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The introduction of ustekinumab, an interleukin [IL]12/23 p40 inhibitor, to the therapeutic armamentarium of Crohn's disease has provided a much needed treatment option for patients who have failed conventional biologics with anti-tumour necrosis factor [TNF] and anti-integrin agents. Despite targeting two major cytokine pathways, the side effect profile of ustekinumab appears to be favourable in clinical trials. In particular, the risk of tuberculosis infection was observed to be lower than in patients who have received anti-TNF agents. The risk of non-tuberculosis mycobacterium infection, however, remains unknown. Here, we report the first case of a patient with Crohn's disease who developed Mycobacterium abscessus infection while on ustekinumab treatment.

Globalization has led to a rapid influx of female workers from Asian countries with high prevalence of HIV to Singapore, with many entering the entertainment industry. We assessed the prevalence of sexual services, condom use, and self-initiated screening for sexually transmitted infections (STIs) and associated variables among foreign female entertainment workers in Singapore. A cross-sectional survey of 317 female entertainment workers, using mystery clients, was conducted on a two-stage proportional cluster sample of 93 entertainment establishments stratified by geographical zone in Singapore. We found a high prevalence (71 %) of sexual services in entertainment establishments with 53 % of the female entertainment workers reporting selling sex. Consistent condom use for sex with paying clients in a usual week in the past 3 months was low, ranging from 37.9 % for oral sex, 46.9 % for anal sex, to 51.9 % for vaginal sex. On multivariate logistic regression, consistent condom use for vaginal sex with clients showed a significant independent association with the entertainment worker’s behavior of asking clients to use condoms and a borderline association with entertainment worker being a Chinese national. Less than half (48.9 %) of the sex workers had ever been screened for STIs either locally or in their home country. The only independent factor significantly associated with STI screening was having to support one’s family. In summary, a high percentage of foreign female entertainment workers in Singapore reported selling sex. Condom use and STI screening were low among them. Access to STI screening, treatment, and education services should be enhanced for foreign female entertainment workers in Singapore.

Background and study aims Endoscopic spray cryoablation is a novel approach for the treatment of Barrett's esophagus. However, few studies have reported its efficacy, especially with the use of carbon dioxide (CO (2)). The aim of the current study was to evaluate the short term efficacy and complications using CO (2) in endoscopic cryoablation of Barrett's esophagus. Methods Patients diagnosed with Barrett's esophagus underwent monthly stepwise cryoablation with pressurized CO (2) gas, with follow-up esophageal biopsies until complete histological reversal was achieved. Responses were analyzed with an intention-to-treat analysis according to complete response for intestinal metaplasia (CR-IM), which was defined as the elimination of all intestinal metaplasia including specialized intestinal metaplasia (SIM), subsquamous SIM, and dysplasia with intestinal metaplasia in the biopsies under narrow-band imaging (NBI). Results In total, 22 patients were enrolled, 20 of whom completed the treatment. Two patients declined further ablation after the first cryotherapy session. A total of 44 sessions were performed; a median of 2 sessions per patient (range 1 - 3 sessions) were needed to complete the ablation of Barrett's esophagus. No severe complications occurred. Follow-up endoscopies were performed in 20 patients (90.9 %). Two patients (9.1 %) were lost to follow-up. Median follow-up was 10 months (range 6 - 18 months). After cryotherapy, 20 patients (90.9 %) reached CR-IM of Barrett's esophagus. Patients underwent a median number of 3 follow-up endoscopies (range 2 - 4) with biopsies. At 6 months, recurrence was evident in three patients (13.6 % of the overall population, 15.0 % of the CR-IM population). One of the three patients developed intestinal metaplasia but no dysplastic change and the other two developed subsquamous SIM. Conclusions The pressurized CO (2) spray cryotherapy is a relatively effective and safe endoscopic treatment for Barrett's esophagus.

Summary Background There are few studies on the prevalence of acne vulgaris among Asian teenagers. Objectives To determine the epidemiology of acne in teenagers in Singapore. Methods A community-based cross-sectional study in 1045 adolescents aged 13–19 years. Results Of these respondents, 88% identified themselves as having acne. Eight hundred and six of these respondents were examined by a dermatologist, and 51·4% were classified as having mild acne, 40% moderate acne and 8·6% severe acne. Isolation of Propionibacterium acnes was attempted in 262 subjects. Cultures were positive in 174 subjects, giving an isolation rate of 66·4%. Antibiotic-resistant strains of P. acnes were detected in 26 isolates (14·9%). Eleven of these 26 subjects (42%) had previously been treated or were presently on antibiotic treatment for acne, but the other 58% of students who had antibiotic-resistant strains of P. acnes did not give a history of prior antibiotic therapy. Teenagers expressed psychological distress over acne, and believed that hormonal factors, diet and hygiene were important factors in causing acne. Conclusions There is a need for accessible, accurate education on acne and its appropriate treatment.

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin involving multiple organ systems. There has been no report so far to describe the epidemiological pattern of cutaneous involvement in sarcoidosis in South-East Asia with diverse ethnic groups. A retrospective study examining the clinicopathological features of all patients diagnosed with sarcoidosis at a tertiary dermatology centre in Singapore from 1980 to 2003 was conducted. Cutaneous sarcoidosis was diagnosed in 25 patients: 13 were Indian, 11 were Chinese and one was Eurasian. Cutaneous manifestations included papules, nodules, plaques and scarring alopecia. Extracutaneous involvement of lymph nodes (four patients), lungs (eight patients) and eyes (two patients) was seen. Eight patients had abnormal chest radiographic findings. Histopathological examination of skin lesions revealed noncaseating, epithelioid granulomatous infiltration in the dermis without evidence of mycobacterial infection, deep fungal infection or polarizable birefringent material. Treatment modalities included corticosteroids, hydroxychloroquine, isotretinoin, methotrexate and surgical excision. Five patients had complete resolution of the cutaneous lesions. Cutaneous sarcoidosis is rare in Asia and indeed in Singapore. Extracutaneous involvement is not uncommon and a thorough clinical evaluation should be undertaken.

