Effectiveness of mindfulness-based interventions on the well-being of healthcare workers: a systematic review and meta-analysis

Background

Growing evidence attests to the efficacy of mindfulness-based interventions (MBIs), but their effectiveness for healthcare workers remains uncertain.

Aims

To evaluate the evidence for MBIs in improving healthcare workers' psychological well-being.

Methods

A systematic literature search was conducted on Medline, Embase, Cumulative Index for Nursing and Allied Health Literature, PsycINFO and Cochrane Central Register of Controlled Trials up to 31 August 2022 using the keywords 'healthcare worker', 'doctor', 'nurse', 'allied health', 'mindfulness', 'wellness', 'workshop' and 'program'. Randomised controlled trials with a defined MBI focusing on healthcare workers and quantitative outcome measures related to subjective or psychological well-being were eligible for inclusion. R V.4.0.3 was used for data analysis, with the standardised mean difference as the primary outcome, employing DerSimonian and Laird's random effects model. Grading of Recommendations, Assessment, Development and Evaluation framework was used to evaluate the quality of evidence. Cochrane's Risk of Bias 2 tool was used to assess the risk of bias in the included studies.

Results

A total of 27 studies with 2506 participants were included, mostly from the USA, involving various healthcare professions. MBIs such as stress reduction programmes, apps, meditation and training showed small to large effects on anxiety, burnout, stress, depression, psychological distress and job strain outcomes of the participants. Positive effects were also seen in self-compassion, empathy, mindfulness and well-being. However, long-term outcomes (1 month or longer postintervention) varied, and the effects were not consistently sustained.

Conclusions

MBIs offer short-term benefits in reducing stress-related symptoms in healthcare workers. The review also highlights limitations such as intervention heterogeneity, reduced power in specific subgroup analyses and variable study quality.

PROSPERO registration number

CRD42022353340.

Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support

BACKGROUND

It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems.

METHODS

A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems.

RESULTS

The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others.

CONCLUSIONS

Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

The impact of elective surgery postponement during COVID-19 on emergency bellwether procedures in a large tertiary centre in Singapore

The coronavirus disease 2019 (COVID-19) pandemic drove many healthcare systems worldwide to postpone elective surgery to increase healthcare capacity, manpower, and reduce infection risk to staff. The aim of this study was to assess the impact of an elective surgery postponement policy in response to the COVID-19 pandemic on surgical volumes and patient outcomes for three emergency bellwether procedures. A retrospective cohort study of patients who underwent any of the three emergency procedures [Caesarean section (CS), emergency laparotomy (EL), and open fracture (OF) fixation] between 1 January 2018 and 31 December 2021 was conducted using clinical and surgical data from electronic medical records. The volumes and outcomes of each surgery were compared across four time periods: pre-COVID (January 2018-January 2020), elective postponement (February-May 2020), recovery (June-November 2020), and postrecovery (December 2020-December 2021) using Kruskal-Wallis test and segmented negative binomial regression. There was a total of 3886, 1396, and 299 EL, CS, and OF, respectively. There was no change in weekly volumes of CS and OF fixations across the four time periods. However, the volume of EL increased by 47% [95% confidence interval: 26-71%, P = 9.13 × 10-7) and 52% (95% confidence interval: 25-85%, P = 3.80 × 10-5) in the recovery and postrecovery period, respectively. Outcomes did not worsen throughout the four time periods for all three procedures and some actually improved for EL from elective postponement onwards. Elective surgery postponement in the early COVID-19 pandemic did not affect volumes of emergency CS and OF fixations but led to an increase in volume for EL after the postponement without any worsening of outcomes.

Going beyond compliance: A qualitative study of the practice of surgical safety checklist

BACKGROUND

The World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices.

METHODS

Direct observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them.

RESULTS

Two broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory.

CONCLUSION

Ritualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

Scoping review of the second victim syndrome among surgeons: Understanding the impact, responses, and support systems

BACKGROUND

It is thought that 50% of healthcare providers experience Second Victim Syndrome (SVS) in the course of their practice. The manifestations of SVS varies between individuals, with potential long-lasting emotional effects that impact both the personal lives and professional clinical practice of affected persons. Although surgeons are known to face challenging and high-stress situations in their profession, which can increase their vulnerability to SVS, majority of studies and reviews have focused squarely on nonsurgical physicians.

