Lateral Flow Urine Lipoarabinomannan Assay for Diagnosis of Active Tuberculosis in Adults With Human Immunodeficiency Virus Infection: A Prospective Cohort Study.

BACKGROUND: Detection of mycobacterial lipoarabinomannan antigen in urine has emerged as a potential point-of-care test for diagnosis of tuberculosis. This study aimed to evaluate the accuracy of the lateral flow urine lipoarabinomannan (LF-LAM) assay for diagnosis of active tuberculosis among Thai adults with advanced human immunodeficiency virus (HIV) infection. METHODS: HIV-infected adult patients with CD4 cell counts ≤200/µL and symptoms suggestive of active tuberculosis were prospectively recruited from both inpatient and outpatient settings at Siriraj Hospital and Chonburi Hospital in Thailand during the study period from December 2015 to March 2017. Freshly collected urine samples were applied to the Alere Determine TB LAM Ag test strip using a grade 1 cutoff, according to the manufacturer's grading system. The diagnostic accuracy of the LF-LAM test was assessed against a microbiological reference standard (definite tuberculosis) or a composite reference standard (definite and probable tuberculosis). RESULTS: Of the 280 patients who were included, 72 (25.7%) had definite and 65 (23.2%) had probable tuberculosis. Among patients with definite tuberculosis, the LF-LAM test yielded a sensitivity of 75.0% and a specificity of 76.0%. It had the highest sensitivity (90.5%) in HIV-infected patients with CD4 cell counts <50/µL. It yielded a lower sensitivity (61.3%) but a higher specificity (86.0%) when compared with the composite reference standard. Among the 20 patients (14%) with false-positive results, strong band intensity was observed mostly in Mycobacterium avium complex infections. An incremental sensitivity of 11% was observed with use of acid-fast bacilli sputum smear or LF-LAM testing, compared with LF-LAM testing alone. CONCLUSIONS: The LF-LAM test performed well in the diagnosis of active tuberculosis in selected patients with more advanced tuberculosis and coexisting HIV disease.

Validation of a clinical risk-scoring algorithm for severe scrub typhus.

OBJECTIVE: The aim of the study reported here was to validate the risk-scoring algorithm for prognostication of scrub typhus severity. METHODS: The risk-scoring algorithm for prognostication of scrub typhus severity developed earlier from two general hospitals in Thailand was validated using an independent dataset of scrub typhus patients in one of the hospitals from a few years later. The predictive performances of the two datasets were compared by analysis of the area under the receiver-operating characteristic curve (AuROC). Classification of patients into non-severe, severe, and fatal cases was also compared. RESULTS: The proportions of non-severe, severe, and fatal patients by operational definition were similar between the development and validation datasets. Patient, clinical, and laboratory profiles were also similar. Scores were similar in both datasets, both in terms of discriminating non-severe from severe and fatal patients (AuROC =88.74% versus 91.48%, P=0.324), and in discriminating fatal from severe and non-severe patients (AuROC =88.66% versus 91.22%, P=0.407). Over- and under-estimations were similar and were clinically acceptable. CONCLUSION: The previously developed risk-scoring algorithm for prognostication of scrub typhus severity performed similarly with the validation data and the first dataset. The scoring algorithm may help in the prognostication of patients according to their severity in routine clinical practice. Clinicians may use this scoring system to help make decisions about more intensive investigations and appropriate treatments.

Ergotism in Thailand caused by increased access to antiretroviral drugs: a global warning.

Ergotism is a toxic condition resulting from overexposure to the ergot compounds produced by various fungi of the genus Claviceps. Traditionally, such exposure was due to ingestion of infected grains, but long-term or excessive use of medications containing ergot derivatives or drug-drug interactions between these medications can result in ergotism. Ergotamine, typically used to treat migraine, has less than 5% bioavailability due to extensive first-pass metabolism by cytochrome P450 3A4 (CYP3A4). Concurrent intake of ergotamine and strong CYP3A4 inhibitors, such as the HIV protease inhibitors (PIs), can lead to clinical ergotism. A total of 13 cases of clinical ergotism in HIV-infected patients has been published since 1997 (most recently reviewed by Frohlich et al).

Clinical risk-scoring algorithm to forecast scrub typhus severity.

