Respiratory complications after surgery in Vietnam: National estimates of the economic burden.

BACKGROUND: Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking. METHODS: We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits. FINDINGS: Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35-3·64) and 1·39 times (95% CI: 1·34-1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7-1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications. INTERPRETATION: The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients. FUNDING: The authors did not receive any funds for conducting this study.

Quality of Life and Suitability with Vietnamese Harmonious Face Index in Class III Malocclusion Patients.

BACKGROUND: Maxillary Lefort I osteotomy, mandibular bilateral sagittal split ramus was frequently used in correcting skeletal class III malocclusion. There was a lack of research on class III malocclusion patients' quality of life (QoL) after bimaxillary osteotomy. AIM: Class I Intermaxillary relationship was achieved, aesthetic was significantly improved. Significant improvement in Class III skeletal patients' quality of life was acquired. The achievement of harmonious face would be beneficial to the facial aesthetics of patients, thus improving the quality of life. METHODS: Harmonious face index is an effective criterion in assessing the surgery's outcome. In this study was conducted on 30 patients at Hanoi National Hospital of Odontostomatology, Viet Duc Hospital, and Hong Ngoc Hospital from April 2017 to April 2018, and it was a quasi-experimental study with self-comparison, 12 months follow up. RESULTS: Orthognathic surgery effectively corrected malocclusion crossbite, dental compensation, and helped to improve facial aesthetics. 100% of patients had the quality of life improved, good quality of life consisted of 86.7%. In comparison with a harmonious facial index of Kinh ethnic in Vietnam, 70% of patients achieved skeletal harmony, 63.3% of patients achieved dental harmony, 80% achieved soft tissue harmony. CONCLUSIONS: Vietnamese harmonious facial index should be used in planning and pre-surgical simulation.

Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology.

BACKGROUND: Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available. METHODS: We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission. RESULTS: Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients' data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use (p < 0.01 for all). This was also true for all VARI (p < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75-3.33, p = 0.23; VARI without VAP HR 0.40, 95% CI 0.14-1.17, p = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were Acinetobacter baumannii (32/73, 43.8%) Klebsiella pneumoniae (26/73, 35.6%), and Pseudomonas aeruginosa (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806-7824) vs 3131 USD (IQR 2108-7551), p = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75-6.75, p = 0.15). CONCLUSIONS: VARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed.

Acute measles encephalitis in partially vaccinated adults.

BACKGROUND: The pathogenesis of acute measles encephalitis (AME) is poorly understood. Treatment with immune-modulators is based on theories that post-infectious autoimmune responses cause demyelination. The clinical course and immunological parameters of AME were examined during an outbreak in Vietnam. METHODS AND FINDINGS: Fifteen measles IgM-positive patients with confusion or Glasgow Coma Scale (GCS) score below 13, and thirteen with uncomplicated measles were enrolled from 2008-2010. Standardized clinical exams were performed and blood collected for lymphocyte and measles- and auto-antibody analysis. The median age of AME patients was 21 years, similar to controls. Eleven reported receiving measles vaccination when aged one year. Confusion developed a median of 4 days after rash. Six patients had GCS <8 and four required mechanical ventilation. CSF showed pleocytosis (64%) and proteinorrhachia (71%) but measles virus RNA was not detected. MRI revealed bilateral lesions in the cerebellum and brain stem in some patients. Most received dexamethasone +/- IVIG within 4 days of admission but symptoms persisted for ≥3 weeks in five. The concentration of voltage gated calcium channel-complex-reactive antibodies was 900 pM in one patient, and declined to 609 pM ∼ 3 months later. Measles-reactive IgG antibody avidity was high in AME patients born after vaccine coverage exceeded 50% (∼ 25 years earlier). AME patients had low CD4 (218/µl, p = 0.029) and CD8 (200/µl, p = 0.012) T-cell counts compared to controls. CONCLUSION: Young adults presenting with AME in Vietnam reported a history of one prior measles immunization, and those aged <25 years had high measles-reactive IgG avidity indicative of prior vaccination. This suggests that one-dose measles immunization is not sufficient to prevent AME in young adults and reinforces the importance of maintaining high coverage with a two-dose measles immunization schedule. Treatment with corticosteroids and IVIG is common practice, and should be assessed in randomized clinical trials.

An outbreak of trichinosis with molecular identification of Trichinella sp. in Vietnam.

The 5th outbreak of trichinosis occurred in a mountainous area of North Vietnam in 2012, involving 24 patients among 27 people who consumed raw pork together. Six of these patients visited several hospitals in Hanoi for treatment. Similar clinical symptoms appeared in these patients within 5-8 days after eating infected raw pork, which consisted of fever, muscle pain, difficult moving, edema, difficult swallowing, and difficult breathing. ELISA revealed all (6/6) positive reactions against Trichinella spiralis antigen and all cases showed positive biopsy results for Trichinella sp. larvae in the muscle. The larvae detected in the patients were identified as T. spiralis (Vietnamese strain) by the molecular analysis of the mitochondrial cytochrome c oxidase subunit III (cox3) gene.

Stimulating the development of national Streptococcus suis guidelines in Viet Nam through a strategic research partnership.

