High anxiety, young age and long waits increase the need for preoperative sedatives in children

OBJECTIVE

This prospective, observational study aimed to identify children likely to require sedation preoperatively by measuring anxiety levels using the modified Yale Preoperative Anxiety Scale (mYPAS). Other possible predictive factors for preoperative sedation were also investigated.

METHODS

A total of 455 patients aged 2-12 years scheduled for surgery requiring general anaesthesia were enrolled in the study. Patients' anxiety levels were measured using the mYPAS in a preoperative holding area just before patients were separated from their parents or guardians and entered the operating theatre. Anaesthetists blindedto the mYPAS assessments judged whether the child could be separated and enter the operating theatre without a sedative. The ability of the mYPAS to predict the need for preoperative sedation was analysed by receiver operating characteristic (ROC) curve analysis.

RESULTS

The optimum mYPAS cut-off for requiring sedatives was 41.7 according to ROC curve analysis. Multivariate logistic regression analysis showed that age, mYPAS>40 and waiting time were independent predictors of the requirement for sedative administration.

CONCLUSIONS

High anxiety levels, young age and long waits contributed to the need for preoperative sedation in children.

Selective control of cyanobacteria in eutrophic pond by a combined device of ultrasonication and water pumps

A combined device consisting of an ultrasonic apparatus and water pumps was operated in a eutrophic pond to study its effect on the control of cyanobacteria as compared with those of a non-treated, neighboring pond. The combined apparatus seemed to be enough to spread the sonicated water to the whole surface of a 9,000 m3 pond. Although the high rainfall in 2003 resulted in an overall dominance of diatoms, cyanobacterial growth was significantly inhibited by the apparatus in the treated pond. In addition, the chlorophyll-a concentration and total algae in the treated pond were 61 and 53%, respectively, of the levels in the control pond. The reduced algal growth (7% of the control) by the combined apparatus was mainly due to the inhibition on the growth of cyanobacteria. The cyanobacterial proportion in the treated pond, however, increased significantly for several days, when the apparatus was stopped. Meanwhile, the proportion of green algae increased in the treated pond. The successful selective control of cyanobacteria using the combined apparatus suggests that ultrasonication can be a practical method to control bloom and toxin production in eutrophic waters.

Growth inhibition of bloom-forming cyanobacterium Microcystis aeruginosa by rice straw extract

AIMS

To inhibit the growth of the bloom-forming cyanobacterium Microcystis aeruginosa using a rice straw extract.

METHODS AND RESULTS

The cell numbers of the algal strain M. aeruginosa UTEX 2388 significantly decreased after treatment with different concentrations (0.01, 0.1, 1 and 10 mg l(-1)) of a rice straw extract for an 8-day cultivation period. Among seven tested allelochemicals from rice straw, salicylic acid at 0.1 mg l(1) exhibited the highest allelopathic activity (26%) on day 8. A synergistic effect on algal growth inhibition was found when adding two or three phenolic compounds from the rice straw.

CONCLUSIONS

The growth of M. aeruginosa was inhibited by rice straw extract concentrations ranging from 0.01 to 10 mg l(1). This activity was due to the synergistic effects of various phenolic compounds in the rice straw.

SIGNIFICANCE AND IMPACT OF THE STUDY

The identification of rice straw as an effective material for the growth inhibition of M. aeruginosa implies it may have the potential to be used as an environment-friendly biomaterial for controlling the algal bloom of M. aeruginosa in eutrophic water.

Harvesting of Spirulina platensis by cellular flotation and growth stage determination

AIM

To investigate an effective harvesting method for Spirulina platensis.

METHODS AND RESULTS

Eighty per cent of S. platensis cells in the logarithmic growth phase were harvested by flotation when the cells were set in a static condition for 2 h. The optimum harvesting time was about day 6 of cultivation. The flotation activity of S. platensis cells was enhanced by the addition of NaCl.

CONCLUSIONS

The harvesting of S. platensis by flotation is a cost-effective and straightforward method that can retain the algal quality. The optimum harvesting time of S. platensis can be predicted by the cellular protein to carbon ratio.

