Bacteriologically-negative pulmonary tuberculosis--the Singapore tuberculosis control unit experience.

INTRODUCTION: Patients with radiological features suggestive of active pulmonary tuberculosis (PTB) from areas with a high prevalence of the disease have a high clinical likelihood of PTB regardless of the bacteriological findings. It is the established practice in many countries to initiate therapy in such patients. Our study aimed to determine if treatment for bacteriologically-negative PTB in our local population was appropriate and to identify features at presentation that would be predictive of active PTB, as defined by good and appropriate response to anti-tuberculous treatment. MATERIALS AND METHODS: A retrospective review of a randomised sample consisting of 100 bacteriologically-negative PTB patients given a course of anti-tuberculous treatment at the Singapore Tuberculosis Control Unit (TBCU). Based on their treatment response and outcome, patients were classified as probable active or unlikely active PTB. Patients' characteristics, clinical presentation and radiological findings were analysed for their association with likelihood of probable active PTB. RESULTS: Fifty-six per cent of patients in this study had probable active PTB. The decision to treat this group of patient was appropriate. There was no serious adverse reaction in the patients treated. The presence of symptoms, especially cough at presentation, a history of contact with tuberculosis and cavitation on chest radiograph, were associated with an increase risk of probable active disease. CONCLUSION: The TBCU's practice to treat patients suspected of having radiological PTB in the setting of negative sputum smear and culture seems to be appropriate in the majority of cases.

Unplanned extubation: a local experience.

OBJECTIVES: To study the outcome of unplanned extubation (UE) in the Medical Intensive Care Unit (MICU) and to identify factors which predict the need for reintubation. METHODS: A prospective study of all mechanically ventilated patients admitted to MICU in 1998. Patients were enrolled into the study at the point of their first UE. The primary endpoint was reintubation after UE and secondary endpoint was death from any cause during hospitalisation. RESULTS: A total of 543 patients were admitted to MICU of which 312 were mechanically ventilated. UE accounted for 8.7% of our mechanically ventilated patients. The mean APACHE 11 score was 20 (+/- 10), mean time between intubation and UE was 3.1 days (+/- 3.1), mean length of MICU stay was 10.1 days (+/- 10.2) and mean hospital stay was 27.0 days (+/- 36.1). Eighty-seven percent of the UE was deliberate. The rate of reintubation after failed UE was 58.3% of which 71.4% had immediate reintubation. Twenty-nine percent of patients were undergoing weaning during UE. The in-hospital mortality was 25%. All deaths occurred in the group who failed UE. Patients who failed UE had a higher mean APACHE 11 score, a higher mean pre-extubation FiO2 level and a lower mean PaO2/ FiO2 ratio (p < 0.05). CONCLUSION: UE accounted for 8.7% of our mechanically ventilated patients and 58.3% of these patients required reintubation. Failed UE was associated with a higher mortality. A higher APACHE 11 score, higher pre-extubation FiO2 level and a lower PaO2/FiO2 ratio were associated with reintubation after failed UE.

Deep vein thrombosis in patients admitted for exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION: There is a lack of data on the prevalence of deep vein thrombosis and pulmonary embolism in patients admitted to hospital for exacerbation of chronic obstructive pulmonary disease. Studies have found that most pulmonary embolism originate from deep vein thrombosis in the lower limbs, thus the prevalence of deep vein thrombosis may give an accurate reflection of the prevalence of pulmonary embolism. The aim of our study was to determine the prevalence of deep vein thrombosis in these patients, using duplex ultrasound of the lower limbs as the screening tool. METHODS: Thirty-three male patients admitted to the general ward for exacerbation of chronic obstructive pulmonary disease were screened for presence of deep vein thrombosis of the lower limbs using duplex ultrasound scan. RESULT: No patient in this study was found to have deep vein thrombosis of the lower limbs. CONCLUSIONS: The prevalence of deep vein thrombosis in local patients admitted for exacerbation of chronic obstructive pulmonary disease is likely to be low. We do not recommend the use of duplex ultrasound to screen for deep vein thrombosis in this group of patients.

The effects of ethnicity on disease patterns in 472 Orientals with systemic lupus erythematosus.

OBJECTIVE: To determine the effects of ethnicity on disease manifestations in Oriental patients with systemic lupus erythematosus (SLE) and to describe the risk of developing renal or central nervous system (CNS) involvement with time. METHODS: A retrospective study of 472 patients with SLE seen at the only Rheumatology Unit in Singapore. The effect of ethnicity on selected disease manifestations at diagnosis was assessed after adjusting for demographic variables using multiple logistic regression. The probability of developing selected disease manifestations with time was determined using the Kaplan-Meier product limit method. RESULTS: At diagnosis, Malays had a higher risk of renal or CNS involvement than Chinese (OR 2.26, 95% CI 1.21 to 4.21, and OR 3.07, 95% CI 1.01 to 9.34, respectively), and Indians a lower risk of malar rash and a higher risk of oral ulcers than Chinese (OR 0.30, 95% CI 0.13 to 0.68, and OR 2.90, 95% CI 1.45 to 7.34, respectively). The prevalence of renal or CNS involvement in the entire cohort increased with time, reaching 75.6% (95% CI 66.1% to 85.0%) and 16.7% (95% CI 11.7% to 21.6%), respectively, after 18 years of disease. CONCLUSION: Ethnicity influenced disease manifestations at diagnosis in this cohort of Oriental patients with SLE. Renal or CNS involvement developed in previously unaffected patients up to 18 years after diagnosis, highlighting the need for continued vigilance in patients with lupus.