CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases.

OBJECTIVES: Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths. METHODS: CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus. RESULTS: Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343-3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1-88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis. CONCLUSIONS: Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings. CLINICAL RELEVANCE STATEMENT: This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases. KEY POINTS: • Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

Incident of violence escalation of patients with psychiatric emergencies boarding in the emergency department in the central region of Thailand and its association: a prospective observational study.

BACKGROUND: This study investigates the incidence of violence escalation among psychiatric emergency patients admitted to general emergency departments in hospitals in central Thailand. In addition, patient and service delivery system factors associated with the survival time of violence escalation in 16 emergency departments in the central region of Thailand are determined. This is a prospective observational study, and the study sample includes 507 psychiatric emergency patients who are ≥ 18 years old. The patients are selected through stratified random and purposive sampling. METHODS: Patient data-including demographic data, emergency services used, and clinical characteristics-are analyzed using descriptive statistics. The Kaplan-Meier method estimates the violence escalation curve, and the log-rank test compares the violence escalation-free time between the levels of the violent behavior group. In addition, univariable and multivariable Cox proportional hazard analyses are performed to investigate the factors affecting violence escalation. RESULTS: The incidence of violence escalation in psychiatric emergency patients in the emergency department is 7.3%, whereas the incidence rate of violence escalation is 3 per 100 psychiatric emergency patient visit hours. Factors affecting violence escalation include the violent behavior score at triage (aHR = 2.004; 95% CI: 1.051-3.823) and the nurse competency score (aHR = 0.147; 95% CI: 0.032-0.680). CONCLUSIONS: Assessing the violent behavior of psychiatric emergency patients at triage may assist emergency providers in monitoring patient behavior and providing early intervention to prevent the escalation of violent behavior. Furthermore, training emergency nurses in psychiatric emergency care is necessary.

Pseudarthrosis risk factors in lumbar fusion: a systematic review and meta-analysis.

This study presents a systematic literature review and meta-analysis of pseudarthrosis risk factors following lumbar fusion procedures. The odds ratio (OR) and 95% confidence interval (95% CI) were used for outcome measurements. The objective of this study was to identify the independent risk factors for pseudarthrosis after lumbar spinal fusion, which is crucial for mitigating morbidity and reoperation. Systematic searches in PubMed, Embase, and Scopus (1990-July 2021) were conducted using specific terms. The inclusion criteria included prospective and retrospective cohorts and case‒control series reporting ORs with 95% CIs from multivariate analysis. The quality assessment utilized the Newcastle-Ottawa scale. Meta-analysis, employing OR and 95% CI, assessed pseudarthrosis risk factors in lumbar fusion surgery, depicted in a forest plot. Of the 568 abstracts identified, 12 met the inclusion criteria (9 retrospective, 2006-2021). The 17 risk factors were categorized into clinical, radiographic, surgical, and bone turnover marker factors. The meta-analysis highlighted two significant clinical risk factors: age (95% CI 1.02-1.11; p = 0.005) and smoking (95% CI 1.68-5.44; p = 0.0002). The sole significant surgical risk factor was the number of fused levels (pooled OR 1.35; 95% CI 1.17-1.55; p < 0.0001). This study identified 17 risk factors for pseudarthrosis after lumbar fusion surgery, emphasizing age, smoking status, and the number of fusion levels. Prospective studies are warranted to explore additional risk factors and assess the impact of surgery and graft type.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms.

BACKGROUND: Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood. METHODS: We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival. RESULTS: Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection. CONCLUSIONS: EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Determinants of continuing mental health service use among older persons diagnosed with depressive disorders in general hospitals: latent class analysis and GEE.