SIGNIFICANCE AND IMPACT OF THE STUDY

Flotation harvesting is also applicable to other cyanobacteria with gas vesicles.

Harvesting of Spirulina platensis by cellular flotation and growth stage determination

AIM

To investigate an effective harvesting method for Spirulina platensis.

METHODS AND RESULTS

Eighty per cent of S. platensis cells in the logarithmic growth phase were harvested by flotation when the cells were set in a static condition for 2 h. The optimum harvesting time was about day 6 of cultivation. The flotation activity of S. platensis cells was enhanced by the addition of NaCl.

CONCLUSIONS

The harvesting of S. platensis by flotation is a cost-effective and straightforward method that can retain the algal quality. The optimum harvesting time of S. platensis can be predicted by the cellular protein to carbon ratio.

SIGNIFICANCE AND IMPACT OF THE STUDY

Flotation harvesting is also applicable to other cyanobacteria with gas vesicles.

An efficient method for the rapid establishment of Epstein-Barr virus immortalization of human B lymphocytes

Several methods have been developed for the immortalization of B lymphocytes by Epstein-Barr virus (EBV). We developed an efficient method which reduces the time from culture initiation to immortalization and cryopreservation. Two infections of EBV to lymphocytes, and the use of phorbol ester-induced EBV stock significantly improved immortalization efficiency and reduced the time between initiation and immortalization and cryopreservation. The resulting cell bank was used to produce DNA for genetic studies focusing on the genes involved in immune and autistic disorders.

Shigella septicaemia in adults: report of two cases and mini-review

INTRODUCTION

We report 2 cases of Shigella septicaemia in adult patients.

CLINICAL PICTURE

Two 57-year-old women presented with non-bloody diarrhoea and fever. The first patient was an inmate of a long-term care facility who was schizophrenic and the second patient was a diabetic who recently travelled to Medan, Indonesia. Both patients were febrile, hypotensive and dehydrated. The first patient was neutropenic, thrombocytopenic and had acute renal failure. Blood cultures yielded Shigella flexneri and stool cultures gave negative results for both patients.

TREATMENT

Rehydration and intravenous ceftriaxone were instituted.

OUTCOME

The patients' symptoms and hypotension resolved.

CONCLUSION

Appropriate antibiotics can decrease the severity and duration of Shigella septicaemia.

Microcystin-induced down-regulation of lymphocyte functions through reduced IL-2 mRNA stability

Here we report that lymphocyte functions were down-regulated by cyanobacterial hepatotoxin microcystin. Treatment of three microcystin (MC) isotypes, MC-LR, MC-YR and nodularin, on B6C3F1 mouse splenocytes produced dose-dependent inhibition of in vitro polyclonal antibody response and lymphoproliferation to LPS. ConA-induced lymphoproliferative response was decreased by MC-YR and nodularin, but no significant effect was observed in the MC-LR treatment. Intraperitoneal administration of nodularin into B6C3F1 mice decreased humoral immune responses to sheep red blood cell (sRBC), and the inhibitory effect became severe when hepatic uptake of nodularin was blocked by rifampicin. Each MC 1 microM suppressed phorbol 12-myristate 13-acetate (PMA) plus ionomycin-induced IL-2 mRNA expression in splenocytes and thymocytes, but not in EL-4 mouse thymoma cells. To further characterize the mechanism for the reduced IL-2 mRNA level, IL-2 mRNA stability was measured using RT-PCR. Deprivation of PMA/ionomycin stimuli from activated splenocytes and blockade of new transcription resulted in destabilization of IL-2 mRNA, which was accelerated by MC treatment. These results demonstrated that MC down-regulated lymphocyte functions and the immunosuppression was mediated, at least in part, through decreased IL-2 mRNA stability.

Teicoplanin-induced neutropenia in a paediatric patient with vertebral osteomyelitis

Teicoplanin is a glycopeptide antibiotic that has been used extensively in adults but less so in children for the treatment of bone and joint infections. It has a good safety profile with low incidences of blood dyscrasias. We report a case of teicoplanin-induced neutropenia in a child.

