Period prevalence and mortality rates associated with hypocholesterolaemia in dogs and cats: 1,375 cases.

To determine the period prevalence of hypocholesterolaemia and the associated mortality rates in dogs and cats at a university teaching hospital. The secondary aim was to identify disease processes associated with hypocholesterolaemia. MATERIALS AND METHODS: Medical records over a 5-year period were reviewed to determine the severity of hypocholesterolaemia and its associated mortality rate. Medical records of animals with moderate to severe hypocholesterolaemia (<2.59 mmol/L in dogs, <1.81 mmol/L in cats) were analysed further. Animals with hospital-acquired hypocholesterolaemia were identified. RESULTS: Among 16,977 dogs and 3,788 cats that had at least one cholesterol measurement, the period prevalence of hypocholesterolaemia was 7.0% in dogs and 4.7% in cats. The mortality rate of hypocholesteraemic dogs and cats was 12% in both species which was significantly higher than that of animals with normal serum cholesterol. The degree of hypocholesterolaemia was significantly associated with mortality. Dogs, but not cats, with hospital-acquired hypocholesterolaemia had a higher mortality rate than those presenting with hypocholesterolaemia. Disease of hepatic, gastrointestinal and lymphoreticular systems were most commonly associated with hypocholesterolaemia, and infectious and neoplastic disease were the most commonly associated pathophysiologic processes in both species. Lymphoma was over-represented in dogs with neoplasia. CLINICAL SIGNIFICANCE: Hypocholesterolaemia is not a frequent abnormality but was associated with mortality in this study and may be a negative prognostic indicator. It is not known if hypocholesterolaemia is simply a marker for disease severity, or if it is has active physiologic effects contributing to poor outcomes.

Latent tuberculosis in patients with diabetes mellitus: prevalence, progression and public health implications.

BACKGROUND: Diabetes mellitus (DM) confers a higher risk for tuberculosis (TB). Yet, TB screening and chemoprophylaxis for latent TB infection (LTBI) in DM remains controversial. We conducted a cross-sectional study to elucidate LTBI prevalence and longitudinal follow-up to ascertain LTBI to active TB progression rate in DM. METHODS: 220 DM patients without previous TB from the outpatient diabetes clinic of the hospital were enrolled. T-Spot TB, tuberculin-skin-test (TST) and chest radiography (CXR) were performed. LTBI was defined by negative CXR with reactive T-Spot TB. Progression to active TB was confirmed by cross-checking against the TB registry. RESULTS: The prevalence of LTBI was 28.2% (62/220) by reactive T-Spot. None progressed to active TB from 2007-2013. Multivariate analysis revealed that any co-morbidity (p=0.016) was positively associated while metformin (p=0.008) was negatively associated with LTBI. CONCLUSIONS: Over a quarter of DM patients harbor LTBI. While the lack of demonstrable progression to active TB within the follow-up time frame up to this point does not unequivocally support a routine TB screening policy or anti-TB chemoprophylaxis for LTBI in a diabetic population for now, this preliminary evidence needs re-evaluation with longer follow-up of this enrolled cohort over the next decade.

Spray application of Bacillus thuringiensis israelensis (Bti strain AM65-52) against Aedes aegypti (L.) and Ae. albopictus Skuse populations and impact on dengue transmission in a dengue endemic residential site in Malaysia.

A one year study was conducted to evaluate the impact of spray application of Bacillus thuringiensis israelensis (Bti), strain AM65-52 on vector populations and dengue transmission in a dengue endemic state in Malaysia. Residential sites with similar populations of Aedes aegypti (L.) and Aedes albopictus Skuse were studied. One site was treated with spray application of Bti into all outdoor target vector habitats, which consisted of natural and artificial containers. The other site was not treated. The impact of spray application was measured with an indoor and outdoor ovitrap index (OI) and epidemiologic data. Significant reductions in both Ae. aegypti and Ae. albopictus, OI were observed both indoors and outdoors, in treated sites compared to untreated sites (p < 0.05). OI reduction was achieved over time in the treated area. The OI was suppressed to below 10%. This was maintained for 4 weeks into the post-treatment phase. The outdoor OI at the untreated site remained at more than 40% for 38 weeks during the evaluation period. One dengue case occurred at the Bti treatment site at the beginning of the treatment phase, but no further cases were detected during the remainder of the treatment phase. However, there was an ongoing dengue outbreak in the untreated area with 15 serologically confirmed cases during weeks 37-54. Intensive fogging operations with pyrethroids at the untreated (Bti) site had a positive impact on Ae. albopictus, but not on Ae. aegypti.