METHODS

This scoping review aimed to consolidate existing studies pertaining to a surgeon's experience with SVS, by broadly examining the prevalence and impact, identifying the types of responses, and evaluating factors that could influence these responses. The scoping review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Three databases (MEDLINE, EMBASE and Cochrane Library) were searched from inception till March 19, 2023.

RESULTS

A total of 13 articles were eligible for thematic analysis based on pre-defined inclusion criteria. Effects of SVS were categorized into Psychological, Physical and Professional impacts, of which Psychological and Professional impacts were particularly significant. Factors affecting the response were categorized into complication type, surgeon factors and support systems.

CONCLUSION

SVS adds immense psychological, emotional and physical burden to the individual surgeon. There are key personal, interpersonal and environmental factors that can mitigate or exacerbate the effects of SVS, and greater emphasis needs to be placed on improving availability and access to services to help surgeons at risk of SVS.

Transforming Team Performance Through Reimplementation of the Surgical Safety Checklist

Importance

Patient safety interventions, like the World Health Organization Surgical Safety Checklist, require effective implementation strategies to achieve meaningful results. Institutions with underperforming checklists require evidence-based guidance for reimplementing these practices to maximize their impact on patient safety.

Objective

To assess the ability of a comprehensive system of safety checklist reimplementation to change behavior, enhance safety culture, and improve outcomes for surgical patients.

Design, Setting, and Participants

This prospective type 2 hybrid implementation-effectiveness study took place at 2 large academic referral centers in Singapore. All operations performed at either hospital were eligible for observation. Surveys were distributed to all operating room staff.

Intervention

The study team developed a comprehensive surgical safety checklist reimplementation package based on the Exploration, Preparation, Implementation, Sustainment framework. Best practices from implementation science and human factors engineering were combined to redesign the checklist. The revised instrument was reimplemented in November 2021.

Main Outcomes and Measures

Implementation outcomes included penetration and fidelity. The primary effectiveness outcome was team performance, assessed by trained observers using the Oxford Non-Technical Skills (NOTECH) system before and after reimplementation. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to assess safety culture and observers tracked device-related interruptions (DRIs). Patient safety events, near-miss events, 30-day mortality, and serious complications were tracked for exploratory analyses.

Results

Observers captured 252 cases (161 baseline and 91 end point). Penetration of the checklist was excellent at both time points, but there were significant improvements in all measures of fidelity after reimplementation. Mean NOTECHS scores increased from 37.1 to 42.4 points (4.3 point adjusted increase; 95% CI, 2.9-5.7; P < .001). DRIs decreased by 86.5% (95% CI, -22.1% to -97.8%; P = .03). Significant improvements were noted in 9 of 12 composite areas on culture of safety surveys. Exploratory analyses suggested reductions in patient safety events, mortality, and serious complications.

Conclusions and Relevance

Comprehensive reimplementation of an established checklist intervention can meaningfully improve team behavior, safety culture, patient safety, and patient outcomes. Future efforts will expand the reach of this system by testing a structured guidebook coupled with light-touch implementation guidance in a variety of settings.

Trade-Offs between Vaccine Effectiveness and Vaccine Safety: Personal versus Policy Decisions

OBJECTIVE

We aimed to investigate whether individuals' trade-offs between vaccine effectiveness and vaccine safety vary if they are asked to consider the perspective of a policymaker making decisions for others compared with the decisions they would make for themselves.

METHOD

A web-enabled discrete choice experiment survey was administered between 1 April and 1 May 2022 to participants recruited from the general population of two Southeast Asian countries (Indonesia and Vietnam). In each country, 500 participants were randomly assigned to make decisions regarding coronavirus disease 2019 (COVID-19) vaccines for others as a policymaker or in a personal capacity for their own use. Vaccines were characterized by three attributes: (1) effectiveness of the vaccine in reducing infection rate; (2) effectiveness of the vaccine in reducing hospitalization among those infected; and (3) risk of death from vaccine-related serious adverse events. A mixed logit model was utilized for analyses.

