Upper Respiratory Tract Infection Trends in a Psychiatric Institute in Singapore.

OBJECTIVES: To compare the incidence of upper respiratory tract infection (URTI) between inpatients at the Institute of Mental Health in Singapore and the general population over 8 years to determine the effectiveness of our infection control strategies. METHODS: Data for cases of influenza and URTI at our institute between January 2012 and December 2019 were collected. National data were derived from weekly infectious disease bulletins that report daily averages of people attending polyclinics/surgeries with influenza and URTI. Interrupted time series analyses were used to determine the impact of infection prevention and control strategies on incidence. RESULTS: Over the 8 years, there were 1607 cases of URTI involving 182 clusters, equal to 3.16 cases per 10 000 patient-bed-days. 965 (60%) cases and 95 (52%) clusters occurred in long-stay wards, whereas 642 (40%) cases and 87 (48%) clusters occurred in acute wards. The median cluster size was 12 in the long-stay wards and 7 in the acute wards (p < 0.0001). The spikes in cases in June and December may be attributed to the increased staff and visitor mobility during school vacations in June and December. Strategies implemented during the study period did not significantly reduce the incidence of URTI. Previous strategies implemented in 2005 to meet accreditation standards are more likely to be contributors. CONCLUSION: Infection control strategies of our institute appear to be effective, because the incidence of URTI was lower in our institute than in the community. The similar incidence of URTI in acute and long-stay wards indicates that service-user turnover is not a contributor. Rather, staff and visitors are more likely to be the vector. The larger clusters in long-stay wards indicates a greater risk of transmission in such settings. Increased activity in our institute during school vacations may be associated with an increase in cases in June and December. It is difficult to determine if strategies implemented during the study period successfully reduce the incidence of URTI.

Reducing Injury During Restraint by Crisis Intervention in Psychiatric Wards in Singapore.

OBJECTIVE: The application of restraints during psychiatric crises is a serious adverse event. We aimed to reduce the number of injuries sustained by patients during the application of restraints. METHODS: Structured interviews were conducted with 10 staff to determine six root causes of patient injury during restraint. Three plan-do-study-act cycles were implemented: (1) reorganising shift rosters to pair trained staff with inexperienced staff, (2) holding monthly session for practising de-escalation and restraint techniques as a team in a supervised setting, and (3) rotating the responsibility for leading the de-escalation in real crises. RESULTS: Pre-intervention period was from January 2014 to December 2014 (28 251 inpatient bed days). Intervention period was from January 2015 to March 2015 (7121 inpatient bed days). Post-intervention period was from April 2015 to December 2016 (51 735 inpatient bed days). Data extracted included the dates and numbers of crises, activation of the crisis team, use of restraints, and injuries. During pre-intervention and intervention periods, only two minor and three moderate injuries were recorded. During post-intervention period, no injury was recorded and the number of restraints decreased gradually although the number of crisis team activations increased in the early phase. Eventually restraints were used only upon arrival of the crisis team. CONCLUSION: Our quality improvement project identified six root causes and implemented three plan-do-study-act cycles to successfully eliminated patient injuries during the use of restraints.

Increasing the Continuity of Care between Primary Care Provider and a Psychiatric Hospital in Singapore.

INTRODUCTION: People who have a mental illness and who are stable on their current treatment may be suitable for follow-up care with a community-based general practitioner. A general practitioner-partnership programme was designed in an institute in Singapore to facilitate the transition to community services. However, the rates of successful referrals were low. METHODS: Our study followed the format of a quality improvement project, and used administrative data from April 2014 to June 2016 to gauge the impact of the interventions chosen to improve uptake of referrals. Three potential areas of improvement were found based on interviews with 25 service users. RESULTS: During the 11 months of pre-intervention period (April 2014 to February 2015), 64% of potentially suitable service users (152 of 238 referrals) transitioned to community services. Low transition was linked to 3 identified causes and consequently, case managers developed personalised financial counselling for service users, assisted in the application for financial supports, and dispelled misconceptions about service provider inability to treat mental illness. Over the 16 months of intervention period (March 2015 to June 2016), the follow-up rate for referrals rose to 92% (260 / 283 referrals). CONCLUSION: Given that financial support entitlements change, it is important for case managers to remain aware of changing policy. Misconceptions of service provider qualifications may have a great impact on service user's willingness to seek services from primary care providers.

Hybrid procedure for orbital venous malformation in the endovascular operation room.

