Lower-extremity amputation: a 6-year follow-up study in Brazil.

PURPOSE: To evaluate the 6-year mortality in 50 patients following lower-limb amputation. METHODS: The cumulative survival rate of 50 (28 men, 22 women) amputees aged 54 to 94 years (mean, 67.3; median, 73.5) was retrospectively studied from 1993 to 1998. Indications for above- or below-knee amputation were trauma (n = 2), vasculitis (n = 2), and critical ischaemia of the lower limbs (n = 46). Leg amputation was performed after anamnesis, physical examination, and angiography. All patients were followed up for 6 years by phone or domiciliary visit. A death certificate was verified when a patient was lost to follow-up. Statistical analysis was expressed by the actuarial survival curve. RESULTS: Of 50 amputees, 36 died in the 6 years following leg amputation: 22 in the first year, 3 in the second year, 5 in the third year, 2 in the fourth year, 2 in the fifth year, 2 in the sixth year; 14 remained alive after 6 years. CONCLUSION: Patients who underwent lower-limb amputation had a high 6-year mortality. Most deaths occurred in the first year.

Clinical presentation of herpes zoster in a Singapore hospital.

BACKGROUND: There is a direct correlation between increasing age and incidence of herpes zoster. There is an increased risk of complications in the elderly and the immunocompromised. OBJECTIVE: To study the clinical epidemiology of hospitalised patients with herpes zoster. METHODS: Medical records of all patients hospitalised with zoster were respectively analysed. RESULTS: Sixty-seven patients (3% of total admissions) were studied. There were 35 males and 32 females with a mean age of 50.35 +/- 21.71. There was an increased proportion of older patients in the study cohort. Nineteen patients (28.4%) were immunocompromised with malignancy occurring in 9 patients. Thirteen had been on cytotoxic and/or steroid therapy. The commonest symptoms were rash, pain and fever. Eighty-five percent of the patients had complications (bacterial super-infection in (61%), dissemination (31%), ocular involvement (5%) and post-herpetic neuralgia (13.4%). There was an increasing frequency of duration of pain with increasing age in the patients with post-herpetic neuralgia. Forty-three patients were treated with acyclovir. The median time to healing of lesions was 11 days. The 41 patients with bacterial super-infection received antibiotics with median time to healing of 12 days. CONCLUSION: Increasing age and immunocompromised state appear to be risk factors for developing herpes zoster in hospitalised patients.

PCR as a confirmatory test for human immunodeficiency virus type 1 infection in individuals with indeterminate western blot (immunoblot) profiles.

A combination of two PCR systems which amplify human immunodeficiency virus type 1 (HIV-1) gag and pol DNA was used to elucidate the HIV-1 infection status of a group of individuals screening positive for anti-HIV but having indeterminate Western blot (immunoblot) profiles. The results obtained suggest PCR could be used to resolve such cases.

Oral acyclovir in the treatment of adult varicella.

An open study was conducted to evaluate the efficacy of oral acyclovir in a group of 295 Singapore Armed Forces male servicemen. The 148 patients who were willing to take acyclovir were given 800 mg orally five times per day for seven days. The other 147 who refused to take acyclovir were monitored as a control group. Each of these groups was further classified into two groups. Group A patients presented with rash within 24 hours of rash onset and Group B presented between 24 and 72 hours. Daily lesion counts, temperature, pruritus scores and laboratory tests were used to monitor disease progression. Early acyclovir intervention (Group A) reduced the time to 100% crusting from 7.19 to 5.71 days (P = 0.0001), decreased the maximum number of all lesions by 26% (P = 0.03) and the maximum number of vesicular lesions by 45% (P = 0.0004). Late therapy (Group B) was effective in reducing the maximum number of vesicular lesions by 38% (P = 0.003). The number of patients requiring antibiotics for suspected secondary skin infection, the duration of fever and paracetamol consumption were significantly reduced in both the early and late intervention groups. However, there were no effects in minimizing pruritus in either group. Serious complications such as pneumonia, encephalitis or death were not observed in this study. The most common adverse effect of acyclovir was mild diarrhoea occurring in 35% of patients treated with the drug. We conclude that early treatment with acyclovir was beneficial whereas late therapy had limited effect in reducing the severity of cutaneous lesions in patients with varicella.

