Diagnostic Errors ; prevention & control ; Emergency Service, Hospital ; Humans ; Severe Acute Respiratory Syndrome ; diagnosis ; World Health Organization

Amphotericin B ; therapeutic use ; Antifungal Agents ; therapeutic use ; Fever ; Histoplasma ; Histoplasmosis ; diagnosis ; drug therapy ; microbiology ; pathology ; Humans ; Jaundice ; Male ; Middle Aged

Cross Infection ; microbiology ; therapy ; Drug Resistance, Multiple, Fungal ; Fungi ; classification ; drug effects ; isolation & purification ; Humans ; Mycoses ; microbiology ; therapy ; Patient Care Management ; methods ; Singapore

INTRODUCTIONThis study objectively evaluates the effectiveness of a 6-week Preparatory Training Phase (PTP) programme prior to Basic Military Training (BMT) for less physically conditioned conscripts in the Singapore Armed Forces.

MATERIALS AND METHODSWe compared exercise test results of a group of less fi t recruits who underwent a 16-week modified-BMT (mBMT) programme (consisting of a 6-week PTP and 10-week BMT phase) with their 'fitter' counterparts enlisted in the traditional 10-week direct-intake BMT (dBMT) programme in this prospective cohort study consisting of 36 subjects. The main outcome measures included cardiopulmonary responses parameters (VO(2)max and V(O2AT)) with clinical exercise testing and distance run timings.

RESULTSAlthough starting off at a lower baseline in terms of physical fitness [VO(2)max 1.73 +/- 0.27 L/min (mBMT group) vs 1.97 +/- 0.43 L/min (dBMT), P = 0.032; V(O2AT) 1.02 +/- 0.19 vs 1.14 +/- 0.32 L/min respectively, P = 0.147], the mBMT group had greater improvement in cardiopulmonary indices and physical performance profiles than the dBMT cohort as determined by cardiopulmonary exercise testing [VO(2)max 2.34 +/- 0.24 (mBMT) vs 2.36 +/- 0.36 L/min (dBMT), P = 0.085; V(O2AT) 1.22 +/- 0.17 vs 1.21 +/- 0.24 L/min respectively, P = 0.303] and 2.4 kilometres timed-run [mBMT group 816.1 sec (pre-BMT) vs 611.1 sec (post-BMT), dBMT group 703.8 sec vs 577.7 sec, respectively; overall P value 0.613] at the end of the training period. Initial mean difference in fitness between mBMT and dBMT groups on enlistment was negated upon graduation from BMT.

CONCLUSIONPre-enlistment fitness stratification with training modification in a progressive albeit longer BMT programme for less-conditioned conscripts appears efficacious when measured by resultant physical fitness.

Adolescent ; Asian Continental Ancestry Group ; Body Mass Index ; Cohort Studies ; Exercise Test ; statistics & numerical data ; Humans ; Male ; Military Personnel ; statistics & numerical data ; Oxygen Consumption ; Physical Education and Training ; methods ; standards ; Physical Fitness ; Program Evaluation ; Prospective Studies ; Risk Assessment ; Running ; physiology ; Singapore ; Time Factors ; Young Adult

There have been recent descriptions of the novel coronavirus disease 2019 (COVID-19) presenting as ‘varicella-like exanthem’. We report three cases of patients with VaricellaZoster Virus (VZV) and COVID-19 co-infections, presenting in three varied ways. These cases highlight the need for heightened alertness to how such co-infections can present, to pick up overlapping ‘dual pathologies’ during this current pandemic given that infection control measures including airborne precautions are crucial for both COVID-19 and VZV.

There have been recent descriptions of the novel coronavirus disease 2019 (COVID-19) presenting as ‘varicella-like exanthem’. We report three cases of patients with VaricellaZoster Virus (VZV) and COVID-19 co-infections, presenting in three varied ways. These cases highlight the need for heightened alertness to how such co-infections can present, to pick up overlapping ‘dual pathologies’ during this current pandemic given that infection control measures including airborne precautions are crucial for both COVID-19 and VZV.

INTRODUCTIONFebrile neutropenia (FN) is a significant cause of mortality and morbidity in oncology and haematology units worldwide. The overall mortality in hospital surveys in Singapore surveys on post-chemotherapy FN has ranged between 3.0% and 8.8%. However, recent evidence indicates that outpatient management of patients with low-risk FN is safe and cost-effective.

MATERIALS AND METHODSWe conducted a prospective audit on a cohort of adult patients with post-chemotherapy FN seen at 2 local public sector cancer centres over a 1-year period in order to define their epidemiological characteristics and outcomes, and also to assess the uptake of early discharge/outpatient management strategies for these patients.