Seasonal variation and indirect monitoring of microcystin concentrations in Daechung reservoir, Korea

Physicochemical and biological water quality, including the microcystin concentration, was investigated from spring to autumn 1999 in the Daechung Reservoir, Korea. The dominant genus in the cyanobacterial blooming season was Microcystis. The microcystin concentration in particulate form increased dramatically from August up to a level of 200 ng liter(-1) in early October and thereafter tended to decrease. The microcystin concentration in dissolved form was about 28% of that of the particulate form. The microcystins detected using a protein phosphatase (PP) inhibition assay were highly correlated with those microcystins detected by a high-performance liquid chromatograph (r = 0.973; P < 0.01). Therefore, the effectiveness of a PP inhibition assay for microcystin detection in a high number of water samples was confirmed as easy, quick, and convenient. The microcystin concentration was highly correlated with the phytoplankton number (r = 0.650; P < 0.01) and chlorophyll-a concentration (r = 0.591; P < 0.01). When the microcystin concentration exceeded about 100 ng liter(-1), the ratio of particulate to dissolved total nitrogen (TN) or total phosphorus (TP) converged at a value of 0.6. Furthermore, the microcystin concentration was lower than 50 ng liter(-1) at a particulate N/P ratio below 8, whereas the microcystin concentration varied quite substantially from 50 to 240 ng liter(-1) at a particulate N/P ratio of >8. Therefore, it seems that the microcystin concentration in water can be estimated and indirectly monitored by analyzing the following: the phytoplankton number and chlorophyll-a concentration, the ratio of the particulate and the dissolved forms of N and P, and the particulate N/P ratio when the dominant genus is toxigenic Microcystis.

Variation of microcystin content of microcystis aeruginosa relative to medium N:P ratio and growth stage

Changes in the microcystin content of Microcystis aeruginosa UTEX 2388 were investigated at several N:P ratios of the medium and various growth stages. Under the P-fixed condition, the microcystin content of the cells changed with different medium N:P ratios, with the highest at 2748 microg g-1 at a N:P ratio of 16 after incubation for 7 d. The microcystin content of M. aeruginosa exhibited a high correlation with the total N content regardless of an N-fixed or P-fixed culture. When the N:P ratio of the medium was fixed to 16 : 1, the microcystin content of M. aeruginosa at various growth stages was highest at 2191 microg g-1 after an incubation of 4 d and the chlorophyll-a content showed a similar tendency. There was a highly significant relationship between the microcystin content of M. aeruginosa and the chlorophyll-a concentration in the culture during the incubation. Accordingly, the microcystin content of M. aeruginosa during incubation can be easily estimated and monitored by measuring the in vivo fluorescence changes in the culture.

Suppression of IL-2 and IL-4 gene expression by nodularin through the reduced NF-AT binding activity

Nodularin is a cyclic peptide produced by cyanobacteria. In the present study, the inhibitory effect of nodularin on T lymphocyte functions was demonstrated. Direct addition of nodularin to B6C3F1 mouse splenocyte cultures produced a concentration-dependent inhibition of the lymphoproliferative response to concanavalin A stimulation. Nodularin inhibited PMA plus ionomycin (Io)-induced IL-2 mRNA expression in murine splenocytes and thymocytes as determined by quantitative/competitive RT-PCR. To further characterize the mechanism for the transcriptional regulation of IL-2, the binding activity of transcription factors, NF-AT, AP-1, NF-kappaB, and Oct, was evaluated by electrophoretic mobility shift assays in mouse splenocytes. Nodularin reduced the NF-AT binding activity in PMA/Io-induced splenocytes, but no significant effect was observed on AP-1, NF-kappaB, or Oct binding activity. Nodularin also inhibited IL-4 mRNA expression in PMA/Io-stimulated murine splenocytes. These results suggest that T lymphocyte is a possible cellular target of nodularin, and the inhibitory effect of nodularin on T-cell specific transcription factor NF-AT induces T-cell dysfunction, which leads to a diminution in IL-2 and IL-4 gene transcription.