BackgroundSingapore is a small industrialized island state with a low accident rate and few hazardous chemical-related injuries reported. However, the use of chemicals continues to increase and pose hazards in the workplace.AimsTo study workplace chemical injuries and exposures to improve worksite safety.MethodsWork-related chemical exposure cases were identified from emergency department (ED) computerized records from 2007 to 2010.ResultsA total of 239 cases were identified. Most of the patients were male (92%) and young adults (73% aged between 21 and 40 years). Fifty per cent of the workers were foreign workers. Most of them were cleaners, labourers and technicians (53%) and worked mainly in the construction and manufacturing industries (47%). All the exposures were acute and presented within 4h of the exposure incident (52%). Most of the chemical exposures were to the eye (55%) and skin (32%). The chemicals involved included corrosives (41%), hydrocarbons (18%) and cleaning solutions (9%). Pre-hospital decontamination (eye and skin irrigation) was performed for 54% of the workers. Antidote treatment with calcium gluconate for hydrofluoric acid exposure was used for five patients in the ED. Only 11% of patients were admitted. Four patients had surgical procedures and five patients had long-term complications. Forty-five incidents were notified to the Ministry of Manpower. The under-reporting rate for cases with >3 days of medical leave was 66%.ConclusionsWork-related chemical exposures that present to the ED had low morbidity. Most of the workers did well with immediate decontamination and supportive treatment but antidotes were required for some exposures. Language: en

Tuberculosis verrucosa cutis (TBVC) is a paucibacillary form of cutaneous tuberculosis caused by exogenous re-infection in previously sensitized individuals. Here, we report an unusual case of TBVC in a 53-year-old Chinese woman that had been present for 44 years and resulted in fixed-flexion deformity of her arm and functional disability. The diagnosis was made by a positive culture for Mycobacterium tuberculosis and she responded well to antituberculous therapy. To our knowledge, this is the first such case of TBVC reported in the English literature with sequelae of functional impairment of the arm.

Wasp stings can present in various ways, ranging from mild self-limiting illness to severe multi organ failure with a potentially fatal outcome. We report a case of multiple wasp stings leading to acute renal failure needing prolonged dialysis support and posterior reversible encephalopathy syndrome.

Objective To compare gender differences in the factors associated with condom use at most recent voluntary intercourse among heterosexual adolescents attending a public clinic for sexually transmitted infections (STIs). Study design Between 2008 and 2011, we conducted a cross-sectional survey on 964 never-married adolescents between 14 and 19 years of age who reported having engaged in voluntary intercourse for most recent sexual encounter and were attending the only public STI clinic in Singapore for screening or treatment of STIs. Data were collected using a self-administered questionnaire. Results The response rate to the questionnaire was 85.2%. In multivariate analysis, condom use at last intercourse for both genders was negatively associated with Malay race and peer connectedness and was positively associated with confidence in the ability to use a condom correctly. Being employed was positively associated with condom use for female respondents only. For male respondents only, condom use showed a positive association with living in better housing, older age at first intercourse, and engaging in sexual intercourse with commercial sex partners. Almost all (90%) commercial sex partners suggested condom use and provided condoms compared with 8.1% of non–sex worker partners. Condom use showed a negative association with inconvenience in its use among male respondents but not female respondents. Conclusion STI prevention programs for adolescents must promote condom use with nonpaying partners, address barriers to condom use, and develop condom application skills, taking into account gender differences. Future research should explore condom use within dating relationships.

Oral isotretinoin is effective for acne vulgaris but concerns remain regarding its adverse effects.This study aims to evaluate the safety and efficacy of isotretinoin for acne vulgaris in Asian patients.We conducted a 4-year retrospective study on all patients with acne vulgaris treated with isotretinoin, between January 2005 and December 2008 at the National Skin Centre in Singapore. Medical records were reviewed for information on patient demographics, acne severity, isotretinoin dose, duration, adverse effects and outcome.There were 2,255 patients, with a mean age of 22.5 years, male:female ratio of 2.5:1 and 82.3% being Chinese. The mean starting dose of isotretinoin was 0.4 mg/kg and on average, patients received 7.8 months of treatment at a mean dose of 0.5 mg/kg. Mean total cumulative dose was 95.6 mg/kg. Vast majority (93.9%) achieved complete remission or substantial improvement. Thirty-eight (2.2%) and 24 patients (2.7%) developed elevated serum levels of alanine and aspartate aminotransferases subsequent to treatment. There were 194 (12.1%) and 80 (4.8%) patients who developed hyperlipidaemia and hypertriglyceridaemia respectively. Isotretinoin was generally well-tolerated, with 6.4% (n = 145) discontinuing due to side-effects.This study reaffirms the overall safety and efficacy of oral isotretinoin in Asian patients with acne vulgaris.

Rhinoscleroma is a chronic, slowly progressive, inflammatory disease of the upper respiratory tract. It is associated with Klebsiella rhinoscleromatis infection. We present the clinical and pathological features of four patients diagnosed with rhinoscleroma at the National Skin Centre, Singapore between 1997 and 2010. All four patients presented with only cutaneous involvement, and the diagnosis was clinched via histological examination. The patients were treated with a combination of antibiotics. Two patients who were on follow-up at the time of this writing responded positively to the antibiotic treatment, while two were lost to follow-up. Rhinoscleroma is a diagnostic challenge, as it is an uncommon disease in Singapore and Malaysia. We highlight this condition to raise awareness of the disease in order to aid in early diagnosis of patients. Without treatment, this condition can result in significant complications, including involvement of the lower airways. Early diagnosis and appropriate treatment help to reduce morbidity.

The Department of Sexually Transmitted Infections (STI) Control (DSC) Clinic is the only public STI clinic in Singapore. This study aimed to determine patients' perception of the clinic as well as the factors that may influence their choice of DSC Clinic over other medical facilities. The concerns of certain risk groups were also assessed.Self-administered anonymous questionnaires were offered to Singaporeans and Permanent Residents over 18 years of age who were seeking treatment at the DSC Clinic. 1,000 responses were collected over a period of four weeks in May 2009.More than two-thirds of the patients had a positive experience at the DSC Clinic and would recommend the clinic to their family and friends. Positive attributes included competence of staff and the convenience of a one-stop treatment facility. The patients' visits to the DSC Clinic also prompted them to engage in safer sexual practices. Stigma was surprisingly not an issue among more than three-quarters of the patients. Confidentiality of medical records was a major concern, with more than half of the patients unwilling to share their records with other healthcare providers, employers or insurance companies. The majority of patients would like to see the provision of clinics catering to special groups such as young people, women as well as men-who-have-sex-with-men.The majority of patients were satisfied with the health services provided at the DSC Clinic. Confidentiality in consultation was of prime importance to patients.

The Health Sciences Authority (HSA) and the Ministry of Health (MOH) publish clinical practice guidelines on Clinical Blood Transfusion to provide doctors and patients in Singapore with evidence-based guidance for blood transfusion. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HSA-MOH clinical practice guidelines on Clinical Blood Transfusion, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=25700). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Ingestional naphthalene mothball poisoning leading to prolonged haemolysis and methaemoglobinaemia can present with diagnostic and therapeutic challenges. A 19-year-old woman ingested 12 mothballs, and presented two days later with haemolysis and methaemoglobinaemia. She was treated with red blood cell transfusions, intravenous methylene blue, N-acetylcysteine and ascorbic acid. Continuous venovenous haemofiltration was conducted for 45 hours. Haemolysis with anaemia and methaemoglobinaemia persisted even after five days post-ingestion. Clinical and biochemical parameters improved. We describe a case of ingestional naphthalene poisoning with a good outcome after treatment.

Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients.The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile).Baseline characteristics were: age 52.9 +/- 11.0 years; Child's A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child's scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE.It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.