Multidrug-resistant typhoid fever in Singapore.

A study was conducted to determine the clinical and epidemiological characteristics of multidrug-resistant (MDR) typhoid fever in Singapore. Twenty-one of 121 patients with typhoid fever had MDR typhoid fever after recent travel to the Indian subcontinent. Fifty patients with drug susceptible typhoid fever were also analysed for comparison. Nineteen of the MDR S. typhi isolates had resistance to ampicillin, chloramphenicol and trimethoprim-sulphamethoxazole (TMP-SMX) while the remainder had resistance to ampicillin and TMP-SMX. The predominant presenting symptoms were fever and diarrhoea. Eleven patients with MDR typhoid fever were treated with oral ciprofloxacin and nine with intravenous ceftriaxone. The patients with MDR typhoid fever had a longer duration of fever defervescence (8 +/- 5 days) compared to those with drug-susceptible typhoid fever (5.7 +/- 4.16 days) (p < 0.01). Eighteen patients were cured and one patient defaulted treatment. Two patients relapsed within two months of treatment. The study showed that 17.4% of patients with typhoid fever had imported MDR S. typhi after recent travel to the Indian subcontinent where MDR typhoid fever is prevalent.

Malaria: prophylaxis and therapy.

Malaria remains a significant cause of morbidity and mortality in many regions of the world. In Singapore, an average of 200 cases of malaria have been reported annually, the majority of which are imported cases. Malaria eradication is a goal that may not be achieved. A more realistic aim is to educate and protect individual travellers. This paper attempts to summarise various therapeutic options including the use of monotherapy and combination therapy. The decision on therapy depends on several factors, such as the Plasmodium species, risk of transmission of the resistant parasite and the severity of infection. So far, none of the chemoprophylactic regimens available can provide an absolute protection from malaria transmission. Therefore, one needs to assess the risk of transmission against the potential risk of adverse drug reaction. Complications of anti-malaria drugs may range from minor cutaneous manifestations to death. General measures to prevent vector transmission of the disease should be emphasised while awaiting the development of an effective malaria vaccine.

Acquired immunodeficiency syndrome and Cryptosporidium infection.

A child suffering from the acquired immunodeficiency syndrome (AIDS) with intestinal cryptosporidiosis is reported. The child presented with profuse diarrhoea up to 15 episodes a day over a period of one week. Management was with intravenous rehydration and oral spiramycin. Diagnosis of intestinal cryptosporidiosis requires examination of multiple stool specimens by several concentration and staining procedures which aid in the visualisation of the oocysts. In the absence of an effective treatment for cryptosporidiosis, the cornerstone of management is mainly supportive therapy.

Fatal varicella infections in Singapore.

Varicella (chickenpox) is common in Singapore. The annual incidence of reported cases for the period 1977-1990 ranged from 790 to 18,934, with a mean of 4,747. Mortality from chickenpox is rare. However, failure to recognise the severity and the potential complications of the disease, especially in immunocompetent patients, exists because of the common knowledge that chickenpox is a mild and self-limiting illness. We report six cases of fatal varicella in immunocompetent patients during the period 1988 to 1990.

A 7-day course of ciprofloxacin for enteric fever.

A prospective, open and non-randomised clinical trial using a 7-day short course of oral ciprofloxacin 500 mg twice daily was conducted on 25 adult patients with bacteraemic enteric fever. Twenty-four patients (96%) were cured and there was one treatment failure. Two patients with typhoid fever relapsed 6 weeks after finishing treatment. Defervescence of fever was rapid (median: 4 days) and the duration of hospitalisation was short (median: 8 days). Both factors resulted in patient satisfaction. A short-course regime of ciprofloxacin for the treatment of enteric fever, is therefore, highly promising.

Cytomegalovirus pneumonitis in AIDS--a case report.