Nipah viral encephalitis or Japanese encephalitis? MR findings in a new zoonotic disease

BACKGROUND AND PURPOSE

An epidemic of suspected Japanese encephalitis occurred in Malaysia in 1998-1999 among pig farmers. In neighboring Singapore, an outbreak occurred among pig slaughterhouse workers. It was subsequently established that the causative agent in the outbreak was not the Japanese encephalitis virus but a previously unknown Hendra-like paramyxovirus named Nipah virus.

METHODS

The brain MR images of eight patients with Nipah virus infection were reviewed. All patients tested negative for acute Japanese encephalitis virus. Seven patients had contrast-enhanced studies and six had diffusion-weighted examinations.

RESULTS

All patients had multiple small bilateral foci of T2 prolongation within the subcortical and deep white matter. The periventricular region and corpus callosum were also involved. In addition to white matter disease, five patients had cortical lesions, three had brain stem involvement, and a single thalamic lesion was detected in one patient. All lesions were less than 1 cm in maximum diameter. In five patients, diffusion-weighted images showed increased signal. Four patients had leptomeningeal enhancement and four had enhancement of parenchymal lesions.

CONCLUSION

The brain MR findings in patients infected with the newly discovered Nipah paramyxovirus are different from those of patients with Japanese encephalitis. In a zoonotic epidemic, this striking difference in the appearance and distribution of lesions is useful in differentiating these diseases. Diffusion-weighted imaging was advantageous in increasing lesion conspicuity.

Attitudes and beliefs of Singapore health care professionals concerning HIV/AIDS

AIM OF STUDY

This study examines the beliefs and attitudes of Singapore doctors, dentists, and nurses concerning HIV/AIDS and persons living with HIV/AIDS (PWAs).

METHOD

A mail survey was done of all doctors and dentists in Singapore as well as a random sample of 1,500 nurses from the Singapore Nursing Board Register.

RESULTS

The results showed that respondents held accurate beliefs concerning transmission of HIV via sex and needle sharing but a significant proportion also expressed belief in transmission via everyday social contact. Respondents were aware of universal precautions when treating persons with HIV/AIDS but tended to be overly cautious in low/no risk situations. A substantial proportion of respondents indicated little or no knowledge or experience with AIDS-related conditions and the majority believed that most health care professionals are unprepared to care for PWAs. Further, there was evidence of substantial stigmatisation and fear of treating PWAs, both of which were significantly and negatively correlated with accuracy of beliefs about HIV transmission and universal precautions.

CONCLUSION

These results point to important misconceptions about HIV/AIDS held by Singapore health care professionals as well as stigma towards and fear of treating PWAs. These are areas that need to be addressed through better professional education concerning HIV/ AIDS. This education needs to address both the factual misconceptions about HIV/AIDS as well as the stigma associated with this disease and the fears that health care professionals have of treating PWAs.

Microcystin production by Microcystis aeruginosa in a phosphorus-limited chemostat

The production of microcystins (MC) from Microcystis aeruginosa UTEX 2388 was investigated in a P-limited continuous culture. MC (MC-LR, MC-RR, and MC-YR) from lyophilized M. aeruginosa were extracted with 5% acetic acid, purified by a Sep-Pak C(18) cartridge, and then analyzed by high-performance liquid chromatography with a UV detector and Nucleosil C(18) reverse-phase column. The specific growth rate (mu) of M. aeruginosa was within the range of 0.1 to 0.8/day and was a function of the cellular P content under a P limitation. The N/P atomic ratio of steady-state cells in a P-limited medium varied from 24 to 15 with an increasing mu. The MC-LR and MC-RR contents on a dry weight basis were highest at mu of 0.1/day at 339 and 774 microg g(-1), respectively, while MC-YR was not detected. The MC content of M. aeruginosa was higher at a lower mu, whereas the MC-producing rate was linearly proportional to mu. The C fixation rate at an ambient irradiance (160 microeinsteins m(-2) s(-1)) increased with mu. The ratios of the MC-producing rate to the C fixation rate were higher at a lower mu. Accordingly, the growth of M. aeruginosa was reduced under a P limitation due to a low C fixation rate, whereas the MC content was higher. Consequently, increases in the MC content per dry weight along with the production of the more toxic form, MC-LR, were observed under more P-limited conditions.