BACKGROUND: Prevalence of depression in older persons was a leading cause of disability. This group has the lowest access to service and retention in care compared to other age groups. This study aimed to explore continuing mental health service use and examined the predictive power of the mental health service delivery system and individual factors on mental health service use among older persons diagnosed with depressive disorders. METHODS: We employed an analytic cross-sectional study design of individual and organizational variables in 12 general hospitals selected using multi-stratified sampling. There were 3 clusters comprising community hospitals, advanced and standard hospitals, and university hospitals. Participants in each group were 150 persons selected by purposive sampling. We included older persons with a first or recurring diagnosis of a depressive disorder in the last 6 to 12 months of the data collection date. Data at the individual level included socio-demographic characteristics, Charlson Comorbidity Index, Attitude toward Depression and its treatment, and perceived social support. Data at the organizational level had hospital level, nurse competency, nurse-patient ratio, and appointment reminders. Descriptive statistics, Pearson chi-square test, latent class analysis (LCA), and marginal logistic regression model using generalized estimating equation (GEE) were used to analyze the data. RESULTS: The continuing mental health service use among older persons diagnosed with depressive disorders was 54%. The latent class analysis of four variables in the mental health services delivery organization yielded distinct and interpretable findings in two groups: high and low resource organization. The marginal logistic multivariable regression model using GEE found that organizational group and attitude toward depression and its treatment were significantly associated with mental health service use (p-value = 0.046; p-value = 0.003). CONCLUSIONS: The findings suggest that improving continuing mental health services use in older persons diagnosed with depressive disorders should emphasize specialty resources of the mental health services delivery system and attitude toward depression and its treatment.

The prevalence, associated factors, clinical impact, and state of diagnosis of delirium in palliative care patients.

PURPOSE: The aim of this study is to establish the prevalence, associated factors, and clinical impact of delirium in newly referred palliative care patients and the percentage of delirium diagnoses missed by primary medical teams. METHODS: Newly referred palliative care patients were evaluated and were reviewed for possible associated factors of delirium. Univariable and multivariable analysis were used to identify associated factors. Median overall survival and survival curves were analyzed. The percentage of missed diagnosis in IPD patients was identified. RESULTS: We included 350 palliative care patients. Nearly all patients had cancer diagnosis (96.6%). The overall prevalence of delirium was 44.0%. The independent associated factors of delirium were age ≥ 63 years (adjusted odds ratio [aOR], 7.0; 95% CI, 2.2-22.9), palliative performance scale ≤ 20% (aOR, 54.5; 95% CI, 13.1-228.0), brain metastasis (aOR, 15.6; 95% CI, 3.7-66.7), urinary tract infection (aOR, 18.8; 95% CI, 4.7-75.5), sepsis (aOR, 59.0; 95% CI, 4.4-797.8), hyponatremia (aOR, 8.8; 95% CI, 2.6-29.8), and hypercalcemia (not applicable). Interestingly, opioids and benzodiazepines were not associated with delirium. Delirious patients had significantly shorter survival (median survival 11 days). Delirium diagnoses were missed for 76.1%. CONCLUSION: Nearly half of the palliative care patients had delirium, which was associated with noticeably short survivals. We identified the independent factors associated with the delirium. Despite having a remarkably high prevalence rate and being a well-known poor prognostic factor, there was still a very high rate of missed delirium diagnoses. Effective, routine, delirium screening of palliative care patients needs to be emphasized.

Validity and Reliability of the Memorial Delirium Assessment Scale-Thai Version (MDAS-T) for Assessment of Delirium in Palliative Care Patients.