Respiratory infections occur commonly in patients with advanced human immunodeficiency virus (HIV) infection. Prompt accurate diagnosis is essential as many of the various available therapies have significant toxicities. We describe a patient previously diagnosed with the acquired immunodeficiency syndrome (AIDS) who was found to have cytomegalovirus (CMV) pneumonitis on bronchoscopy. His pneumonitis responded to treatment with the nucleoside analogue ganciclovir. Our patient is the first documented CMV pneumonitis in the Singapore HIV seropositive population.

Diagnostic value of the Widal test for typhoid fever in Singapore.

A study was conducted to assess the diagnostic value of the Widal test in patients with bacteraemic typhoid fever. The Widal test was carried out on 25 bacteriologically proven cases of typhoid fever and 50 patients with non-typhoid fever. All the patients with non-typhoid fever had an O agglutinin titre of less than 1:40, while 82% had an H agglutinin titre of less than 1:40. In the patients with typhoid fever, 56% had an O agglutinin titre of greater than or equal to 1:40 and 72% had an H agglutinin titre of greater than or equal to 1:40. Typhoid patients with titres greater than or equal to 1:40 for O and H antigens of Salmonella typhi were significantly different (P less than 0.01) from those with non-typhoid fever. The O agglutinin was highly specific (100%) in the diagnosis of the disease. The study shows that a single Widal test is useful in the diagnosis of typhoid fever in Singapore.

Epidemiology and control of an outbreak of typhoid in a psychiatric institution.

An outbreak of typhoid caused by Salmonella typhi of the same Vi-phage type (D1) and of the same antibiogram was reported in a large psychiatric institution in Singapore. A total of 95 (4.8%) of the 1965 inmates were infected, 47 with symptoms and 48 asymptomatic. Transmission was through close person-to-person contact and not through contaminated food or water. The source of infection could not be established. The outbreak was brought under control by maintaining a high standard of environmental sanitation, active search for fever and diarrhoeal cases, identification of asymptomatic cases by rectal swabbing, and isolation of those found to be infected. Mass immunization with two doses of heat-phenol inactivated typhoid vaccine was also carried out concurrently. The vaccine was found to have an efficacy of 65.8% in preventing clinical illness.

Typhoid fever in Singapore: a review of 370 cases.

The medical records of 370 patients treated for typhoid fever between 1986 and 1988 at the Communicable Disease Centre, Singapore, were reviewed. The disease was generally mild. There was no mortality. Fever was found in 98.4% of patients on admission and diarrhoea in 21%. Cough was predominantly a symptom of children and occurred in 7.1% of patients aged below 15 years. Other symptoms were uncommon. Hepatomegaly was found in 71% and splenomegaly in 47%. Leucopenia was not a helpful diagnostic marker. Chloramphenicol was the drug of choice. The relapse rate was 5.4% and the convalescent and temporary carrier rates 11.6%. The risk of developing the carrier state was significantly higher among patients who were afebrile on admission compared with those who were febrile (P less than 0.001); it was also higher in patients treated with ampicillin as compared to those treated with chloramphenicol (P less than 0.001, chi 2 = 22.7, odds ratio = 5.25, 95% confidence limits: 2.46 and 11.29). The role of ampicillin as a first line treatment for acute typhoid fever may need further re-evaluation.

Human immunodeficiency virus infection in Singapore--containment strategies.

The worldwide occurrence of the Acquired Immunodeficiency Syndrome (AIDS) since its advent in the United States in 1981 has resulted in a global dilemma on how best to reduce transmission of the Human Immunodeficiency Virus (HIV). In Singapore, a national AIDS programme was established in 1985 to control the spread of the disease in the country. The programme included health care delivery, education of health care workers and the community, surveillance and counselling of individuals with high risk behaviours, as well as protection of the nation's blood supply. This paper examines the global response to the HIV pandemic and containment strategies appropriate to Singapore based on established epidemiological data.

Human immunodeficiency virus infection in Singapore--the first 50 cases.