The methanol extract of Spiraea prunifolia var. simpliciflora root inhibits the generation of nitric oxide and superoxide in RAW 264.7 cells

It is well established that nitric oxide (NO) and superoxide radicals play pivotal roles in the pathogenesis of inflammatory diseases and fever. This study is undertaken to address whether the methanol extract of Spiraea prunifolia var. simpliciflora root, a traditional medicine as an antipyretic, modulates the generation of NO and superoxide in IFN-gamma primed or polymyristic acetate (PMA) stimulated RAW 264.7 cells, respectively. The generation of NO as well as the expression of inducible nitric oxide synthase (iNOS) protein from IFN-gamma primed RAW 264.7 cells is markedly decreased by the methanol extract in a dose dependent manner. However, the methanol extract does not affect the viability of RAW 264.7 cells, as assessed by methylthiazol-2-yl-2,5-diphenyl tetrazolium bromide (MTT) assay. In addition, the methanol extract suppresses the generation of superoxide in PMA-stimulated RAW 264.7 cells in a dose and a time dependent manner. Taken together, anti-pyretic effects of Spiraea prunifolia var. simpliciflora root extract could result from direct suppression of NO and decreased superoxide generation.

Characterization of a biosurfactant, mannosylerythritol lipid produced from Candida sp. SY16

One yeast strain, SY16, was selected as a potential producer of a biosurfactant, and identified as a Candida species. A biosurfactant produced from Candida sp. SY16 was purified and confirmed to be a glycolipid. This glycolipid-type biosurfactant lowered the surface tension of water to 29 dyne/cm at critical micelle concentration of 10 mg/l (1.5 x 10(-5) M), and the minimum interfacial tension was 0.1 dyne/cm against kerosene. Thin-layer and high-pressure liquid chromatography studies demonstrated that the glycolipid contained mannosylerythritol as a hydrophilic moiety. The hydrophilic sugar moiety of the biosurfactant was determined to be beta-D-mannopyranosyl-(1-->4)-O-meso-erythritol by nuclear magnetic resonance (NMR) and fast atom bombardment mass-spectroscopy analyses. The hydrophobic moiety, fatty acids, of the biosurfactant was determined to be hexanoic, dodecanoic, tetradecanoic, and tetradecenoic acid by gas chromatography-mass spectroscopy. The structure of the native biosurfactant was determined to be 6-O-acetyl-2,3-di-O-alkanoyl-beta-D-mannopyranosyl-(1-->4)-O-meso- erythritol by NMR analyses. We newly determined that an acetyl group was linked to the C-6 position of the D-mannose unit in the hydrophilic sugar moiety.

The neurological manifestations of Nipah virus encephalitis, a novel paramyxovirus

A novel Hendra-like paramyxovirus named Nipah virus (NiV) was the cause of an outbreak among workers from one abattoir who had contact with pigs. Two patients had only respiratory symptoms, while 9 patients had encephalitis, 7 of whom are described in this report. Neurological involvement was diverse and multifocal, including aseptic meningitis, diffuse encephalitis, and focal brainstem involvement. Cerebellar signs were relatively common. Magnetic resonance imaging scans of the brain showed scattered lesions. IgM antibodies against Hendra virus (HeV) were present in the serum of all patients. Two patients recovered completely. Five had residual deficits 8 weeks later.

Imported malaria in a Singapore hospital: clinical presentation and outcome

OBJECTIVE

To evaluate the clinical presentation and outcome of imported malaria.

METHODS

A retrospective chart review was conducted of patients with imported malaria admitted to the Communicable Disease Centre (CDC), Singapore (a 130-bed tertiary referral center) from January 1992 to December 1993. An imported case was defined as a smear-positive infection that was acquired in another country.

