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Chowdhury G, Carland JE, Kumar S, Olsen N, Graham G, Kumarasinghe G, Hayward CS, Greenfield JR, Macdonald P, Day RO, Stocker SL. The safe use of metformin in heart failure patients both with and without T2DM: a cross-sectional and longitudinal study. Br J Clin Pharmacol 2023. [PMID: 37016750 DOI: 10.1111/bcp.15737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 04/06/2023] Open
Abstract
AIMS This study investigated the safe use of metformin in patients with (1) type 2 diabetes mellitus (T2DM) and heart failure on metformin, and (2) heart failure without T2DM and metformin naïve. METHODS Two prospective studies on heart failure patients were undertaken. The first was a cross-sectional study with two patient cohorts, one with T2DM on metformin (n=44) and one without T2DM metformin naive (n=47). The second was a 12-week interventional study of patients without T2DM (n=27) where metformin (500 mg immediate release, twice daily) was prescribed. Plasma metformin and lactate concentrations were monitored. Individual pharmacokinetics were compared between cohorts. Univariable and multivariable analysis analysed the effects of variables on plasma lactate concentrations. RESULTS Plasma metformin and lactate concentrations mostly (99.9%) remained below safety thresholds (5 mg/L and 5 mmol/L, respectively). Metformin concentration had no significant relationship with lactic acidosis safety markers. In the interventional study, New York Heart Association (NYHA) II (p<0.03) and III (p<0.001) grading was associated with higher plasma lactate concentrations, whereas male sex was associated with 47% higher plasma lactate concentrations (p<0.05). The pharmacokinetics of heart failure patients with and without T2DM were similar. CONCLUSIONS We observed no unsafe plasma lactate concentrations in patients with heart failure treated with metformin. Metformin exposure did not influence plasma lactate concentrations; however, NYHA class and sex did. The pharmacokinetics of metformin in heart failure patients are similar irrespective of T2DM. These findings may support the safe use of metformin in heart failure patients with and without T2DM.
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Nayyar D, Kumarasinghe G, Irwin S, Sharma L, Premawardhana U, Rajaratnam R, Kadappu K. Five-Year Outcome Data from the Budyari Cardiology Outreach Program. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Iyer A, Gao L, Doyle A, Rao P, Cropper JR, Soto C, Dinale A, Kumarasinghe G, Jabbour A, Hicks M, Jansz PC, Feneley MP, Harvey RP, Graham RM, Dhital KK, MacDonald PS. Normothermic ex vivo perfusion provides superior organ preservation and enables viability assessment of hearts from DCD donors. Am J Transplant 2015; 15:371-80. [PMID: 25612491 DOI: 10.1111/ajt.12994] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/11/2014] [Accepted: 08/25/2014] [Indexed: 01/25/2023]
Abstract
The shortage of donors in cardiac transplantation may be alleviated by the use of allografts from donation after circulatory death (DCD) donors. We have previously shown that hearts exposed to 30 min warm ischemic time and then flushed with Celsior supplemented with agents that activate ischemic postconditioning pathways, show complete recovery on a blood-perfused ex vivo working heart apparatus. In this study, these findings were assessed in a porcine orthotopic heart transplant model. DCD hearts were preserved with either normothermic ex vivo perfusion (NEVP) using a clinically approved device, or with standard cold storage (CS) for 4 h. Orthotopic transplantation into recipient animals was subsequently undertaken. Five of six hearts preserved with NEVP demonstrated favorable lactate profiles during NEVP and all five could be weaned off cardiopulmonary bypass posttransplant, compared with 0 of 3 hearts preserved with CS (p < 0.05, Fisher's exact test). In conclusion, DCD hearts flushed with supplemented Celsior solution and preserved with NEVP display viability before and after transplantation. Viability studies of human DCD hearts using NEVP are warranted.
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Iyer A, Gao L, Doyle A, Rao P, Jayewardene D, Wan B, Kumarasinghe G, Jabbour A, Hicks M, Jansz PC, Feneley MP, Harvey RP, Graham RM, Dhital KK, Macdonald PS. Increasing the tolerance of DCD hearts to warm ischemia by pharmacological postconditioning. Am J Transplant 2014; 14:1744-52. [PMID: 25040306 DOI: 10.1111/ajt.12782] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/10/2014] [Accepted: 03/30/2014] [Indexed: 01/25/2023]
Abstract
Donation after circulatory death (DCD) offers a potential additional source of cardiac allografts. We used a porcine asphyxia model to evaluate viability of DCD hearts subjected to warm ischemic times (WIT) of 20–40 min prior to flushing with Celsior (C) solution. We then assessed potential benefits of supplementing C with erythropoietin, glyceryl trinitrate and zoniporide (Cs), a combination that we have shown previously to activate ischemic postconditioning pathways. Hearts flushed with C/Cs were assessed for functional, biochemical and metabolic recovery on an ex vivo working heart apparatus. Hearts exposed to 20-min WIT showed full recovery of functional and metabolic profiles compared with control hearts (no WIT). Hearts subjected to 30- or 40-min WIT prior to C solution showed partial and no recovery, respectively. Hearts exposed to 30-min WIT and Cs solution displayed complete recovery, while hearts exposed to 40-min WIT and Cs solution demonstrated partial recovery. We conclude that DCD hearts flushed with C solution demonstrate complete recovery up to 20-min WIT after which there is rapid loss of viability. Cs extends the limit of WIT tolerability to 30 min. DCD hearts with ≤30-min WIT may be suitable for transplantation and warrant assessment in a transplant model.