RESULTS

Based on the attributes and levels used in this study, the most important vaccine attribute was the risk of death from vaccine-related adverse events, followed by effectiveness in reducing infection rate and hospitalizations. Compared with personal decisions, the mean probability of choosing a vaccine was (1) lower, and (2) more sensitive to the changes in risk of death from adverse events in policy decisions (p ≤ 0.01).

CONCLUSIONS AND RELEVANCE

Our results suggest that, in the face of an infectious disease pandemic, individuals are likely to be more risk-averse to vaccine-related deaths when making decisions for others as a policymaker than they would for themselves.

Knowledge, attitudes and practices towards COVID-19 among multiethnic elderly Asian residents in Singapore: a mixed-methods study

Introduction

We investigated the knowledge, attitudes and practice (KAP) towards coronavirus disease 2019 (COVID-19) and its related preventive measures in Singaporeans aged ≥60 years.

Methods

This was a population-based, cross-sectional, mixed-methods study (13 May 2020-9 June 2020) of participants aged ≥ 60 years. Self-reported KAP about ten symptoms and six government-endorsed preventive measures related to COVID-19 were evaluated. Multivariable regression models were used to identify sociodemographic and health-related factors associated with KAP in our sample. Associations between knowledge/attitude scores and practice categories were determined using logistic regression. Seventy-eight participants were interviewed qualitatively about the practice of additional preventive measures and data were analysed thematically.

Results

Mean awareness score of COVID-19 symptoms was 7.2/10. The most known symptom was fever (93.0%) and the least known was diarrhoea (33.5%). Most participants knew all six preventive measures (90.4%), perceived them as effective (78.7%) and practised 'wear a mask' (97.2%). Indians, Malays and participants living in smaller housing had poorer mean scores for knowledge of COVID-19 symptoms. Older participants had poorer attitudes towards preventive measures. Compared to Chinese, Indians had lower odds of practising three out of six recommendations. A one-point increase in score for knowledge and attitudes regarding preventive measures resulted in higher odds of always practising three of six and two of six measures, respectively. Qualitative interviews revealed use of other preventive measures, for example, maintaining a healthy lifestyle.

Conclusions

Elderly Singaporeans displayed high levels of KAP about COVID-19 and its related preventive measures, with a positive association between levels of knowledge/attitude and practice. However, important ethnic and socioeconomic disparities were evident, indicating that key vulnerabilities remain, which require immediate attention.

A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore

PURPOSE

In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs.

METHODS

We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS.

RESULTS

1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0 days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6 days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001).

CONCLUSION

Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.

Battling against the great disruption to surgical care in a pandemic: experiences of 11 South and Southeast Asian countries

OBJECTIVES

The majority of the cancelled elective surgeries caused by the COVID-19 pandemic globally were estimated to occur in low- and middle-income countries (LMICs), where surgical services had long been in short supply even before the pandemic. Therefore, minimising disruption to existing surgical care in LMICs is of crucial importance during a pandemic. This study aimed to explore contributory factors to the continuity of surgical care in LMICs in the face of a pandemic.

DESIGN

Semistructured interviews were conducted over zoom with surgical leaders of 25 tertiary hospitals from 11 LMICs in South and Southeast Asia in September to October 2020. Key themes were subsequently identified from the interview transcripts using the Braun and Clarke's method of thematic analysis.

RESULTS

The COVID-19 pandemic affected all surgical services of participating institutions to varying degrees. Overall, elective surgeries suffered the gravest disruption, followed by outpatient surgical care, and finally emergency surgeries. Keeping healthcare workers safe and striving for continuity of essential surgical care emerged as notable response strategies observed across all participating institutions.

CONCLUSION

This study suggested that four factors are important for the resilience of surgical care against COVID-19: adequate COVID-19 testing capacity and effective institutional infection control measures, designated COVID-19 treatment facilities, whole-system approach to balancing pandemic response and meeting essential surgical needs, and active community engagement. These findings can inform healthcare institutions in other countries, especially LMICs, in their effort to tread a fine line between preserving healthcare capacity for pandemic response and protecting surgical services against pandemic disruption.