This study was performed to compare nested-polymerase chain reaction (PCR) with viral culture as a diagnostic tool for genital herpes simplex virus (HSV) infection in a sexually transmitted infection (STI) clinic in Singapore.103 consecutive patients presenting with clinical features suggestive of genital herpes were enrolled in the study. Two swabs were obtained from each patient. On one swab, cell culture and typing was performed, and on the second swab, nested-PCR was performed and the infecting viral type was determined by using type-specific primers.63 patients (61.2 percent) had a positive PCR test for HSV. Of these, 13 patients (20.6 percent) had HSV type 1 (HSV-1), 50 patients (79.4 percent) had HSV type 2 (HSV-2). HSV-1 and HSV-2 were detected by viral culture in only six patients and 24 patients, respectively. The sensitivity of cell culture compared to PCR was 46.1 percent for HSV-1 infection and 48 percent for HSV-2 infection. PCR further detected an additional 52.4 percent of HSV cases. The specificity of PCR was 100 percent.Nested-PCR has been shown in this study to be an effective diagnostic and typing method for HSV infection in a STI clinic in Singapore with its higher sensitivity and specificity to routine viral isolation in cell culture.

Background: Primary care physicians manage a significant number of sexually transmissible infections (STI); however, there has not been a survey to assess the standard of medical care, completeness of notifications, provision of counselling and contact tracing by primary care physicians in Singapore. Methods: An anonymous postal survey was conducted in which 1557 questionnaires were mailed out to general practitioners (GP), and government primary care and emergency department doctors. Results: In all, 736 questionnaires (47.3%) were returned, and the majority of respondents were graduates from the local medical school, worked in solo or group practices and were males. One hundred and thirty doctors (17.7%) indicated they had received training attachments or postings in dermato-venereology departments. Almost one-third (30.8%) had been working as doctors for fewer than 10 years and 87.8% reported that they managed STI in their practice. Almost half did not investigate genital discharge patients, and one-third would still use ciprofloxacin to treat discharges. In the management of ulcers, over half indicated that they would order syphilis serology, and a significant minority would use parenteral penicillin. Most doctors provided history taking, screening for other STI, testing for HIV infection and STI counselling. A small minority of doctors undertook contact tracing, and there was incomplete notification of many STI. Conclusions: Overall medical management of STI by primary care physicians was acceptable. Skills in contact tracing and reminders on disease notification are areas that need particular attention.

A 53-year-old woman presented with a chronic, non-healing painless ulcer over her right clavicular area of a two-month duration. Skin biopsy, microbiological and radiological investigations confirmed the diagnosis of scrofuloderma arising from an underlying tuberculous infection of her acromioclavicular joint. She was treated successfully with anti-tuberculosis therapy with complete healing of the ulcer. Awareness of this uncommon presentation of osteoarticular tuberculosis may assist in earlier diagnosis.

OBJECTIVE: Because HIV rapid tests are considered for self-testing, this study aims to determine the user acceptability and feasibility of self-testing. METHODS: A cross-sectional study was performed on 350 systematically sampled participants across 2 Singapore HIV testing centers using the Abbott Determine HIV 1/2 blood sample rapid test (Abbott Laboratories, Abbott Park, IL). Participants were surveyed on knowledge of and attitudes toward rapid testing. To determine interrater agreement between self-testing and trained personnel testing, participants performed self-testing with visual instructions, followed by trained personnel testing. Ability to identify test outcomes was determined through interpretation of sample test results. RESULTS: Eighty-nine percent of participants preferred testing in private, but most indicated that confidential counseling by trained counselors was necessary. Almost 90% found the kit easy to use and instructions easy to understand. Nevertheless, 85% failed to perform all steps correctly, especially blood sampling, and 56% had invalid results because of incorrect test performance. Interrater agreement between results from self-testing and trained personnel testing had a kappa value of 0.28. Twelve percent could not correctly determine results using sample tests, including 2% and 7% who read positive and negative samples, respectively, incorrectly. CONCLUSIONS: A substantial proportion could not perform self-testing or identify outcomes. Self-testing with the Determine HIV 1/2 kit in Singapore should be deferred.

Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (cox-2) inhibitors are structurally heterogeneous drugs that share similar therapeutic actions and adverse effects. Hepatotoxicity, although a relatively rare adverse effect of this class of drugs, can be severe. This has led to the withdrawal of some NSAIDs from the market. Nimesulide is an NSAID, with cox-2 preference, which has been reported to cause death from hepatic failure. However, most reports have been from European countries. Asian reports include that from Israel and India. We report three patients who presented with acute hepatitis after being prescribed nimesulide, one of whom died from fulminant hepatic failure.

A 28-year-old Malay woman presented with recurrent abdominal pain for five years. She had delivered her child seven months earlier. She was found to have bicytopenia, with a haemoglobin level of 7.9 g/dL and a platelet count of 85 x 10(9)/L. Computed tomography revealed a wandering spleen. Complications of a wandering spleen, for which splenectomy is advocated, include functional asplenia (due to torsion of the splenic pedicle), splenic infarction or splenic vessel thrombosis. A splenectomy was performed and at operation, splenomegaly with a long mesentery was found. Splenic histology was negative for malignancy. The bicytopenia resolved postoperatively, and she remains well.

Individuals with diabetes and prediabetes are at risk of vascular injury. However, the exact mechanisms are unclear. The mitochondria mobile electron carrier coenzyme Q(10) (CoQ(10)) is a potent lipophilic antioxidant. We hypothesize that oxidative stress, detectable as changes in plasma CoQ(10) concentrations and composition, plays an important role in vascular disease in diabetes.We measured plasma CoQ(10) concentrations (including reduced ubiquinol and oxidized ubiquinone subfractions) in 60 subjects with normal glucose tolerance [NGT; fasting plasma glucose (FPG)5.5 mmol/l], 63 with impaired fasting glucose (IFG; FPG 5.6-6.9 mmol/l) and 69 with Type 2 diabetes (DM; FPG6.9 mmol/l).In men and women, the total CoQ(10)/total cholesterol ratio was reduced in DM (mean +/-sd) [male (M) 0.09 +/- 0.04; female (F) 0.07 +/- 0.04] compared with NGT (0.29 +/- 0.08; 0.21 +/- 0.07) and IFG (0.27 +/- 0.07; 0.23 +/- 0.07) (DM vs. NGT and IFG P = 0.001). A stepwise reduction in the plasma ubiquinol fraction (ubiquinol/total CoQ10) was observed from NGT (M 0.93 +/- 0.06; F 0.95 +/- 0.06) compared with IFG (0.43 +/- 0.25; 0.41 +/- 0.15) and DM (0.24 +/- 0.11; F 0.29 +/- 0.16) (DM vs. IFG vs. NGT P = 0.001). In contrast, the plasma ubiquinone/ubiquinol ratio increased from NGT (M 0.08 +/- 0.07, F 0.06 +/- 0.08) to IFG (2.14 +/- 1.84, 1.75 +/- 1.04) to DM (4.77 +/- 4.88, 3.81 +/- 3.71) (DM vs. IFG vs. NGT P = 0.001). These differences remained after adjusting for age, body mass index and FPG.The change in CoQ(10) with increasing FPG concentration suggests an increase in oxidative burden, already evident in the prediabetic IFG individuals. This increase in oxidative stress might contribute to the increased risk of vascular disease.

