Diagnostic role of pleural fluid adenosine deaminase in tuberculous pleural effusion.

Between June 1998 and June 2000, 132 consecutive patients with symptomatic exudative lymphocytic pleural effusion were studied to evaluate the diagnostic role of pleural fluid adenosine deaminase (ADAPF) levels. The mean age was 52.2 (SD 16.3) years. The male to female ratio was 1.4:1. The analysis of ADAPF levels was measured base on Giusti's method. Tuberculous pleural effusion was diagnosed in 50 patients (37.9%). Another 59 patients (44.7%) had malignancies, 23 patients (17.4%) had miscellaneous other etiologies (including; 19 with chronic inflammations, 3 with melioidosis, and 1 with systemic lupus erythrematosus). The percentages of pleural fluid lymphocytes and pleural fluid protein in the tuberculous pleural effusion were similar to those with malignancies, but higher than those in the miscellaneous group. The mean value of ADAPF in the tuberculosis group was 93.2 (SD 56.5) U/l, which was significantly higher than for the malignancy and miscellaneous groups (p<0.05, one-way ANOVA). The mean values of ADAPF in the malignancy group were 36.7 (SD 39.2) U/l, and 31.3 (SD 23.4) U/l in miscellaneous group. Three patients were diagnosed with melioidosis and had ADAPF levels of 15, 46.9, and 49.8 U/l, respectively. One patient with systemic lupus erythrematosus had ADAPF levels of 24.1 U/l. A receiver operating characteristic (ROC) curve identified ADAPF level of 48 U/l as the best cut-off value, which in turn yielded a sensitivity of 80% (95% CI, 73 to 87%) and specificity of 80.5% (95% CI, 73.6 to 87.4%). The positive and negative predictive values at this cut-off value were 71.4% and 86.8%, respectively. The likelihood ratios for the diagnosis of tuberculous pleural effusion in patients with ADAPF levels less than 45 U/ l were 1:4, between 45 and 100 U/l were 5:2, and greater than 100 U/l were 7:1. We concluded that ADAPF levels are a useful diagnostic test for tuberculous pleural effusion. In addition, The analyis of ADA levels can be done simply, quickly, and cheaply.

Rapid diagnosis of tuberculous pleural effusion using polymerase chain reaction.

Between October 1998 and September 1999, 98 patients with symptomatic exudative lymphocytic pleural effusion were enrolled in our study to evaluate the diagnostic sensitivity of polymerase chain reaction (PCR) assay. The mean age was 53.3 years ranging from 18 to 78 years. There were 61 men and 37 women. Pleural fluid was sent for gram staining, AFB staining, aerobic culture, culture of Mycobacterium tuberculosis on LJ media, and cytology. Additional fluid was used for a PCR-assay of the 16 S-23 S rRNA gene spacer sequences and for a nested PCR of the 16 S rRNA gene as a blind control. In cases of free-flow pleural tapping, histopathological analysis was done on three pleural biopsies. Overall etiologies comprised malignancy 53.1%, tuberculosis 36.7%, lymphoma 2.0% and chronic nonspecific inflammation 8.2%. The sensitivity and specificity of AFB-staining were 6% and 79%, respectively; while cultures on LJ media were 17% and 100%, respectively. The sensitivity of the PCR-assay was 50% (95% CI: 40 to 60%) and the specificity was 61% (95 CI: 52 to 71%). When PCR was nested, the sensitivity was 72% (95% CI: 63 to 81%) and specificity was 53% (95% CI: 43 to 63%). Two thirds (26 of 36) of tuberculous pleural effusion cases underwent pleural biopsy, and 62% were diagnosed by histopathology. There were no complications from thoracocentesis or pleural biopsy in any of the patients. We concluded that PCR assay was more sensitive than AFB staining and mycobacteria culture for diagnosis tuberculous pleural effusion but its specificity was quite low.

Human pythiosis in Srinagarind Hospital: one year's experience.

We have reported four cases of human pythiosis arteritis from Srinagarind Hospital, Khon Kaen, Thailand. This unusual human infection occurring perhaps exclusively in thalassemia and hemoglobinopathy patients, should be noted by physicians, who work in areas with a high incidence of hemoglobinopathy, and for patients who present with unexplained arterial insufficiency. As our reported cases occurred within only one year, this condition may be more common than originally suspected and found more frequently if actively searched for.

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.

Discriminant analysis among septicemic melioidosis and other bacterial septicemia.

The clinical manifestations of septicemic melioidosis and other bacterial septicemia were studied at Srinagarind Hospital, Khon Kaen University. Forty-three cases of septicemic melioidosis and 68 non-melioidosis septicemia cases were analysed. By univariate analysis, the following clinical features are associated with septicemic melioidosis: male patients; age below 45 years; underlying diabetes mellitus or renal failure; pulmonary infection, impending respiratory failure and multiorgan involvement, while abdominal pain and urinary tract infection were more common in non-melioidosis septicemia. By using discriminant analysis and logistic regression, 3 features (diabetes mellitus, multiorgan involvement, and no abdominal pain or pulmonary infection) could discriminate the two groups with the accuracy of more than 85 per cent.

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.