The effect of lateral position on oxygenation in ARDS patients: a pilot study.

BACKGROUND: The effect of body position on oxygenation in acute respiratory distress syndrome (ARDS) patients has long been known. Prone position improves the PaO2 in 60-70% of ARDS patients. However the effect of the lateral positions, which are used in routine critical care, has never been reported. OBJECTIVE: To determine whether placing the patient in a lateral position has any effect on oxygenation in ARDS. MATERIAL AND METHOD: Prospective observational study, comparing oxygenation in ARDS patients between supine, right and left lateral positions (> or = 60 degree). RESULTS: We included 18 ARDS patients, their mean aged was 52.2 +/- 19.6 years, 14 were men and the ICU mortality rate was 61.1%. There was no significant change in the mean PaO2, arterial blood gas parameters, respiratory mechanics and hemodynamic parameters between the supine and decubitus positions in the overall group. However there was a trend toward increasing the mean PaO2 during right lateral position compared with the supine position (90.3 +/- 29.0 vs 84.6 +/- 20.4, p = 0.23). Nine patients who responded to the right lateral position had significantly higher mean PaO2 during the right lateral position than in the supine position (107.8 +/- 29.0 vs 85.6 +/- 21.8, p < 0.0001). In this group, four patients had predominant left pulmonary infiltration and five patients had equally bilateral pulmonary infiltration on chest X-ray. Unfortunately, the PaO2 in three patients decreased more than 10 mmHg during right lateral decubitus. CONCLUSION: The PaO2 increased while in the right lateral position in patients with predominant left pulmonary infiltration or bilateral infiltration. This effect may be due to the small sample size. A further large-sized randomized controlled study is needed.

Prediction of mortality by using the standard scoring systems in a medical intensive care unit in Thailand.

In order to evaluate and compare the predictive ability of the APACHE II (Acute Physiology and Chronic Health Evaluation II) and the SAPS (Simplified Acute Physiology Score) scoring systems in relation to outcome in a medical intensive care unit (ICU). The authors reviewed consecutive medical ICU admissions (n = 482) at a tertiary hospital over a 2-year period. For each patient, demographic data, diagnosis, APACHE II score, SAPS score and ICU outcome complied during the first 24 hrs of the ICU stay were obtained. The comparison of predictive ability between APACHE II and SAPS was assessed by forward stepwise logistic regression and area under the receiver operating characteristic (ROC) curves. Overall ICU mortality was 36.93%. Mean APACHE II and SAPS scores were 21.17 +/- 9.35 and 14.61 +/- 6.47, respectively. APACHE II and SAPS scores of nonsurvivors (26.97 +/- 8.27 and 18.01 +/- 5.84 respectively) were significantly higher than those of survivors (17.77 +/- 8.22 and 12.62 +/- 5.99 respectively) (p < 0. 001). Correlation between both systems was excellent (Pearson correlation coefficient, r = 0.825: p < 0.001). The predicted risk of death calculated by using the APACHE II risk of death equation was 38.98%. The predictive ability to discriminate between survivors and nonsurvivors of APACHE II was higher than SAPS according to forward stepwise logistic regression and area under the ROC curves (APACHE II was 0.788 while SAPS was 0.746). In conclusion, the APACHE II scoring system is an efficient predictor for monitoring the hospital outcome and has more predictive ability than the SAPS in the medical ICU patients.

Thrombocytopenic purpura associated with miliary tuberculosis.

The authors report a case of thrombocytopenia associated with miliary tuberculosis. The patient was a 28-year-old woman who was admitted because of massive upper gastrointestinal hemorrhage and acute respiratory failure. Chest radiographs revealed diffuse bilateral reticulonodular infiltration and complete blood count was significant for severe thrombocytopenia. Bone marrow biopsy was performed to investigate the cause of thrombocytopenia and demonstrated multiple tiny caseating granulomas suggesting miliary tuberculosis (TB). She received anti-TB therapy and a short course of steroid with good response. Platelet count returned to normal limit within 10 days. Although isolated thrombocytopenia is uncommon in TB, it is still important to consider TB in the differential diagnosis of thrombocytopenia, particularly in patients with abnormal chest radiographs. Bone marrow examination is very helpful in this situation.

Clinical spectrum of hepatic tuberculosis: comparison between immunocompetent and immunocompromised hosts.

BACKGROUND: Hepatic tuberculosis has been reported in normal and immunocompromised hosts. However, no published comparisons between these two groups of subjects with hepatic tuberculosis have been found. The aim of this study was to compare the clinical manifestations, biochemical tests, radiologic features and pathological findings of hepatic tuberculosis in immunocompromised and immunocompetent patients. METHOD: The authors reviewed retrospectively 20 patients with hepatic tuberculosis admitted between January 1993 and October 2000 to Chulalongkorn University Hospital, Thailand. There were 12 immunocompromised patients (10 HIV-infected males, 1 systemic lupus erythematosus (SLE) male, 1 SLE female) and 8 immunocompetent patients (6 males, 2 females). The clinical manifestations, biochemical tests, radiologic features and pathological findings were compared between these 2 groups. The diagnosis of Mycobacterium tuberculosis (M. tb) was the combination of a demonstrated organism in hemo- or specimen culture, histopathology (positive acid fast bacilli) and rapid identification of M. tb from nested polymerase chain reaction (nPCR) assay based on amplification of the IS 6110 insertion sequences. RESULTS: The clinical features were similar in both groups with fever, weight loss and hepatomegaly as the main manifestations. The biochemical findings were also similar but the alkaline phosphatase (ALP) was significantly higher in the immunocompromised group (p < 0.001). Hepatomegaly and diffuse increased echogenicity were common in both groups. Ascitis and calcifications were found more commonly in the immunocompetent subjects, although the differences were not statistically significant. Non-caseating granuloma without detection of acid fast bacilli was a common finding in both groups. The nested PCR assay increased the sensitivity from 49 per cent to 86 per cent compared to the regular PCR assay but specificity was 100 per cent in both techniques. The mortality was significantly higher in immunocompetent patients (p < 0.05) due to the extreme age and severe coexisting diseases. CONCLUSION: Fever, weight loss, hepatomegaly, disproportionate elevation of ALP and reverse A/G ratio were common in hepatic tuberculosis. A disproportionate elevation of ALP was significantly higher in the immunocompromised hosts. Nested PCR assay showed good sensitivity and specificity in the diagnosis of this disease.

Streptococcus suis infection in Thailand.

This is a retrospective study of Streptococcus suis infection in humans submitted to the National Streptococcal Referrence Center of Thailand from 1994 to 2001. There were 11 men and 6 women whose mean age was 46.24 years (range 1 month to 75 years). Among the men, two had known occupational and behavioral exposure to pork or meat products. Among the women, one was a butcher and three were housewives. Half of the patients had underlying diseases. One patient had congenital hydrocephalus, three patients had rheumatic heart disease and three were alcoholics. Two of these patients had a history of skin injury before infection. Nine patients had evidence of acute bacterial meningitis, four patients had infective endocarditis, two had the sepsis syndrome and two suffered from pneumonia and spontaneous bacterial peritonitis. The authors suspected that many cases are not reported particularly where pig-rearing or pork consumption are common. In the absence of an effective vaccine, prevention by public health surveillance is important. Prompt treatment of any cuts and wounds among pork-handlers is a sensible precaution. Furthermore, a high index of suspicion and early detection in order to identify and apply effective antimicrobial agents is necessary to successfully treat S. suis infection.