Chulalongkorn Research Articles

Bipolarity among pregnant women at King Chulalongkorn Memorial Hospital and relationship with depression score during pregnancy and postpartum periods (P. 19)

Bipolarity among pregnant women at King Chulalongkorn Memorial Hospital and relationship with depression score during pregnancy and postpartum periods (P. 19)

Predictors and Level of Knowledge Regarding Parkinson's Disease among Patients: A Cross-sectional Study from Thailand.

Background:Parkinson's disease (PD) is a neurodegenerative disorder that results in gradual decline of motor, autonomic, and neuropsychiatric functions of the patient. Knowledge and factors responsible for Parkinson's disease (PD) are important among patients that could positively affect their attitude and perceptions. This study was conducted to determine the factors influencing and level of the knowledge regarding Parkinson's disease in Thailand.Methods:This cross-sectional study was conducted on 125 patients admitted in King Chulalongkorn Memorial Hospital Bangkok, Thailand. Sociodemographic variables and clinical characteristics were collected as predictors of knowledge, treatment, and self-care for PD. A validated, piloted, pretested tool was used for data collection. Multiple linear regressions were used to find the most influencing predictor of knowledge about PD. The study was approved by the Ethical Board of Chulalongkorn University, Thailand.Results:The level of education was found to be the most significant (P = 0.005) predictor of PD knowledge. PD patients with high education had significantly higher knowledge scores than those with low education in all aspects of disease (P = 0.041), treatment (P = 0.014), and self-care (P = 0.011). PD knowledge was poor in variables such as levodopa (62%), nonmotor symptoms (54%), and stem cell transplantation (40%), respectively.Conclusion:The study results conclude that educational level is the most important predictor of knowledge about Parkinson's disease.

Common orthopedic problems in the neonate: a comparative study of 2 periods at a tertiary-care hospital

Abstract Background In 1975, King Chulalongkorn Memorial Hospital (KCMH) in Bangkok, Thailand, published data on common orthopedic problems in neonates. Objectives To determine the more recent incidence of these conditions and to compare the results with those reported 40 years ago by KCMH. The data were also compared with a recent report from Siriraj Hospital. Methods We reviewed medical records of newborn infants from 2012 to 2016, all of whom were born in KCMH with deformities of upper and lower extremities or other birth-related injuries. The cases were grouped according to International Classification of Diseases, 10th edition. The incidence of common neonatal orthopedic problems was calculated as cases per 1,000 live births and compared, using a chi-squared test, with the earlier data from KCMH and with the data recently reported by Siriraj hospital. Results Of the 24,825 live births, 54% were male and 46% were female. The average birth weight was 3,052.2 ± 516.1 g (range, 535–5,320 g) for infants. The most common deformity was postural clubfoot, followed by calcaneovalgus and hip dysplasia, with incidences of 1.37, 0.93 and 0.52 per 1,000 live births, respectively. The incidence of calcaneovalgus, metatarsus adductus, and clubfoot was lower than in the 1975 study and in the report from Siriraj. In all 3 studies, the incidence of birth-related injury was similar and clavicular fracture was the most common, with a rate of 1.3/1,000 live births. Conclusion The incidence of common neonatal orthopedic problems varies among institutions. Birth-related injury is a major challenge. The results may be utilized as updated data and as a starting point for parental education.

Ultrasound-Guided Physiological Saline Injection for Patients with Myofascial Pain.

Background:Based on the histological confirmation of the presence of nerve structure in the fascia, hence, myofascial pain was treated by the mechanism referred to as interfascial block. To date, the studies of physiological saline for treating patients with myofascial pain has been limited. Ultrasound (US) guided with physiological saline injection (PSI) technique has been routinely practiced among patients with myofascial pain in outpatient service at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. The main objective of this present study is to find the overview data including the percentage of patients responding, acceptable pain period, and adverse events.Materials and Methods:Electronic medical reports among 142 patients receiving US-guided PSI from August 1, 2016, to November 20, 2017, at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, were retrospectively reviewed by the first author. Procedures were performed by the last author. The analysis was independently performed by the first author.Results:One hundred and forty-two patients with complete medical records were compatible with analysis. The average age of patients was 55 years. Most of the patients were female (68.3%). Most of the patients (76.8%) had chronic suffering from myofascial pain. Approximately half of the patients (56.4%) are currently received pain-relieving medications. Upper trapezius muscle (19.5%) was the most common muscle receiving the procedure, followed by multifidus (10.0%) and quadratus lumborum (9.5%). Most of the patients (86.8%) received the procedure one muscle. Approximately 30% of the patients were able to stop pain-relieving medications after the procedure. The median of acceptable pain period was 63 days. The percentage of patients having an acceptable pain period >3 months was 43.9%. No major adverse events were demonstrated.Conclusion:US-guided PSI technique demonstrated pain reduction in 72.8% of the analyzed patients, with an acceptable pain period of 63 days. No major adverse events were demonstrated among all the patients. This technique should be considered as another invasive procedure for eradication myofascial trigger point.