Characterization of the inflammatory cell infiltrate in herald patches and fully developed eruptions of pityriasis rosea.

BACKGROUND: Pityriasis rosea (PR) is a common cutaneous papulosquamous disorder affecting young adults. Previous studies have suggested possibilities of a viral aetiology and the involvement of cell-mediated immunity, but these remain unproven to date. AIM: To elucidate the possible pathomechanisms in PR by characterizing the inflammatory cellular infiltrate in herald patches and fully developed PR eruptions. METHODS: In total, 12 biopsy specimens from 6 patients diagnosed with PR were examined. For each patient, biopsies were taken from both a herald patch and a secondary patch. Specimens were processed for histopathological examination and immunohistochemical staining with a large panel of monoclonal antibodies. RESULTS: Histopathologically, all specimens showed epidermal changes such as parakeratosis, orthokeratosis, epidermal hyperplasia and spongiosis. Less common results included epidermal exocytosis and focal parakeratosis. In all biopsies, the dermal infiltrate of lymphocytes stained positively for monoclonal antibodies specific for T cells. The ratio of the CD4+ (helper) vs. CD8+ (cytotoxic) T cells in the dermal infiltrate was increased in most specimens. Increased staining for Langerhans cells was seen within the dermis of lesional skin. There were no marked differences found in histopathology and immunohistochemistry between the herald patch and secondary lesions. Overall, there was a lack of natural killer cell and B-cell activities in PR lesions. CONCLUSIONS: Our results support a predominantly T-cell mediated immunity in the development of PR.

Enhanced expression of interferon-inducible protein-10 correlates with disease activity and clinical manifestations in systemic lupus erythematosus.

Our objective was to investigate the serum levels of interferon-inducible protein-10 (IP-10) in systemic lupus erythematosus (SLE) and their correlation with disease activity and organ manifestations. Serum IP-10 levels were assessed in 464 SLE patients and 50 healthy donors. Disease activity was assessed by the revised SLE Activity Measure, and the concomitant active organ manifestations, anti-ds DNA antibody titres, complement levels and erythrocyte sedimentation rates recorded. Peripheral blood mononuclear cell (PBMC) synthesis of IP-10 in SLE patients and controls was determined by in vitro cultures stimulated with mitogen or lipopolysaccharide. Elevated serum IP-10 levels were observed in SLE patients, which were significantly higher in the presence of active haematological and mucocutaneous manifestations. SLE PBMCs exhibited enhanced spontaneous IP-10 production in vitro. Serial IP-10 levels correlated with longitudinal change in SLE activity, even at low levels where anti-dsDNA antibody and complement levels remain unchanged. These data demonstrate that IP-10 levels are increased in SLE and serum IP-10 may represent a more sensitive marker for monitoring disease activity than standard serological tests.

Scrotal pyoderma gangrenosum associated with Crohn's disease.

Scrotal pyoderma gangrenosum is uncommon. We present a 17-year-old Chinese male patient with newly diagnosed Crohn's disease presenting with scrotal pyoderma gangrenosum. Biopsy and other investigations were done to diagnose and look for associated diseases of pyoderma gangrenosum. Treatment with high-dose prednisolone failed. Subsequent treatment with oral cyclosporine was successful.

Drug interactions in dermatological practice.

Systemic drugs are increasingly used in the treatment of dermatological diseases. Due to the high prevalence of polypharmacy, dermatologists are increasingly faced with the complex problem of drug interaction. Unlike adverse drug reactions, which are often unpredictable, drug interactions can be avoided. This article presents the significant drug interactions that are encountered in clinical practice, with the interactions categorized into those involving antimicrobials, immunosuppressants, antimalarials and colchicine, retinoids and psychiatric medications. There are few commonly used drugs that often cause drug interactions. These include ciclosporin, azole antifungal drugs, erythromycin, sulfonamides and rifampicin, and dermatologists should be alert whenever encountering them. A section on interactions of drugs with health supplements, herbs and food is also included, in view of the increasing use of alternative and complementary therapies in many parts of the world.