PURPOSE: To describe a hybrid procedure for orbital venous malformation in the endovascular operating room (EVOR). METHODS: Five consecutive patients with venous malformation in the periocular and orbital region were included. All patients received a one-stage direct puncture venogram, image-guided glue injection, and surgical resection in the EVOR equipped with a biplane digital subtraction angiography system (BDSAS). RESULTS: The mean age at the time of operation was 37.4 years (range, 22-69 years). The mean operative time was 193 min (range, 138-324 min). No intraoperative complications were noted. The mean follow-up duration was 18.8 months (range, 10-24 months). Three patients had complete removal of the vascular lesions. At the latest follow-up, no recurrence of symptoms related to the lesions was noted. All patients had an uneventful recovery and satisfactory outcome. CONCLUSIONS: The hybrid procedure of orbital venous malformation in the EVOR is a novel application in ophthalmology. It is a safe and well-controlled procedure with real-time high-quality BDSAS surveillance to facilitate surgical resection. Its success requires collaboration between the interventional radiologist, the surgeon, and the ophthalmologist.

Omega-3 fatty acids in the management of autism spectrum disorders: findings from an open-label pilot study in Singapore.

The goal of this open-label trial was to examine the efficacy and safety of a 12-week omega-3 fatty acids supplementation among children suffering with Autism Spectrum Disorders (ASD). A total of 41 children and adolescents aged 7-18 years (36 boys, 5 girls; mean age = 11.66, s.d. = 3.05) diagnosed with ASD participated in the study. At post-treatment, participants showed significant improvements on all subscales of the Social Responsiveness Scale (P < 0.01) and the Social and Attention Problems syndrome scales of the Child Behavior Checklist (P < 0.05). Blood fatty acid levels were significantly correlated with changes in the core symptoms of ASD. Baseline levels of blood fatty acid levels were also predictive of response to the omega-3 treatment. Omega-3 fatty acids supplementation was well-tolerated and did not cause any serious side effects. Our findings lend some preliminary support for the use of omega-3 fatty acids supplementation in addressing ASD. Future randomized controlled trials of omega-3 fatty acids in ASD with blood fatty acid measurements with a larger sample and longer follow-up period is warranted.

Ultrafine particle emissions from essential-oil-based mosquito repellent products.

UNLABELLED: Ultrafine particle (UFP) emissions from three essential-oil-based mosquito repellent products (lemon eucalyptus (LE), natural insects (NI), and bite shield (BS)) were tested in a 386 l chamber at a high air exchange rate of 24/h with filtered laboratory air. Total particle number concentration and size distribution were monitored by a condensation particle counter and a scanning mobility particle sizer, respectively. UFPs were emitted from all three products under indoor relevant ozone concentrations (~ 17 ppb). LE showed a nucleation burst followed by a relatively stable and continuous emission while the other two products (NI and BS) showed episodic emissions. The estimated maximum particle emission rate varied from 5.4 × 10(9) to 1.2 × 10(12) particles/min and was directly related to the dose of mosquito repellent used. These rates are comparable to those due to other indoor activities such as cooking and printing. The emission duration for LE lasted for 8-78 min depending on the dose applied while the emission duration for NI and BS lasted for 2-3 h. PRACTICAL IMPLICATIONS: Certain essential-oil-based mosquito repellents can produce high concentrations of UFPs when applied, even at low ozone levels. Household and personal care products that contain essential oil may need to be tested at indoor relevant ozone levels to determine their potential to increase personal UFP exposures.

Comparison of 3 agar media in Fung double tubes and Petri plates to detect and enumerate Clostridium spp. in broiler chicken intestines.

Clostridium perfringens is an anaerobic, spore-forming bacterium that may lead to necrotic enteritis, resulting in poor feed efficiency and increased mortality in chickens. It is estimated that C. perfringens infects almost 1 million people in the United States every year. The objective of this research was to compare the Fung double tube (FDT) and conventional Petri plates using 3 different media to detect and enumerate Clostridium spp. in chicken intestines. Nine Cobb 500 broilers were randomly selected and euthanized at 21 and 42 d of age for a total of 18 samples. The jejunum and ileum from each broiler were harvested and studied in 2 methods and 3 media combinations, utilizing a 2 × 3 factorial totaling 6 treatments. The 2 methods were FDT and conventional Petri plates, and the 3 media were Shahidi-Ferguson Perfringens (SFP) with egg yolk supplement, polymyxin B, and kanamycin (E); SFP with polymyxin B and kanamycin (P); and SFP with d-cycloserine (C). Enumerations were performed after 24 h of incubation at 37°C. At 21 d, counts using medium C with FDT (4.51 log10 cfu/g) and plates (2.38 log10 cfu/g) were higher (P < 0.05) than using media E or P. On d 42, there were no differences among plate treatments and medium E had the highest counts (0.98 log10 cfu/g). Of all the FDT, medium C (5.35 log10 cfu/g) had the highest counts (P < 0.05), followed by medium P (3.54 log10 cfu/g). This study illustrates that the FDT method is able to enumerate Clostridium spp. at higher levels (P < 0.001) than the conventional Petri plate method; therefore, the FDT should be implemented and further explored.