Pathways to parental anxiety: effect of coping strategies for disruptive behaviors in children with attention deficit-hyperactivity disorder

AbstractBackgroundDisruptive behaviors are commonly found in children with attention deficit-hyperactivity disorder (ADHD) and affect the mental health of parents. However, a study of the direct and indirect effects between disruptive behaviors in children with ADHD and parental anxiety and coping strategies is apparently lacking.ObjectiveTo examine the direct and indirect relationship between disruptive behaviors in children with ADHD and parental anxiety and coping strategies as a mediator.MethodA cross-sectional study was conducted at King Chulalongkorn Memorial Hospital, Thailand between March 2015 and January 2016. Participants comprised 200 parents whose children were diagnosed with ADHD by physicians. Participants completed questionnaires regarding sociodemographic characteristics including The Thai Hospital Anxiety and Depression Scale, The Swanson, Nolan and Pelham (SNAP-IV): parent form (Thai version), and The Coping Scale Questionnaire (Thai version).ResultsThe direct path between disruptive behaviors and anxiety was significant (b = 0.21,P= 0.002). Moreover, a significant indirect path was found between disruptive behaviors and coping behavior with escape–avoidance (β = 0.20,P= 0.005), and an indirect path was found between escape–avoidance and anxiety (b = 0.31,P<0.001).ConclusionsHealth care professionals should evaluate the use of coping strategies by parents of children with ADHD and encourage the parents to use a positive strategy for coping with the disruptive behaviors of their children.

Effects of ginger adjunct to the standard prophylaxis on reducing carboplatin and paclitaxel-induced nausea vomiting: a randomized controlled study.

To determine effects of ginger on reducing the severity of nausea and/or vomiting among gynecologic cancer patients receiving a combined carboplatin-paclitaxel regimen. The research was a randomized, double-blinded, crossover, placebo-controlled trial. Participants were patients with gynecologic malignancies receiving carboplatin-paclitaxel chemotherapy at King Chulalongkorn Memorial Hospital. Either ginger (2 g per day) or placebo was prescribed in adjunct to standard antiemetic prophylaxis, in alternated cycles between groups: in group 1, ginger was prescribed in odd cycles and placebo in even cycles and vice versa in group 2. Patients with gut obstruction or brain or bowel metastasis, those using anticoagulants or other ginger or antiemetic medications, or patients who had ginger allergy were excluded from the study. Statistics were analyzed by STATA version 15.1. Overall, 47 participants were recruited. Mean age was 53.9 years. Seventeen subjects were chemotherapy-naïve. In an acute phase of nausea, ginger therapy significantly reduced the mean nausea score comparing to placebo (P = 0.03). However, in the delayed phase, there were no significant differences between groups. For the acute and delayed phase of vomiting, there was no difference between the groups. No serious adverse effects were demonstrated in the ginger group (P > 0.05). Adjunct ginger therapy on standard nausea and vomiting prophylaxis protocol especially in day 1 has benefit in reducing an acute phase nausea in patients receiving a combined carboplatin-paclitaxel regimen. The benefit on delayed phase nausea and vomiting is still equivocal.

Cyclin D1 expression as a potential prognostic factor in advanced KRAS-mutant non-small cell lung cancer.

