The impact of environmental cleaning protocol featuring PX-UV in reducing the incidence of multidrug-resistant gram-negative healthcare-associated infection and colonization in intensive care units in Thailand

In this quasi-experimental study, implementing PX-UV to the standard environmental cleaning protocol was associated with a reduction in the overall incidence of multidrug-resistant (MDR) gram-negative organisms (P = .01) and MDR Acinetobacter baumannii (P = .001) in intervention intensive care units. However, the intervention did not reduce patient length of stay and 30-day mortality.

Real-life effectiveness of COVID-19 vaccine during the Omicron variant-dominant pandemic: how many booster doses do we need?

The surge in coronavirus disease 2019 (COVID-19) caused by the Omicron variants of the severe acute respiratory syndrome coronavirus 2 necessitates researches to inform vaccine effectiveness (VE) and other preventive measures to halt the pandemic. A test-negative case-control study was conducted among adults (age ≥18 years) who were at-risk for COVID-19 and presented for nasopharyngeal real-time polymerase chain reaction testing during the Omicron variant-dominant period in Thailand (1 January 2022-15 June 2022). All participants were prospectively followed up for COVID-19 development for 14 days after the enrolment. Vaccine effectiveness was estimated and adjusted for characteristics associated with COVID-19. Of the 7971 included individuals, there were 3104 cases and 4867 controls. The adjusted VE among persons receiving 2-dose, 3-dose, and 4-dose vaccine regimens for preventing infection and preventing moderate-to-critical diseases were 33%, 48%, 62% and 60%, 74%, 76%, respectively. The VE were generally higher among those receiving the last dose of vaccine within 90 days compared to those receiving the last dose more than 90 days prior to the enrolment. The highest VE were observed in individuals receiving the 4-dose regimen, CoronaVac-CoronaVac-ChAdOx1 nCoV-19-BNT162b2 for both preventing infection (65%) and preventing moderate-to-critical diseases (82%). Our study demonstrated increased VE along with an increase in number of vaccine doses received. Current vaccination programmes should focus on reducing COVID-19 severity and mandate at least one booster dose. The heterologous boosters with viral vector and mRNA vaccines were highly effective and can be used in individuals who previously received the primary series of inactivated vaccine.

The role of procalcitonin and Clinical Pulmonary for Infection Score (CPIS) score to reduce inappropriate antibiotics use among moderate to severe coronavirus disease 2019 (COVID-19) pneumonia: A quasi-experimental multicenter study

In this quasi-experimental study, implementing a procalcitonin and Clinical Pulmonary Infection Score (CPIS) successfully reduced inappropriate antibiotic use among severely-to-critically ill COVID-19 patients, multidrug-resistant organisms, and invasive fungal infections during the intervention period in 2 medical centers. However, this strategy did not improve inappropriate antibiotic use among mildly-to-moderately ill COVID-19 patients.

The Prediction Score of Acute Kidney Injury in Patients with Severe COVID-19 Infection

BACKGROUND

The incidence and risk factors for acute kidney injury in COVID-19 patients vary across studies, and predicting models for AKI are limited. This study aimed to identify the risk factors for AKI in severe COVID-19 infection and develop a predictive model for AKI.

METHOD

Data were collected from patients admitted to the ICU at Thammasat University Hospital in Thailand with PCR-confirmed COVID-19 between 1 January 2021, and 30 June 2022.

RESULTS

Among the 215 severe-COVID-19-infected patients, 102 (47.4%) experienced AKI. Of these, 45 (44.1%), 29 (28.4%), and 28 (27.4%) patients were classified as AKI stage 1, 2, and 3, respectively. AKI was associated with 30-day mortality. Multivariate logistic regression analysis revealed that prior diuretic use (odds ratio [OR] 7.87, 95% confidence interval [CI] 1.98-31.3; p = 0.003), use of a mechanical ventilator (MV) (OR 5.34, 95%CI 1.76-16.18; p = 0.003), and an APACHE II score ≥ 12 (OR 1.14, 95%CI 1.05-1.24; p = 0.002) were independent risk factors for AKI. A predictive model for AKI demonstrated good performance (AUROC 0.814, 95%CI 0.757-0.870).

CONCLUSIONS

Our study identified risk factors for AKI in severe COVID-19 infection, including prior diuretic use, an APACHE II score ≥ 12, and the use of a MV. The predictive tool exhibited good performance for predicting AKI.

Prevalence and associating factors of long COVID in pediatric patients during the Delta and the Omicron variants

Introduction

The number of pediatric COVID-19 infections is increasing; however, the data on long COVID conditions in children is still limited. Our study aimed to find the prevalence of long COVID in children during the Delta and Omicron waves, as well as associated factors.