BACKGROUND: Delirium, a neuropsychiatric syndrome that occurs throughout medical illness trajectories, is frequently misdiagnosed. The Memorial Delirium Assessment Scale (MDAS) is a commonly used tool in palliative care (PC) settings. Our objective was to establish and validate the Memorial Delirium Assessment Scale-Thai version (MDAS-T) in PC patients. MATERIALS AND METHODS: The MDAS was translated into Thai. Content validity, inter-rater reliability, and internal consistency were explored. The construct validity of the MDAS-T was analyzed using exploratory factor analysis. Instrument testing of the MDAS-T, the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU-T), and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as the gold standard was performed. The receiver operating characteristic (ROC) curve was used to determine the optimal cutoff score. The duration of each assessment was recorded. RESULTS: The study enrolled 194 patients. The content validity index was 0.97. The intraclass correlation coefficient and Cronbach's α coefficient were 0.98 and 0.96, respectively. A principal component analysis indicated a homogeneous, one-factor structure. The area under the ROC curve was 0.96 (95% confidence interval [CI], 0.93-0.99). The best combination of sensitivity and specificity (95% CI) of the MDAS-T were 0.92 (0.85-0.96) and 0.90 (0.82-0.94), respectively, with a cutoff score of 9, whereas the CAM-ICU-T yielded 0.58 (0.48-0.67) and 0.98 (0.93-0.99), respectively. The median MDAS-T assessment time was 5 minutes. CONCLUSION: This study established and validated the MDAS-T as a good and feasible tool for delirium screening and severity rating in PC settings. IMPLICATIONS FOR PRACTICE: Delirium is prevalent in palliative care (PC) settings and causes distress to patients and families, thereby making delirium screening necessary. This study found that the MDAS-T is a highly objective and feasible test for delirium screening and severity monitoring in PC settings and can greatly improve the quality of care for this population.

Effect of NUDT15 on incidence of neutropenia in children with acute lymphoblastic leukemia.

BACKGROUND: 6-Mercaptopurine (6-MP) is considered the backbone of therapy in the maintenance phase of acute lymphoblastic leukemia (ALL). Gene polymorphisms involved in thiopurine degradation are predictors of toxicity in patients treated with 6-MP. We investigated the effects of nucleoside diphosphate linked moiety X (nudix) type motif 15 (NUDT15) polymorphism NUDT15c.415C>T on neutropenia incidence, dose adjustment for 6-MP, and survival rates in Thai children with ALL. METHODS: Children diagnosed with ALL who received 6-MP in the maintenance phase of treatment, in 2005-2016, were retrospectively enrolled. RESULTS: The subjects consisted of 102 patients (median age, 5.2 years; 58 boys). On genetic testing 78, 22, and two patients were normal (CC), heterozygous (CT), and homozygous (TT), respectively. The incidence of neutropenia at 3 months was significantly higher in the CT/TT than CC polymorphism groups (OR, 12; 95%CI: 3.781-38.085, P < 0.001). The mean dose of 6-MP at 3, 6, and 12 months was significantly lower in the CT/TT versus the CC group (P < 0.001). The 5 year overall survival (OS) rate for CC was 80.4%, and for CT/TT, 95.5% (P = 0.34). The 5 year event-free survival (EFS) for CC and CT/TT was 75.1% and 85.7%, respectively (P = 0.17). After adjusted risk classification, no significant differences were observed for OS or EFS between the CC and CT/TT groups. CONCLUSION: Patients harboring the CT/TT polymorphism of NUDT15 had a significantly higher incidence of neutropenia during the first 3 months of maintenance, resulting in significantly lower doses of 6-MP.

Outcomes of pediatric retinoblastoma treated with ICEV regimen: A single-center study.

Retinoblastoma is the most common intraocular malignancy in children. The aim of this study was to investigate the efficacy and toxicity of combination ifosfamide, carboplatin, etoposide, and vincristine (ICEV) in advanced-stage pediatric retinoblastoma [International Classification of Retinoblastoma (ICRB) group D or E], and in ICRB group C in the second eye in simultaneously treated bilateral retinoblastoma. The medical records of retinoblastoma patients treated with concurrent ICEV regimen and focal therapy were retrospectively reviewed. The ICEV treatment protocol was, as follows: ifosfamide 1800 mg/m2 on Days 1-3; MESNA 600 mg/m2 on Days 1-3; carboplatin 560 mg/m2 on Day 1; etoposide 150 mg/m2 on Days 1-3; and vincristine 1.5 mg/m2 on Day 1. Of 16 retinoblastoma patients, 13 had bilateral disease. Seven first eyes in bilateral disease that were enucleated prior to ICEV therapy were excluded. Twenty-two eyes were finally included (six group C, six group D, and ten group E). Median follow-up was 3.4 years, and the median number of ICEV courses was 7. Fifteen globes could be salvaged, 12 responded to ICEV (six group C, five group D, and one group E), and three unresponsive eyes could be salvaged with external beam radiation therapy (EBRT). Enucleation-free and relapse-free survival was 68.2 and 54.5%, respectively. The results of this study suggest ICEV as an alternative therapeutic approach for globe salvage in pediatric retinoblastoma, especially in ICRB groups C and D with manageable acute toxicity. Further study in larger cohort is needed to confirm the effectiveness of treatment.