East Asian, including Thailand, lung cancer population may have a relatively lower prevalence of KRAS mutations than Caucasians. We investigated the prevalence and clinical characteristics of KRAS-driven non-small cell lung cancer (NSCLC) patients and the expression of cyclin D1, one of the KRAS downstream targets. Lung cancer patients who received treatment at the King Chulalongkorn Memorial Hospital between January 2015 and July 2017 were enrolled. We identified KRAS mutations using allele specific PCR KRAS mutation testing. Cyclin D1 expression was determined using immunohistochemistry. After excluding 376 EGFR mutations and inadequate samples, we enrolled 95 patients eligible for KRAS mutation testing. KRAS mutations were identified in 28 out of 95 patients. There were 26 patients with KRAS codon 12/13 and 2 patients with KRAS codon 61 mutations. The prevalence of KRAS mutations among informative samples was 28 out of 357 (7.8%) which was relatively lower than that reported in Caucasian population. Smoking and male were significantly associated with KRAS mutations. The prognosis of KRAS-mutant NSCLC patients in particular codon 61 mutations was worse than that found in KRAS- and EGFR-wild-type (KRAS WT/EGFR WT) NSCLC patients (P=0.048). The levels of cyclin D1 expression in KRAS-mutant NSCLC were significantly higher than those in KRAS WT/EGFR WT NSCLC (P=0.02). A better prognosis of KRAS-mutant NSCLC patients with low cyclin D1 expression was observed when compared with those with high cyclin D1 expression (median overall survival 41.7 vs. 3.5 months, P=0.037). We found a moderate prevalence of KRAS mutations in lung cancer in Thailand. Clinical characteristics were similar to those of Caucasian population. Most KRAS-mutant NSCLC had high cyclin D1 expression. Cyclin D1 expression may serve as a useful prognostic biomarker in KRAS-mutant lung cancer. Validation of this finding in larger cohort is required.

Plasmapheresis Reduces Mycophenolic Acid Concentration: A Study of Full AUC0-12 in Kidney Transplant Recipients.

Background: Mycophenolic acid (MPA), a crucial immunosuppressive drug, and plasmapheresis, an effective immunoreduction method, are simultaneously used for the management of various immune-related diseases, including kidney transplantation. While plasmapheresis has been proven efficient in removing many substances from the blood, its effect on MPA plasma levels remains unestablished. Objectives: To evaluate the full pharmacokinetics of MPA by measuring the area under the time–concentration curve (AUC0–12), which is the best indicator for MPA treatment monitoring after each plasmapheresis session, and to compare the AUC0–12 measurements on the day with and on the day without plasmapheresis. Methods: A cross-sectional study was conducted in kidney transplantation recipients who were taking a twice-daily oral dose of mycophenolate mofetil (MMF, Cellcept®) and undergoing plasmapheresis at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, during January 2018 and January 2019. The MPA levels were measured by an enzymatic method (Roche diagnostic®) 0, 1/2, 1, 2, 3, 4, 6, 8, and 12 h after MMF administration, for AUC0–12 calculation on the day with and on the day without plasmapheresis sessions. Plasmapheresis was started within 4 h after administering the oral morning dose of MMF. Our primary outcome was the difference of AUC0–12 between the day with and the day without plasmapheresis. Results: Forty complete AUC measurements included 20 measurements on the plasmapheresis day and other 20 measurements on the day without plasmapheresis in six kidney transplant patients. The mean age of the patients was 56.2 ± 20.7 years. All patients had received 1000 mg/day of MMF for at least 72 h before undergoing 3.5 ± 1.2 plasmapheresis sessions. The mean AUC on the day with plasmapheresis was lower than that on the day without plasmapheresis (28.22 ± 8.21 vs. 36.79 ± 10.29 mg × h/L, p = 0.001), and the percentage of AUC reduction was 19.49 ± 24.83%. This was mainly the result of a decrease in AUC0–4 of MPA (23.96 ± 28.12% reduction). Conclusions: Plasmapheresis significantly reduces the level of full AUC0–12 of MPA. The present study is the first to measure the full AUC0–12 in MPA-treated patients undergoing plasmapheresis. Our study suggests that a supplementary dose of MPA is necessary for patients undergoing plasmapheresis.

Walled-off peripancreatic fluid collections in Asian population: Paradigm shift from surgical and percutaneous to endoscopic drainage

