Chronic wounds in a multiethnic Asian population: a cost of illness study.

OBJECTIVE: To estimate the 'cost of illness' arising from chronic wounds in Singapore. DESIGN: Incidence-based cost of illness study using evidence from a range of sources. SETTING: Singapore health services. PARTICIPANTS: We consider 3.49 million Singapore citizens and permanent residents. There are 16 752 new individuals with a chronic wound in 2017, with 598 venous ulcers, 2206 arterial insufficiency ulcers, 6680 diabetic ulcers and 7268 pressure injuries.Primary outcome measures expressed in monetary terms are the value of all hospital bed days lost for the population; monetary value of quality-adjusted life years (QALYs) lost in the population; costs of all outpatient visits; and costs of all poly clinic, use of Community Health Assist Scheme (CHAS) and emergency departments (EDs) visits. Intermediate outcomes that inform the primary outcomes are also estimated. RESULTS: Total annual cost of illness was $350 million (range $72-$1779 million). With 168 503 acute bed days taken up annually (range 141 966-196 032) that incurred costs of $139 million (range 117-161 million). Total costs to health services were $184 million (range $120-$1179 million). Total annual costs of lost health outcomes were 2077 QALYs (range -2657 to 29 029) valued at $166 million (range -212 to 2399 million). CONCLUSIONS: The costs of chronic wounds are large to Singapore. Costs can be reduced by making positive investments for comprehensive wound prevention and treatment programmes.

[Efficacy of hyperbaric oxygen therapy in the treatment of ischemic toe ulcer in a patient presenting systemic sclerosis]. / Efficacité de l'oxygénothérapie hyperbare dans le traitement d'un ulcère nécrotique d'orteil au cours d'une sclérodermie systémique.

BACKGROUND: The medical treatment of ischemic ulcers in patients with systemic sclerosis remains difficult. Despite the major help provided by vasodilator treatments, the risk of spontaneous or surgical amputation remains high. OBSERVATION: A 48-year-old female patient from Guadeloupe was treated in our department for diffuse systemic sclerosis present for 15 years complicated by lung, joint and digestive involvement, and associated with severe Raynaud's phenomenon. The clinical course was marked by the occurrence of multiple ischemic ulcers, which were resistant to conventional medical treatment and resulted in two surgical amputations (to the 2nd and 3rd interphalangeal joints of the toes of the left foot). Treatment with an endothelin-receptor antagonist and a calcium inhibitor was then introduced for secondary prevention. Two years later, the patient consulted for a further ischemic ulcer of the left 4th toe. She refused the proposed treatment with iloprost. Because of the unfavorable outcome and the absence of therapeutic alternative to amputation, hyperbaric oxygen therapy was initiated. Thirty 90-minutes sessions of pure oxygen at 2.5 ATA were conducted over a 10-week period. Complete healing was obtained after 8 months. DISCUSSION: We report herein a clinical case illustrating the efficacy of hyperbaric oxygen therapy for the treatment of ischemic ulcers of the toes in systemic sclerosis. It could offer an alternative therapeutic option, in particular for patients presenting resistant ischemic ulcers and a contraindication for or intolerance to the conventional medical treatment.

Penile ulceration caused by a foreign body reaction in a crew member on board a cruise ship.

A crew member had a foreign body implanted subcutaneously on his dorsum penis stealthily 6 years earlier by a fellow crew member without any medical training. He presented to the ship's medical centre after a week of pain, erythema and oedema over the foreign body, which was eventually removed by the patient, leaving behind a penile ulceration. He was treated conservatively initially with intravenous and then with oral antibiotics until complete secondary wound closure was achieved.

Endoscopic findings of gastrointestinal involvement in Chinese patients with Behcet's disease.

AIM: To report the incidence, clinical features and outcomes of gastrointestinal (GI) involvement in Behcet's disease (BD). METHODS: A total of 168 consecutive patients with BD were screened and upper and lower GI endoscopies were performed in 148 patients. Four hundred age- and sex-matched controls were enrolled for comparison. RESULTS: Fifty-two (35.1%) patients had GI lesions. After a mean follow-up of 10 mo, ileocecal ulcers had been confirmed in 20 patients, including active ulcer(s) in 18 patients, but no ileocecal ulceration was found in controls. GI symptoms were present in 14 patients with active ulcer(s), while 4 patients with smaller ulcer were asymptomatic. Endoscopic features of ileocecal ulcer were: a single ulcer (50%), larger than 1 cm in diameter (72.2%), and round/oval or volcano-type in shape (83.3%). Compared with patients without GI involvement, less ocular lesions, lower levels of albumin, erythrocyte count and hemoglobin, and higher levels of C-reactive protein and erythrocyte sedimentation rate were confirmed in the intestinal BD group. Four patients had esophageal ulcers in the BD group but no case in controls. The other endoscopic findings were similar between the two groups. The prevalence of Helicobacter pylori infection was similar in both groups. Most patients received an immunomodulator and responded well. CONCLUSION: GI lesions commonly occur in Chinese BD patients. The most frequently involved area is the ileocecal region. Esophageal ulcer might be a rare but unique lesion.