As at 31 May 1990, fifty Singaporeans with the Human Immunodeficiency Virus (HIV) infection had been detected. Of these, nineteen had the Acquired Immunodeficiency Syndrome (AIDS). The majority of infected persons had been infected through sexual contact (homosexual 52%; bisexual 24%; heterosexual 20%) with men and women from countries where HIV infection was prevalent. The majority of infected patients (88%) were in the age range 20-39 years. There was one case of blood transfusion-associated AIDS. There were no infected paediatric or haemophiliac cases or intravenous drug use in any of the patients. A spectrum of AIDS-related opportunistic infections and cancers was observed, and Pneumocystis carinii pneumonia was the most frequent presentation. Thirteen patients with AIDS had died and the median survival time was about seven months.

Chloramphenicol concentrations in sera of patients with typhoid fever being treated with oral or intravenous preparation.

Serum chloramphenicol and chloramphenicol succinate concentrations in patients given equivalent doses of chloramphenicol base either intravenously or orally for typhoid fever were measured by high-performance liquid chromatography. The mean serum chloramphenicol concentrations were significantly lower in the 11 patients treated with intravenous chloramphenicol succinate than in the 15 patients treated with oral chloramphenicol capsules.

Case report--the acquired immunodeficiency syndrome and isospora belli infection.

A patient with the acquired immunodeficiency syndrome (AIDS) presenting with isospora belli infection is reported. The difficulties encountered in the diagnosis and therapy of isosporiasis are discussed. The diarrhoea responded to treatment with intravenous fluid replacement and oral furazolidone.

The acquired immunodeficiency syndrome in Singapore--epidemiological perspectives.

The Acquired Immunodeficiency Syndrome (AIDS) is caused by a retrovirus, the Human Immunodeficiency Virus (HIV). As at 30 April 1988, there were 22 infected individuals in Singapore, of which 4 had AIDS. A comprehensive retrospective study was carried out to establish the clinico-epidemiological features of the disease and its transmission in Singapore. The infected patients have been related mainly to sexual transmission through sexual contact (homosexual, bisexual or heterosexual) with men and women from countries where HIV infection is more prevalent. The majority of the infected were homosexual males in the age range 20-39 years. There was one case of transfusion-associated AIDS and another was infected through heterosexual transmission. The local pattern is consistent with the Western pattern (Pattern 1), with the notable absence of intravenous drug abusers, paediatric cases or infected haemophiliacs.

Acute hepatitis A in Singapore: importance of shellfish ingestion in a non-epidemic period.

A case-control study based on 28 serologically confirmed cases of hepatitis A and 42 home contacts with no recent or past evidence of hepatitis A virus (HAV) infection was conducted to determine the importance of shellfish exposure in the transmission of HAV during a non-epidemic period in Singapore. It was found that consumption of partially-cooked cockles (Anadara granosa) was significantly associated with the illness (p less than 0.001). No other types of locally available shellfish including oysters, mussels and clams were incriminated. The public should be constantly reminded to refrain from consuming raw and inadequately cooked bivalve molluscs all the time, and not just during epidemics.

Ceftriaxone therapy in bacteremic typhoid fever.

The efficacy and safety of ceftriaxone in the treatment of bacteremic typhoid fever was studied in 14 patients. Ceftriaxone at a dosage of 50 to 60 mg/kg per day was administered intravenously in two divided doses in 13 patients and as a single dose in 1 patient. When the two patients with medical complications causing persistent fever and the patient who was febrile during therapy were excluded from the calculations, the mean period of defervescence was 4 days. Five to eight days of ceftriaxone therapy was adequate for the patients who were cured. The 14 patients treated with ceftriaxone included 13 patients who were considered cured, although 1 was a convalescent carrier, and one patient who was a treatment failure. There were no relapses in the 11 patients who were monitored for 1 to 8 months. Both peak and trough concentrations of ceftriaxone were well above the ceftriaxone MICs for the Salmonella typhi strains isolated from the patients. We have demonstrated that ceftriaxone can be used successfully in the treatment of typhoid fever in some patients. The advantages of its use include rapid clinical response, short course of treatment, and lack of serious adverse drug reactions.