Methods

A single-center prospective cohort study was conducted. We included 802 RT-PCR-confirmed COVID-19 pediatric patients in the Delta and Omicron periods. Long COVID was defined as having symptoms for ≥3 months after infection. Parents and/or patients were interviewed by phone. Multivariable logistic regression was performed to find associated factors with long COVID.

Results

The overall prevalence of long COVID was 30.2%. The Delta period had more prevalence than the Omicron (36.3% vs. 23.9%). Common symptoms for patients 0-3 years' old were loss of appetite, rhinorrhea, and nasal congestion. Conversely, patients 3-18 years' old had hair loss, dyspnea on exertion, rhinorrhea, and nasal congestion. However, there was no significant negative impact on daily life. Most symptoms improved after a 6-month follow-up. Factors associated with long COVID-19 conditions were infection during the Omicron period (adjusted OR: 0.54; 95% CI: 0.39-0.74, P < 0.001), fever (adjusted OR: 1.49, 95% CI: 1.01-2.20, P = 0.04) and rhinorrhea (adjusted OR: 1.47, 95% CI: 1.06-2.02, P = 0.02).

Conclusion

Infection during the Omicron wave has a lower prevalence of long COVID. The prognosis is often favorable, and most symptoms gradually become less. However, pediatricians may schedule appointments to surveil long COVID in children with fever or rhinorrhea as an initial symptom.

Predictors for Unsuccessful Reductions in Hemodialysis Frequency during the Pandemic

Background and Objectives: Patients receiving in-center hemodialysis are at a high risk of coronavirus disease 2019 (COVID-19) infection. A reduction in hemodialysis frequency is one of the proposed measures for preventing COVID-19 infection. However, the predictors for determining an unsuccessful reduction in hemodialysis frequency are still lacking. Materials and Methods: This retrospective observational study enrolled patients who were receiving long-term thrice-weekly hemodialysis at the Thammasat University Hospital in 2021 and who decreased their dialysis frequency to twice weekly during the COVID-19 outbreak. The outcomes were to determine the predictors and a prediction model of unsuccessful reduction in dialysis frequency at 4 weeks. Bootstrapping was performed for the purposes of internal validation. Results: Of the 161 patients, 83 patients achieved a dialysis frequency reduction. Further, 33% and 82% of the patients failed to reduce their dialysis frequency at 4 and 8 weeks, respectively. The predictors for unsuccessful reduction were diabetes, congestive heart failure (CHF), pre-dialysis overhydration, set dry weight (DW), DW from bioelectrical impedance analysis, and the mean pre- and post-dialysis body weight. The final model including these predictors demonstrated an AUROC of 0.763 (95% CI 0.654–0.866) for the prediction of an unsuccessful reduction. Conclusions: The prediction score involving diabetes, CHF, pre-dialysis overhydration, DW difference, and net ultrafiltration demonstrated a good performance in predicting an unsuccessful reduction in hemodialysis frequency at 4 weeks.

Effects of the Consumption of Low to Medium Glycemic Index-Based Rice on the Rate of Insulin Initiation in Patients with Gestational Diabetes: A Triple-blind, Randomized, Controlled Trial

INTRODUCTION

Medical nutritional therapy is vital in patients with diabetes. A low glycemic index (GI) is generally advised in the management of women with gestational diabetes mellitus (GDM). However, the efficacy of this advice has not been systematically examined. The purpose of this study was to determine whether recommending a low to moderate GI rice (RD43 rice; GI = 56.9) in women with GDM would reduce the number of women requiring insulin, compared with rice of high GI (Thai Hom Mali [THM] rice; GI = 80.1).

METHODS

Ninety-six participants with GDM were randomly assigned to receive either RD43 rice or THM rice.

RESULTS

The mean ± SD ages in the RD43 and THM groups were 33.1 ± 13.1 and 33.6 ± 4.1 years, respectively. The mean gestational ages at the sampling in the RD43 and THM groups were 23.3 ± 5.9 and 23.5 ± 5.4 weeks. Both groups had comparable baseline characteristics, including age, gestational age, body mass index prior to pregnancy and at enrollment, baseline postprandial (oral glucose tolerance test) plasma glucose level, and hemoglobin A_1c. Of the 48 women assigned to the RD43 group, 3 (6.3%) required insulin; in the THM group, 11 (22.9%) met the criteria for insulin therapy (P = 0.017). However, 10 of these 11 women were able to avoid insulin use by changing to the low to moderate GI rice.