Community-based study of acne vulgaris in adolescents in Singapore.

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.

Ocular manifestations and complications of Stevens-Johnson syndrome and toxic epidermal necrolysis: an Asian series.

BACKGROUND: To describe the acute and late ocular manifestations and complications in toxic epidermal necrosis (TEN) and Stevens-Johnson syndrome (SJS), and identify predictors for development of late complications. METHODS: Cases of TEN and SJS during a 9-year period were included. Patients with ocular involvement were reviewed for acute ocular complications. Patients with a minimum 6 months follow-up were reviewed for late complications. Records were reviewed for their demographics, etiology, and severity of ocular involvement. RESULTS: There were 117 patients with a mean age of 52.2 +/- 18.6 years. Eighty-one of these (69%) had acute ocular involvement. This was mild in 40%, moderate in 25% and severe in 4%. Adverse drug reactions were the predominant cause. Patients with thrombocytopenia had more severe acute ocular involvement. Forty-four patients had a minimum 6 months of follow-up and half developed late complications. Severe dry eyes and trichiatic lashes were the commonest late complications. Patients treated with topical antibiotic were more likely to have late complications, particularly dry eyes. There was no difference in the severity of acute eye involvement or late complications when SJS and TEN patients were compared. The severity of the acute ocular disease and abnormal laboratory tests were not found to be the significant risk factors of late complications. CONCLUSIONS: Ocular involvement is common in SJS and TEN and can be severe and blinding. The severity of acute ocular complications does not predict late complications. The diagnosis of TEN does not imply a more severe ocular involvement or increased frequency of late ocular complications compared with SJS. Care should be taken even in mild cases. Appropriate intervention during acute ocular disease may prevent late complications.

Sweet's syndrome: a spectrum of unusual clinical presentations and associations.

BACKGROUND: Sweet's syndrome (SS) is the prototypic neutrophilic dermatosis. First described in 1964, the characterization of new clinical associations, unique histopathological findings and clinical variants have stimulated much interest and discussion recently. However, the prevalence of these unusual variants and clinical associations within a single cohort of patients, has not been described. OBJECTIVES: To describe and evaluate the prevalence of unusual clinical and histopathological features, as well as the clinical associations of SS seen in patients from the National Skin Centre, Singapore. METHODS: This is a retrospective study of all consecutive cases of SS seen at our centre over a 5.5-year period (June 1999-December 2004). Data on associated systemic diseases was obtained from the medical records and matched with information from the National Cancer Registry, Singapore. Patients not actively followed up for more than 3 months were contacted for their updated health status. RESULTS: Thirty-seven patients were identified. Ten (27%) had non-idiopathic SS. These were associated with haematological disorders, connective tissue disorders, infections or a drug. Twenty-nine patients (78%) had at least one atypical clinical or histopathological feature. Atypical clinical features included bullous lesions, SS with hand involvement or neutrophilic dermatoses of the hands and the concomitant existence of subcutaneous SS with pyoderma gangrenosum. SS was the presenting feature in three patients with infections caused by atypical organisms, including Mycobacterium chelonae, Penicillium species and Salmonella type D. Unique histopathological variants included subcutaneous SS and lesions containing an admixture of mature and immature neutrophils. Subcutaneous neutrophilic inflammation seemed to be more common in patients with an underlying haematological disorder. This group of patients also had a lower mean haemoglobin level. CONCLUSIONS: Unusual clinical and histopathological variants of SS described in the literature are similarly encountered in our cohort of patients, with some features being more common than others. We highlight and discuss some unique clinical and histopathological observations seen in our patients with SS.

Trigeminal trophic syndrome: an unusual cause of a non-healing cheek ulcer.

Trigeminal trophic syndrome (TTS) is an uncommon condition characterised by anaesthesia, paraesthesias and ala nasi ulceration, following peripheral or central damage to the trigeminal nerve. Only about 100 cases have been described in the literature to date. We report a 74-year-old woman who presented with a right cheek ulcer accompanied by pruritus and paraesthesia for three months. An old right cerebellar infarct was demonstrated on magnetic resonance imaging of the brain. Vertebrobasilar insufficiency leading to the cerebellar infarct is likely to have predisposed her to developing TTS. An underlying infectious, malignant and vasculitic cause for the ulcer was excluded by a skin biopsy. An increased awareness of the predisposing factors and clinical presentations of this important disfiguring condition is necessary to ensure prompt diagnosis and treatment.