Background and ObjectivesDrainage of symptomatic walled-off peripancreatic fluid collections (WPFCs) can be achieved by endoscopic, percutaneous, and surgical techniques. The aim of this study was to determine the current trends in management of WPFCs and the outcome of such modalities in Asian population.MethodsIn this retrospective analysis, all patients diagnosed with pancreatitis from 2013 to 2016 in King Chulalongkorn Memorial Hospital, Bangkok, Thailand, were analyzed. Relevant clinical data of all patients with peripancreatic fluid collections (PFCs) was reviewed. Clinical success was defined as improvement in symptoms after drainage.ResultsOf the total 636 patients with pancreatitis, 72 (11.3%) had WPFCs, of which 55 (8.6%) and 17 (2.7%) had pancreatic pseudocyst (PP) and walled-off necrosis (WON), respectively. The commonest etiologies of WPFCs were alcohol (38.9%) and biliary stone (29.2%). Post-procedure and pancreatic tumor related pancreatitis was found in 8.3% and 6.9% patients, respectively. PP was more common in chronic (27.8%) than acute (5.5%) pancreatitis. Of the 72 patients with WPFCs, 31 (43.1%) had local complications. Supportive, endoscopic, percutaneous, and surgical drainage were employed in 58.3%, 27.8%, 8.3%, and 5.6% with success rates being 100%, 100%, 50%, and 100%, respectively. Complications that developed after percutaneous drainage included bleeding at procedure site (n = 1), infection of PFC (n = 1), and pancreatic duct leakage (n = 1).ConclusionOver the past few years, endoscopic drainage has become the most common route of drainage of WPFCs followed by percutaneous and surgical routes. The success rate of endoscopic route is better than percutaneous and comparable to surgical modality.

Comparison of potential drug-drug interactions with metabolic syndrome medications detected by two databases.

BackgroundDrug-drug interactions (DDIs) are one of the most common drug-related problems. Recently, electronic databases have drug interaction tools to search for potential DDIs, for example, Micromedex and Drugs.com. However, Micromedex and Drugs.com have different abilities in detecting potential DDIs, and this might cause misinformation to occur between patients and health care providers.Methods and findingsThe aim of this study was to compare the ability of Micromedex and Drugs.com to detect potential DDIs with metabolic syndrome medications using the drug list from the U-central database, King Chulalongkorn Memorial Hospital in April 2019. There were 90 available drugs for the treatment of the metabolic syndrome and its associated complications, but six were not found in the Micromedex and Drugs.com databases; therefore, only 84 items were used in the present study. There were 1,285 potential DDI pairs found by the two databases. Micromedex reported DDIs of 724 pairs, while, Drugs.com reported 1,122 pairs. For the severity of the potential DDI reports, the same severity occurred between the two databases of 481 pairs (37.43%) and a different severity for 804 pairs (62.57%).ConclusionDrugs.com had a higher sensitivity to detect potential DDIs by approximately 1.5-fold, but Micromedex supplied more informative documentation for the severity classification. Therefore, pharmacists should use at least two databases to evaluate potential DDIs and determine the appropriate drug regimens for physician communications and patient consultations.

Differences and diversity of autoimmune encephalitis in 77 cases from a single tertiary care center

BackgroundThe incidence of autoimmune encephalitis has risen globally. There are two general categories of disease-associated antibodies that can be tested for: neuronal surface and intracellular. However, testing both groups of autoantibodies are costly. This study aims to identify differences between groups by comparing clinical presentations, radiological findings and CSF profile of patients, and determine if any parameters are indicative of one group of autoantibodies over another. Additionally, we aim to report the local incidence of less common groups of disease-associated antibodies as well.MethodsSeventy-seven records of autoimmune encephalitis/encephalomyelitis patients admitted to King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between October 2010 and February 2017 were reviewed. Patients with infections or those with classic central nervous system demyelinating features were excluded.ResultsOf 77 patients, 40% presented with neuronal surface antibodies and 33% had intracellular antibodies. The most common autoantibody detected in each group was anti-NMDAr antibody (25/31, 81%) and anti-Ri antibody (7/25, 28%) respectively. In the neuronal surface antibody group, behavioral change was the most common complaint (45%), followed by seizures (39%) and abnormal movements (29%). In the latter group, seizure was the most common presenting symptom (32%), followed by motor weakness (20%), behavioural change (16%) and abnormal movements (16%). Patients with neuronal surface antibodies were younger (35 vs 48 years old, p = 0.04) and more likely to present with behavioral change (45% vs 16%, p = 0.02). Mortality rate was higher in the intracellular group (16% vs 3.2%, p = 0.09). No differences were detected in magnetic resonance imaging (MRI) and CSF profile.ConclusionsIn the early stages of the disease, both groups have comparable clinical outcomes. Although there were significant differences in age and percentage of patients with behavioral change, both groups of autoimmune encephalitis still shared many clinical features and could not be distinguished based on MRI and CSF profiles. Therefore, we recommend that patients with features of autoimmune encephalitis should be screened for both the neuronal surface and intracellular antibodies regardless of clinical presentation.