We studied the seroprevalence of herpes simplex virus (HSV)-1 and 2 in sex workers attending a sexually transmitted infection clinic in Singapore and examined their knowledge and attitudes towards HSV infection. A total of 300 participants were recruited. Questionnaires were administered and blood was taken and analysed, using the HerpeSelect 1 and 2 Elisa IgG assays (type-specific serological test). HSV-1 serology was positive in 230 (76.7%), negative in 67 (22.3%) sex workers and indeterminate in three (1.0%) sex workers. HSV-2 serology was positive in 237 (79.0%) and negative in 63 (21.0%) sex workers. On univariate analysis, there was significant association between HSV-2 seropositivity and increasing age, nationality (locals) ( P

Infections caused by Chlamydia trachomatis (C. trachomatis) is one of the commonest sexually transmitted infections (STI). As there is currently no laboratory in Singapore that offers the chlamydia culture tests, alternative laboratory methods were developed and antigen detection methods such as enzyme immunoassays (EIA) proved to be even less sensitive than cell culture. This study was done to assess the accuracy and sensitivity of pooling five endocervical swabs collected for C. trachomatis testing by polymerase chain reaction (PCR) technology, as compared to the currently used EIA on individual swabs, in female sex workers who were seen at a STI clinic in Singapore.A total of 1,182 endocervical swab specimens were analysed by EIA as well as in pools of five specimens using PCR. Any pool with a positive PCR result for C. trachomatis infections was subjected to repeat PCR testing of the five individual specimens in the pool.There were a total of 48 confirmed cases of C. trachomatis infection. EIA detected 19 positive samples for C. trachomatis, yielding a prevalence of 1.6 percent among the sex workers tested. Pooled PCR testing showed a higher prevalence rate of 4.1 percent, with 48 PCR positive samples. All cases that were EIA positive were also PCR positive. Individual runs on 200 random samples as well as on 220 individual samples from positive pooled results showed PCR inhibition rates ranging from 1.5 percent to 2.3 percent. However, the PCR inhibition rate was 0 percent with the use of pooling. Sensitivity of EIA was 39.6 percent, with 100 percent specificity. EIA tests had a false negative rate of 60.4 percent. PCR was found to be 100 percent sensitive and specific.C. trachomatis infections among female sex workers attending the clinic were found to be higher using PCR technology. Less sensitive methods such as EIA result in undertreatment of otherwise undetected cases. The pooling strategy using pool sizes of five specimens, with a disease prevalence of 4.1 percent is reliable and cost-effective, and has since been introduced in the current medical surveillance scheme for sex workers in the clinic.

Background Lowering cholesterol is highly effective in reducing morbidity and mortality in high-risk people with prevalent cardiovascular disease. Aims To investigate lipid-lowering therapy use for secondary prevention of coronary heart disease in all diabetic patients in Tayside, Scotland Methods Among the 385 500 Tayside residents on 31 March 2001, the DARTS database identified all people with Types 1 and 2 diabetes with prevalent macrovascular disease, defined as a history of angina or coronary heart disease. The uptake of lipid-lowering drug was ascertained from MEMO's database of prescriptions dispensed at Tayside pharmacies. Results Among the 1128 Type 1 patients, 11.3% had prevalent macrovascular disease and 7.9% used lipid-lowering therapy with 42.2% for patients with macrovascular disease. Current/former smokers (OR 2.40, 95% CI: 1.15–5.03) and those with a history of coronary heart disease (OR 2.26, 95% CI: 1.04–4.90) were more likely to use lipid-lowering therapy. Among the 8686 Type 2 patients, 38.8% had prevalent macrovascular disease and 18.3% used lipid-lowering therapy, with 26.7% for patients with macrovascular disease. Current/former smokers (OR 1.37; 95% CI 1.17–1.61) and those with a history of coronary heart disease (OR 2.07, 95% CI 1.66–2.59) or angina (OR 1.30, CI 1.03–1.63) were more likely to use lipid-lowering therapy. A duration of 4 years or less from the first macrovascular event was associated with increased use (OR 1.27; 95% CI 1.05–1.54). Age > 70 years reduced the likelihood (OR 0.51, CI 0.44–0.60). Conclusion A clear gap exists between those requiring lipid-lowering drug therapy and those who are actually receiving it in Tayside.

Mycobacterium haemophilum, a nontuberculous mycobacterium (NTM) that was first described in 1978, is a pathogen that can cause an array of symptoms in immunocompromised patients, predominantly cutaneous.We report our hospital's experience with the first 3 patients diagnosed with this infection from 1994 to 2002. All were women; one had systemic lupus erythematosus (SLE), one had mycosis fungoides and the last had Sjogren's syndrome with recurrent bacterial infections, although the specific nature of her immunocompromised state has not been defined. All were HIV negative. All 3 women presented with cutaneous lesions--the first with recurrent erythematous plaques on the limbs and back, the second with tender nodules and abscesses on the knees, and the third with papular eruptions on the cheek.All responded to a combination of antibiotics and are presently still undergoing treatment and follow-up.Infections caused by M. haemophilum occur mainly in immunocompromised patients. They can present with a variety of cutaneous manifestations, which require a high index of suspicion and coordination between the treating physician and the laboratory for diagnosis. Combination antibiotic treatment is recommended, and patients should be followed up after treatment to survey for possible relapse.

The objective was to evaluate the incidence of gastrointestinal abnormalities amongst those fetuses with antenatally diagnosed echogenic bowel (EB).A retrospective review of all cases delivered from April 2002 to March 2003 with antenatally diagnosed EB was conducted. This was defined as bowel that appeared as echogenic as (if not greater than) the iliac bone on a real-time image. The postnatal outcomes with regard to gastrointestinal abnormalities, till their discharge, were noted.Of the 13,941 patients delivered, there were 70 cases with antenatally diagnosed EB, giving an incidence of 70/13,941 or 0.50%. Of these, 6 defaulted follow-up and 1 had a mid-trimester termination of pregnancy at 21 weeks' gestation for social reasons. Of the remaining 63 cases with EB, 2 were stillbirths at 31 weeks and 35 weeks of gestation, respectively. Three fetuses (3/63 or 4.76%) were diagnosed with gastrointestinal abnormalities. Meconium plug syndrome was diagnosed postnatally in 2 cases, of which, 1 resolved with conservative management while the other required an emergency laparotomy. Intestinal atresia was diagnosed in the postmortem of one of the stillbirths. There was evidence of intrauterine growth retardation (IUGR) in both the stillbirth and the fetus that had required laparotomy. None of the 3 fetuses exhibited clinical features of aneuploidy.As the quoted background risk for gastrointestinal pathology is 0.23%, an increased incidence (4.76%) is observed in those fetuses found to have antenatal EB. It is possible that the presence of IUGR is associated with a worse prognosis. Further prospective studies are needed to verify this association.