Creating a high-performance surgical safety checklist: A multimodal evaluation plan to reinvigorate the checklist

RATIONALE, AIMS, AND OBJECTIVES

The WHO Surgical Safety Checklist is a communication tool designed to improve surgical safety processes and enhance teamwork. It has been widely adopted since its introduction over ten years ago. As surgical safety needs evolve, organizations should periodically review and update their checklists. A holistic evaluation of the checklist in the context of an organization is the first step to making informed updates. In this article, we describe a comprehensive but feasible strategy for checklist evaluation which we developed and implemented as part of a surgical safety initiative in a high-performing center.

METHODS

A three-part evaluation plan was developed and carried out by a multidisciplinary team. The evaluation included assessment of 1. Quality of care through a review of surgical safety events; 2. Safety culture through a validated survey and informal feedback; and 3. Checklist performance through direct observations and a staff survey. To prepare for re-implementation the current institutional checklist was critically evaluated and a context assessment survey was administered to surgical staff.

RESULTS

The evaluation revealed challenges in communication and teamwork, with surgical staff often perceived to be working in silos. The quality of care assessment indicated room for improvement in safety processes. Deficiencies in the safety culture measures of communication and feedback shed light on an overall lack of engagement with the checklist. Checklist performance demonstrated good adherence to the items on the checklist but limited engagement by the surgical team and minimal communication between subteams. These findings informed our revisions to the checklist and its implementation processes.

CONCLUSIONS

We developed and implemented a comprehensive, scalable approach to checklist evaluation which directly informed improvements to the checklist that were tailored to the organization's current context. Organizations can apply this framework to breathe new life into their checklist and transform their safety culture.

Development and testing of a multi-lingual Natural Language Processing-based deep learning system in 10 languages for COVID-19 pandemic crisis: A multi-center study

Purpose

The COVID-19 pandemic has drastically disrupted global healthcare systems. With the higher demand for healthcare and misinformation related to COVID-19, there is a need to explore alternative models to improve communication. Artificial Intelligence (AI) and Natural Language Processing (NLP) have emerged as promising solutions to improve healthcare delivery. Chatbots could fill a pivotal role in the dissemination and easy accessibility of accurate information in a pandemic. In this study, we developed a multi-lingual NLP-based AI chatbot, DR-COVID, which responds accurately to open-ended, COVID-19 related questions. This was used to facilitate pandemic education and healthcare delivery.

Methods

First, we developed DR-COVID with an ensemble NLP model on the Telegram platform (https://t.me/drcovid_nlp_chatbot). Second, we evaluated various performance metrics. Third, we evaluated multi-lingual text-to-text translation to Chinese, Malay, Tamil, Filipino, Thai, Japanese, French, Spanish, and Portuguese. We utilized 2,728 training questions and 821 test questions in English. Primary outcome measurements were (A) overall and top 3 accuracies; (B) Area Under the Curve (AUC), precision, recall, and F1 score. Overall accuracy referred to a correct response for the top answer, whereas top 3 accuracy referred to an appropriate response for any one answer amongst the top 3 answers. AUC and its relevant matrices were obtained from the Receiver Operation Characteristics (ROC) curve. Secondary outcomes were (A) multi-lingual accuracy; (B) comparison to enterprise-grade chatbot systems. The sharing of training and testing datasets on an open-source platform will also contribute to existing data.

Results

Our NLP model, utilizing the ensemble architecture, achieved overall and top 3 accuracies of 0.838 [95% confidence interval (CI): 0.826-0.851] and 0.922 [95% CI: 0.913-0.932] respectively. For overall and top 3 results, AUC scores of 0.917 [95% CI: 0.911-0.925] and 0.960 [95% CI: 0.955-0.964] were achieved respectively. We achieved multi-linguicism with nine non-English languages, with Portuguese performing the best overall at 0.900. Lastly, DR-COVID generated answers more accurately and quickly than other chatbots, within 1.12-2.15 s across three devices tested.

Conclusion

DR-COVID is a clinically effective NLP-based conversational AI chatbot, and a promising solution for healthcare delivery in the pandemic era.

