Incidence of active tuberculosis among people living with HIV receiving long-term antiretroviral therapy in high TB/HIV burden settings in Thailand: implication for tuberculosis preventive therapy.

INTRODUCTION: Among high tuberculosis (TB) and HIV burden countries in Asia, tuberculosis preventive therapy (TPT) in people living with HIV (PLWH) has been underutilized despite its proven benefits independent of antiretroviral therapy (ART). Therefore, we determined the incidence of active TB and mortality among 9179 adult PLWH who attended and received ART from 15 tertiary care hospitals across Thailand. METHODS: A retrospective study was conducted in 2018 using follow-up data from 1999 to 2018. The primary endpoint was incident TB disease after ART initiation. Factors associated with TB incidence were analysed using competing risk regression. The Kaplan-Meier method was used to estimate mortality after ART initiation. RESULTS: During a median of 5.1 years of ART (IQR 2.2-9.5 years), 442 (4.8%) PLWH developed TB (TB/HIV), giving an overall incidence of 750 (95% CI 683-823) per 100,000 persons-year of follow up (PYFU). In multivariate analysis, lower CD4 at ART initiation (≤100 cells/mm3 , adjusted sub-distribution hazard ratio [aSHR]: 2.08, 95% CI, 1.47-2.92; 101-200 cells/mm3 , aSHR: 2.21, 95% CI, 1.54-3.16; 201-350 cells/mm3 , aSHR: 1.59, 95% CI, 1.11-2.28 vs. >350 cells/mm3 ), male sex (aSHR: 1.40, 95% CI, 1.11-1.78), lower body weight (<50 kg, aSHR: 1.52, 95% CI, 1.17-1.95) and prior TB event (aSHR: 3.50, 95% CI, 2.72-4.52) were associated with TB incidence. PLWH with HIV RNA ≥50 copies/ml had 5-9 times higher risk of active TB disease higher than those with HIV RNA <50 copies/ml at the same CD4 level. The risk for developing TB was remarkably high during the initial period of ART (175,511 per 100,000 PYFU at<3 months) and was comparable to the general population after 10 years of ART (151 per 100,000 PYFU). TB/HIV had higher mortality (10% vs. 5%) and poorer HIV treatment outcomes: HIV RNA <50 copies/ml (63.8% vs. 82.8%), CD4 cells count (317 vs. 508 cells/mm3 ) at the most recent visit. CONCLUSIONS: In this high TB burden country, TB incidence was remarkably high during the first few years after ART initiation and thereafter decreased significantly. Rapid ART initiation and appropriate TPT can be potential key interventions to tackle the TB epidemic and reduce mortality among PLWH in TB/HIV high burden settings.

Correction to: Postoperative delirium in critically ill surgical patients: incidence, risk factors, and predictive scores.

Following publication of the original article [1], the authors reported a missing data on Table 1 in their paper. The original article [1] has been updated.

Postoperative delirium in critically ill surgical patients: incidence, risk factors, and predictive scores.

BACKGROUND: A common postoperative complication found among patients who are critically ill is delirium, which has a high mortality rate. A predictive model is needed to identify high-risk patients in order to apply strategies which will prevent and/or reduce adverse outcomes. OBJECTIVES: To identify the incidence of, and the risk factors for, postoperative delirium (POD) in surgical intensive care unit (SICU) patients, and to determine predictive scores for the development of POD. METHODS: This study enrolled adults aged over 18 years who had undergone an operation within the preceding week and who had been admitted to a SICU for a period that was expected to be longer than 24 h. The CAM - ICU score was used to determine the occurrence of delirium. RESULTS: Of the 250 patients enrolled, delirium was found in 61 (24.4%). The independent risk factors for delirium that were identified by a multivariate analysis comprised age, diabetes mellitus, severity of disease (SOFA score), perioperative use of benzodiazepine, and mechanical ventilation. A predictive score (age + (5 × SOFA) + (15 × Benzodiazepine use) + (20 × DM) + (20 × mechanical ventilation) + (20 × modified IQCODE > 3.42)) was created. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.84 (95% CI: 0.786 to 0.897). The cut point of 125 demonstrated a sensitivity of 72.13% and a specificity of 80.95%, and the hospital mortality rate was significantly greater among the delirious than the non-delirious patients (25% vs. 6%, p < 0.01). CONCLUSIONS: POD was experienced postoperatively by a quarter of the surgical patients who were critically ill. A risk score utilizing 6 variables was able to predict which patients would develop POD. The identification of high-risk patients following SICU admission can provide a basis for intervention strategies to improve outcomes. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20181204006 . Date registered on December 4, 2018. Retrospectively registered.

Impact of bronchoalveolar lavage galactomannan on the outcome of patients at risk for invasive pulmonary aspergillosis.

BACKGROUND: Invasive pulmonary aspergillosis (IPA) is an important cause of morbidity and mortality among immunocompromised patients especially in neutropenic and patients treated with immunosuppressive drugs. New diagnostic tools have been developed to improve treatment and outcome. Compared with serum galactomannan, bronchoalveolar lavage galactomannan (BAL GM) detection has higher sensitivity (81% vs. 71%) and comparable specificity (87.6% vs. 89%). No study has correlated this test result to clinical outcome. MATERIAL AND METHOD: A prospective non-randomised study was conducted from March to December 2008 in adult patients who were suspected to have invasive pulmonary aspergillosis (IPA). Serum galactomannan levels were measured and bronchoscopy was performed to obtained BAL fluid for direct examination, culture, and measurement of galactomannan level. Response to treatment and mortality within 6-weeks of follow-up were compared between positive and negative BAL GM groups. Factors influencing outcome were also analysed. RESULTS: There were 30 patients with 3 probable, 11 possible and 17 no IPA. Other causative organisms can be identified in 8 of 17 patients in the no IPA group. Overall, BAL GM at the 0.5 cut-off yielded a 46% positive result compared with 13% of serum GM (p = 0.005). There was no significant difference in positive result between BAL GM at 1.0 cut-off and serum GM. By using BAL GM as a mycological criteria, 54% of possible IPA was upgraded to probable IPA. Neither BAL GM nor serum GM results were associated with clinical response and mortality. Recovery of neutropenia was the only factor associated with response to treatment and outcome (p = 0.003). CONCLUSION: BAL GM detection has a higher positive rate than serum GM in patients at risk for IPA. It is helpful in diagnosis and categorization of IPA, but its impact on clinical outcome cannot be demonstrated in this study.