[Behçet's disease: clinical and demographic associations].

AIM: To comparatively study the clinical manifestations, sexual and HLA-B51 associations in patients with Behçet's disease (BD) in two ethnic groups. SUBJECTS AND METHODS: The authors examined 143 patients with the valid diagnosis of BED who were divided into 2 groups: 1) 85 patients, the dwellers of Dagestan (a multiethnic cohort), 63 men and 22 women (mean age 29 +/- 7.4 years); 2) 58 Russian men and women (mean age 33 +/- 11.7 years). RESULTS: Two major criteria for BD, such as aphthous stomatitis and external genital ulcers, were found with the same frequency. Panuveitis and angiitis of the retina were diagnosed more frequently in the Dagestani population with BD than in the Russians. Out of the minor criteria for BD, the incidence of lower limb deep venous thrombosis was 23% for the Dagestanis versus 3% for the Russians. Arterial thromboses and pulmonary artery aneurysms became causes of death in 4 in 5 men aged 19-23 years from their Dagestani ancestry. HLA B51 (B marker) was found in the dwellers of Dagestan: in 70% of the men and 40% of the women who had BD. CONCLUSION: BD runs a more severe course in male patients and is characterized by severe eye diseases and the systematic pattern of the process at young age. Gender-specific and genetic aspects call for further comparative investigations on large ethnic patient cohorts of other ancestries.

[Ulcerating tumor of the esophagus as a primary manifestation of extrapulmonary tuberculosis]. / Ulzeröser Tumor der Speiseröhre als Erstmanifestation einer extrapulmonalen Tuberkulose.

HISTORY AND ADMISSION FINDINGS: The patient, a 36-year-old man from Somalia, who had moved to Germany a year before, was referred for a diagnostic work-up of an ulcerating tumour. He suffered from thoracic tightness for the last weeks albeit without any further symptoms. There were no pre-existing illnesses. No further pathological signs were found during a preliminary physical examination. INVESTIGATIONS: After ruling out any malignancies by means of an analysis of biopsy samples, further differential diagnostic measures were undertaken. Besides mechanical and chemical factors, an infectious genesis of the esophageal lesion was considered and investigated further through histological, immunohistochemical, laboratory and microbiological tests. DIAGNOSIS, TREATMENT AND COURSE: Mycobacterium tuberculosis was detected in cultures sampled from biopsy material. This strain turned out to be responsive to medical treatment. Further diagnostics regarding a potential primary pulmonary tuberculosis were negative. Histological analysis of a liver biopsy confirmed noncaseating epithelioid cellular granuloma as typically seen in granulomatous hepatitis without any direct evidence of mycobacteria. Thus, tuberculosis of the liver appeared most likely considering the differential diagnosis of a granulomatous hepatitis. The patient underwent standard treatment using antituberculous drugs over six months. Endoscopic control after two months showed a significant reduction of the ulcerating lesion. CONCLUSION: Ulcerating tumors of the esophagus are primarily classified as potential malignancies. Crohn's disease is an important differential diagnosis. Apart from mechanical and chemical causes, infectious diseases should be taken into consideration. However, tuberculosis is one of the most relevant differential diagnoses, particularly in patients immigrating from TB-prone countries, pre-existing immune deficiency or environmentally induced elevated infection risk.

Herpes simplex virus infection in women in the WIHS: epidemiology and effect of antiretroviral therapy on clinical manifestations.