Proportion of vulvar premalignant and malignant lesions in overall vulvar specimens in Thailand

Abstract Background Vulvar lesion is one of the common gynecologic problems. Objective To assess the proportion of vulvar premalignant and malignant lesions in overall vulvar specimens and to evaluate the clinicopathologic features of each vulvar lesion in King Chulalongkorn Memorial Hospital (KCMH). Methods Pathological microscopic slides and medical records of the patients who underwent vulvar-related operations between January 1, 2002 and December 31, 2015 were reviewed. Patients’ clinical characteristics and pathologic features were evaluated and analyzed. Results A total number of 700 patients were included. The proportion of malignant and premalignant lesions in overall vulvar specimens were 16.3% and 8.4%, respectively. Squamous cell carcinoma was the most common malignant vulvar lesion (48.2%), whereas vulvar intraepithelial neoplasia 1 (VIN1) (33.9%) was the most common lesion in the premalignant group. On multivariate analysis, four clinical factors were significantly associated with malignancy risk: increased parity (odds ratio [OR] 1.19, P = 0.010), large tumor size (OR 2.00, P < 0.001), lesion at clitoris (OR 16.67, P = 0.002), and erythematous lesion (OR 2.41, P = 0.026). Conclusions The proportion of malignant and premalignant lesions in overall vulvar specimens was 24.7% in KCMH. Increased parity, large tumor size, clitoris-located lesion, and erythematous lesion were associated with increasing malignancy risk.

1693. Risk Factors Associated with Mortality of Invasive Aspergillosis in King Chulalongkorn Memorial Hospital

BackgroundInvasive aspergillosis is the serious fungal infection that often found in the immunocompromised host such as hematologic malignancy, bone marrow transplantation, organ transplantation, and patient who received chemotherapy. Nowadays the patient who diagnosed with invasive aspergillosis has a high mortality rate of 50–60%. There were some studies about the risk factor of mortality of invasive aspergillosis but most of them were not in Thailand. The objective of this study was to identify risk factors related to mortality and the mortality rate of invasive aspergillosis in King Chulalongkorn Memorial Hospital.MethodsThe retrospective study by collected and analyzed the data from medical record by ICD 10, between 1 January 2012 and 30 October 2017.ResultsTotal patients were 176 patients; the mortality rate of invasive aspergillosis patient was 46%. The most common underlying condition was AML (27.8%). The risk of invasive aspergillosis was prolonged neutropenia (31.3%), prolonged corticosteroid therapy 27.8% and induction phase chemotherapy 22.7%. The most infection site was the pulmonary system at 80.1%, sinus 13.6%, and CNS 5.7%. The significant factor which affect the mortality rate was cirrhosis [HR 4.21, 95% CI 1.46–11.69, P = 0.008], HIV infection/AIDS [HR 3.24, 95% CI 1.03–10.24, P = 0.045], tracheal infection [HR 21.81, 95% CI 1.48–320.41, P = 0.025] and empirical treatment with itraconazole [HR 11.65, 95% CI 3.14–43.17, P ≤ 0.001]ConclusionThe Risk factors associated with mortality of invasive aspergillosis in King Chulalongkorn Memorial Hospital was cirrhosis, HIV infection/AIDS, tracheal infection, and the empirical treatment with itraconazole. The overall mortality rate of invasive aspergillosis was 46%. Disclosures All authors: No reported disclosures.

280. Monitoring Serum Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) in Correlation with (1–3)-β-d-Glucan Levels in Vascular Pythiosis: A Preliminary Study

BackgroundVascular pythiosis, caused by Pythium insidiosum, is a life-threatening disease despite aggressive treatment. Our recent study showed that serum β-d-glucan (BG) trends can be used to monitor disease activity after treatment initiation. A significant decline in BG by 0.5 month indicated complete resection without residual disease. However, BG assay is cost probihitive and available only at King Chulalongkorn Memorial Hospital in Thailand. This study was conducted to preliminarily evaluate erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as monitoring tools.MethodsA prospective study included proven vascular pythiosis patients receiving treatment with combination therapy from November 2018 to January 2019. Clinical information, BG, ESR, and CRP were collected at 0, 0.5, 1.5, and 3 months post diagnosis. Spearman’s correlation coefficient and analysis of response profiles were used.ResultsSix patients were enrolled. All had thalassemia. Four developed disease at popliteal artery, 1 at common iliac artery, and 1 at brachial artery. All underwent amputation with negative surgical margins achievement. All received itraconazole, azithromycin, and P. insidiosum immunotherapy. One received terbinafine and one received doxycycline additionally. All had positive BG > 500 pg/mL at diagnosis. After treatment initiation, means of ESR were significantly decreased at 0.5 months (P = 0.02). Means of CRP were not significantly changed until 1 month (P = 0.02) (Figure 1a and b). Correlation coefficients between BG and ESR vs. BG and CRP were 0.74 and 0.65, respectively. All survived without relapse at 3 months.ConclusionESR and CRP are potentially valuable markers to monitor vascular pythiosis in resource-limited countries. However, ESR levels and trends seem to be correlated with BG better than CRP. Further studies are needed to enroll more patients, especially patients with incomplete resection or non-surgical candidates. Disclosures All authors: No reported disclosures.