Ministry of Health clinical practice guidelines: depression.

The Ministry of Health (MOH) have updated the clinical practice guidelines on Depression to provide doctors and patients in Singapore with evidence-based treatment for depression. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Depression, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/home/Publications/guidelines/cpg/2012/depression.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Ministry of Health clinical practice guidelines: schizophrenia.

The Ministry of Health (MOH) has updated the clinical practice guidelines on Schizophrenia to provide doctors and patients in Singapore with evidence-based treatment for schizophrenia. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Schizophrenia, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov. sg/mohcorp/publications.aspx?id=26138. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Effects of cognitive-behavioural therapy on anxiety for children with high-functioning autistic spectrum disorders.

INTRODUCTION: Children with autistic spectrum disorders (ASD) often exhibit one or more comorbid disorders, including anxiety, disruptive behaviour, mental retardation, and depression. Various studies have documented the effectiveness of cognitive-behavioural therapy (CBT) in treating children with anxiety. Although studies have indicated a high prevalence of anxiety in individuals with ASD, there is a lack of systematic studies substantiating the effectiveness of cognitive-behavioural interventions among children with high-functioning autism. METHODS: This pilot study investigated the effects of a 16-session CBT programme on six high-functioning children diagnosed with ASD (mean age 11.50 years, standard deviation 0.84 years). These children were diagnosed with ASD or Asperger's syndrome by the DSM-IV criteria. Measures on levels of child's anxiety, parental and teacher stress were administered at pre- and post-treatment. RESULTS: Children showed lower levels of anxiety at post-treatment. Parents and teachers also reported lower levels of stress following the CBT programme. CONCLUSION: Findings from the present study provided some evidence of the effects of CBT for high-functioning autistic children in reducing anxiety, parental and teacher stress. Interpretation of the findings, recommendations for future research and implications of the present study are presented.

Case report: Denys- Drash syndrome.

BACKGROUND: Denys-Drash Syndrome (DDS) is an uncommon disorder that appears sporadically and in rare cases may be inherited as an autosomal dominant trait It manifests either at birth or within the first year of life and typically consists of the triad of congenital nephropathy, Wilms tumour and intersex disorder. CASE REPORT: A 10 year-old Caucasian girl was referred to the Dental Department, at Glasgow Royal Hospital for Sick Children by her Paediatric Nephrologist Consultant. The patient was being teased by her peers over her markedly discoloured teeth. The dental history revealed that the patient was a regular dental attendee from an early age. She was dentally anxious having only experienced dental treatment under general anaesthesia (GA) when she was 4 years old. Apparently her primary dentition also showed a generalised discolouration. TREATMENT: This consisted of multiple visits for diet analysis and tooth brushing instruction with the use of disclosing tablets. Plaque control significantly improved when using a battery operated toothbrush because of its larger handle which the patient found easier to use and a 0.05% sodium fluoride mouthwash was given for daily use. Dyract(AP) veneers directly bonded onto maxillary permanent incisors and mandibular permanent anterior teeth was carried out. This was an interim measure to improve the patient's appearance while assessing the patient co-operation. The compomer facings were replaced with BelleGlass NG veneers which were cemented onto the maxillary incisors and mandibular anterior teeth using Adhesive By Choice (ABC) system under rubber dam on two separate visits. FOLLOW-UP: At her last visit, 27 months after treatment, the patient was still satisfied with the restorative treatment. However, further teeth had erupted including all the premolars. BelleGlass NG crowns were indicated. It was also decided to replace the preformed chrome cobalt crowns with full coverage BelleGlass NG crowns.

Emotional and behavioural problems in Singaporean children based on parent, teacher and child reports.