Effectiveness and Safety of Generic Formulation of Cefoperazone/Sulbactam (Bacticep®) in Treatment of Infections at Siriraj Hospital.

OBJECTIVE: To compare the effectiveness and safety of generic cefoperazone/sulbactam (Bacticep®) and original cefoperazone/ sulbactam (Sulperazon®) in treatment of infections in hospitalized patients at Siriraj Hospital. MATERIAL AND METHOD: Hospitalized patients aged 18 years and older who received cefoperazone/sulbactam for at least 48 hours were identifed from the Siriraj Hospital pharmacy database. Medical records of identified patients were reviewed and relevant information was extracted and transferred onto pre-printed case record forms. Patient data relating to demographics, clinical features of infections, antibiotic therapy, and treatment outcomes were evaluated and compared between patients who received generic and original cefoperazone/sulbactam. RESULTS: Two hundred twenty nine hospitalized patients who had infections and received original or generic cefoperazonel sulbactam were included. Baseline characteristics and clinical features of infections in both groups were comparable. Favorable outcomes (72.9% vs. 72.2%, p = 1.00) and infection-related deaths (4.7% vs. 11.1%, p = 0.16) between generic cefoperazone/sulbactam group and original cefoperazone/sulbactam group, respectively, were not significantly different. Generic cefoperazone/sulbactam favorable outcomes were found to be non-inferior to original cefoperazone/sulbactam (p = 0.04), with lower bound of one-sided 95% CI for difference in favorable outcome within the pre-specified non-inferiority margin of -10% (95% CI: 0.7% with lower bound of -9.3). No significant differences in adverse events were observed between groups. CONCLUSION: Generic cefoperazone/sulbactam (Bacticep®) was found to be non-inferior to original cefoperazone/sulbactam for therapy of infections in hospitalized patients at Siriraj Hospital.

Predictors and pathways of in-hospital mortality in active vascular contrast extravasation detected on abdominopelvic CT.

OBJECTIVES: This study aimed to identify factors influencing in-hospital mortality in adult patients with active vascular contrast extravasation (AVCE) on abdominopelvic computed tomography (CT). METHODS: All consecutive patients with AVCE detected on CT between January 2019 and May 2022 were retrospectively included. Their data were compared through uni- and multivariable analyses between patients with and without in-hospital mortality. Path analysis was utilized to clarify the relationships among factors affecting mortality. RESULTS: There were 272 patients (60.2 ± 19.4 years, 150 men) included, of whom 70 experienced in-hospital mortality. Multivariable analysis revealed nonsurgery, chronic kidney disease (CKD) stage 4-5 or dialysis, prolonged partial thromboplastin time (PTT), minimum AVCE length > 8 mm, and a lower rate of packed red cell (PRC) transfusion were identified as independent predictors of in-hospital mortality (p = 0.005-0.048). Path analysis demonstrated direct influences of CKD4-5 or dialysis, prolonged PTT, and minimum AVCE length on mortality (coefficients 0.525-0.616; p = 0.009 to < 0.001). PRC transfusion impacted mortality through nonsurgery (coefficient 0.798, p = 0.003) and intensive care unit (ICU) admission (coefficients 0.025, p = 0.016), leading to subsequent death. Three AVCE spaces (free, loose, and tight) defined on CT were not directly associated with in-hospital mortality. CONCLUSION: In adults with AVCE on CT, AVCE size had a direct independent influence on mortality, highlighting the critical role of radiologists in detecting and characterizing this finding. Additionally, CKD4-5 or dialysis and prolonged PTT also directly influenced mortality, while the lower rate of PRC transfusion impacted mortality through nonsurgery and ICU admission. CLINICAL RELEVANCE STATEMENT: In patients with active vascular contrast extravasation (AVCE) on abdominopelvic CT, larger AVCE directly increased in-hospital mortality. Radiologists' detection and characterization of this finding is crucial, along with recognizing factors like CKD4-5, dialysis, and prolonged PTT to improve patient outcomes. KEY POINTS: Several factors independently predicted in-hospital mortality in patients with abdominopelvic AVCE. Extravasation length > 8 mm was the only imaging marker predictive of in-hospital mortality. Non-imaging factors correlated with in-hospital mortality, and PRC transfusion impacted mortality through nonsurgery and ICU admission pathways.