1151. A Comparison of Periurethral Cleaning Between Normal Saline and Savlon Solutions Before Indwelling Urinary Catheterization in Reducing Catheter-Associated Bacteriuria: A Randomized Controlled Study

BackgroundCatheter-associated urinary tract infection (CAUTI) is one of the most common nosocomial infections. To date, there have been no randomized controlled studies to recommend the most appropriate antiseptic solution for periurethral cleaning before indwelling urinary catheterization. This study was aimed to compare normal saline solution (NSS) and Savlon solution for periurethral cleaning before indwelling urinary catheterization in reducing catheter-associated bacteriuria.MethodsA randomized controlled, noninferiority, cross-over study to determine the incidence of significant bacteriuria (SB) on day 5 after Foley catheterization, using 2 different solutions for periurethral cleaning (NSS and Savlon solutions), was carried out in all adult patients admitted in the 2 medical intensive care units (ICUs), 1 surgical ICU, 2 neurosurgical ICUs, 4 medical wards, 4 surgical wards and 1 emergency room (ER) of King Chulalongkorn Memorial Hospital, Thailand, from June 2018 to March 2019. The acceptable prespecified noninferiority margin was set to be 10%. Each solution was used alternately every 3 months in each unit. Urine culture was collected on day 1, 3, and 5 of Foley catheter.ResultsDuring the study period, there were 207 and 160 patients in the NSS and Savlon groups, respectively. 202 (55%) patients had received Foley catheterization in the emergency room. There were no significant differences in the indication, the current illness, and preexisting condition between the 2 groups. The overall incidence of SB on day 3 and 5 after catheterization was 4% and 8.2%. The incidence of CAUTI was 3.43/1,000 catheter-day. The median duration of catheterization was 5 (IQR 3, 7) days. On day 5 after catheterization, noninferiority was demonstrated for the incidence of SB with an adjusted difference of 4 (95% CI of the difference: −2.1% to 8.9%, P = 0.05). Regarding the incidence of CAUTI, there was no significant difference between the 2 groups.ConclusionTo the best of our knowledge, our study was the first randomized controlled study to compare the 2 solutions for periurethral cleaning before indwelling urinary catheterization in different departments. This study demonstrates the noninferiority of NSS to Savlon solution in reducing the incidence of SB.Disclosures All authors: No reported disclosures.

Impact of Hypoglycemia on Health-Related Quality of Life among Type 2 Diabetes: A Cross-Sectional Study in Thailand.

Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases. Patients are generally advised lifestyle changes with antihyperglycemic agents prescribed. The major drawback of prescribing antihyperglycemic agents is the risk of hypoglycemia which subsequently impacts on health-related quality of life (HRQoL). This study is aimed at examining association between previous history of hypoglycemia and HRQoL. The study was a multicenter cross-sectional study, conducted from February 2013 to March 2015 at 5 tertiary care hospitals in Thailand (Srinagarind, Phramongkutklao, Ramathibodi, King Chulalongkorn Memorial, and Siriraj hospitals). The study population were males or females diagnosed with type 2 DM according to ADA criteria, 30 years of age or older, who had been treated with sulfonylurea (SU) monotherapy or SU and metformin combination for at least 6 months. Prespecified medical factors were extracted from medical records 12 months prior to patients' enrolment. The experience of hypoglycemia questionnaire was used to collect and measure severity of hypoglycemia experienced during the previous 6 months. HRQoL was assessed using the 3-level version of EuroQol-5-dimension (EQ-5D-3L) and visual analogue scale (EQ-VAS) questionnaires. Of 659 eligible patients surveyed, 202 patients (30.65%) had experienced symptoms of hypoglycemia. HRQoL was significantly lower among patients reporting at least one of hypoglycemic symptoms, measured by EQ-VAS scores (mean ± SD; 73.66 ± 13.18, 73.56 ± 15.10, or 68.93 ± 14.76 vs. 77.01 ± 13.02, one-way ANOVA; p = 0.006) and EQ-5D-3L index scores (0.62 ± 0.47, 0.68 ± 0.38, or 0.58 ± 0.51 vs. 0.79 ± 0.31, one-way ANOVA; p < 0.001) for mild, moderate, or severe/very severe hypoglycemic patients compared with patients without hypoglycemic symptoms. After adjusting for confounding factors in a multiple linear regression model, patients with hypoglycemic symptoms either mild, moderate, or severe/very severe demonstrated significantly higher impairment for EQ-VAS and EQ-5D indexes than those who did not experience hypoglycemic symptoms. In conclusion, our study showed decreased HRQoL determined by EQ-5D and EQ-VAS in patients reporting symptoms of hypoglycemia compared with patients not reporting hypoglycemic symptoms, relative to severity of hypoglycemia.