Melioidosis is a tropical infectious disease caused by the gram-negative bacterium Burkholderia pseudomallei. It is endemic in many parts of the world, including Southeast Asia, and has a mortality rate of about 45%. We report a case of localized nonfatal cutaneous melioidosis presenting as a persistent ulcer in an otherwise healthy young woman.

Sotalol is a potent antiarrhythmic often used in patients with atrial fibrillation. However, it has been associated with a risk of provoking other potentially dangerous arrhythmias, especially if used in high doses and in patients with uncorrected electrolyte imbalance or impaired renal and cardiac function.We present 4 patients with atrial fibrillation treated with sotalol who developed torsade de pointes due to marked prolongation of the QT interval. While 1 patient had renal failure, all had normal left ventricular function. One patient had been treated with sotalol for more than 10 months before developing torsade de pointes precipitated by hypokalaemia, while another had tolerated sotalol for a 3-month period before the drug was discontinued, and only developed torsade de pointes when the drug was restarted 2 years later. Significantly, the doses used in all patients were relatively low, in contrast to most other reported cases where higher doses were used.As with all antiarrhythmic therapy, these cases illustrate the need for close follow-up of patients treated with sotalol, even if relatively low doses are used. In addition, patients who had previously tolerated the drug well are still susceptible to its proarrhythmic effects.

To use the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to investigate the physical diagnoses, psychologic distress, and psychosocial dysfunction in Asian TMD patients. The RDC/TMD Axis I and II findings were compared to those of Swedish and American TMD patients.One hundred ninety-one patients (53 male and 138 female) referred to 2 institutionalized TMD clinics in Singapore were enrolled in the study. The mean age of the predominantly Chinese population (83.2%) was 33.6 +/- 9.3 years. Data from a RDC/TMD history questionnaire and clinical examination were fed directly by patients and clinicians into a computerized diagnostic system (NUS TMDv1.1). Axis I and II findings were generated on-line, based on RDC/TMD rule engines. Data were automatically exported to SPSS for statistical analysis.Group I (muscle) disorders were found in 31.4% of the patients; Group II (disc displacement) disorders were found in 15.1% and 15.7% of the patients in the left and right temporomandibular joints, respectively; and Group III (arthralgia, arthritis, and arthrosis) disorders were found in 12.6% and 13.0% of the patients in the left and right joints, respectively. Axis II assessment of psychologic status showed that 39.8% of patients experienced moderate to severe depression and 47.6% had moderate to severe nonspecific physical symptom scores. Psychosocial dysfunction was observed in only 4.2% of patients based on graded chronic pain scores.Axis I and II findings of Asian TMD patients were generally similar to their Swedish and American cohorts. In all 3 populations, women of child-bearing age represented the majority of patients. Muscle disorders were the most prevalent type of TMD. A substantial portion of TMD patients were depressed and experienced moderate to severe somatization.

This is a review of sexual knowledge, behaviour and the extent of sexually transmitted infections (STI), including human immunodeficiency virus (HIV) infection, in Singapore adolescents.Data were retrieved from relevant studies, reports and statistics concerning STI and HIV in Singapore.For many reasons, adolescents are at a higher risk of acquiring STI and HIV infections. Adolescents in Singapore are still relatively conservative in their sexual attitudes and behaviour. Most of those who had sex never used condoms. Fortunately, the incidence of STI and HIV infections among adolescents is relatively low. However, this may be changing, and there is a proportion of individuals who exhibit higher risk behaviours.In this age of rapidly changing morals and values, accurate information and skills need to be provided to young people to ensure that they are adequately prepared to protect themselves from acquiring STI/HIV infection.

Since the introduction of BCG vaccination in 1921, there have been numerous reports of cutaneous complications. Although common local effects such as erythema, soreness and local abscesses are well known, the incidence of cutaneous granulomas and BCG-induced lupus vulgaris is rare.This is a retrospective analysis of our local experience in dealing with cases of cutaneous granulomas following BCG vaccination. Cases were seen at a local tertiary level dermatological referral centre.There were 14 cases seen over an 8-year period. Of these cases, 4 were clinically suggestive of BCG-induced lupus vulgaris, but only 1 of these cases was confirmed by culture. All but one of these cases had developed these complications after multiple BCG vaccinations. The 3 suspected but unconfirmed cases were treated with isoniazid. The 1 case of confirmed BCG-induced lupus vulgaris was treated with rifampicin and ethambutol, as sensitivity testing revealed resistance to isoniazid. All 4 cases responded well to treatment. The other 10 cases of vaccine-induced cutaneous granulomas responded to local symptomatic treatment.Although local effects such as induration and pustule formation at the injection site are not rare, the development of cutaneous granulomas is uncommon. Incidence of complications increases with multiple vaccinations. Cases usually respond to local symptomatic therapy, while more aggressive lesions responded to the use of oral isoniazid. Confirmed cases of BCG-induced lupus vulgaris should be treated based on antibiotic sensitivity profile.

This study assessed multiple pain conditions and their association with psychosocial functioning, psychologic distress, and somatization in patients with temporomandibular disorders (TMD) based on RDC/TMD Axis II findings. Nonspecific pain items examined included headaches, heart/chest pain, lower back pain, nausea/abdominal pain, and muscle pain.In this study, 202 TMD patients (58 men and 144 women) referred to two TMD clinics participated. The mean age of the predominantly Chinese patient population (82%) was 32.6 years (range 13 to 65). The RDC/TMD history questionnaire was input directly into computers by patients. Graded chronic pain and SCL-90 scales were generated online and automatically archived for statistical analysis. Data were subjected to Spearman's rank-order correlation and Kruskal-Wallis and Mann-Whitney tests at a significance level of .05.Of the patients, 43% were moderately to extremely distressed by headaches. The percentage of patients who were distressed by heart/chest pain (7%), lower back pain (26%), nausea/abdominal pain (17%) and soreness of muscles (22%) was lower. Of the TMD patients, 16% experienced more than three pain items. Significant and positive correlations were observed between number of pain items experienced and graded chronic pain severity, depression, and somatization. Correlation coefficients ranged from .27 to .65 for graded chronic pain scales and somatization (without pain items) scores, respectively.Results suggest that the number of nonspecific pain conditions reported may be a predictor of psychosocial dysfunction, depression, and somatization.