Effectiveness and safety of generic formulation of piperacillin/tazobactam (Astaz-P) for treatment of infected patients at Siriraj Hospital.

OBJECTIVE: To determine effectiveness and safety of generic piperacillin/tazobactam (Astaz-P) that has been available as a substitute for original piperacillin/tazobactam (Tazocin) in Siriraj Hospital since October 2011. MATERIAL AND METHOD: Medical records of hospitalized adult patients who received piperacillin/tazobactam for at least 48 hours from January 2011 to June 2012 were reviewed. The data on demographics, clinical features of infections, antibiotic treatments, clinical courses and outcomes of the patients who received original piperacillin/tazobactam and generic piperacillin/ tazobactam were analyzed and compared. RESULTS: The medical records of 300 patients who received original piperacillin/tazobactam and 300 patients who received generic piperacillin/tazobactam were included. The characteristics of the patients and clinical and microbiological features of infections of the patients in both groups were not significantly different. Overall favorable clinical outcome and overall mortality were comparable between generic and original groups (74.0% vs. 74.7%, p = 0.93; 18.3% vs. 18.0%, p = 1.00, respectively). No significant difference of adverse effect was found between two groups. The non-inferiority test indicated that the clinical outcome and overall mortality of the patients who received generic piperacillin/tazobactam were not inferior to those who received original piperacillin/tazobactam (p = 0.004 and p = 0.001, respectively). CONCLUSION: Generic piperacillin/tazobactam (Astaz-P) was not inferior to original piperacillin/tazobactam (Tazocin) for therapy of infections in the hospitalized patients at Siriraj Hospital.

The Correlation of Aortic Neck Angle and Length in Abdominal Aortic Aneurysm with Severe Neck Angulation for Prediction of Intraoperative Neck Complications and Postoperative Outcomes after Endovascular Aneurysm Repair.

OBJECTIVES: Endovascular aneurysm repair (EVAR) in a hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and postoperative outcomes. METHODS: This was a retrospective review of patients with an intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (>60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated as the optimal cutoff value of the aortic neck angle-length index. The patients were categorized into two distinct groups using latent profile analysis, a statistical technique employed to identify concealed subgroups within a larger population by examining a predetermined set of variables. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared. RESULTS: 115 patients were included. Group 1 (G1) had 95 patients with an aortic neck angle-length index ≤ 4.8, and Group 2 (G2) had 20 patients with an aortic neck angle-length index > 4.8. Demographic data and aneurysm morphology were not significantly different between groups except for neck length (p < 0.001). G2 had more intraoperative neck complications than G1 (21.1% vs. 55%, p = 0.005). Adjunctive neck procedures were more common in G2 (18.9% vs. 60%, p < 0.001). The thirty-day mortality rate was not statistically different. G1 patients had a 5-year proximal neck re-intervention-free rate comparable to G2 patients (93.7% G1 vs. 87.5% G2, p = 0.785). The 5-year overall survival rate was not statistically different (59.9% G1 vs. 69.2% G2, p = 0.891). CONCLUSIONS: Patients with an aortic neck angle-length index > 4.8 are at greater risk of intraoperative neck complications and adjunctive neck procedures than patients with an aortic neck angle-length index ≤ 4.8. The 5-year proximal neck re-intervention-free rate and the 5-year survival rate were not statistically different. Based on our findings, this study suggests that the aortic neck angle-length index is a reliable predictor of intraoperative neck complications during EVAR in AAA with severe neck angulation.