1369. Clinical Manifestations, Treatment, and Outcome of Nontuberculous Mycobacteria (NTM) Infection in Adult-Onset Immunodeficiency Associated with Anti-interferon-gamma Autoantibodies in King Chulalongkorn Memorial Hospital

BackgroundThere is an increase of anti-interferon-γ autoantibodies syndromes because it is now well recognized, especially in the Southeast Asia region. One of the clinical features is an infection caused by nontuberculous mycobacteria (NTM). NTM infection in patients with anti-interferon-γ autoantibodies is usually severe, recurrent, and disseminated. In this study, we describe the clinical characteristics, treatment, and outcome of NTM infection in patients with anti-interferon-γ autoantibodiesMethodsA retrospective cohort study was conducted at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand, during 2010–2018. Demographic, clinical, and microbiological data were collected and analyzed.ResultsA total of 45 patients were enrolled in this study. Twenty-nine patients were males, and 16 patients were females. The most common clinical manifestations were fever with lymphadenopathy. The median age of the study population was 55 years. The most common organ that was infected was the lymph node (91%). Sweet’s syndrome (68%) was the most common immunological skin reaction. The proportion of infection caused by rapid-growing NTM was more prevalent than slow-growing NTM. The most common NTM was Mycobacterium abscessus (44.4%). The most common co-pathogen identified in this study was Salmonella (37.8%). All patients had positive antibody to interferon-γin the serum which was detected by enzyme-linked immunosorbent assay (ELISA) and mean optical density was 3.28. Fifty-one percent of the patients received long-term antimycobacterial therapy due to chronic active infection, new infections and relapsed. 22.2% of the patients developed a new infection during treatment. However, 28.9% of patients were completely cured of the infection during the follow-up period. The overall mortality rate was 11.1%ConclusionAdult-onset immunodeficiency with anti-interferon-γ autoantibodies is a unique clinical syndrome that has been recognized in Thailand. Treatment of this disorder requires a long duration of the combination of antimycobacterial agents. Sweet’s syndrome is an indicator of recurrence/relapse of NTM infection during the clinical course. Long-term monitoring and immunomodulator are essential for the management of this condition.Disclosures All authors: No reported disclosures.

279. Evaluation of β-d-Glucan Utilization in Thailand: Single Academic Center Experience

Backgroundβ-d-glucan (BG) detection was first available in Thailand in 2016 to aid diagnosis of invasive fungal infections (IFIs). Given a paucity of real-world experience of BG use in resource-limited countries, this study was conducted to describe appropriateness of BG testing and sequelae of BG results.MethodsA retrospective study included all patients with at least 1 BG ordered at King Chulalongkorn Memorial Hospital, Bangkok, Thailand during March 2016 to December 2018. Descriptive statistics were used.Results83 patients were tested by BG assay (Fungitell, Associates of Cape Cod, Inc.): 6 with hematopoietic stem cell transplant, 12 with solid-organ transplant, 20 with active cancer receiving chemotherapy, 34 receiving high dose steroids (≥20 mg/day of prednisone for ≥3 weeks) and 11 with other conditions. Seventy-three patients were tested under infectious disease (ID) service’s recommendations. There were 13 and 20 cases of proven and probable IFIs, respectively. Among 13 proven IFIs, there were 11 positive, 1 indeterminate and 1 negative (mucormycosis) BG results. Among 49 cases with positive BG results, 24 were determined to be false-positive results. Median turn-around time for BG results was 16 (IQR: 9–23) days. Due to high turn-around time, only 8 patients were started on antifungal agent(s) and 3 underwent bronchoscopy due to positive BG results. All proven IFI cases were started on antifungal treatment prior to BG availability.ConclusionApproximately 87% of BG use in Thailand was ordered in patients with risk factors for IFIs. This could be due to majority of BG test was recommended by ID specialist. Despite being used in right clinical context, 49% had false-positive BG results. Another barrier of BG use in Thailand was high turn-around time due to small numbers of BG ordered and relative high cost to run the assay. Therefore, the utility of BG for aiding diagnosis or management of fungal infection in our setting is limited.Disclosures All authors: No reported disclosures.