Understanding the needs of health care workers in Singapore during the COVID-19 outbreak: A qualitative analysis

BACKGROUND

A successful public health response during the COVID-19 pandemic pivots on the ability of health care workers (HCWs) to work through immense workplace-related physical and psychological pressures.

OBJECTIVE

The aim of current study was to explore support needs of HCWs during the COVID-19 outbreak in Singapore and to identify implications for practice and workplace policies.

METHODS

A descriptive qualitative approach was adopted in this study. HCWs from a major public health care cluster in Singapore (n = 612) responded to an open-ended question in an online survey. Results were analyzed using content analysis via an inductive approach.

RESULTS

Five main themes that borrows from Maslow's Hierarchy of Needs emerged from content analysis, with 17 categories under the themes. The 5 main themes are: physical needs, safety needs, love and belonging needs, esteem needs and self-actualization needs.

CONCLUSIONS

Findings from this study indicate that there were many unmet needs among HCWs during the COVID-19 pandemic. An overview of various need areas identified in this study may guide future research and development of interventions to mitigate the negative impact of disease outbreaks on HCWs.

A year after COVID-19: its impact on nurses' psychological well-being

Background

Nurses' burnout and psychological well‐being are a significant concern during the pandemic.

Aims

The aim of this study is to (i) examine the level of burnout, anxiety, depression, perceived stress and self‐rated health for nurses at two time‐points, 2020 and 2021, and (ii) examine the socio‐demographic characteristics, work‐related factors and perceived workplace support factors in relation to the level of burnout.

Methods

This is a cross‐sectional study with a longitudinal approach. A convenience sample of registered nurses who worked in an acute care tertiary hospital in Singapore were surveyed during two time‐points. Participants' health, socio‐demographic characteristics, work‐related factors and perceived workplace support factors were collected.

Results

Among the 179 nurses, there was a significant increase in burnout level, poorer self‐rated health and reduced job dedication. A decrease in the percentage of nurses who felt appreciated at work was reported in 2021 (p = 0.04). Nurses who felt their team was not working well together were 3.30 times more likely to experience burnout (95% CI 1.12 to 9.69; p = 0.03). Nurses who reported that they never felt appreciated by their department/hospital were 8.84 times more likely to experience burnout (95% CI 2.67 to 29.21; p < 0.001). Nurses with poorer self‐rated health were more likely to report burnout (95% CI: 1.32–6.03; p = 0.008).

Conclusion

Nurses had an increased experience of burnout, reduced job dedication and poorer self‐rated health after the outbreak.

Implications for Nursing Management

Interventions at the departmental and organizational levels are needed to improve the workplace support. Strategies to support nurses' psychological well‐being during the aftermath of COVID‐19 are vital to managing nurses' burnout and improving job dedication and self‐rated health.

Utility of a Device Briefing Tool to Improve Surgical Safety

INTRODUCTION

Clear communication around surgical device use is crucial to patient safety. We evaluated the utility of the Device Briefing Tool (DBT) as an adjunct to the Surgical Safety Checklist.

METHODS

A nonrandomized, controlled pilot of the DBT was conducted with surgical teams at an academic referral center. Intervention departments used the DBT in all cases involving a surgical device for 10 wk. Utility, relative advantage, and implementation effectiveness were evaluated via surveys. Trained observers assessed adherence and team performance using the Oxford NOTECHS system.

RESULTS

Of 113 individuals surveyed, 91 responded. Most respondents rated the DBT as moderately to extremely useful. Utility was greatest for complex devices (89%) and new devices (88%). Advantages included insight into the team's familiarity with devices (70%) and improved teamwork and communication (68%). Users found it unrealistic to review all device instructional materials (54%). Free text responses suggested that the DBT heightened awareness of deficiencies in device familiarity and training but lacked a clear mechanism to correct them. DBT adherence was 82%. NOTECHS scores in intervention departments improved over the course of the study but did not significantly differ from comparator departments.

CONCLUSIONS

The DBT was rated highly by both surgeons and nurses. Adherence was high and we found no evidence of "checklist fatigue." Centers interested in implementing the DBT should focus on devices that are complex or new to any surgical team member. Guidance for correcting deficiencies identified by the DBT will be provided in future iterations of the tool.

