Transthoracic ultrasound assessment of B-lines for identifying the increment of extravascular lung water in shock patients requiring fluid resuscitation

Introduction:

Several studies have shown that the number of B-lines was related to the amount of extravascular lung water (EVLW). In our study, we aimed to demonstrate the magnitude of the incremental B-lines in shock patients with positive net fluid balance and the association with gas exchange impairment.

Materials and Methods:

We performed trans-thoracic ultrasound at admission (T₀) and at follow-up period (T_FL) to demonstrate the change of B lines (ΔB-lines) after fluid therapy. We compared the total B-line score (TBS) at T₀ and T_FL and calculated the Pearson''s correlation coefficient between the ΔB-lines and PaO₂/FiO₂ ratio.

Results:

A total of 20 patients were analyzed. All patients had septic shock. Net fluid balance was + 2228.05 ± 1982.15 ml. The TBS at T₀ and T_FL were 36.6 ± 23.73 and 63.80 ± 29.25 (P < 0.01). The ΔB-lines along anterior axillary line (AAL) correlated to the ΔTBS (r = 0.90, P < 0.01). The ΔB-lines along AAL had inverse correlation to PaO₂/FiO₂ ratio (r = −0.704, P < 0.05). The increase of B-lines ≥ 10 was related to the decrease of PaO₂/FiO₂ ratio. The inter-observer reliability between two ultrasound readers was high (r = 0.92, P < 0.01).

Discussion:

The number of B-lines increased in shock patients with positive net fluid balance and correlated to impaired oxygenation. These data supported the benefit of ultrasound for assessing the EVLW.     

TB, HIV-associated TB and multidrug-resistant TB on Thailand's border with Myanmar, 2006-2007

Objective To measure the burden and improve management of tuberculosis (TB), HIV‐associated TB and MDR TB in Tak Province, Thailand, which borders Myanmar. Methods From September 2006 to August 2007, we collected uniform data about TB cases and enhanced human immunodeficiency virus (HIV) counselling and testing. We provided mycobacterial culture and drug‐susceptibility testing in public or non‐governmental organization facilities. Patients were classified by nationality and, for non‐Thais, by migration status. Results Of 1662 TB cases in the 12‐month period, 1087 (65%) occurred in non‐Thais. Of non‐Thais, 415 (38%) lived in Myanmar but crossed the border for healthcare. HIV infection was diagnosed in 18% of Thais compared with 12% of non‐Thais (P < 0.01); HIV status was unknown for 22% of Thais and 27% of non‐Thais (P = 0.02). Overall, multidrug‐resistant (MDR) TB was diagnosed in 27 patients, 19 (70%) in non‐Thais. Among TB cases never previously treated for TB, no MDR cases were diagnosed in Thais or in Myanmar refugees, but six cases were diagnosed in migrants from Myanmar. Conclusions In Thailand, TB, HIV‐associated TB and MDR TB in migrants from Myanmar are important public health problems; they need to be resolved in both the countries.     

Identifying non-tuberculous mycobacterium lung diseases in acid-fast bacilli positive patients

We conducted a case-control study by comparing the clinical and radiographic features of acid-fast bacilli positive patients with pulmonary tuberculosis (PTB) to those with non-tuberculous mycobacterium (NTM) lung diseases diagnosed according to American Thoracic Society (ATS) criteria. The occurrence of NTM lung disease was associated with persistence in symptoms after the fifth month of treatment (p=0.018), middle lobe involvement (p<0.01), lower lobe involvement (p=0.004), multiple lobe involvement (p=0.001) and reticulo-nodular infiltration (p=0.041). On logistic regression analysis, persistence of symptoms after 5 months of treatment (p<0.001), middle lobe involvement (p<0.001) and lower lobe involvement (p<0.05) were significant predictors of NTM lung disease.These findings suggest physicians should consider NTM lung disease if there is involvement of the middle lobe or lower lobes on chest radiography or the persistence of symptoms at the fifth month of treatment.     