CONCLUSION

Using a low to moderate GI rice in GDM effectively reduced the number of patients requiring insulin therapy. Thai Clinical Trials Registry ID: TCTR20210524007.

Difference in Immunogenic Responses to COVID-19 Vaccines in Patients With Cancer Receiving Chemotherapy Versus Nonchemotherapy Treatment

PURPOSE

The COVID-19 pandemic has affected public health worldwide. The efficacy and safety of COVID-19 vaccines have been evaluated in the general population; however, data on patients with malignancies are limited.

METHODS

This prospective longitudinal observational cohort study was conducted between June and July 2021. Enrolled adult patients with cancer were divided into chemotherapy and nonchemotherapy groups. All participants were immunized with two doses of the ChAdOx1 nCoV-19 or CoronaVac COVID-19 vaccines. The primary outcome was a comparison of the immunogenicity (as assessed by spike protein [anti-S] immunoglobulin G [IgG] antibody titers) of two doses of COVID-19 vaccine in the chemotherapy and nonchemotherapy groups. The secondary outcomes included the anti-S IgG seroconversion rate and vaccine safety in both groups.

RESULTS

Among the 173 enrolled patients with solid cancer, after COVID-19 vaccination, the chemotherapy group had a significantly lower median anti-S IgG titer than the nonchemotherapy group (26 v 237 U/mL, P < .001). A statistically significant difference in anti-S IgG titer was found between groups vaccinated with CoronaVac (7 v 90 U/mL, P < .001), but no difference was found in those vaccinated with ChAdOx1 nCoV-19 (818 v 1061 U/mL, P = .075). The anti-S IgG seroconversion rate was significantly lower in the chemotherapy group than that in the nonchemotherapy group (78.9% v 96.5%, P = .001). No new or serious vaccine-related adverse events were reported.

CONCLUSION

Patients with solid cancer receiving a COVID-19 vaccine while undergoing chemotherapy had lower immunogenicity responses to vaccination than those who were vaccinated while undergoing nonchemotherapy treatment. No statistically significant difference was observed in the COVID-19 vaccine safety profiles between groups.

Maintenance intravenous iron in hemodialysis patients to minimize erythropoietin doses: a double-blinded, randomized controlled trial (the MAINTAIN IRON trial)

In patients on chronic hemodialysis, there is no standard protocol for maintenance iron supplementation. This study aimed to compare two fixed-dose intravenous (IV) iron protocols to reduce erythropoiesis-stimulating agents (ESA). We conducted a double-blinded, randomized controlled study on hemodialysis patients having ferritin levels between 200 and 700 ng/dl and transferrin saturation values between 20 and 40%. Patients were assigned to receive either 100 or 200 mg of IV iron each month. ESA was adjusted every month to keep Hb between 10 and 12 g/dl. ESA dose at 12 months was the primary outcome. The secondary outcomes were all-cause mortality, cardiovascular events, absolute iron deficiency anemia (IDA), blood transfusion, adverse events, and iron withholding rate. Of the 79 eligible patients, 40 received 100 mg of IV iron, while 39 received 200 mg. At month 12, the mean monthly ESA dose in the 100-mg IV iron group was 35,706 ± 21,637 IU, compared to 26,382 ± 14,983 IU in the 200-mg group (P = 0.03). IDA was found in twelve patients (30%) in the 100-mg group and four patients (10.5%) in the 200-mg group (P = 0.05). In each group, three patients died (P = 0.9). Hospitalization, venous access thrombosis, and infection rates were similar in both groups. The withholding rate of IV iron was higher in 200-mg group (25% vs. 64.1%), but the protocol compliance was found more in 100-mg group (50% vs. 28.2%) (P = 0.001). In conclusion, monthly 200-mg IV iron infusions significantly reduce ESA doses but have a higher withholding rate. (Funded by the Kidney Foundation of Thailand and the Research Group in Nephrology and Renal Replacement Therapy from the Faculty of Medicine, Thammasat University).Thai Clinical Trials Registry number, TCTR20190707001.

Development and validation of the predictive score for pediatric COVID-19 pneumonia: A nationwide, multicenter study

Background

Due to the possibility of asymptomatic pneumonia in children with COVID-19 leading to overexposure to radiation and problems in limited-resource settings, we conducted a nationwide, multi-center study to determine the risk factors of pneumonia in children with COVID-19 in order to create a pediatric pneumonia predictive score, with score validation.

Methods

This was a retrospective cohort study done by chart review of all children aged 0–15 years admitted to 13 medical centers across Thailand during the study period. Univariate and multivariate analyses as well as backward and forward stepwise logistic regression were used to generate a final prediction model of the pneumonia score. Data during the pre-Delta era was used to create a prediction model whilst data from the Delta one was used as a validation cohort.