PROBLEM: Streptococcus suis is a common cause of adult bacterial meningitis in Viet Nam, and possibly other parts of Asia, yet this disabling infection has been largely neglected. Prevention, diagnosis and treatment are relatively straightforward and affordable but, in early 2007, no national diagnostic, case management or prevention guidelines existed in Viet Nam. APPROACH: Enhanced detection of S. suis infections was established in 2007 as part of a collaborative research programme between the National Hospital for Tropical Diseases, a key national hospital with very close links to the Ministry of Health, and a research group affiliated with Oxford University based in Viet Nam. The results were reported directly to policy-makers at the Ministry of Health. LOCAL SETTING: Viet Nam is a low-income country with a health-care system that has seen considerable improvements and increased autonomy. However, parts of the system remain fairly centralized the Ministry of Health. RELEVANT CHANGES: Following the improved detection and reporting of S. suis cases, the Ministry of Health issued guidance to all hospitals in Viet Nam on the clinical and laboratory diagnosis, treatment and prevention of S. suis. A public health laboratory diagnostic service was established at the National Institute of Hygiene and Epidemiology and training courses were conducted for clinicians and microbiologists. Ministry of Health guidance on surveillance and control of communicable diseases was updated to include a section on S. suis. LESSONS LEARNT: Research collaborations can efficiently inform and influence national responses if they are well positioned to reach policy-makers.

Influenza A H5N1 and HIV co-infection: case report.

BACKGROUND: The role of adaptive immunity in severe influenza is poorly understood. The occurrence of influenza A/H5N1 in a patient with HIV provided a rare opportunity to investigate this. CASE PRESENTATION: A 30-year-old male was admitted on day 4 of influenza-like-illness with tachycardia, tachypnea, hypoxemia and bilateral pulmonary infiltrates. Influenza A/H5N1 and HIV tests were positive and the patient was treated with Oseltamivir and broad-spectrum antibiotics. Initially his condition improved coinciding with virus clearance by day 6. He clinically deteriorated as of day 10 with fever recrudescence and increasing neutrophil counts and died on day 16. His admission CD4 count was 100/microl and decreased until virus was cleared. CD8 T cells shifted to a CD27+CD28- phenotype. Plasma chemokine and cytokine levels were similar to those found previously in fatal H5N1. CONCLUSIONS: The course of H5N1 infection was not notably different from other cases. Virus was cleared despite profound CD4 T cell depletion and aberrant CD8 T cell activation but this may have increased susceptibility to a fatal secondary infection.

Human infection with highly pathogenic avian influenza virus (H5N1) in northern Vietnam, 2004-2005.

We performed a retrospective case-series study of patients with influenza A (H5N1) admitted to the National Institute of Infectious and Tropical Diseases in Hanoi, Vietnam, from January 2004 through July 2005 with symptoms of acute respiratory tract infection, a history of high-risk exposure or chest radiographic findings such as pneumonia, and positive findings for A/H5 viral RNA by reverse transcription-PCR. We investigated data from 29 patients (mean age 35.1 years) of whom 7 (24.1%) had died. Mortality rates were 20% (5/25) and 50% (2/4) among patients treated with or without oseltamivir (p = 0.24), respectively, and were 33.3% (5/15) and 14.2% (2/14) among patients treated with and without methylprednisolone (p = 0.39), respectively. After exact logistic regression analysis was adjusted for variation in severity, no significant effectiveness for survival was observed among patients treated with oseltamivir or methylprednisolone.

Oseltamivir is adequately absorbed following nasogastric administration to adult patients with severe H5N1 influenza.

In the absence of a parenteral drug, oral oseltamivir is currently recommended by the WHO for treating H5N1 influenza. Whether oseltamivir absorption is adequate in severe influenza is unknown. We measured the steady state, plasma concentrations of nasogastrically administered oseltamivir 150 mg bid and its active metabolite, oseltamivir carboxylate (OC), in three, mechanically ventilated patients with severe H5N1 (male, 30 yrs; pregnant female, 22 yrs) and severe H3N2 (female, 76 yrs). Treatments were started 6, 7 and 8 days after illness onset, respectively. Both females were sampled while on continuous venovenous haemofiltration. Admission and follow up specimens (trachea, nose, throat, rectum, blood) were tested for RNA viral load by reverse transcriptase PCR. In vitro virus susceptibility to OC was measured by a neuraminidase inhibition assay. Admission creatinine clearances were 66 (male, H5N1), 82 (female, H5N1) and 6 (H3N2) ml/min. Corresponding AUC(0-12) values (5932, 10,951 and 34,670 ng.h/ml) and trough OC concentrations (376, 575 and 2730 ng/ml) were higher than previously reported in healthy volunteers; the latter exceeded 545 to 3956 fold the H5N1 IC(50) (0.69 ng/ml) isolated from the H5N1 infected female. Two patients with follow-up respiratory specimens cleared their viruses after 5 (H5N1 male) and 5 (H3N2 female) days of oseltamivir. Both female patients died of respiratory failure; the male survived. 150 mg bid of oseltamivir was well absorbed and converted extensively to OC. Virus was cleared in two patients but two patients died, suggesting viral efficacy but poor clinical efficacy.