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Kumarasinghe G, Lavee O, Nivison-Smith I, Parker A, Malouf M, Keogh A, Milliken S, Dodds A, Plit M, Hayward C, Ma D, Fay K, Joseph J, Kotlyar E, Havryk A, Jabbour A, Glanville A, Macdonald P, Moore J. Defining Prognostic Markers in Heart and Lung Transplant Recipients with PTLD. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Iyer A, Gao L, Hicks M, Kumarasinghe G, Jansz P, Jabbour A, Al-Soufi S, Aneman A, Flynn G, Rajamani A, Cheng A, Raper R, Goh D, MacPartlin M, Saul P, Dhital K, Macdonald P. Case Report of Cardiac Allografts Retrieved From Human Donation After Circulatory Death (DCD) Donors - Assessment on Ex Vivo Beating Heart Perfusion Device. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Iyer A, Doyle A, Gao L, Kumarasinghe G, Wan B, Jabbour A, Hicks M, Jansz P, Dhital K, Macdonald P. Hearts from Donations After Circulatory Death (DCD) Donors – Assessment on Clinically Approved Ex-vivo Organ Care System. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Iyer A, Gao L, Doyle A, Kumarasinghe G, Jabbour A, Hicks M, Jansz P, Dhital K, Macdonald P. Hearts from Donations after Circulatory Death (DCD) Donors – Assessment in a Porcine Transplant Model Utilising Transmedics Organ Care System for Organ Perfusion Preservation. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kumarasinghe G, Lavee O, Parker A, Keogh A, Hayward C, Kotlyar E, Jabbour A, Havryk A, Malouf M, Plit M, Glanville A, Macdonald P, Moore J. Risk Factors and Response to Therapy in Heart and Lung Transplant Recipients with Post-Transplant Lymphoproliferative Disease. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kumarasinghe G, Hayward C, Macdonald P, Keogh A, Kotlyar E, Granger E, Dhital K, Jansz P, Spratt P, Jabbour A. Continuous Flow Left Ventricular Assist Devices Improve Survival in Reactive But Not Fixed Type 2 Pulmonary Hypertension. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kumarasinghe G, Yu C, Moffat K, Otton J, Holloway C, McCrohon J, Jabbour A. Cardiovascular Magnetic Resonance (CMR) Imaging Produces Highly Reproducible Rodent Cardiac Volumetric and Functional Data Using a 1.5Tesla Clinical Scanner. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kumarasinghe G, Iyer A, Hicks M, Gao L, Doyle A, Keogh A, Hayward C, Kotlyar E, Granger E, Dhital K, Jansz P, Spratt P, Macdonald P. 422 Early Clinical Experience Supplementing Celsior Preservation Solution with Pro-Survival Kinase Agents Glyceryl Trinitrate and Erythropoietin Demonstrates Improved Myocardial Recovery Post Cardiac Transplantation. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kumarasinghe G, Macdonald P, Danta M. Liver Elastography in Cardiac Disease (LECD) Trial. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kumarasinghe G, Iyer A, Hicks M, Gao L, Watson A, Jansz P, Dhital K, Granger E, Spratt P, Macdonald P. Heart Transplantation: Early Clinical Experience of Supplementing Celsior® Preservation Solution with Pro-survival Kinase Agents Erythropoietin and Glyceryl Trinitrate. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Muthiah K, Hayward C, Macdonald P, Kotlyar E, Spratt P, Granger E, Jansz P, Kumarasinghe G. Gastrointestinal Bleeding Due to Angiodysplasia in Patients With Continuous Flow Left Ventricular Assist Device. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kumarasinghe G. Reversal of Secondary Pulmonary Hypertension and Successful Bridging to Heart Transplant with LVAD support. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Vasoo S, Ong W, Tambyah P, Kumarasinghe G, Singh K. In-vitro Activity of Ertapenem against Bloodstream Isolates of Bacteria at the National University Hospital, Singapore. Int J Infect Dis 2008. [DOI: 10.1016/j.ijid.2008.05.1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Ng T, Sun X, Teo F, Eales A, Liew C, Lin R, Kumarasinghe G. P3.17 Control and Prevention of Acinetobacter Baumanii in Intensive Care Unit. J Hosp Infect 2006. [DOI: 10.1016/s0195-6701(06)60060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Fisher DA, Lin R, Chai L, Kumarasinghe G, Singh K, Tambyah PA. Vancomycin-resistant enterococci in a Singapore teaching hospital prior to 2005. Singapore Med J 2005; 46:311-2. [PMID: 15902362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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Ti TY, Kumarasinghe G, Taylor MB, Tan SL, Ee A, Chua C, Low A. What is true community-acquired urinary tract infection? Comparison of pathogens identified in urine from routine outpatient specimens and from community clinics in a prospective study. Eur J Clin Microbiol Infect Dis 2003; 22:242-5. [PMID: 12709838 DOI: 10.1007/s10096-003-0893-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In order to identify the true nature of community-acquired urinary tract infections, the uropathogens isolated from 100 patients with urinary tract infection included in a prospective study conducted in community clinics were compared to 244 isolates from outpatient urine specimens routinely submitted to the laboratory. Significant differences in both the spectrum of bacteria and their antibiograms were found between the two groups. Laboratory data analysis of uropathogens from outpatient urine specimens may not reflect the true bacteriology of urinary tract infections acquired in the community. Hence, surveys based on laboratory data alone may overestimate resistance rates, leading to misinformed choices being made when treatment is empirical.