Early bone reformation after cranial vault remodelling for sagittal craniosynostosis: A retrospective 3D analysis.

This study aims to measure postoperative bone reformation percentage, rates and patterns after cranial vault remodelling (CVR) in isolated non-syndromic sagittal craniosynostosis. Volumetric bone measurements were performed starting from the DICOM files of previously available postoperative CT scans. The 3D images were then resampled into the master box, and 'Skull 3D models' were derived. The percentage of bone reformation was investigated using automated 3D analysis software. The intra-rater reliability analysis revealed high reliability (Intraclass correlation coefficient = 0.99, p < 0.001). The median bone reformation volume and rate were 11.2 ml and 1.98 ml/week, respectively. The median percentage of bone reformation was 56.7% when the median postoperative CT timing was 6.1 weeks. As a statistic model, the linear plateau showed the highest Pseudo R2 in both volume and percentage of bone reformation predicting patterns. By using the calculated model at 9 weeks postoperatively, the re-osteogenesis reaches 80% of the total cranial defect. After CVR, the early bone reformation pattern was demonstrated as a linear plateau model rather than logarithmic. This study gives a better understanding of the pattern and quantity of re-osteogenesis at cranial defects after CVR. The statistic model can facilitate healthcare practitioners to predict bone reformation and improve postoperative care protocol in sagittal craniosynostosis management.

Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings.

OBJECTIVES: The study aimed to evaluate scoring systems for predicting complicated appendicitis in adults diagnosed with acute appendicitis on computed tomography. METHODS: Three hundred twenty-five consecutive adult patients (mean age 51.9 ± 19.6 years, 212 women) diagnosed with acute appendicitis on computed tomography were retrospectively included. Clinical and imaging findings were compared between patients with and without complicated appendicitis, and independent associations were identified. As C-reactive protein was not available for most patients, 5 out of 8 scoring systems were modified. They, and a newly proposed system, were compared via area under the receiver operating characteristics (ROC) curve (AUC), Additionally, the latter was internally validated. Pairwise comparison was performed, and diagnostic performance of these scoring systems was obtained. RESULTS: One hundred twenty-seven patients (36.8%) had complicated appendicitis. Significant independent associations were found between complicated appendicitis and duration of symptoms > 12 h, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air (p values < 0.001 to 0.037; AUCs of 0.824-0.829). AUCs of 9 scoring systems ranged from 0.692 to 0.831. Of these, modified Atema, Kim HY, and proposed scores had similarly high and non-significantly different AUCs (0.793-0.831) on pairwise comparison. Their sensitivities, specificities, and accuracies were 73.0-90.6%, 48.5-70.6%, and 64.3-72.3%, respectively. Internal validity test demonstrated high AUCs (0.826-0.844) with one of the proposed scores using odds ratio having 100% sensitivity and 100% negative predictive value. CONCLUSIONS: Few scoring systems, including proposed ones, had high AUCs, sensitivity, and reasonable specificities, which could potentially aid in safely selecting adult patients with acute appendicitis for nonoperative management. CRITICAL RELEVANCE STATEMENT: The study suggests few scoring systems for predicting complicated appendicitis with high AUCs and reasonable sensitivities, potentially aiding in selecting patients for nonoperative management. KEY POINTS: • The study evaluated existing and proposed new scoring systems to predict complicated appendicitis in adults with acute appendicitis on computed tomography. • Several factors were found to be significantly associated with complicated appendicitis, including duration of symptoms, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air. • The modified Atema, Kim HY, and newly proposed scoring systems performed well, potentially aiding in nonoperative management selection.

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults.

OBJECTIVES: Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery. METHODS: A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated. RESULTS: Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47-100%, and 54-100%, which increased to 53-100%, and 60-100%, respectively, when considering only radiologists' reinterpretations. CONCLUSIONS: In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

ITPA Polymorphisms and the Incidence of Toxicities in Children with Acute Lymphoblastic Leukemia.

