Ramathibodi Medical Journal

Treatment of Pythiosis

Hanna Yolanda — 2024-09-27

Dear Editor: Due to its rising global incidence, I have dedicated years to studying pythiosis, a rare yet deadly infectious disease caused by Pythium insidiosum.¹ Pythiosis typically presents with the infection of the artery, eye, gastrointestinal tract, and skin, and if left untreated, it can lead to organ loss or even death. In recent decades, a deeper understanding of P. insidiosum has been seen across molecular, serological, and histological studies, enhancing clinical awareness and diagnostic advancements.^1, ² Traditionally mistaken for a fungus because of its microscopic appearance, P. insidiosum was treated with antifungal medications like terbinafine and amphotericin B.^3, ⁴ Molecular research clarifies that P. insidiosum is an oomycete, more closely related to algae, with significant biological differences from fungi, impacting drug efficacy.⁵ Since the 1980s, P. insidiosum antigen immunotherapy (PIAI) has emerged as a treatment alternative, with ongoing enhancements to increase efficacy.⁶ Surgery often serves as a last resort to limit the disease progression or to save lives.⁷

Current treatment strategies for pythiosis include antimicrobial drugs, PIAI, and surgery. Antimicrobial susceptibility testing reveals a higher sensitivity of P. insidiosum to antibacterials like macrolides, oxazolidinones, and tetracyclines, reducing the reliance on surgery.⁸ Though less effective, antifungals, sometimes in combination with antibacterials, can treat pythiosis.^9, ¹⁰ PIAI, prepared by crude antigen extract of P. insidiosum, is beneficial for humans and animals with pythiosis, potentially reducing surgery needs and increasing survival rates. However, its efficacy varies across different disease manifestations.⁶ Surgical intervention, typically reserved for unresponsive cases, ranges from organ-preserving procedures to more radical approaches like amputation, depending on disease progression.^2, ^3, ⁷ Additional treatments, including dimethyl sulfoxide, potassium iodide, steroids, ethanol, and mefenoxam, applied singly or combined, have shown promise in treating specific pythiosis forms.^11, ¹²

Treatment is the most challenging aspect of pythiosis, but there is hope. The morbidity and mortality of affected patients remain high. However, with continued attention and basic/clinical research by the medical community, we can gain insight into the disease and find a better way of pythiosis control, potentially improving their clinical outcomes.

Associations Between Time to Administration of Antiseizure Medications and Short-Term Clinical Outcomes in Adults With Status Epilepticus

Pongsakorn Kongsakorn — 2024-09-27

Background: Status epilepticus (SE) is a time-sensitive emergency that requires immediate treatment.

Objective: To analyze the associations between time to administration of antiseizure medications (ASM) and short-term clinical outcomes.

Methods: From January 1, 2014, to December 31, 2020, we performed a retrospective cohort study in adult patients who presented with SE. The primary objective was to analyze the association between the timing of ASM administration and mortality. The second and third objectives were to determine the relationship between the timing of ASM administration and length of hospital stay along with the modified Rankin Scale (mRS) at discharge, respectively.

Results: A total of 83 patients were enrolled. The mean age was 57 years. The mean length of hospital stay was 32 days. Benzodiazepine (BDZ) was prescribed as the first ASM in 79 (95.2%) patients. Levetiracetam was the second most frequently administered ASM (39, [47%]), followed by phenytoin (28 [33.7%]) and valproate (13 [15.7%]). Seventy-one patients (85.5%) had a seizure duration longer than t₂ period. Therapy delay in SE and underdosing of ASM were noted in both alive and dead groups. Although the mortality rate was 20.5% and was highest in super-refractory SE (15 [88.2%]), we found no statistically significant difference between in-hospital mortality and timing of ASM administration. For secondary outcomes, including length of hospital stay and mRS, a statistically significant finding was only noted in the category of timing of seizure onset to the first ASM (P = .002 and P = .004, respectively).

Conclusions: This study showed no significant association between timing of ASM administration and in-hospital mortality. Prolonged duration of SE tends to be associated with increased mortality. SE guidelines were not followed in a substantial proportion of SE patients.

Morphine-Sparing Effect of Intermittent Versus Continuous Intravenous Infusion of Nefopam in Patients After Total Knee Arthroplasty: A Randomized Trial

Woratanat Kachacheewa — 2024-09-27

Background: Nefopam, a nonopioid analgesic, is recommended to improve pain control and minimize opioid-related side effects following total knee arthroplasty (TKA).

Objective: To compare cumulative morphine consumption between intermittent infusion (II) and continuous infusion (CI) of nefopam, combined with other multimodal analgesics, in TKA patients.

Methods: Fifty-eight patients were randomly assigned to receive either intermittent nefopam infusion (II group) (20 mg IV every 6 hours) or continuous infusion (CI group) (80 mg/day). The primary outcome was cumulative morphine consumption via patient-controlled analgesia, with secondary outcomes including pain scores every 4 hours and adverse drug reactions (ADRs).