Insecticide susceptibility of mosquitoes invading tsunami-affected areas of Thailand

In order to control the mosquitoes invading tsunami-affected areas of Thailand, the insecticide susceptibility status of field larvae and mosquitoes (Anopheles sundaicus and Culex sitiens) was tested under laboratory conditions. Larval bioassay tests were conducted using the WHO standard method. Three larvicides: temephos, malathion, and plant extract (ethanolic extract of the Southeast Asian long pepper. Piper retrofractum Vahl), were used in the experiments. The results revealed that Cx. sitiens was more susceptible to temephos than malathion and the plant extract, with LC50 ranges of 0.0008-0.0014 mg/l, 0.0046-0.0078 mg/l, and 5.3180-10.1030 mg/l, respectively. Cx. quinquefasciatus showed greater tolerance to every tested larvicide than Cr sitiens. Adult bioassay tests using a WHO test kit and diagnostic doses of 5% malathion, 0.75% permethrin, 0.05% deltamethrin, and 4% DDT were also conducted. The results revealed that Cx. sitiens and An. sundaicus were susceptible to all tested insecticides. The LT50 of 5% malathion ranged between 25.7-26.0 minutes for Cx. sitiens, and 44.7 minutes for An. sundaicus. In addition, Cx. quinquefasciatus showed susceptibility to malathion, with LT10 of 19.7 minutes. However, it showed resistance to both pyrethroid insecticides, with LT50 of 33.1 minutes for 0.75% permethrin, and 19.6 minutes. for 0.05% deltamethrin; it showed low percentage mortality at 24 hour post-exposure, of 48 and 32%, respectively. In conclusion, every tested larvicide could be used for controlling Cx. sitiens larvae, even in brackish water, pyrethroid insecticides for adult Cx. sitiens and An. sundaicus, and malathion for all three species.     

Bloodstream Infections among HIV-Infected Outpatients, Southeast Asia

Bloodstream infections (BSIs) are a major cause of illness in HIV-infected persons. To evaluate prevalence of and risk factors for BSIs in 2,009 HIV-infected outpatients in Cambodia, Thailand, and Vietnam, we performed a single Myco/F Lytic blood culture. Fifty-eight (2.9%) had a clinically significant BSI (i.e., a blood culture positive for an organism known to be a pathogen). Mycobacterium tuberculosis accounted for 31 (54%) of all BSIs, followed by fungi (13 [22%]) and bacteria (9 [16%]). Of patients for whom data were recorded about antiretroviral therapy, 0 of 119 who had received antiretroviral therapy for >14 days had a BSI, compared with 3% of 1,801 patients who had not. In multivariate analysis, factors consistently associated with BSI were fever, low CD4+ T-lymphocyte count, abnormalities on chest radiograph, and signs or symptoms of abdominal illness. For HIV-infected outpatients with these risk factors, clinicians should place their highest priority on diagnosing tuberculosis.Bloodstream infections (BSIs) are a major cause of illness in HIV-infected persons. A series of studies, most of which were conducted in sub-Saharan Africa during the 1990s, demonstrated a high prevalence of BSIs (ranging from 10% to 63%) among hospitalized HIV-infected persons who had fever (1–17). In studies that measured clinical outcomes, the in-hospital death rate for patients with a BSI was high (19%–47%). A variety of pathogens cause BSIs in febrile, hospitalized persons with HIV, most notably non-Typhi Salmonella spp. (6%–15%) and Mycobacterium tuberculosis (2%–19%). BSI with M. tuberculosis appears to be particularly lethal, causing death during hospitalization in up to 47% of patients (9). Although untreated BSIs are believed to lead rapidly to severe illness, sepsis, and death, patients with BSIs may be able to be identified before they are ill enough to require hospitalization, potentially improving clinical outcomes. Despite the large number of studies that have evaluated BSIs in HIV-infected persons, all previous studies have focused on patients seeking care at hospitals because of fever and did not evaluate infections among outpatients with or without fever.Although overall transmission rates have declined and antiretroviral therapy (ART) has become more widely available, HIV infection remains a major public health problem in Southeast Asia (18). Previous studies of BSI in Southeast Asia enrolled only inpatients, and only 1 evaluated a predominantly HIV-infected population (1,19–21). In this study, we prospectively enrolled patients from multiple HIV testing and treatment clinics in Cambodia, Thailand, and Vietnam to assess BSI prevalence, etiology, and risk factors in outpatients with HIV.