Results

The score development cohort consisted of 1,076 patients in the pre-Delta era, and the validation cohort included 2,856 patients in the Delta one. Four predictors remained after backward and forward stepwise logistic regression: age < 5 years, number of comorbidities, fever, and dyspnea symptoms. The predictive ability of the novel pneumonia score was acceptable with the area under the receiver operating characteristics curve of 0.677 and a well-calibrated goodness-of-fit test (p = 0.098). The positive likelihood ratio for pneumonia was 0.544 (95% confidence interval (CI): 0.491–0.602) in the low-risk category, 1.563 (95% CI: 1.454–1.679) in the moderate, and 4.339 (95% CI: 2.527–7.449) in the high-risk.

Conclusion

This study created an acceptable clinical prediction model which can aid clinicians in performing an appropriate triage for children with COVID-19.

Comparing real-life effectiveness of various COVID-19 vaccine regimens during the delta variant-dominant pandemic: A test-negative case-control study

Data on real-life vaccine effectiveness (VE), against the delta variant (B.1.617.2) of the severe acute respiratory syndrome coronavirus 2 among various coronavirus disease 2019 (COVID-19) vaccine regimens are urgently needed to impede the COVID-19 pandemic. We conducted a test-negative case-control study to assess the VE of various vaccine regimens for preventing COVID-19 during the period when the delta variant was the dominant causative virus (≥ 95%) in Thailand (25 July 2021–23 Oct 2021). All individuals (age ≥18 years) at-risk for COVID-19, presented for nasopharyngeal real-time polymerase chain reaction (RT-PCR) testing, were prospectively enrolled and followed up for disease development. Vaccine effectiveness was estimated with adjustment for individual demographic and clinical characteristics. Of 3353 included individuals, there were 1118 cases and 2235 controls. The adjusted VE among persons receiving two-dose CoronaVac plus one BNT162b2 booster was highest (98%; 95% confidence interval [CI] 87–100), followed by those receiving two-dose CoronaVac plus one ChAdOx1 nCoV-19 booster (86%; 95% CI 74–93), two-dose ChAdOx1 nCoV-19 (83%; 95% CI 70–90), one CoronaVac dose and one ChAdOx1 nCoV-19 dose (74%; 95% CI 43–88) and two-dose CoronaVac (60%; 95% CI 49–69). One dose of CoronaVac or ChAdOx1 nCoV-19 had a VE of less than 50%. Our study demonstrated the incremental VE with the increase in the number of vaccine doses received. The two-dose CoronaVac plus one BNT162b2 or ChAdOx1 nCoV-19 booster regimens was highly effective in preventing COVID-19 during the rise of delta variant.

Plasma Cystatin C Level is a Prognostic Marker of Morbidity and Mortality in Hospitalized Decompensated Cirrhotic Patients

Introduction : Cystatin C (CysC) is biomarker for early detection of acute kidney injury (AKI). However, there is limited evidence in decompensated cirrhotic patients without AKI at admission. This study aimed to assess CysC as a predictor of 90-day mortality. Methods : Decompensated cirrhotic patients without AKI were prospectively enrolled. CysC and creatinine were measured within 24 hours of admission and compared between patients with in-hospital complications (AKI, hepatorenal syndrome (HRS), acute-on-chronic liver failure (ACLF)) vs. those without, and survivors vs. non-survivors. The AUROC and cut-off point of CysC in predicting 90-day mortality were determined. Results : Of 137 decompensated cirrhotic patients, 46 without AKI at admission were included (58.7% male, age 60.8 ± 11.2years, MELD 13.1 ± 5.1, ChildA / B / C 43.5% / 39.1% / 17.4%). The mean CysC level tended to be higher in patients with ACLF (1.52 ± 0.60 vs. 1.11 ± 0.28, p = 0.05), and significantly higher in non-survivors than survivors (1.61 ± 0.53 vs. 1.08 ± 0.28, p = 0.013). The 90-day mortality rate was 21.7%. After adjusting with age and bacterial infection on admission, CysC level  ≥ 1.25 mg / L was significantly associated with 90-day mortality. The CysC cut-off level  ≥ 1.25 mg / L provided 80% sensitivity and 75% specificity for predicting 90-day mortality. Conclusion : Plasma CysC within 24 hours could be used as a predictor for 90-day mortality and development of ACLF in decompensated cirrhotic patients. J. Med. Invest. 68 : 302-308, August, 2021.

