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.

A case report of duplex gallbladder and review of the literature.

Gallbladder duplication is a rare congenital abnormality first described by Boyden in 1926. Pre-operative diagnosis is essential in identifying anatomical abnormalities in order to avoid biliary injuries at the time of surgery or performance of an incomplete operation. We present a case of a duplex gallbladder and review of the literature.

Distal antral gastropexy - a novel technique to prevent recurrence of giant hiatus hernia in selected cases - a cohort study.

INTRODUCTION: The recurrence rate of giant hiatus hernias (GHH) following repair is high (30%) and increases with the hernia size and previous revision surgery. The mechanism of recurrence is poorly understood. METHODS: This is a retrospective cohort study of all consecutive patients who underwent repair of giant hiatus hernia in a tertiary upper GI referral centre from November 2000 to November 2014. Patients who underwent redo surgery were identified and data on intra-operative findings and procedure performed at primary and redo surgery from their operation notes were collected. RESULTS: A total of 81 patients underwent primary repair of GHH over the 14 year study period. 10 (12.3%) had symptomatic/radiological recurrence of which 4 were found to have the distal stomach herniating into the chest despite having an intact intra-abdominal wrap/gastropexy. To prevent migration of the distal stomach into the chest, distal gastropexy - fixing the antrum to the anterior abdominal wall, was added to 'conventional' gastropexy in 5 subsequent cases, in whom the antrum was in the chest preoperatively. These cases have no evidence of recurrence at the end of 6 months follow up. CONCLUSION: Securing the antrum of stomach to the anterior abdominal wall may prevent migration of the distal stomach and other infracolic organs into the chest and thus reduce recurrence of some GHH where antrum had been in chest previously.

DNA fingerprinting of human isolates of Salmonella enterica serotype Paratyphi B in Malaysia.

AIMS: DNA fingerprinting of Salmonella enterica serotype Paratyphi B isolated in Malaysia during 1982-83, 1992 and 1996-2002 was carried out by pulsed-field gel electrophoresis (PFGE), antimicrobial susceptibility tests and D-tartrate utilization tests to assess the extent of genetic diversity of these isolates in Malaysia. METHODS AND RESULTS: Eighty-six human isolates and one food isolate of Salm. Paratyphi B were analysed by PFGE, antimicrobial susceptibility tests and D-tartrate utilization tests. Sixty-five strains were D-tartrate-negative (dT-) while 22 strains were D-tartrate-positive (dT+). Thirty-seven per cent of the Salm. Paratyphi B strains were resistant to one or more antimicrobial agents. PFGE analysis clearly distinguished the dT- and dT+ strains into two clusters based on the unweighted pair group average method (UPGMA). Twenty-two XbaI-pulsotypes were observed among the 65 dT- strains while 17 XbaI-pulsotypes were observed among the 22 isolates of Salm. Paratyphi B dT+. CONCLUSIONS: The present study showed that PFGE was very discriminative with 33.7% of the strains yielding distinct fingerprints. Paratyphoid fever in Malaysia is probably caused by one predominant, endemic clone of Salm. Paratyphi B dT- with various subtypes. There was no association between the pulsotypes and the severity of the disease indicating that the severity of the disease is probably multifactorial. SIGNIFICANCE AND IMPACT OF THE STUDY: The findings of the present study verify the usefulness of PFGE in characterizing strains of Salm. Paratyphi B. This is the first report on the application of PFGE on a large collection of Salm. Paratyphi B in Malaysia.

Genetic diversity of clinical and environmental strains of Salmonella enterica serotype Weltevreden isolated in Malaysia.

The incidence of food-borne salmonellosis due to Salmonella enterica serotype Weltevreden is reported to be on the increase in Malaysia. The pulsed-field gel electrophoresis (PFGE) subtyping method was used to assess the extent of genetic diversity and clonality of Salmonella serotype Weltevreden strains from humans and the environment. PFGE of XbaI-digested chromosomal DNA from 95 strains of Salmonella serotype Weltevreden gave 39 distinct profiles with a wide range of Dice coefficients (0.27 to 1.00), indicating that PFGE is very discriminative and that multiple clones of Salmonella serotype Weltevreden exist among clinical and environmental isolates. Strains of one dominant pulsotype (pulsotype X1/X2) appeared to be endemic in this region, as they were consistently recovered from humans with salmonellosis between 1996 and 2001 and from raw vegetables. In addition, the sharing of similar PFGE profiles among isolates from humans, vegetables, and beef provides indirect evidence of the possible transmission of salmonellosis from contaminated raw vegetables and meat to humans. Furthermore, the recurrence of PFGE profile X21 among isolates found in samples of vegetables from one wet market indicated the persistence of this clone. The environment in the wet markets may represent a major source of cross-contamination of vegetables with Salmonella serotype Weltevreden. Antibiotic sensitivity tests showed that the clinical isolates of Salmonella serotype Weltevreden remained drug sensitive but that the vegetable isolates were resistant to at least two antibiotics. To the best of our knowledge, this is the first study to compare clinical and environmental isolates of Salmonella serotype Weltevreden in Malaysia.

Genetic diversity of Salmonella enterica serovar Paratyphi A from different geographical regions in Asia.

AIMS: Subtyping of Salmonella Paratyphi A isolates from India, Pakistan, Indonesia and Malaysia was carried out by pulsed-field gel electrophoresis (PFGE) to assess the extent of genetic diversity of these isolates from different endemic countries. METHODS AND RESULTS: A total of 39 human isolates of Salmonella Paratyphi A from Pakistan, India, Indonesia and Malaysia were studied using PFGE analysis following digestion of chromosomal DNA with XbaI. Seven isolates from Pakistan were resistant to ampicillin, tetracycline and cotrimoxazole. It was noted that Salmonella Paratyphi A isolates obtained from outbreaks in India had limited genetic diversity and probably belonged to closely related clones. Significant genetic homogeneity was observed among antimicrobial-resistant isolates from Pakistan and antimicrobial-sensitive isolates from Pakistan and Indonesia, respectively. CONCLUSIONS: PFGE was a useful subtyping technique to differentiate Salmonella Paratyphi A from different endemic countries. However, it fails to differentiate the antimicrobial-resistant and -sensitive strains. SIGNIFICANCE AND IMPACT OF THE STUDY: The findings of the present study verify the usefulness of PFGE in characterizing and comparing strains of Salmonella Paratyphi A. Our study suggests that a limited number of clones are responsible for paratyphoid fever in these countries.

Application of ribosomal RNA gene restriction patterns analysis and pulsed-field gel electrophoresis in distinguishing Salmonella weltevreden isolates in Malaysia.

A representative sample of 20 isolates of Salmonella weltevreden strains from stool cultures of patients admitted at the University Hospital, Kuala Lumpur, Malaysia were analyzed. All the strains were susceptible to ampicillin, ceftriaxone, ciprofloxacin, chloramphenicol, tetracycline, trimethoprim, gentamicin and co-trimoxazole. Ribosomal RNA gene restriction pattern analysis of PstI-digested DNA gave three ribotypes while pulsed-field gel electrophoresis (PFGE) analysis of XbaI-digested DNA gave ten distinct profiles. PFGE was more discriminative than ribotyping in distinguishing the strains. The majority of the strains analyzed were very closely related with similarity coefficient values ranging from 0.8 to 1.0. Both PFGE and ribotyping could distinguish one of the strains which was obtained from a patient following a bone marrow transplant for beta-thalassemia major, indicating that this particular strain was unrelated to the rest of the strains from patients with acute gastroenteritis.