Sexually transmitted diseases (STDs) in persons older than 50 years are rarely studied because STDs are more common in young people.To study the distribution and types of STDs in older persons, defined in our study as individuals aged 50 years or older.Retrospective analysis of surveillance data for diseases notified under the Infectious Disease Act, which include syphilis, gonorrhoea, non-gonococcal urethritis (NGU), vaginal discharge and chancroid. Human immunodeficiency virus (HIV) infections were not included. Data from notifications of diseases, such as genital herpes and genital warts, which are not compulsory, were also analysed. Period of study was from January 1996 to December 2000.During the study period, STD notifications for persons aged 50 years and older accounted for 7.6% of all notifications. Among these older persons, males were predominantly affected. The most common disease notified in older persons was gonorrhoea (600 cases), followed by non-infectious syphilis (578 cases) and NGU (339 cases). There were 76 cases of infectious syphilis. The age-specific disease rates for this group of older patients were as follows (number of cases per 100,000 patients per year): gonorrhoea-17.61, non-infectious syphilis-16.96, infectious syphilis-2.23, NGU-20.66, genital warts-6.92 and genital herpes-7.33.Although STDs occur mainly in the young, it affects a small but significant proportion of persons aged 50 years and older. A better understanding of the epidemiology of STDs in these population is important for reducing STD morbidity and improving STD care.

Women with history of gestational diabetes mellitus (GDM) have up to 50% lifetime risk of developing frank diabetes mellitus (DM). They are an ideal group of patients to implement early interventional measures to halt the progression to diabetes. The success of any early intervention programme would depend largely on postpartum follow-up. We set out to study the response rate to postpartum oral glucose tolerance test (OGTT) and to profile the non-responders on 105 women who attended our Gestational Diabetes Joint Clinic (GDJC).We divided these women into 3 groups according to their response to postpartum OGTT and compared their weights, glycaemic parameters and other clinical characteristics during gestation. Group A comprised non-responders or those who did not turn up for postpartum OGTT; group B comprised responders with a normal postpartum OGTT; and group C comprised responders with an abnormal postpartum OGTT defined as 2-hour plasma glucose equal or more than 7.8 mmol/L.The non-respondent rate to postpartum diabetes screening was 37.1%. The non-responders were found to be significantly heavier, with more severe hyperglycaemia during their pregnancy (in terms of glycosylated haemoglobin and results of antepartum OGTT) and had bigger babies compared to the responders with normal postpartum OGTT. Their features instead resembled those who had failed their postpartum OGTT.The group of non-responders was probably at similar risk of developing glucose intolerance postpartum as those who were tested abnormal. A more effective call and recall system and education programme is, therefore, needed to ensure postpartum attendance of all patients with GDM.

An adult presenting with diabetes is usually assumed to have type 2 diabetes. Since the 1980s, type 2 diabetic subjects who had failed sulphonylurea therapy soon after diagnosis have been thought to be actually slowly progressive type I patients. This diabetes sub-type is currently referred to as latent autoimmune diabetes in adults (LADA). Early recognition of such patients has important clinical implications. To assist local doctors in the recognition of such patients, we performed a retrospective study to profile and highlight distinctive features of thirteen LADA patients. We found that these patients were mostly females with a mean body mass index of 17.2 kg/m2, diagnosed with type 2 diabetes in their fourth decade of life and becoming insulin dependent after a mean of 2.5 years.

Granuloma annulare (GA) is a benign, inflammatory skin disorder that has no proven aetiology or widely accepted theory of pathogenesis. We present the results of a local study examining the characteristics of this disorder.This is a retrospective study of 41 patients with granuloma annulare seen at a tertiary dermatological skin hospital in Singapore. The disease was classified based on whether it was localised or generalised. Remission rates and associated diseases were documented.The majority (93.9%) of lesions were localised. GA tends to occur within the first three decades of life, and 39.4% of patients were 10 years old and below. There was a slight female preponderance, and no predilection for any particular racial group. Remissions were seen in 67.6% of patients who were followed up for at least 12 months, and remissions only occurred with the localised form of GA. There were 4 cases of disseminated GA and 1 case of perforating GA. There were 6 patients with associated diabetes mellitus, 2 with pulmonary tuberculosis, and 4 patients each with hypercholesterolaemia and a history of atopy.The characteristics of GA in our local population do not differ significantly from that of overseas studies. While localised forms of GA have a high chance of resolving, the generalised forms of the disease are difficult to treat and do not tend to resolve totally.

To study the minimum inhibitory concentrations (MICs) of Propionibacterium acnes (P. acnes) isolates to selected antibiotics from patients with acne vulgaris in Singapore and determine if resistance increases with prolonged use of antibiotics.A single-centre prospective study.Tertiary dermatological referral centre in Singapore.One hundred and fifty patients with acne vulgaris seen at the National Skin Centre.In patients who had never been on antibiotics, there were no resistant isolates of P. acnes. In patients who had been on short-term antibiotics (between 6 to 18 weeks), there were 2 resistant strains among the 34 isolates (6.25%); in patients who had been on antibiotics for longer periods, there were 11 resistant strains among the 51 isolates (21.6%). The differences in the rates of isolation of resistant strains between patients who had not been on antibiotics to those that had been on long-term antibiotics were statistically significant (P = 0.015). There was also a significant difference in isolation of resistant strains from those on short-term antibiotics compared to those who had been on long-term antibiotics (P = 0.036). Resistance to erythromycin was most commonly encountered. Most of the erythromycin-resistant strains also showed cross-resistance to clindamycin. The average MICs to antibiotics such as minocycline, erythromycin and clindamycin in those on long-term antibiotics were significantly higher when compared to patients who had not been on antibiotics.Antibiotic resistance in P. acnes isolates in Singapore follows similar patterns to studies conducted in Europe. Resistance to erythromycin was most commonly seen, and this is associated with cross-resistance to clindamycin. Among the tetracycline group of drugs, the average MICs to tetracycline was higher than that for doxycycline, which in turn was higher than that for minocycline. Antibiotic resistance can occur with short-term antibiotic courses, and the rate of resistance increases as the duration of antibiotic consumption increases.

The role of polymerase chain reaction (PCR) in the diagnosis of cutaneous tuberculosis in clinical practice has not been defined as no PCR assay has been tested in a large-scale clinical study. The objective of this study was to test the clinical utility of a PCR assay in the diagnosis of different types of cutaneous tuberculosis and tuberculids.Analysis of archival biopsy specimens by a nested PCR assay targeting IS6110 of Mycobacterium tuberculosis (M. tb) DNA was performed in a tertiary-care skin hospital in Singapore. PCR results were compared with cultures and concordance with final diagnosis. PATIENTS AND SPECIMENS: One hundred and nineteen skin biopsies from 105 patients comprising 58 cases of confirmed or highly probable cutaneous tuberculosis, ranging from multibacillary infections to paucibacillary forms and 47 cases of possible tuberculids were analysed. Twenty-four subjects with non-tuberculous granulomas and normal skin controls were included.In 14 immunocompromised patients with multibacillary mycobacterial infections (AFB+ on biopsy), PCR was positive in 9 patients. Correlating PCR results with the final diagnosis, the PCR technique was 100% sensitive and specific in this group. In paucibacillary tuberculosis, PCR positivity rates were 55% for tuberculosis verrucosa cutis (38 cases) and 60% for lupus vulgaris (5 cases). When confirmed cases of tuberculosis were considered, the overall sensitivity was 73%. In 26 cases of erythema induratum, PCR was positive in 54% and correlated with a documented response to anti-tuberculous treatment in 80%.The use of PCR in the routine diagnostic panel for cutaneous tuberculosis should take into consideration the differential sensitivities for different clinical types. In the setting of an immunocompromised patient with AFB+ lesions, PCR has a definite role in rapid diagnosis and in differentiating atypical mycobacterial infection from tuberculosis. Where paucibacillary tuberculosis is suspected, clinical decision should not be based on PCR results alone. In erythema induratum, we found some correlation between PCR results and response to anti-tuberculous therapy.