INTRODUCTION: This study aims to determine the prevalence of emotional and behavioural problems in a community sample of Singaporean children aged 6-12 years, and its agreement according to parent, teacher and child reports. METHODS: The Child Behaviour Checklist (CBCL), Teacher Rating Form (TRF) and child report questionnaires for depression and anxiety were administered to a community sample of primary school children. 60 percent of the children sampled (n = 2,139) agreed to participate. Parents of a sub-sample of 203 children underwent a structured clinical interview. RESULTS: Higher prevalence of emotional and behavioural problems was identified by CBCL (12.5 percent) than by TRF (2.5 percent). According to parent reports, higher rates of internalising problems (12.2 percent) compared to externalising problems (4.9 percent), were found. Parent-teacher agreement was higher for externalising problems than for internalising problems. Correlations between child-reported depression and anxiety, and parent and teacher reports were low to moderate, but were better for parent reports than for teacher reports. CONCLUSION: The prevalence rates of emotional and behavioural problems in Singaporean children based on CBCL ratings are comparable to those in the West, but the low response rate and exclusion of children with special needs limit the generalisability of our findings. Singaporean children have higher rates of internalising problems compared to externalising problems, while Western children have higher rates of externalising problems compared to internalising problems.

The dental health and preventative habits of cardiac patients attending the Royal Hospital for Sick Children Glasgow.

AIM: To assess the dental health and preventive practices of child patients with congenital heart disease treated at the Royal Hospital for Sick Children, Glasgow. STUDY DESIGN: A retrospective study using an audit data collection sheet. METHODS: Data collected for 370 paediatric cardiac patients between January 2002 and December 2003 was analysed to obtain an insight into these patients' tooth brushing methods, use of fluoride (F), dental attendance and past dental treatment. An oral examination assessed the patient's caries experience. RESULTS: There were 195 subjects aged between 1 and 5 years, 105 were 6 - 11 years and 70 were 12 -16 years of whom 291 (78%) children were registered for dental care. Of these children 331 (90%) maintained that they brushed their teeth regularly with F- toothpaste. Experience of dental treatment revealed that 132 (36%) children had undergone previous dental treatment. Oral examination showed that out of 370 patients, 236 (64%) had no active caries. The dental health of the cardiac subjects was poor compared with that of Scottish primary school children (5 year-olds) and the 12 year-olds but compared favourably with the 14-year old group. STATISTICS: The relationship between caries activity and frequency of toothbrushing was significant (p<0.01). The relationship between caries activity and attendance for dental care was not significant. CONCLUSION: Children with cardiac problems should be identified in early infancy through liaison with medical colleagues and the family offered all the preventive advice and regular dental care necessary to prevent dental disease.

Combined treatment of therapeutic laser and herbal application improves the strength of repairing ligament.

The present study investigated the effects of combined therapeutic laser and herbal medication protocols on injured medial collateral ligaments (MCLs) of rat knees. Fully 36 rats were evenly divided into 9 groups. Right MCLs of groups 1 to 6 and 8 were transected, while that of groups 7 and 9 remained intact. After surgery, group 1 was treated with 1 session of high-dosed laser; group 2 with 9 sessions of low-dosed laser; group 3 with an herbal plaster; groups 4 and 5 received combined treatments of groups 1 and ss and 2, and 3 respectively; groups 6 and 7 received only bandaging; groups 8 and 9 received placebo laser and no treatment, respectively. All MCLs were subjected to biomechanical testing at 3 weeks postsurgery. Results revealed significant differences among groups in ultimate tensile strength (UTS) and stiffness (p < 0.01). Combination of multiple low-dosed laser treatment with herbal treatment (group 5) resulted in higher UTS than either no treatment (groups 6 and 8), single high-dosed laser treatment (group 1), multiple low-dosed laser treatment (group 2), or herbal treatment (group 2) alone. We concluded that combined applications of laser and herb can enhance further biomechanical properties of repairing rat MCLs than separate applications at 3 weeks postinjury.

Herbal remedies improve the strength of repairing ligament in a rat model.

Herbal remedies have been reported to be effective in controlling inflammation for acute soft tissue injuries. There exist, however, no reports of their effects on collagen production and remodeling; thus mechanical strength studies of the tissues have not been reported. This study tested the effects of a herbal remedy on the strength of healing medial collateral ligaments (MCL) in rats. Sixteen rats receiving surgical transection to their right MCLs and eight receiving sham operation were tested. Eight of the MCL-injured animals were treated with an adhesive herbal plaster application to their right knees, while the other eight in the MCL injured group and the sham group were treated with plain adhesive plaster to their right knees. The MCLs were harvested and tested at either 3 or 6 weeks post-operation. The ultimate tensile strength (UTS) and stiffness normalized to the uninjured side of each animal of the herb and sham groups were significantly larger than those of the control at both 3 and 6 weeks (p = 0.001). No significant difference was found in stiffness between the herb and sham groups (p > 0.05). We concluded that the herbal remedy improves the UTS and stiffness of repairing MCLs at 3 and 6 weeks after injury.

Antibacterial effect of water-soluble tea extracts on foodborne pathogens in laboratory medium and in a food model.

