%) were healthy children who came to the well baby clinic. Two hundred and twenty-eight children (77.3%) came to the hospital because of some illnesses other than melioidosis. Eighty-three percent of the children had an IHA titer of at least 1:10 or greater. Twenty-two percent had an IHA titer of 1:80 or greater. The prevalence of positive IHA titer and the mean titer were higher in the older age group. The age of children should be considered when interpreting IHA titer for milioidosis.

Comparison of immunogenicity of hepatitis B vaccine between low and normal birth weight infants.

A comparative study was conducted to evaluate the immunogenicity of hepatitis B vaccine in low and normal birth weight infants. Hepatitis B vaccine (Hevac B Pasteur) was given to 50 low birth weight infants and 50 controls, matched by sex and date of delivery. The vaccine was given at birth, 1, 2 and 12 months of age. HBsAg and anti-HBs were assessed at birth, 4, 9 and 13 months of age by the micro-ELISA technique. Using the geometric mean titre of anti-HBs and the seroconversion rate as indicators, the immunogenicity of hepatitis B vaccine in low birth weight infants was as good as in normal birth weight infants.

Post-cesarean section puerperal morbidity. The incidence and risk factors at Srinagarind Hospital.

We found that the incidence of post-cesarean puerperal morbidity at Srinagarind Hospital, Khon Kaen University was 5.5 per cent, which is very low compared to other reports. Statistically significant risk factors for post-cesarean puerperal morbidity included having less than 4 antenatal care visits, duration of labour longer than 12 hours and absence of prophylactic antibiotics.

Febrile and infectious morbidity after abdominal hysterectomy at Srinagarind Hospital.

Two hundred and fifty-seven patients who had undergone total abdominal hysterectomy (TAH) in a rural University Hospital in Thailand between September, 1989 and May, 1990 were found to have an incidence of postoperative febrile and infectious morbidity of 35.4 per cent and 10.1 per cent respectively. The risk factors for febrile morbidity are administration of prophylactic antibiotics, a resident being the surgeon and duration of operation time of more than 120 minutes. The risk factors for infectious morbidity included history of previous surgery, performing TAH alone without adnexectomy and omentectomy and also operation time longer than 120 minutes.

Hospital acquired Janthinobacterium lividum septicemia in Srinagarind Hospital.

Nine patients admitted to the intensive care unit, Srinagarind Hospital, who had septicaemia by J. lividum were reported. Seven patients died, one directly of septicaemia, despite intensive antimicrobial therapy. Investigation revealed that the sources of infection were: special mouth wash solution, distilled water and normal saline used in the ward. After changing to uncontaminated solution and more meticulous care of medical equipment, there was no evidence of the micro-organism after one year follow-up.

Intervention of inappropriate antibiotic use at a university teaching hospital.

The magnitude of inappropriate antibiotic use is high (52.3%). In the empiric treatment group, 41.1 per cent were inappropriate, mostly due to no indication of use. In the surgical prophylaxis, 79.7 per cent were inappropriate, mostly due to delayed prophylaxis and length more than 3 days. In documented infection, 40.2 per cent were inappropriate, mostly due to wrong choice and too many drugs. Intervention by education decreased the overall inappropriate use, empiric inappropriate use and prophylactic use, while there was no change in inappropriate documented infection use and inappropriate economic use. We propose further interventions by other strategies, repeated education and a wider scale of intervention.

Antibiotic use at a university hospital. Antibiotic Working Group of Srinagarind Hospital.

A prospective survey of antibiotic use in 5 departments (MED, SURG, OB-GYN, PED, ORTHO) in Srinagarind Hospital was done during May 1988. The majority of prescribers were interns and residents, except in the department of OB-GYN. Out of 400 prescriptions, 52.3 per cent were inappropriate and 5 per cent were inappropriate for economic reasons. For empirical use, the inappropriateness was 42.3 per cent mostly due to no indication of use. For surgical prophylaxis, 82.4 per cent were inappropriate mostly due to delayed prophylaxis and excessive length of treatment of more than 72 hours. For the treatment of documented infection, 39.6 per cent were inappropriate, mostly due to wrong choice and too many drugs used. There were no statistical differences in mortality, total hospital stay, hospital stay after treatment between the appropriate and inappropriate use.

Pre-exposure vaccination with purified chick embryo cell rabies vaccines in children.

Children who have close contact with rabid dogs, with a history of neither being bitten nor scratched nor licked on broken skin or on mucous membranes were given purified chick embryo rabies vaccine as pre-exposure prophylaxis. Thirteen children received 0.5 ml of the vaccine, while 12 children received 1 ml of the vaccine intramuscularly on days 0, 7 and 28. The rabies antibody level was measured by a standard mouse neutralization test. Before vaccination, all vaccinees had no detectable level of antibody to rabies. On day 14, all children had antibody levels higher than 0.5 IU/ml; the titer peaked from day 28 to day 56 and then was lower on day 90. Children of the 1 ml group had antibody levels higher than the 0.5 ml group, but there was no statistically significant difference. No serious reaction occurred. At 2-3 years of follow up, all children were doing well.