Thirty Chinese primiparous mothers were asked during the antenatal period their breastfeeding intention and then interviewed at delivery and 6 weeks post delivery. One mother had no intention to breastfeed. Ten mothers intended exclusive breastfeeding for one month and 19 for 6 weeks or more. At 6 weeks post delivery only 4 mothers were still breastfeeding. A total of 22 (73%) did not achieve their initial intention. For any future pregnancy, 5 chose exclusive breastfeeding, 22 complementary and 3 formula feeding. Chinese primiparous mothers have high breastfeeding intentions but the majority do not achieve them and their experience has discouraged them from exclusive breastfeeding in future pregnancies.

Vegetative lead infection is an uncommon complication of permanent pacemaker implantation. The diagnosis is difficult using conventional imaging methods.An elderly Indian woman with a history of diabetes mellitus developed Staphylococcus aureus infection after implementation of a permanent pacemaker. Following a non-diagnostic transthoracic echocardiogram, transoesophageal echocardiography was performed and showed a large vegetative mass attached to the pacemaker lead within the right atrium.The pacemaker was removed and intravenous vancomycin administered for six weeks.She was discharged well but demised two months later from a second episode of septicaemia.Pacemaker lead infection remains a challenging management problem. Transoesophageal echocardiography can facilitate its diagnosis.

To assess the safety of blood collection for autologous transfusion in pregnant women and the effects of the procedure on the fetus.Prospective study involving obstetric patients undergoing elective lower segment Caesarean section (LSCS) between 1993 and 1994 were recruited for autologous transfusion. Continuous cardiotocograph monitoring was carried out throughout the duration of the procedure and the fetal haemodynamics was studied before and after by doppler blood flow ultrasound.The results show that there was no fetal deceleration or increased uterine activity as monitored by cardiotocography. The mean pulsatility index (PI) for the umbilical artery before the procedure was 0.9560 and after was 0.0820 which is a significant difference (p value = 0.035).Autologous blood collection seems to be a safe procedure for both the mother and the fetus. However, autologous transfusion remains an unpopular choice amongst pregnant women.

The aim of this study was to compare the clinical and microbiological efficacy of a single 1 gram dose of azithromycin against 1 week of doxycycline at 100 mg twice a day in the treatment of: (1) uncomplicated non-gonococcal urethritis (NGU) in male patients, and (2) culture proven Chlamydia trachomatis cervicitis in female sex workers.The subjects were 53 male patients who attended the clinic and were diagnosed to have non gonococcal urethritis based on clinical symptoms and a urethral smear, and 63 female sex workers, who had both a positive enzyme immunoassay (EIA) test and Chlamydia trachomatis cultures. Follow-up visits were made at one and two weeks post-treatment to assess efficacy, subsequent relapse and presence of side effects. The male patients were also assessed at four weeks post treatment to determine default and reinfection rates.Both azithromycin (clinical cure rates 62.5% at one week, 86.4% at two weeks in male patients; 96.6% at two weeks in female sex workers) and doxycycline (clinical cure rates 65.4% at one week, 90.9% at two weeks in male patients; 100% at two weeks in female sex workers) were effective in treating non-gonococcal urethritis and chlamydial cervicitis. Both drugs were very effective in eradicating proven Chlamydia trachomatis infections, with success in 100% of cases of Chlamydia trachomatis NGU in males, and 96.6% and 100% cure rates, for azithromycin and doxycycline respectively, in female sex workers with cervicitis. There were no statistically significant differences between the two drugs in terms of clinical efficacy, influence on default rates or subsequent risk of reinfection.We conclude that a single dose of azithromycin is as effective as a one week course of doxycycline in treating non-gonococcal urethritis in males and in the elimination of Chlamydia trachomatis in females with cervicitis, with the added advantage of a convenient single dose that can be supervised.

Resistance to activated protein C (APC-R) is the commonest inherited cause of thrombosis among Caucasians. Few studies have been carried out on its prevalence in Asians. We conducted a prospective study on 60 patients with thromboembolism to determine its prevalence in our local population. The Factor V Leiden (VaQ506) mutation associated with this condition was detected by amplification of the Factor V gene by polymerase chain reaction (PCR) and digestion of the fragment with Mnl I. Three patients were found to be heterozygous for this mutation. None of the 3 patients had other concomitant hypercoagulable states. In addition, we studied the prevalence of this condition in Malays which was found to be 0.5%. Our study suggests that the incidence of APC-R is much lower here compared to the West.

This study was done to assess the specificity and sensitivity of the DNA amplification assays of ligase chain reaction (LCR) and polymerase chain reaction (PCR) on urine specimens to detect Chlamydia trachomatis infections in both male and female patients seen at a sexually transmitted diseases (STD) clinic in Singapore, compared with other diagnostic methods currently in use. A total of 100 patients were selected; 50 male patients diagnosed with non-gonococcal urethritis based on symptoms and a positive Gram-stained urethral smear and 50 female asymptomatic sex workers were assessed. Automated assays using LCR and PCR were used, and compared to enzyme immunoassays, chlamydial cell cultures and PCR of urethral and endocervical swab specimens. In male patients, LCR and PCR of urine specimens had sensitivities of 100%, compared to 87.0% for PCR of urethral swab specimen, 82.6% for enzyme immunoassay (EIA) and 91.3% for cell cultures. In female patients, LCR and PCR of urine samples achieved sensitivities of 77.8% and 88.9% respectively, compared with 55.6% for PCR of endocervical swab specimens, 22.2% for EIA and 66.7% for cell cultures. LCR and PCR of urine samples provided higher sensitivity compared to cell cultures, EIA and PCR of urethral and endocervical swab specimens. The use of LCR and PCR on urine as a non-invasive means of detecting chlamydial infections is viable, and may have a role to play in population-based screening programmes.