RESULTS

Among 200 malaria patients hospitalized at CDC, 168 imported cases (137 males and 31 females, 131 nonresidents and 37 residents) were studied. The mean age was 31.6 6 10.5 years. The countries visited were India (49.4%), Indonesia (16.7%), and Bangladesh (13%). Five patients had chemoprophylaxis and 36 patients had experienced previous malaria infection. The predominant symptoms were fever (97.6%), chills (79.2%), and rigors (67.9%). Hepatomegaly was detected in 56 (33.3%) and splenomegaly in 49 patients (29.2%). Plasmodium vivax was present in 132 patients, Plasmodium falciparum in 29, and mixed P. vivax and P. falciparum in 7 patients. Parasitemia ranged from 0.1% to 8.0%. Of the vivax cases, 130 were treated with chloroquine, followed by primaquine in 123 patients. Quinine was given to 36 patients (29 falciparum malaria and 7 mixed infections). Median time to fever defervescence was 2 days. Complications occurred in three patients (2 with shock and 1 with pulmonary edema). According to World Health Organization gravity criteria, body temperature over 40 degrees C was detected in six patients, bilirubinemia higher than 50 mmol/L in nine, parasitemia over 5% in five, glycemia less than 2.2 mmol/L in two patients. There were five relapses. No death was recorded.

CONCLUSION

Plasmodium vivax is the most common cause of imported malaria, with the majority acquired from the Indian subcontinent. Only a few patients presented with severe malaria.

Enhancement of nitric oxide synthesis by the aqueous extract of Spiraea prunifolia var. simpliciflora's root in RAW 264.7 cells

The effects of aqueous extract of Spiraea prunifolia var. simpliciflora's root, a traditional medicine for the treatment of malaria in Chinese medicine, on the generation of nitric oxide (NO) are investigated in RAW 264.7 cells. NO generation from IFN-gamma primed RAW 264.7 cells is markedly increased by the addition of aqueous extract in a dose-dependent manner. The enhancement of NO generation by the aqueous extract is accompanied by a significantly increased expression of inducible nitric oxide synthase (iNOS). However, the aqueous extract of Spiraea prunifolia var. simpliciflora's root does not affect the viability of RAW 264.7 cells, as assessed by MTT assay. Polymyxin B does not inhibit NO generation by the aqueous extract in IFN-gamma primed RAW 264.7 cells. However, polymyxin B significantly decreases NO generation by lipopolysaccharide (LPS) in IFN-gamma primed RAW 264.7 cells. These data indicate that the signaling pathway of the aqueous extract-induced NO generation is not dependent on PKC. These results strongly support the mechanism by which the aqueous extract may exert anti-malarial effect via direct cytotoxicity of NO as well as NO-mediated modulation of immune functions.

Emerging therapies for sepsis and septic shock

Despite advances in antimicrobial therapy and medical support, septic shock remains a leading cause of death. Emerging adjunctive therapy for septic shock can be divided into those directed against bacterial components, those directed against host-derived inflammatory-mediators and those designed to limit tissue damage. All trials of new adjunctive therapies for sepsis and septic shock conducted to data have failed to show efficacy. Therapies against endotoxin, tumour necrosis factor, interleukin-1 and platelet activating factor did not reduce mortality. Future effective therapies will probably use combination of agents depending upon the nature of the infection and the type of patient.

Isolation of a novel pentachlorophenol-degrading bacterium, Pseudomonas sp. Bu34

A pentachlorophenol (PCP)-degrading bacterium was isolated from possible PCP-contaminated soil from Pusan, Korea and identified as a member of the genus Pseudomonas. It used PCP as its sole source of carbon and energy. This micro-organism was capable of degrading PCP more effectively, certified by the increase in cell density and the decrease in PCP substrate. Pseudomonas sp. Bu34 was able to degrade a much higher concentration of PCP (4000 mg l-1) than any previously reported PCP-degrading bacteria and fungi and to grow in mineral salts solution containing one of a variety of chlorophenols. In non-acclimated strain Bu34, the cell number decreased from 87 to 99.9% in 75-4000 mg l-1 PCP at 24 h. In the acclimated strain the PCP toxic effect did not appear with 75 mg l-1 PCP treatment, but 1000-4000 mg l-1 PCP decreased the cell number of strain Bu34 by 25% to 24 h and then the cell number slightly increased at 48 h. Therefore, it suggested that the maximum resistance of acclimated strain Bu34 to PCP was 4000 mg l-1 PCP. We suggest that strain Bu34 could be used as a micro-organism for the bioremediation of highly PCP-contaminated soils, water or wood products.