The microbial inhibition of foodborne pathogens was determined in brain heart infusion broth with 10% (wt/vol) water-soluble extracts of green, jasmine, black, dungglre, and oolong tea against Escherichia coli O157:H7, Salmonella enterica serovar Enteritidis, Listeria monocytogenes, and Staphylococcus aureus. The mixed culture (approximately 6.0 log CFU/ml), which was composed of the four pathogens, was inoculated into brain heart infusion broth with and without tea extracts. After incubation at 35 degrees C for 0, 1, 3, and 5 days, proper dilution of each sample was spiral plated on each selective agar. Viable cell counts were performed after incubation at 35 degrees C for 24 to 36 h. Green, jasmine, and black tea exhibited an approximately 5.0 log suppression of S. aureus compared with the control from days 1 to 5. Green and jasmine tea also suppressed the growth of L. monocytogenes by approximately 3.0 log CFU/ml on day 5. In contrast, no tea extracts inactivated E. coli O157:H7 and Salmonella Enteritidis. Based on the result in liquid medium, green and jasmine teas of 0.1% (vol/wt) were individually evaluated for their antimicrobial activity against L. monocytogenes and S. aureus in a food model (ground beef) stored at 7 degrees C for 0, 1, 3, 5, and 7 days. Viable cell counts of total bacteria, L. monocytogenes, and S. aureus in ground beef were not significantly different among green and jasmine tea and the control.

Missing C, supplemental D and supplemental premolar all in one quadrant: a case report.

This case report describes a non-syndromic Caucasian patient who presented with a missing upper right primary canine and a supplemental upper right primary first molar. Later, a supplemental premolar developed in the upper right quadrant. The report highlights the importance of early diagnosis of dental anomalies and a multidisciplinary approach to treatment planning. A regular review and radiographic examination are essential.

Running exercises improve the strength of a partially ruptured Achilles tendon.

OBJECTIVES: To examine the effects of running and swimming exercises on the functional performance and mechanical strength of a recovering Achilles tendon. METHODS: 30 Sprague-Dawley rats had surgical transection of their right medial Achilles tendon. The rats were divided into running (n = 11), swimming (n = 10), and control (n = 9) groups. The running and swimming groups were given daily exercise training, starting from the fifth day after the injury; the control group did not exercise throughout the period of the experiment. An Achilles functional index (AFI) was recorded before the operation and on the third, 10th, and 30th days after the operation. On the 30th day, the rats were killed and their Achilles tendons harvested for biomechanical testing of load relaxation properties, stiffness, and ultimate tensile strength (UTS). The AFI data were analysed by two way analysis of variance; load relaxation, stiffness, and UTS data were analysed by multivariate analysis, with alpha at 0.05. RESULTS: The UTS of the running group was higher than in the control group (p = 0.015), while there was no significant difference between the swimming and control groups (p = 0.228). Differences in stiffness and load relaxation were non-significant (p = 0.823 and 0.633, respectively). The AFI results did not differ among the three groups (p = 0.242). CONCLUSIONS: Running exercises can improve the strength of partially ruptured Achilles tendons at 30 days after injury.

Antibacterial effect of crude water-soluble arrowroot (Puerariae radix) tea extracts on food-borne pathogens in liquid medium.

AIMS: To evaluate the effect of crude water-soluble arrowroot tea extracts on microbial growth of food-borne pathogens in liquid medium and to confirm the damage to bacterial cells using Transmission Electronic Microscopy (TEM). METHODS AND RESULTS: Inhibition of growth of Escherichia coli O157:H7, Salmonella enterica serovar Enteritidis, Listeria monocytogenes and Staphylococcus aureus was investigated using Brain Heart Infusion (BHI) broth containing 0 (control), 0.63, 1.25, 2.5 and 5.0% (w/v) arrowroot tea. Bacterial cell counts were performed on specific selective agar on days 0, 1, 3 and 5. BHI containing 5.0% arrowroot tea extract showed a 6-7 log suppression of growth for all test strains on days 3 and 5, compared with the control. Even 0.63% arrowroot tea effectively inhibited microbial growth of all test strains on day 5. TEM images of the samples treated with 5.0% arrowroot tea revealed the rupture of cell walls and nonhomogeneous disposition of cytoplasmic materials within treated bacteria. CONCLUSIONS: Crude water-soluble arrowroot tea extract strongly inhibited microbial growth of all test pathogens in liquid medium. SIGNIFICANCE AND IMPACT OF THE STUDY: Water-soluble arrowroot tea extract has the potential to be used directly on foods or as a spray on the surfaces of food handling and processing facilities in order to prevent microbial growth of both Gram-negative and Gram-positive bacteria.