RESULTSWe reviewed 306 FN episodes from 248 patients. Patient characteristics and outcomes were similar between both institutions. Eleven (3.7%) FN episodes were managed as outpatient and none developed complications. Overall 30-day mortality was 6.6%, while the median length of stay (LOS) was 7 days (IQR: 4 to 11 days). The only independent risk factor for mortality was severe sepsis (OR:13.19; 95% CI: 1.98 to 87.7; P = 0.008). Factors independently associated with a longer LOS were vancomycin prescription (coefficient: 0.25; 95% CI: 0.08 to 0.41; P = 0.003), longer duration of intravenous antibiotics (coefficient: 0.08; 95% CI: 0.06 to 0.10; P <0.001), and prior review by an infectious diseases physician (coefficient: 0.16; 95% CI: 0.01 to 0.31; P = 0.034).

CONCLUSIONThis audit demonstrated that mortality from FN in our 2 cancer centres is low and comparable to international institutions. It also demonstrates that outpatient management of FN is safe in selected patients, and can be further expanded for right-siting of resources.

Adult ; Anti-Bacterial Agents ; therapeutic use ; Antineoplastic Agents ; adverse effects ; Bacterial Infections ; epidemiology ; Cohort Studies ; Female ; Fever ; epidemiology ; etiology ; Humans ; Male ; Middle Aged ; Mycoses ; epidemiology ; Neoplasms ; complications ; drug therapy ; Neutropenia ; epidemiology ; etiology ; Prospective Studies ; Singapore ; epidemiology

INTRODUCTIONInstitutional febrile neutropenia (FN) management protocols were changed following the finding of a high prevalence of ceftazidime-resistant Gram-negative bacteraemia (CR-GNB) among haematology patients with FN. Piperacillin/tazobactam replaced ceftazidime as the initial empirical antibiotic of choice, whereas carbapenems were prescribed empirically for patients with recent extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae colonisation/infection. An audit was conducted to determine the impact of these changes.

METHODSData from all FN episodes between October 2008 and December 2010 were collected prospectively, with mid-November 2009 demarking the transition between pre-intervention and intervention periods. Outcomes measured included 30-day mortality post-development of FN and the presence of CR-GNB.

RESULTSThere were 427 FN episodes (200 in the pre-intervention period) from 225 patients. The prevalence of CRGNB was 10.3%, while the 30-day mortality was 4.7%, with no difference between pre-intervention and intervention periods. Independent risk factors for 30-day mortality included the presence of active haematological disease, vancomycin prescription and older age. Independent factors associated with initial CR-GNB were profound neutropenia, the presence of severe sepsis and active haematological disease. Recent ESBL-producing Enterobacteriaceae colonisation/infection was not predictive of subsequent CR-GNB (positive predictive value 17.3%), whereas a model based on independent risk factors had better negative predictive value (95.4%) but similarly poor positive predictive value (21.4%), despite higher sensitivity.

CONCLUSIONA change in the FN protocol did not result in improved outcomes. Nonetheless, the audit highlighted that empirical carbapenem prescription may be unnecessary in FN episodes without evidence of severe sepsis or septic shock, regardless of previous microbiology results.

Academic Medical Centers ; Adult ; Bacteremia ; complications ; drug therapy ; Carbapenems ; therapeutic use ; Ceftazidime ; pharmacology ; Drug Resistance, Multiple ; Febrile Neutropenia ; complications ; drug therapy ; Female ; Gram-Negative Bacteria ; Humans ; Male ; Middle Aged ; Penicillanic Acid ; administration & dosage ; analogs & derivatives ; Piperacillin ; administration & dosage ; Prevalence ; Prospective Studies ; Risk Factors ; Sepsis ; Singapore ; Treatment Outcome ; Universities

INTRODUCTIONSingapore saw a resurgence of dengue infections in 2005. Concurrent bacterial co-infections in dengue is rare.

CLINICAL PICTUREWe report a cluster of serious methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia or severe soft tissue infection in 5 epidemiologically linked construction workers presenting with dengue and non-resolving fever.

TREATMENTSurgical intervention was indicated in 4 of the 5 patients despite appropriate antistaphylococcal therapy.

OUTCOMEAll but 1 patient were eventually discharged. Clonality and Panton-Valentine leucocidin genes were not demonstrated. Epidemiological investigations suggested that occupational contact dermatitis could have predisposed the patients to this opportunistic co-infection.

CONCLUSIONClinicians need to be vigilant to unusual manifestations of dengue which may signal a concomitant aetiology.

Adult ; Cluster Analysis ; Dengue ; complications ; epidemiology ; Humans ; Male ; Methicillin ; pharmacology ; Occupations ; Singapore ; epidemiology ; Soft Tissue Infections ; transmission ; Staphylococcal Infections ; complications ; epidemiology ; therapy ; transmission ; Staphylococcal Skin Infections ; transmission ; Staphylococcus aureus ; drug effects