Clinical presentation of herpes zoster in a Singapore hospital

BACKGROUND

There is a direct correlation between increasing age and incidence of herpes zoster. There is an increased risk of complications in the elderly and the immunocompromised.

OBJECTIVE

To study the clinical epidemiology of hospitalised patients with herpes zoster.

METHODS

Medical records of all patients hospitalised with zoster were respectively analysed.

RESULTS

Sixty-seven patients (3% of total admissions) were studied. There were 35 males and 32 females with a mean age of 50.35 +/- 21.71. There was an increased proportion of older patients in the study cohort. Nineteen patients (28.4%) were immunocompromised with malignancy occurring in 9 patients. Thirteen had been on cytotoxic and/or steroid therapy. The commonest symptoms were rash, pain and fever. Eighty-five percent of the patients had complications (bacterial super-infection in (61%), dissemination (31%), ocular involvement (5%) and post-herpetic neuralgia (13.4%). There was an increasing frequency of duration of pain with increasing age in the patients with post-herpetic neuralgia. Forty-three patients were treated with acyclovir. The median time to healing of lesions was 11 days. The 41 patients with bacterial super-infection received antibiotics with median time to healing of 12 days.

CONCLUSION

Increasing age and immunocompromised state appear to be risk factors for developing herpes zoster in hospitalised patients.

Typhoid fever in hospitalized children in Singapore

A study was conducted to determine the clinical features and severity of typhoid fever in children admitted to the Communicable Disease Centre, Singapore. Over a 5 year period (1990-94), 40 children had documented culture-proven typhoid fever. Nine of the 40 children (22.5%) were below the age of 5 years. The predominant presenting symptoms were fever and diarrhoea. Pneumonia and ileus were the only complications observed. No patient in the series died. Ten Salmonella typhi isolates were multi-drug resistant. The majority of the children were treated with chloramphenicol and ceftriaxone. Typhoid fever appears to be a mild disease in Singapore children.

Varicella pneumonia in adults--clinical spectrum

Varicella pneumonia is the most common complication of chickenpox and it also has the highest mortality. A retrospective study was carried out on 10 patients with varicella pneumonia over a period of one year. Seven of the 10 patients with varicella pneumonia had a history of smoking. The majority of the patients with varicella pneumonia presented with cough, dyspnoea, hypoxia and a compatible chest radiograph. All the patients with varicella pneumonia were treated with intravenous acyclovir. Four patients required mechanical ventilation. Nine out of the 10 patients were cured with only one death. It may be reasonable to select adults with varicella and who smoke, for early treatment with acyclovir.

Cefuroxime compared to amoxicillin-clavulanic acid in the treatment of community-acquired pneumonia

The study compared the efficacy and safety of cefuroxime (CFX) versus amoxicillin-clavulanic acid (AC) in the treatment of community-acquired pneumonia. A total of 48 patients (mean age 44 years; 32 males and 16 females) were randomised to receive sequential intravenous/oral CFX (750 mg i.v. 8H for 48 H/500 mg p.o bid) and sequential intravenous/oral AC (1.2 g i.v. 8 H for 48 H/ 750 mg p.o. tid) for 7-14 days. The two groups were well matched for age, sex and treatment duration (median 7 days). The most frequent causative organisms were Mycoplasma (3), Klebsiella species (2), Pseudomonas aeruginosa (2) and hemolytic streptococcus (2). clinical cure was obtained in 20 patients (83.3%) and 18 patients (75%) of CFX and AC group respectively. Clinical improvement was observed in one patient of the CFX group. There were 3 failures in the CFX group and 4 failures in the AC group. Two patients in the AC group developed adverse drug reactions (namely vomiting and rash) and were withdrawn from the study. In conclusion, cefuroxime and amoxicillin-clavulanic acid have comparable efficacy and safety in the treatment of community-acquired pneumonia.