PURPOSE: To develop a simple risk-scoring system to forecast scrub typhus severity. PATIENTS AND METHODS: Seven years' retrospective data of patients diagnosed with scrub typhus from two university-affiliated hospitals in the north of Thailand were analyzed. Patients were categorized into three severity groups: nonsevere, severe, and dead. Predictors for severity were analyzed under multivariable ordinal continuation ratio logistic regression. Significant coefficients were transformed into item score and summed to total scores. RESULTS: Predictors of scrub typhus severity were age >15 years, (odds ratio [OR] =4.09), pulse rate >100/minute (OR 3.19), crepitation (OR 2.97), serum aspartate aminotransferase >160 IU/L (OR 2.89), serum albumin ≤3.0 g/dL (OR 4.69), and serum creatinine >1.4 mg/dL (OR 8.19). The scores which ranged from 0 to 16, classified patients into three risk levels: non-severe (score ≤5, n=278, 52.8%), severe (score 6-9, n=143, 27.2%), and fatal (score ≥10, n=105, 20.0%). Exact severity classification was obtained in 68.3% of cases. Underestimations of 5.9% and overestimations of 25.8% were clinically acceptable. CONCLUSION: The derived scrub typhus severity score classified patients into their severity levels with high levels of prediction, with clinically acceptable under- and overestimations. This classification may assist clinicians in patient prognostication, investigation, and management. The scoring algorithm should be validated by independent data before adoption into routine clinical practice.

Using the Health Action Process Approach and implementation intentions to increase flu vaccine uptake in high risk Thai individuals: a controlled before-after trial.

OBJECTIVE: Influenza vaccination rates remain suboptimal in many countries, including Thailand. This study compared the effect of a theory-based educational leaflet, based on the Health Action Process Approach (HAPA), and action planning intervention with a standard government information leaflet designed to increase influenza vaccination uptake among high-risk Thai adults. DESIGN: A controlled before and after trial was conducted. Participants in the intervention (n = 99) received a leaflet based on the HAPA and asking them to form an action plan identifying where, when, and how they would seek vaccination. Those in the comparison condition (n = 102) received a standard government information leaflet. MAIN OUTCOMES MEASURES: There are 2 sets of outcome measures: (a) process measures of HAPA related variables taken at T1 and T2, and (b) vaccination rates during the subsequent 2 months. RESULTS: The HAPA intervention resulted in greater changes on measures of risk perception, outcome expectancies, self-efficacy, and intention than the comparison condition. Stronger intentions to obtain vaccination were explained by changes in outcome expectancies, perceived self-efficacy for arranging time and transportation, and planning. No significant difference in vaccination rates was observed between two groups. Influenza vaccination was directly predicted by self-efficacy and intention. CONCLUSION: Results demonstrate that a HAPA-based leaflet may be a useful tool to enhance individual's vaccination intention, but larger trials are required to confirm these findings.

Randomized controlled trial and meta-analysis of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia.

OBJECTIVE: To determine the effectiveness of oral decontamination with 2% chlorhexidine solution for the prevention of ventilator-associated pneumonia (VAP). DESIGN: Randomized controlled trial and meta-analysis. SETTING: A tertiary care university hospital in Bangkok, Thailand. PARTICIPANTS: Adult patients who received mechanical ventilation and who were hospitalized in intensive care units and general medical wards. METHODS: The patients were randomized to receive oral decontamination with 2% chlorhexidine solution or normal saline solution 4 times per day until their endotracheal tubes were removed. The outcome measures were the development of VAP and oropharyngeal colonization with gram-negative bacilli. Meta-analysis was performed by combining the results of the present study with those from another randomized controlled trial that also used a 2% chlorhexidine formulation for oral decontamination. RESULTS: The characteristics of the patients in the chlorhexidine group (n=102) and the normal saline group (n=105) were not significantly different. The incidence of VAP in the chlorhexidine group was 4.9% (5 of 102), and the incidence in the normal saline group was 11.4% (12 of 105) (P=.08). The rate of VAP in the chlorhexidine group was 7 episodes per 1,000 ventilator-days, and the rate in the normal saline group was 21 episodes per 1,000 ventilator-days (P=.04). Irritation of the oral mucosa was observed in 10 (9.8%) of the patients in the chlorhexidine group and in 1 (0.9%) of the patients in the normal saline group (P=.001). Oropharyngeal colonization with gram-negative bacilli was either reduced or delayed in the chlorhexidine group. Overall mortality of the patients did not differ significantly between the groups. Meta-analysis of 2 randomized controlled trials revealed an overall relative risk of VAP for patients in the chlorhexidine group of 0.53 (95% confidence interval, 0.31-0.90; P=.02). CONCLUSION: Oral decontamination with 2% chlorhexidine solution is an effective and safe method for preventing VAP in patients who receive mechanical ventilation.