Distinguishing fall activities from normal activities by angular rate characteristics and high-speed camera characterization.

Distinguishing sideways and backward falls from normal activities of daily living using angular rate sensors (gyroscopes) was explored in this paper. Gyroscopes were secured on a shirt at the positions of sternum (S), front of the waist (FW) and right underarm (RU) to measure angular rate in lateral and sagittal planes of the body during falls and normal activities. Moreover, the motions of the fall incidents were captured by a high-speed camera at a frame rate of 250 frames per second (fps) to study the body configuration during fall. The high-speed camera and the sensor data capture system were activated simultaneously to synchronize the picture frame of high-speed camera and the sensor data. The threshold level for each sensor was set to distinguish fall activities from normal activities. Lead time of fall activities (time after threshold value is surpassed to the time when the hip hits the ground) and relative angle of body configuration (angle beta between the vertical line and the line from the center point of the foot or the center point between the two legs to that of the waist) at the threshold level were studied. For sideways falls, lead times of sensors at positions FW and S were about 200-220ms and 135-182ms, respectively. The lead time of the slippery backward fall (about 98ms) from the sensor at position RU was shorter than that of the sideways falls from the sensors at positions FW and S. The relative angle of body configuration at threshold level for sideways and backward falls were about 40-43 degrees for the sensor at position FW, about 43-52 degrees for the sensor at position S and about 54 degrees for the sensor at position RU, respectively. This is the first study that investigates fall dynamics in detection of fall before the person hits the ground using angular rate sensors (gyroscopes).

Synthesis of enantiopure (5R)-hydroxyhexane-2-one with immobilised whole cells of Lactobacillus kefiri.

Whole-cell reduction of (2,5)-hexanedione to yield highly enantiopure (5R)-hydroxyhexane-2-one (enantiomeric excess >99%) with Lactobacillus kefiri DSM 20587 was investigated. Cell immobilisation with sodium cellulose sulphate was chosen as the most suitable encapsulation matrix, giving an immobilisation yield of 40%. Despite the lowered biocatalytic activity from cell immobilisation, the bioreduction process was vastly improved with the help of reaction engineering techniques (batch to a plug flow reactor set-up). High selectivity (95%) and space-time yield (87 g L(-1) day(-1)) were achieved in the plug flow reactor. The biocatalyst remained active (68% residual activity) after 6 days of operation.

Experience with ARRAY multifocal lenses in a Singapore population.

INTRODUCTION: To evaluate the clinical efficiency, safety and subjective visual outcomes of multifocal intraocular lenses (IOL) in the Singapore population. METHODS: This is a retrospective case series of 45 phacoemulsification with multifocal lens implantation performed in 27 patients for cataracts, over a two-year period. The efficacy, stability and safety of the lens were assessed up to six months of follow-up. A telephone interview enquiring about ratings of vision, spectacle independence, glare, driving difficulty and photic phenomena, was conducted and the results were compared with those published in the literature. RESULTS: The best corrected distance Logmar acuity was 0.1 (0.1 and near visual acuity was N5 (range N5 to N8) at six months. The distance visual acuity stabilised by one month whereas near vision remained unchanged from day one post-surgery. Posterior capsular opacification was seen in 17 patients (38.6 percent) of which two patients (4.55 percent) required YAG capsulotomy. Total spectacle independence was achieved in 12 patients (54.4 percent). Among those who required spectacles, 50 percent required spectacles more than 50 percent of the time. Five patients (22.7 percent) reported glare usually at night (80 percent) as compared with daytime glare (20 percent). The most common photic phenomena report after surgery was halo. CONCLUSION: The Advanced Medical Optics ARRAY multifocal IOL showed good efficacy, predictability, stability and safety. The subjective visual outcomes in the Singapore population were comparable to those of their Western counterparts.

High-dose intravenous immunoglobulin in the treatment of toxic epidermal necrolysis: a study of ocular benefits.