Bacterial skin infections in children and adults are caused by different organisms with different antimicrobial susceptibility.A comparative retrospective study was carried out on 233 adults and 53 children with bacterial skin infections. Skin swab cultures and sensitivity tests were performed using standard methods. Statistical analysis was performed using the Pearson chi-squared and Fisher tests. A P value of0.05 was considered to be significant.Primary and secondary skin infections occurred in equal proportions in children, whereas secondary skin infections were more common in adults (70.8%). Staphylococcus aureus was the main cause of skin infections, particularly in children (72.6%). S. aureus in children and adults was highly susceptible to cloxacillin, cephalexin, chloramphenicol, neomycin, cotrimoxazole, and clindamycin, moderately susceptible to erythromycin, and insensitive to tetracycline, ampicillin, and penicillin.It is important to monitor the trends of bacterial infections and their antibiotic susceptibility as this can assist medical practitioners in their choice of antimicrobial therapy. Such monitoring will also help to detect the emergence of resistant bacterial strains and caution us to take care in the use of certain drugs.

Bacterial skin infections are common clinical problems encountered in most fields of clinical medicine. Staphylococcus aureus and group A streptococci are common invaders of eczematous, traumatised or immunocompromised skin. Advances in pharmacology have introduced a wide array of new antibiotics into the physician's armamentarium, but the rising incidence of bacterial resistance continues to be a problem. A retrospective study was carried out on 331 patients at the National Skin Centre, Singapore, to establish the causes of common primary and secondary pyodermas, as well as to determine the antibiotic sensitivities of the microorganisms responsible.A retrospective study of the medical records of 331 patients seen at the Centre for skin infections between October 1995 and May 1996 was done. Skin cultures and antibiotic sensitivity testing was carried out and the data analysed. Both primary pyodermas (impetigo, folliculitis, furuncles/carbuncles and cellulitis) and secondary pyodermas (infected ulcers and infected eczemas) were included. The results of bacterial isolation cultures and sensitivity of the organisms isolated to the commonly used antibiotics such as cloxacillin, penicillin, erythromycin and the tetracyclines were analysed.Staphylococcus aureus was the commonest organism isolated from both primary and secondary pyodermas, accounting for 67% and 46.7% of the organisms isolated, respectively. There was no significant difference in the racial representation in each of the various skin infections, but there was a significantly greater female representation in the infected ulcers. The secondary pyodermas had a significantly higher incidence of gram negative organisms causing infections, as well as culture results showing multiple bacterial pathogens. The methicillin resistant strains of S. aureus were commoner in the secondary pyodermas, and accounted for 4.2% of the total organisms isolated and 7% of the total strains of S. aureus. The S. aureus had a high rate of resistance (89.5%) to penicillin and ampicillin, but was very sensitive (93%) to cloxacillin, cephalexin and cotrimoxazole. The incidence of erythromycin resistance was 18.7%.In patients with primary pyodermas, cloxacillin should be the first line antibiotic used, with erythromycin as a useful but less preferred alternative. The favoured combination of ampicillin and cloxacillin has little place in routine treatment of skin infections, except for cellulitis and infected eczemas. A cephalosporin can also be used in these conditions if single drug therapy is desired. The secondarily infected ulcers are difficult to treat and would probably require the use of combination therapy in view of frequent mixed infections.

Of 149 workers from the electronics industry with occupational dermatoses seen at the Joint Occupational Dermatoses Clinic at the National Skin Centre, Singapore, 51.0% (76) were diagnosed to have irritant contact dermatitis, 40.9% (61) had allergic contact dermatitis, and 8.1% (12) had noncontact dermatitis. More than half of the patients were younger than 30 years of age. Common irritants were soldering flux, oils and coolants, solvents, and acids/alkalis. The most common allergens were nickel and resins, followed by rubber chemicals and the constituents of flux. Of the noncontact dermatitis, 8 were caused by occupationally relevant exacerbation of endogenous eczema, whereas there was one case each of miliaria, frictional dermatitis, and fatal toxic epidermal necrolysis caused by trichloroethylene allergy.

BACKGROUND: The United States FDA approved an over-the-counter HIV self-test, to facilitate increased HIV testing and earlier linkage to care. We assessed the accuracy of self-testing by untrained participants compared to healthcare worker (HCW) testing, participants' ability to interpret sample results and user-acceptability of self-tests in Singapore. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study, involving 200 known HIV-positive patients and 794 unknown HIV status at-risk participants was conducted. Participants (all without prior self-test experience) performed self-testing guided solely by visual instructions, followed by HCW testing, both using the OraQuick ADVANCE Rapid HIV 1/2 Antibody Test, with both results interpreted by the HCW. To assess ability to interpret results, participants were provided 3 sample results (positive, negative, and invalid) to interpret. Of 192 participants who tested positive on HCW testing, self-testing was positive in 186 (96.9%), negative in 5 (2.6%), and invalid in 1 (0.5%). Of 794 participants who tested negative on HCW testing, self-testing was negative in 791 (99.6%), positive in 1 (0.1%), and invalid in 2 (0.3%). Excluding invalid tests, self-testing had sensitivity of 97.4% (95% CI 95.1% to 99.7%) and specificity of 99.9% (95% CI: 99.6% to 100%). When interpreting results, 96%, 93.1% and 95.2% correctly read the positive, negative and invalid respectively. There were no significant demographic predictors for false negative self-testing or wrongly interpreting positive or invalid sample results as negative. Eighty-seven percent would purchase the kit over-the-counter; 89% preferred to take HIV tests in private. 72.5% and 74.9% felt the need for pre- and post-test counseling respectively. Only 28% would pay at least USD15 for the test. CONCLUSIONS/SIGNIFICANCE: Self-testing was associated with high specificity, and a small but significant number of false negatives. Incorrectly identifying model results as invalid was a major reason for incorrect result interpretation. Survey responses were supportive of making self-testing available.

Background: We studied the seroprevalance of HSV (herpes simplex virus)-1 and HSV-2 in outpatient attendees of a sexually transmitted infection (STI) clinic in Singapore and examined their knowledge and attitudes towards HSV infection. Methods: Two hundred male and 200 female participants were recruited in the study. Questionnaires were administered and blood samples were taken and analysed using the HerpeSelect 1 and 2 enzyme-linked immunosorbent assay (ELISA) IgG assays (type-specific serological tests). Results: HSV-1 was positive in 223 (55.8%) individuals, negative in 175 (43.8%) and indeterminate in two (0.5%), whereas HSV-2 was positive in 114 (28.5%) individuals, negative in 284 (71.0%) and indeterminate in two (0.5%). The seroprevalance of HSV-2 was 26% and 31% in males and females, respectively. The correlation between a previous history of cold sores and HSV-1 infection was poor. On univariate analysis, there was a significant association with age, marital status and years of sex (P < 0.05) but after adjusting for confounders, none of the variables were significantly associated with HSV-2 seroprevalance. Most of the respondents (65.8%) were aware that herpes is an STI, whereas only half of them were aware of the possibility of asymptomatic transmission. Conclusion: Although HSV-2 is a common infection among STI clinic attendees in Singapore, there is an unsatisfactory level of knowledge among the attendees about HSV infection and public education programs should be introduced to address this.