OBJECTIVE: To determine the prevalence of infection with herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) among women with and at high risk for HIV infection, and to evaluate the effect of HAART on the recurrence of genital lesions. METHODS: We evaluated the epidemiology and clinical manifestations associated with HSV-1 and HSV-2 among 1796 HIV-infected and 476 HIV-uninfected women enrolled in a multisite cohort study. Serum antibodies to HSV-1 and HSV-2 at baseline and self-reported history of genital herpes, reports of recent genital sores and presence of genital ulcers on examination, and use of HAART regimen at each study visit were analyzed. RESULTS: Reactivity to HSV-1 only and HSV-2 only was detected in 18% and 20% of HIV-infected, and in 28% and 18% of HIV-uninfected participants respectively; 58% of HIV-infected women and 45% of HIV-uninfected women were seropositive for both HSV types. Reactivity to HSV-2 was associated with increasing age, more male sexual partners, earlier sexual debut, African-American race, Latina ethnicity, less education and lower income. HIV-uninfected women reported significantly fewer genital sores than HIV-infected women who had used HAART for at least 1 year and had optimal CD4 cell gain and viral suppression (adjusted odds ratio (OR), 0.19; 95% confidence interval (CI), 0.13-0.28). CONCLUSION: Use of HAART and subsequent immune recovery does not completely eliminate the effect of HIV infection on genital lesions among women with concurrent HSV-2 infection.

Sexual behaviour in Zulu men and women with genital ulcer disease.

OBJECTIVE--To investigate patterns of sexual behaviour in men and women with genital ulcer disease (GUD) and their relevance to HIV-1 transmission. METHODS--A sexual behaviour questionnaire was administered by the same interviewer to all participants who were also entered into a study of the microbial aetiology of GUD. SETTING--City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 Zulu men and 100 Zulu women. RESULTS--36 (%) of men and 36 (%) of women had continued with sexual intercourse despite GUD. Patients with donovanosis and secondary syphilis were more likely than those with other causes of GUD to have intercourse despite ulcers. During swab collection bleeding was observed from ulcers in 59 women and 26 men. Prostitutes were not identified and were rarely named as source contacts. Men had more sexual partners (190) than women (122) during the previous three months. Condom use was minimal. Men who migrated between urban and rural areas appeared to have the most sexual partners. Urban women had more partners than women from rural areas. CONCLUSIONS--Men and women with GUD are practising riskful sexual behaviour and could benefit from behaviour modification programmes. In this community men who travel between urban and rural areas and who present late with GUD that bleeds easily are probably the most important high-frequency HIV transmitter core group. A significant potential risk of blood to blood contact during sexual intercourse exists in patients with GUD.

PIP: This study sought to investigate the patterns of sexual behavior in men and women with genital ulcer disease (GUD) and their relevance to HIV-1 transmission. Participants were 100 Zulu men and 100 Zulu women at the City Health Sexually Transmitted Disease Clinic. King Edward VIII Hospital, in Durban, South Africa; a sexual behavior questionnaire was administered by the same interviewer to all of the above participants who were also included in a study of the microbial etiology of GUD. 36% of the men and 36% of the women continued with sexual intercourse despite GUD. Patients with donovanosis and secondary syphilis were more likely than those with other causes for their GUD to have intercourse despite ulcers. During swab collection, bleeding was observed from ulcers in 59 women and 26 men. Prostitutes were not identified and were rarely named as source contacts. Men had more sexual partner (190) than women (122) during the previous 3 months. Condom use was minimal. Men who migrated between urban and rural areas appeared to have the most sexual partners. Urban women had more partners than women from rural areas. The authors concluded that men and women with GUD are practicing risky sexual behavior and could benefit from behavior modification programs. In this community, men who travel between rural and urban areas and who present late with GUD that bleeds easily are probably the most important high-frequency HIV transmitter core group. A significant potential risk of blood-to-blood contact during sexual intercourse exists in patients with GUD.

Multisystem disorder of Punjabi children exhibiting spontaneous dermal and submucosal granulation tissue formation: LOGIC syndrome.

We describe a multisystem disease that affects children of Muslim families originating in the Punjab region of Pakistan and India. An altered cry due to vocal cord thickening, skin ulceration, nail abnormalities, and conjunctival scarring appear in the first few months of life. Progression and spread of the disease in these sites may be accompanied by involvement of other epithelial surfaces. The teeth may exhibit defective enamel formation. Histology reveals the formation of simple granulation tissue arising in the dermis and submucosa which become massively thickened and ulcerated. There is good evidence for an autosomal recessive gene defect, but the actual mechanism of the disease is not known. Medical and surgical therapy have been ineffective in altering the course of this devastating and usually fatal condition. We suggest the term LOGIC (laryngeal and ocular granulation tissue in children from the Indian subcontinent) for this newly established disease.