Clinical characteristics and outcomes of adults with peripheral extracorporeal membrane oxygenation in a developing country: A single center 8-year retrospective study

INTRODUCTION

In our institute, we began using peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in 2010, and peripheral veno-venous (VV) ECMO in 2015. This study aimed to describe clinical characteristics and outcomes in those patients.

METHODS

We reviewed retrospective data of adults receiving peripheral ECMO from January 2010 to December 2017 and divided it into two groups for analysis: VA- and VV-ECMO.

RESULTS

There were 28 patients in the VA group and 12 in VV. For VA, the mean (SD) age was 58.5 (17.2) years. The most common indication was cardiac arrest (12 patients, 42.9%); 15 patients (53.6%) were on intra-aortic balloon pump concomitantly. In the VV cohort, the mean age was 53.3 (16.2) years. Eleven (91.7%) patients had acute respiratory distress syndrome as an indication. The mortality rate of VA-ECMO was 85.7%, and VV was 58.3%.

CONCLUSION

The mortality rate in our ECMO center was considerably higher than that in the international registry report. Improved team education, rigid patient selection criteria, and a reimbursement protocol should lead to ameliorated outcomes.

TRIAL REGISTRATION

TCTR20190120001. Registered January 19, 2019.

Ultrafiltration rates and intradialytic hypotension: A case-control sampling of pooled haemodialysis data

BACKGROUND

Intradialytic hypotension (IDH) is one of the most critical adverse events during maintenance haemodialysis. Previous studies reported the association of fluid removal rate with the occurrence of IDH.

OBJECTIVE

We aimed to identify the optimal threshold of ultrafiltration rate to prevent the occurrence of IDH events. DESIGN, PARTICIPANTS AND MEASUREMENTS: Prognostic factor research with a retrospective case-control design was conducted. Patient data were gathered from four haemodialysis units from January to December 2017. All the haemodialysis records were independently justified, whether IDH occurred or not, based on the standard definition. A total of 10 haemodialysis sessions were sampled from each patient's pool based on the incidence of events. The association of ultrafiltration rates and IDH events was explored by multivariable multilevel logistic regression.

RESULTS

A total of 1080 haemodialysis sessions from 108 patients were included: 149 (13.8%) with IDH and 931 (86.2%) without IDH. After adjusting for all pre-specified risk factors and imbalance baselines, the odds ratio of IDH were 1.22 (95% confidence interval [CI]: 0.59, 2.52) for rate 10-12 ml/kg/h; 2.52 (95% CI: 1.20, 5.29) for rate 12-14 ml/kg/h; 4.02 (95% CI: 1.61, 10.03) for rate 14-16 ml/kg/h; and 7.41 (95% CI: 2.53, 21.68) for rate >16 ml/kg/h comparing to the referent rate of <10 ml/kg/h.

CONCLUSION

The ultrafiltration rate should be limited to 12 ml/kg/h. If a higher rate of fluid removal was indicated, it should not exceed 16 ml/kg/h to avoid the occurrence of IDH.

Changes in clinical indicators related to the transition from dialysis to kidney transplantation-data from the ERA-EDTA Registry

Background

Kidney transplantation should improve abnormalities that are common during dialysis treatment, like anaemia and mineral and bone disorder. However, its impact is incompletely understood. We therefore aimed to assess changes in clinical indicators after the transition from chronic dialysis to kidney transplantation.

Methods

We used European Renal Association–European Dialysis and Transplant Association Registry data and included adult dialysis patients for whom data on clinical indicators before and after transplantation (2005–15) were available. Linear mixed models were used to quantify the effect of transplantation and of time after transplantation for each indicator.

Results

In total, 16 312 patients were included. The mean age at transplantation was 50.1 (standard deviation 14.2) years, 62.9% were male and 70.2% were on haemodialysis before transplantation. Total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol and triglycerides increased right after transplantation but decreased thereafter. All other indicators normalized or approached the target range soon after transplantation and these improvements were sustained for the first 4 years of follow-up. In patients with higher estimated glomerular filtration rate (eGFR) levels (30–60 and >60 mL/min/1.73 m²), the improvement of haemoglobin, ferritin, ionized calcium, phosphate, parathyroid hormone, HDL cholesterol, triglycerides, albumin and C-reactive protein levels was more pronounced than in patients with a lower eGFR (<30 mL/min/1.73 m²).

Conclusions

Except for total cholesterol, LDL cholesterol and triglycerides, all clinical indicators improved after transplantation. These improvements were related to eGFR. Nevertheless, values remained out of range in a considerable proportion of patients and anaemia and hyperparathyroidism were still common problems. Further research is needed to understand the complex relationship between eGFR and the different clinical indicators.