Percutaneous endoscopic gastrostomy (PEG) is commonly performed for feeding difficulties, in patients suffering from complications of nasopharyngeal carcinoma and its treatment, namely radiotherapy and surgery. This case report describes the challenges in hemostasis and subsequent re-establishment of enteral access for feeding, in an elderly patient with a history of NPC, treated surgically, followed by radiotherapy, who presented with massive hematemesis following reinsertion of her PEG shortly after an accidental dislodgement. Her previous nasopharyngectomy, wide field radiation therapy, and radical neck dissection precluded nasogastric tube feeding, and the presence of a large hiatus hernia made reinsertion of a new PEG technically challenging. This case highlights the methods used to overcome the above challenges.
Aged ; Enteral Nutrition ; Esophageal Stenosis ; Gastrostomy ; Hematemesis ; Hemostasis ; Hernia, Hiatal ; Humans ; Intubation, Gastrointestinal ; Neck Dissection ; Radiotherapy ; Stomach Ulcer ; Ulcer

INTRODUCTIONWe investigated the 2005 outbreak of dengue fever (DF)/dengue haemorrhagic fever (DHF) to determine its epidemiological, virological and entomological features to further understand the unprecedented resurgence.

MATERIALS AND METHODSAll physician-diagnosed, laboratory-confirmed cases of DF/DHF notified to the Ministry of Health, Singapore during the outbreak as well as entomological and virological data were analysed retrospectively.

RESULTSA total of 14,006 cases of DF/DHF comprising 13,625 cases of DF and 381 cases of DHF, including 27 deaths were reported, giving an incidence rate of 322.6 per 100,000 and a case-fatality rate of 0.19%. The median age of the cases and deaths were 32 and 59.5 years, respectively. The incidence rate of those living in compound houses was more than twice that of residents living in public and private apartments. The distribution of DF/DHF cases was more closely associated with Aedes aegypti compared to Aedes albopictus breeding sites and the overall Aedes premises index was 1.15% (2.28% in compound houses and 0.33% to 0.8% in public and private apartments). The predominant dengue serotype was DEN-1. A significant correlation between weekly mean temperature and cases was noted. The correlation was strongest when the increase in temperature preceded rise in cases by a period of 18 weeks.

CONCLUSIONThe resurgence occurred in a highly densely populated city-state in the presence of low Aedes mosquito population. Factors contributing to this resurgence included lower herd immunity and change in dominant dengue serotype from DEN-2 to DEN-1. There was no evidence from gene sequencing of the dengue viruses that the epidemic was precipitated by the introduction of a new virulent strain. The current epidemiological situation is highly conducive to periodic dengue recurrences. A high degree of vigilance and active community participation in source reduction should be maintained.

Adult ; Aedes ; Animals ; Dengue ; epidemiology ; prevention & control ; transmission ; Dengue Virus ; immunology ; isolation & purification ; pathogenicity ; Disease Outbreaks ; Female ; Humans ; Immunity, Herd ; Incidence ; Insect Vectors ; Male ; Middle Aged ; Mosquito Control ; Primary Prevention ; methods ; Public Health ; Retrospective Studies ; Risk Factors ; Serotyping ; Singapore ; epidemiology