Background: 6-Mercaptopurine (6-MP), a thiopurine agent, is a essential medication for treating pediatric acute lymphoblastic leukemia (ALL). However, its side effects of neutropenia and hepatotoxicity might interrupt treatment, resulting in poor outcomes. Inosine triphosphate pyrophosphatase (ITPA), an enzyme in the thiopurine pathway, may prevent the accumulation of toxic thiopurine metabolites. Studies on ITPA and thiopurine-associated toxicities are scarce. Methods: This study retrospectively investigated 1- to 15-year-old children with ALL who received 6-MP during the maintenance phase of treatment between 2000 and 2020. Toxicity during the first year of maintenance therapy and the mean dose of 6-MP were analyzed. Results: The 209 patients had a median age of 4.8 (0.3-14.8) years. Of these, 124 patients (59.3%) had wild-type ITPA, 73 patients (34.9%) had heterozygous ITPA 94C>A (hetITPA), and 12 patients (5.7%) had homozygous ITPA 94C>A (homITPA), with an allele frequency of 0.23. The incidence of neutropenia among ITPA polymorphisms did not significantly differ (P = 0.813). In patients harboring homITPA, transaminitis was more frequent than other polymorphisms but without a significant difference (P = 0.063). The mean dose of 6-MP for patients with homITPA was significantly lower than that for patients with hetITPA or wild-type ITPA (P = 0.016). Conclusions: HomITPA had a higher incidence of transaminitis and required a significantly larger dose reduction of 6-MP than wild-type ITPA. Further study is warranted to elucidate the effects of ITPA polymorphisms on toxicity in patients with ALL treated with 6-MP.

Effectiveness and safety of generic formulation of meropenem (Penem) for treatment of infections at Siriraj Hospital.

OBJECTIVE: Generic meropenem (Penem) has been available and was substituted for original meropenem in Siriraj Hospital, but its effectiveness and safety for treatment of infection in clinical setting are the main concern. MATERIAL AND METHOD: From July 2007 to July 2010, hospitalized patients aged 18 or older who received meropenem for at least 48 hours were identified retrospectively from the pharmacy database of Siriraj Hospital. 260 patients per group were required to demonstrate non-inferiority of generic meropenem (Penem) versus original meropenem in term of overall favorable outcome. RESULTS: 275 and 273 patients receiving original and generic meropenem were enrolled and analyzed. Overall favorable outcome and overall mortality were comparable between generic and original group (72.5% vs. 65.8%, p = 0.108; 38.6% vs. 39.3%, p = 0.918, respectively). No significant difference of adverse effect was found between two groups. The non-inferiority test indicated that the clinical outcome and overall mortality of the generic meropenem were non-inferior to the original meropenem (p < 0.001, p = 0.005, respectively). The independent factors associated with unfavorable outcome were previous use of an antibiotic, having respiratory tract infection, receiving lower dose and shorter duration of antibiotic. The independent factors associated with the overall mortality were underlying pulmonary disease, previous use of antibiotic, having respiratory tract or catheter related blood stream infection. Treatment with either generic or original meropenem did not relate to unfavorable outcome (p = 0.320) or overall mortality (p = 0.640). CONCLUSION: Generic meropenem (Penem) was not inferior to original meropenem for therapy of infections in the hospitalized patients at Siriraj Hospital.

Acinetobacter baumannii nosocomial pneumonia in tertiary care hospitals in Thailand.