Upper respiratory tract infections - otitis media, sinusitis and pharyngitis

Management of the patient with otitis media, sinusitis or pharyngotonsillitis is based on information about the host, the organism and the antimicrobial agent. Otitis media (OM) is a common infection in children but selected children have recurrent and chronic OM. The predominant organisms responsible for OM are Streptococcus pneumonia, Haemophilus influenzae and Moraxella catarrhalis. Changes in the antimicrobial susceptibility govern the choice of antimicrobial agents. Surgical treatment should be considered if the child has persistent hearing loss in both ears. Sinusitis shares with OM similar pathogenesis, microbiology and choices of antimicrobial therapy. Endoscopic surgery is the treatment of choice for chronic sinusitis. Pharyngitis may be either viral or bacterial in origin. Penicillin remains the treatment of choice for bacterial pharyngotonsillitis. In patients with recurrent infection, the emergence of B-lactamase producing strains has to be considered and erythromycin or oral cephalosporins might be indicated.

A descriptive profile and the immune status of some hospitalised patients with measles

The incidence of measles in Singapore has declined with the introduction of measles vaccination in 1976. However, a progressive increase in notified measles cases has occurred since 1990. To characterise the current profile of hospitalised patients with measles, particularly their measles immunity status, we analysed 46 cases over a period of 3 months. The majority (69.6%) were school-going children (aged 5-19 years). Of the 25 patients (54.3%) classified as preventable by immunisation according to the current strategy, 68% were school-age persons. Five previously vaccinated patients had measles enzyme immunoassay immunoglobulin M and immunoglobulin G antibodies present. The occurrence of preventable cases among school-age children indicates that the implementation of the current immunisation programme should be improved.

Bacteraemia caused by Rahnella aquatilis: report of two cases and review

Rahnella aquatilis, a rare Gram-negative rod, usually found in fresh water, was isolated from blood of a diabetic patient and a patient with laryngeal carcinoma. Both recovered from the infection after treatment with parenteral antibiotics including gentamicin.

Multidrug-resistant typhoid fever in Singapore

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

Advice for the international traveller

International travel has increased in recent years. The spectrum of disease associated with travel is wide. All travellers should be encouraged to seek pre-travel medical advice which include the need for vaccination and malaria prophylaxis and advice on preventive health measures during travel. The returning traveller with an illness should be advised to seek post-travel treatment.

Acquired immunodeficiency syndrome and Cryptosporidium infection

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

Infections in systemic lupus erythematosus

A prospective study was carried out on the occurrence of infections in 28 hospitalised systemic lupus erythematosus (SLE) patients. In 38 episodes of infections, 23 were bacterial (60.5%), 4 were viral (10.6%) and culture negative infections were present in 10 (26.3%). The most common isolated organisms were Staphylococcus aureus (30.4%), Salmonella species (21.7%), Pseudomonas species (13.0%), and Klebsiella species (13.0%). The care rate was 94.7%. Death occurred in 2 patients. Lupus activity, impaired renal function, and cytotoxic therapy did not predispose to infection.

Actinomycosis of the brain

Actinomyces species are rare but treatable causes of central nervous system infection. A case of actinomycotic cerebral abscess is reported. The primary source of infection was probably the lung based on radiological findings although culture of the bronchial brushings was negative. The patient had surgical excision and repeated drainage with two prolonged causes of antibiotic therapy. At follow-up examination 36 months later, the patient was well except for a residual left hemiplegia. Diagnosis of cerebral actinomycosis can be made by anaerobic culture of the appropriate specimens or on histologic grounds. Optimal management combines adequate surgical drainage and prolonged antibiotic therapy.