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Lim CS, Kumarasinghe G, Chow VTK. Sequence and phylogenetic analysis of SH, G, and F genes and proteins of Human respiratory syncytial virus isolates from Singapore. Acta Virol 2003; 47:97-104. [PMID: 14524476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
To study the genetic variability and molecular epidemiology of Human respiratory syncytial virus (HRSV) occurring in Singapore, nucleotide sequencing of three membrane-associated genes (SH, G and F) of four local isolates was performed. Comparison of their nucleotide and amino acid sequences with those of the prototype strains A2 (subgroup A) and CH-18537 (subgroup B) indicated that the Singapore isolates belong to the subgroup A. Comparison of the Singapore isolates with the reference strain A2 showed that whereas the G protein was the most divergent with up to 15% difference, the F and SH proteins showed less diversity of only up to 4%. Each gene exhibited its distinct variable and conserved regions. The N- and O-glycosylation sites within the G protein of the isolates were analyzed to ascertain their potential implications on the antigenicity of the viral glycoprotein. Based on the second variable region of the G protein, phylogenetic analysis of the Singapore isolates with 91 previously identified genotypes of subgroup A revealed that more than one genotype (GA2 and GA5) may circulate in the local population at a given time. This epidemiological study reflects the pattern of genetic relationships between the HRSV isolates from Singapore to those from other parts of the world.
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Chan YC, Wilder-Smith A, Ong BKC, Kumarasinghe G, Wilder-Smith E. Adult community acquired bacterial meningitis in a Singaporean teaching hospital. A seven-year overview (1993-2000). Singapore Med J 2002; 43:632-6. [PMID: 12693768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND The objective of this study is to describe the bacteriological, clinical and laboratory features of community acquired bacterial meningitis in adults admitted to a Singapore tertiary-care hospital. METHODS Two hundred sixty-nine cases of meningitis or meningoencephalitis admitted between 1993 and 2000 were identified by their discharge diagnosis codes. All case records except for 57 which could not be retrieved were retrospectively reviewed. Patients less than 14 years or with skull fractures, post-neurosurgery or with indwelling intracranial devices were excluded. Inclusion criteria was a clinical picture compatible with a diagnosis of bacterial meningitis with either (1) positive cerebral-spinal fluid (CSF) cultures or latex coagglutination or CSF neutrophilic pleocytosis accompanied by positive blood cultures or (2) in the absence of positive blood cultures, CSF cultures and latex agglutination, presence of CSF pleocytosis of at least 100 neutrophils per microL. RESULTS Fifteen "culture-positive" and 11 "culture negative" cases were identified. Six (55%) of the "culture-negative" cases received antibiotics prior to admission. Cultures grew Streptococcus pneumoniae in four cases, three cases each of Group B streptococci and Neisseria meningitides. Listeria monocytogenes and Klebsiella pneumoniae were each seen twice and Streptococcus suis once. All cases of Group B streptococci occurred in the year 1998. Mortality was 19% (n = 5), six developed infections in other sites, three epileptic seizures, three developed hydrocephalus, and two hearing loss. CONCLUSIONS Pathogens are similar to those reported in other studies but for an outbreak of Group B Streptococcus in 1998. There were a high number of "culture-negative" cases which may be due to preceding antibiotic intervention.