PURPOSE: To compare acute ocular complications of toxic epidermal necrolysis (TEN) following treatment with high-dose human intravenous immunoglobulin (IVIG) with a historical cohort not treated with IVIG. METHODS: Retrospective, historically controlled study. In all, 10 consecutive patients with TEN (treatment cohort) presenting between 1 July 2001 and 30 June 2002. Totally, 18 consecutive patients with TEN (historical cohort). SettingTan Tock Seng Hospital, Singapore. The treatment cohort received high-dose IVIG (2 g/kg body weight over 2 days). Patients' records were retrospectively reviewed for their demographic characteristics, causative drug, treatment, ocular involvement (if any, as assessed by an ophthamologist), and its severity. The historical cohort comprised patients coded with a diagnosis of TEN (ICD Code 695.1) between 1 July 1995 and 30 June 2001. RESULTS: Nine (90%) of 10 patients treated with IVIG had ocular involvement. Phenytoin was the implicated drug in three (37.5%) patients. Of the nine patients, 1 died of septic shock. Of the eight survivors, IVIG was initiated immediately upon onset of TEN as all the patients were hospitalized by the time of onset of an exanthema. Acute ocular complications were mild in two (25%) (lid oedema or mild conjunctival injection), moderate in four (50%) (pseudomembranes) and severe in two (25%) (nonhealing epithelial defect with visual loss and symblepharon). In total, 10 (55.6%) of 18 patients in the historical cohort with TEN had acute ocular involvement. Two patients died. Ocular involvement in survivors was mild in five (62.5%) cases and moderate in three (37.5%), with no severe cases. CONCLUSIONS: IVIG did not appear to reduce the severity of visually significant ocular complications. Larger studies are needed to confirm this finding.

A case of nephrogenic fibrosing dermopathy.

INTRODUCTION: Nephrogenic fibrosing dermopathy is a recently recognised fibrosing disorder originally identified as a scleromyxoedema-like cutaneous disease in patients with renal disease. CLINICAL PICTURE: A 45-year-old lady with systemic lupus erythematosus presented with well-defined erythematous, non-tender, indurated plaques on both legs 4 months after haemodialysis for rapidly progressive glomerulonephritis and acute renal failure. Skin biopsy showed dermal fibrosis with increased proliferation of dermal fibroblasts and collagen bundles separated by clefts. There were increased dermal deposits of mucin and an increase in elastic fibres. TREATMENT AND OUTCOME: Haemodialysis was instituted for 2 weeks followed by monthly intravenous cyclophosphamide. Skin lesions remained unchanged 8 months later despite normalisation of renal function. CONCLUSION: Nephrogenic fibrosing dermopathy appears to be a definite new entity in patients with underlying renal insufficiency. Further multi-centre collaborative study is necessary to identify the prevalence, cause, treatment and prognosis of this disorder.

Cyclosporin in the treatment of severe atopic dermatitis: a retrospective study.

INTRODUCTION: The aims of this study were to determine the clinical profile of patients with atopic dermatitis who were treated with cyclosporin, and to assess the treatment duration, dose and response to cyclosporin therapy. MATERIALS AND METHODS: Casenotes of patients with atopic dermatitis treated with cyclosporin from January 2000 to February 2002 were analysed. RESULTS: There were 15 patients (9 males and 6 females) (age range, 1 to 58 years). All had severe disease. The mean initiating dose of cyclosporin was 2.8 mg/kg/day and the mean maximum dose was 3.3 mg/kg/day. Average duration of treatment was 6 months. Rapid improvement was seen within the first 2 weeks and maximum benefit was attained at a mean of 10 weeks. At the end of treatment, 73 % of patients had improved from severe to none, mild or moderate disease. Five patients had a flare of eczema during therapy, 3 related to decrease in dose of medication. All patients relapsed within 3 months of cessation of cyclosporin. One patient with borderline hypertension developed worsening of blood pressure, which returned to baseline after cessation of cyclosporin and treatment with atenolol. No patient had sustained rises in serum creatinine. CONCLUSION: Cyclosporin is very useful in patients with severe, recalcitrant atopic dermatitis who have failed conventional therapy. It offers rapid relief of an otherwise disabling skin disease, but its effect is not long-lasting and relapses occur in almost all cases if followed up for long enough.