Results: No significant difference was found in cumulative morphine consumption (median [range], 4 [0 -12] mg in II and 6 [0 - 18] mg in CI; P = .579) and the ADRs over 48 hours between groups. At 4 hours, the II group had significantly lower pain scores compared to the CI group (median [range], 0 [0 - 4] and 0 [0 - 8]; P = .008). However, by 24 and 36 hours, the CI group reported significantly lower pain scores compared to the II group; median (range), 0 (0 - 5) vs 2 (0 - 9) at 24 hours (P = .020) and 0 (0 - 4) vs 2 (0 - 8) at 36 hours (P = .014).

Conclusions: Both intermittent and continuous nefopam infusion in primary TKA showed no significant difference in morphine-sparing or occurrence of ADRs within the 48-hour follow-up period. These findings suggest that both infusion methods are comparable in managing post-operative pain in TKA patients.

A Cross-Sectional Study on Hospital-Based Knowledge Regarding Prevention of Recurrent Urolithiasis

Huynh Thi Thuy Tien — 2024-09-27

Background: Urolithiasis which is a prevalent disease that can be prevented. Additionally, the rate of recurrence has been increasing. Prevention of the recurrence plays a vital role in limiting complications. One of the best ways to achieve this is by enhancing patients’ knowledge about preventing urolithiasis. However, there are few studies conducted on this issue in Vietnam.

Objectives: To explore the level of knowledge regarding the prevention of urolithiasis recurrence and identify predicted factors.

Methods: A cross-sectional design was used in the study. The respondents were over 18 years, used to diagnose urolithiasis, and attended the Department of Medical Examination and General Surgery Ward of C Da Nang Hospital. Ethical approval was obtained from the university and the hospital. Frequency and descriptive tests were applied to describe variables. Binominal logistic regression was used for detecting factors predicting knowledge regarding the prevention of urolithiasis recurrence.

Results: There were 254 patients participating in the study, and 68.9% of participants had good knowledge toward prevention of urolithiasis recurrence. The study revealed that occupation, duration of urolithiasis, number of hospitalizations, and source of information were significantly predictable factors (P < .05). Age, gender, residence, educational level, and treatment methods did not affect this knowledge.

Conclusions: Improving knowledge regarding the prevention of recurrent urolithiasis in patients was important, especially in general knowledge and diet including fluid intake. The development should be through the source of obtained information. It is necessary to emphasize the role of healthcare workers in providing the appropriate information.

Assessment of the Characteristics and the Uncertainty of Radiophotoluminescence Glass Dosimeter for Low Energy Photon

Chanidapa Jaroenpat — 2024-09-27

Background: Medical dosimetry has become critical. Recognizing the efficiency of glass dosimeters, which exhibit good reproducibility, small fading effect, and linearity over a wide range, it has brought to this study that aims to assess the characteristics and the uncertainty of radiophotoluminescence glass dosimeter (RPLGD) for low energy photon in diagnostic radiology.

Objective: To assess the characteristics and estimate the uncertainty of RPLGD for low energy photon.

Methods: Following IAEA Technical Reports Series No. 457, the determination of the half-value layer of Varian Acuity simulator was followed by the calibration of a model GD-352M RPLGD. The dosimetric characteristics (uniformity, dose linearity, accuracy, energy response, reproducibility, reader reproducibility, and magazine positioning reproducibility) were determined. The minimum detectable dose and the uncertainty were then estimated.

Results: This study showed good uniformity within 0.09%, dose linearity with R² = 1 around 0 - 10 mGy, the accuracy of measurement was 0.21% around 0.5 - 10 mGy, low energy response (70 - 120 kVp) within 0.05%, good reproducibility within 0.04%, magazine positioning reproducibility within 0.01%. The minimum detectable dose for a model GD-352M RPLGD was 0.01 mGy. The measurement of uncertainty was 3.83%.

Conclusions: RPLGD was accurate to measure low energy photon beams. Moreover, the understanding of characteristics of RPLGD helps measuring radiation dose appropriately according to the situation.

A Case Report of Cellulitis Caused by Leclercia adecarboxylata in a Thai Boy: A Common Infection From a Rare Pathogen

Satetha Vasaruchapong — 2024-09-27

Leclercia adecarboxylata is a gram-negative bacillus that rarely causes infections in children, especially in Thailand. We report a case of a boy with a wound infection and cellulitis after a punctate injury caused by L. adecarboxylata. A previously healthy 12-year-old boy presented with a 2-month history of infected wound and cellulitis on his left sole after a punctate injury in the garden. He experienced recurrent swelling and purulent discharge despite an incision and drainage and a full course of appropriate antibiotics. Plain films of his left foot showed no radiopaque foreign body or evidence of osteomyelitis. L. adecarboxylata was isolated from the wound tissue culture. Incision and drainage followed by a 2-week course of oral amoxicillin/clavulanic acid was prescribed which resulted in a complete resolution of the lesion. This case emphasizes the significance of identifying L. adecarboxylata as a possible cause of soft tissue infections in Thai children, especially those with a history of puncture wounds. Unusual pathogens should be considered when standard treatments fail to eliminate the infection.