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Yee YC, Gough A, Kumarasinghe G, Lim TK. The pattern of utilisation and accuracy of a commercial nucleic acid amplification test for the rapid diagnosis of Mycobacterium tuberculosis in routine clinical practice. Singapore Med J 2002; 43:415-20. [PMID: 12507028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
BACKGROUND Several nucleic acid amplification (NAA) tests are available for the rapid detection of Mycobacterium tuberculosis (MTB) in clinical specimens. AIMS To identify the pattern of utilisation and accuracy of the AMPLICOR test in routine clinical practice in an acute care setting. DESIGN A retrospective descriptive study. METHOD We studied 159 consecutive specimens in which the AMPLICOR (Roche; Branchburg, NJ) test was requested by attending doctors. The sensitivities and specificities of the AMPLICOR for detection of active tuberculosis (TB) were calculated in relation to types of specimens, smear and culture results. RESULTS The number of requests more than doubled from 1999 to 2000. Thirty-eight percent of the specimens were not from the respiratory tract. The majority of the specimens had requests for one or more additional test (mean 1.8). The rate of active TB was 18%. The sensitivities of the AMPLICOR on per specimen, per patient, per smear negative specimen and per smear negative patient basis were found to be 81%, 80%, 66.7% and 71.4% respectively. The specificities for these groups accordingly were 99%, 98.6%, 99% and 98.6% respectively. The sensitivity and specificity for respiratory specimens were 97.5% and 98.5%, while for non-respiratory specimens, they were 60% and 100%. In smear negative specimens, the sensitivity and specificity for respiratory specimens were 60% and 98.5%, while for non-respiratory specimens, they were 75% and 100%. The AMPLICOR assay was negative in all 21 specimens of pleural or spinal fluid. CONCLUSIONS There is a growing demand for NAA in the rapid diagnosis of TB with a high proportion of non-respiratory specimens. The number of additional diagnostic tests performed on each specimen should be limited. In routine clinical practice, the AMPLICOR assay is a useful confirmatory test for active pulmonary TB. The utility of the AMPLICOR assay for MTB detection in exudative fluid specimens needs further evaluation.
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Ong AK, Tambyah PA, Ooi S, Kumarasinghe G, Chow C. Endemic typhus in Singapore--a re-emerging infectious disease? Singapore Med J 2001; 42:549-52. [PMID: 11989574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
UNLABELLED Singapore is a modern urban city and endemic typhus is thought to be a disease of the past. This may be due to lack of specific serological testing as indirect immunoperoxidase testing using specific rickettsial antigens (U.S. Army Medical Research Unit, Institute of Medical Research, Kuala Lumpur, Malaysia) has only recently become available. In the last fourteen months, twenty-one cases of endemic typhus were diagnosed in patients hospitalised for acute febrile illnesses at the National University Hospital. We conducted a case control study to define the clinical and laboratory features of endemic typhus in Singapore. METHOD Demographic, clinical and laboratory data were reviewed for cases and twenty-one age and sex matched controls who had negative serologic tests as part of a work-up for fever of unknown origin. RESULTS Apart from a higher initial temperature (39 degrees C vs 37.9 degrees C (p < 0.001)) and ALT(p = 0.002), cases and controls had similar presentations of fever, myalgia, headache, cough, normal WBC and platelet counts. Singapore residents and migrant workers were represented in both groups (p = ns). CONCLUSION Endemic typhus remains an important cause of acute febrile illness in Singaporein both the local and migrant worker populations. The presentation is similar to other causes of acute febrile illnesses and the diagnosis will be missed unless it is specifically sought.
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Chen MI, Chua JK, Lee CC, Leo YS, Kumarasinghe G. Epidemiological, clinical and laboratory characteristics of 19 serologically confirmed rickettsial disease in Singapore. Singapore Med J 2001; 42:553-8. [PMID: 11989575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
AIM To identify epidemiological, clinical and laboratory features of serologically-proven typhus in the local setting. METHOD & RESULTS Retrospective study looking at rickettsial serologies done over a six-month period and collection of the epidemological, clinical, laboratory and treatment response data from the case notes of the patients with an ordered rickettsial serology. Twenty of the 35 cases had a positive serology. Of these 20 patients, 18 were already clinically diagnosed as having murine typhus. All except one were males and all were migrant workers. Majority of the patients were construction workers staying in containers where rats abound. The most consistent clinical features were high fever (100%) for a median period of seven days, headache (94%) and cough (47%). The white cell count was usually normal (74%) but thrombocytopenia was common (68%). Transaminitis was also common (90%) with the AST component higher than the ALT in half of the cases. Response to doxycycline therapy was rapid and most (88%) were afebrile by 72 hours. CONCLUSION Typhus (notably murine type) can be confidently diagnosed from consistent clinical features supported by epidemiological and laboratory clues. Early recognition with the prompt treatment response will result in shorter hospital stay with decreased cost. Serological testing may only prove useful in difficult situations when the clinical diagnosis is less clear.
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