BACKGROUND: Nosocomial pneumonia (NP) is an important cause of morbidity and mortality in hospitalized patients. Acinetobacter baumannii is one of the common causative pathogens in NP. The prevalence of multi-drug resistance in A. baumannii has been increasing. The information on clinical features and clinical courses of A. baumannii NP in Thai patients are limited. OBJECTIVE: To determine the clinical features, risk factors and clinical courses of A. baumannii NP in Thai patients hospitalized in tertiary care hospitals in Thailand. MATERIAL AND METHOD: This was a prospective, hospital-based, active surveillance study on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in adults hospitalized in 12 tertiary care hospitals in Thailand between 2008 and 2009. RESULTS: There were 651 NP patients. A. baumannii was the most common cause of NP in 198 patients (30.4%). Most of NP patients were males with median age of 71 years. About 80% had late onset NP with the median duration of 10 days after admission in both A. baumannii and non-A. baumannii NP. Most of NP occurred in patients hospitalized in general medical wards. Most of the features of NP in A. baumannii NP and non-A. baumannii NP were not significantly different. The initial antibiotics prescribed were concordant in about 50% of the patients in both groups. Colistin was usually prescribed to the patients who received antibiotic modifications. The initial clinical responses in A. baumannii NP were less favorable than those in non-A. baumannii NP. The mortality rate in A. baumannii NP seemed to be more than that in non-A. baumannii NP. There was a trend of more persistence of pathogen in A. baumannii NP. Most isolates of A. baumannii were resistant to antibiotics including carbapenems. The patients with extensive drug resistant A. baumannii NP had less favorable responses than NP due to other bacteria, including non-extensive drug resistant A. baumannii. VAP, NP developed in medical ICU and NP with bilateral lung involvements on chest X-ray were associated with A. baumannii as the isolated pathogen. CONCLUSION: A. baumannii is the most common causative pathogen for NP in tertiary care hospitals in Thailand and most of A. baumannii isolates were resistant to many antibiotics including carbapenems. The hospitalized patient in tertiary care hospitals with VAP, or NP that was developed in medical ICU, or NP with bilateral lung involvements on chest x-ray was likely to be due to A. baumannii. Many NP patients received inappropriate initial antibiotic regimens leading to a high mortality.

Comparison of the efficacy and safety between generic intravenous omeprazole (Zefxon) and original omeprazole (Losec) in the adjunct treatment of non-variceal upper gastrointestinal bleeding in Siriraj Hospital.

BACKGROUND: Clinical efficacy and safety of generic omeprazole have not been well studied in Thailand. OBJECTIVE: Determine whether generic omeprazole (Zefxon) is inferior to original omeprazole (Losec) in the treatment of non-variceal upper gastrointestinal bleeding (UGIB) in Siriraj Hospital. MATERIAL AND METHOD: Medical records of adult patients with the diagnosis of non-variceal UGIB receiving intravenous omeprazole (either Zefxon or Losec) in Siriraj Hospital between January 2006 and September 2010 were reviewed Noninferiority study was used to investigate whether the generic omeprazole was no more than 10% less effective than the original omeprazole. The primary endpoints were recurrent bleeding and mortality within seven and 30 days. Surgery, endoscopic retreatment, blood transfusions, length of hospital stay and safety were also analyzed RESULTS: Of 200 randomly selected patients in each group, there was no difference in age, gender co-morbidities, severity of UGIB, endoscopic findings and endoscopic intervention between patients receiving generic omeprazole and original omeprazole. Overall rate of recurrent bleeding, mortality, and surgical intervention within 30 days were 12.3%, 5.5% and 2.0%, respectively. The rates of recurrent bleeding, overall mortality, and non-variceal UGIB related mortality within seven and 30 days were not significantly different between the two groups. Neither were the rates of endoscopic retreatment and surgery. The incidence of adverse side effects was 3.5% in each group. Cox regression analysis showed no significant association between type of omeprazole and recurrent bleeding or mortality. Compared to the original omeprazole, the hazard ratio of recurrent bleeding, overall mortality, and non-variceal UGIB related mortality in patients receiving generic omeprazole was 1.44 (95% CI 0.82-2.53; p = 0.21), 2.12 (95% CI 0.90-5.43; p = 0.08) and 1.82 (95% CI 0.53-6.21; p = 0.34), respectively. CONCLUSION: Although the original omeprazole Losec tended to have more favorable outcomes in the treatment of non-variceal UGIB in the present study, non-inferiority test showed that the efficacy and safety of the generic omeprazole Zefxon was not inferior to those of the original omeprazole.