1378. Clinical Characteristics of Tuberculosis Among Patients with Cancer in an Endemic Country

BackgroundTuberculosis (TB) is an infection caused by reactivation of Mycobacterium tuberculosis. Decreasing host immune system plays an important role in pathophysiology especially in patients with human immunodeficiency virus (HIV) infection and transplant recipients. Exposure to immunosuppressive agents among patients with solid and hematologic malignancy is likely to increase risk of TB. However, characteristics of TB in this population remain scarce.MethodsA single-center, retrospective descriptive study was conducted at King Chulalongkorn Memorial Hospital. Adult patients who developed TB between January 2008 and October 2018 after diagnosis of solid or hematologic malignancy were identified using ICD-10 code. Baseline, clinical characteristics, and treatment outcomes were collected.ResultsA total of 114 patients developed TB after diagnosis of malignancy including, 67 (58.8%) with solid tumor and 47 (41.2%) with hematologic malignancy. Lung cancer was the most common solid malignancy with TB (17.9%) followed by head and neck carcinoma (14.9%) and colorectal cancer (13.4%). For hematologic malignancies, non-Hodgkin’s lymphoma was the most common malignancy (53.2%) followed by leukemia (29.8%) and multiple myeloma (14.9%). Among patients who received immunosuppressive treatment, the mean onset of TB was 4.97 months (range 0.25 to 57 months) and 2.55 months (range 0.1 to 18 months) after treatment of solid and hematologic malignancies. Pulmonary and pleural involvement remained the most common site of infection in both groups. Mortality was highest among patients with hematologic malignancies (40.4%) while mortality in solid malignancies was 11.9%.ConclusionTB in patients with solid and hematologic malignancies contained substantial morbidity and mortality. Immunosuppressive agents and chemotherapy may play an important role especially in the endemic area. Disclosures All authors: No reported disclosures.

2679. Factors Associated with Multidrug-resistant Gram-Negative Bacteremia in Acute Leukemia Patients with Neutropenic Fever, a Retrospective Study

BackgroundGram--negative bacteremia in acute leukemia patients with neutropenia is associated with high morbidity and mortality rate. Appropriate antibiotic for empirical treatment is crucial; however, antibiotic selection is challenging especially in setting with high prevalence of infections with multidrug-resistant (MDR) organisms. Data on associated factors of MDR Gram-negative bacteremia in this population is limited.MethodsA retrospective study was conducted in King Chulalongkorn Hospital, Bangkok, Thailand. Medical records of patients aged ≥15 years with acute leukemia who were hospitalized in our institute and had neutropenic fever between 1 January 2001 and 31 December 2016 were reviewed. Demographic data, causative organisms, treatment and outcomes were documented. Episodes of MDR Gram-negative bacteremia were compared with non-MDR group. Associated risk factor was assessed by multivariate logistic regressionResultsFrom total 405 admission records of 227 acute leukemia patients, 587 episodes of neutropenic fever occurred with 131 episodes of Gram-negative bacteremia. Majority (81.68%) were bacteremia without source of infection. Most common causative pathogens were E. coli, P. aeruginosa and K. pneumoniae, respectively. Sixty episodes of Gram-negative bacteremia (53.57%) were caused by MDR pathogen. Associated factor for MDR Gram-negative bacteremia was prior colonization or infection with MDR Gram-negative bacteria within 3 months (P = 0.049). Subgroup analysis in patients with non-lactose fermenter bacteremia showed higher rate of intensive care unit (ICU) admission and in-hospital death in MDR group (P = 0.03 and P = 0.004).ConclusionPrior colonization or infection by MDR Gram-negative bacteria within 3 months was associated with MDR Gram-negative bacteremia in acute leukemia patients with neutropenic fever. Thoroughly review of previous culture data and active screening for colonization may increase chance of appropriate empirical antibiotics. Disclosures All authors: No reported disclosures.