Estimation of Surgery Durations Using Machine Learning Methods-A Cross-Country Multi-Site Collaborative Study

The scheduling of operating room (OR) slots requires the accurate prediction of surgery duration. We evaluated the performance of existing Moving Average (MA) based estimates with novel machine learning (ML)-based models of surgery durations across two sites in the US and Singapore. We used the Duke Protected Analytics Computing Environment (PACE) to facilitate data-sharing and big data analytics across the US and Singapore. Data from all colorectal surgery patients between 1 January 2012 and 31 December 2017 in Singapore and, 1 January 2015 to 31 December 2019 in the US were used, and 7585 cases and 3597 single and multiple procedure cases from Singapore and US were included. The ML models were based on categorical gradient boosting (CatBoost) models trained on common data fields shared by both institutions. The procedure codes were based on the Table of Surgical Procedure (TOSP) (Singapore) and the Current Procedural Terminology (CPT) codes (US). The two types of codes were mapped by surgical experts. The CPT codes were then transformed into the relative value unit (RVU). The ML models outperformed the baseline MA models. The MA, scheduled durations and procedure codes were found to have higher loadings as compared to surgeon factors. We further demonstrated the use of the Duke PACE in facilitating data-sharing and big data analytics.

Non-technical skills in surgery during the COVID-19 pandemic: An observational study

BACKGROUND

Non-technical skills are critical to surgical safety. We examined the impact of the COVID-19 pandemic on non-technical skills of operating room (OR) teams in Singapore.

MATERIALS AND METHODS

Observers rated live operations using the Oxford NOTECHS system. Pre- and post-COVID observations were captured from November 2019 to January 2020 and from January 2021 to February 2021, respectively. Scores were compared using Schuirmann's Two One-Sided Test procedure. Multivariable linear regression was used to adjust for case mix. A 10% margin of equivalence was set a priori.

RESULTS

Observers rated 159 cases: 75 pre-COVID and 84 post-COVID. There were significant differences between groups in surgical department and surgeon-reported case complexity (both P < 0.001). Total NOTECHS scores increased post-COVID on raw analysis (36.1 vs 38.0, P < 0.001) but remained within the margin of equivalence (90% CI 1.3 to 2.6, P < 0.001). Multivariable analysis demonstrated a similar increase within the margin of equivalence (2.0, 90% CI 1.3 to 2.7). Teamwork and cooperation scores increased by 1.0 post-COVID (90% CI 0.8 to 1.3); all other subcomponent scores were equivalent.

CONCLUSION

Non-technical skills before and after the peak of the COVID-19 pandemic were equivalent but not equal. A small but statistically significant improvement post-COVID was driven by an increase in teamwork and cooperation skills. These findings may reflect an improvement in team cohesion, which has been observed in teams under duress in other settings such as the military. Future work should explore the effect of the pandemic on OR culture, team cohesion, and resilience.

Virtual non-technical skills assessment training is an effective, scalable approach for novice raters

OBJECTIVES

The COVID-19 pandemic has forced a creative transition to virtual platforms due to physical distancing and travel restrictions. We designed and tested a highly scalable virtual training curriculum for novice raters using the Oxford NOTECHS non-technical skills rating system.

DESIGN

A three-day training course comprising virtual didactics, virtually facilitated simulations, and independent live observations was implemented. NOTECHS scores were submitted for eleven standardized video simulations and four live operations. Intraclass correlation coefficients (ICCs) were calculated for total NOTECHS scores and subcomponent scores. Raters previously trained in-person with the same standardized videos served as a comparator group for equivalence testing.

SETTING

All study activities were conducted in a large academic tertiary referral center in Singapore as part of an ongoing surgical safety initiative.

PARTICIPANTS

Seven staff members underwent training (three virtually and four in-person).  None had prior surgical experience or non-technical skills assessment training.

RESULTS

ICCs for total NOTECHS scores were 0.85 (95% CI, 0.73-0.98) for virtually trained raters and 0.83 for those trained in-person (95% CI, 0.68-0.99).  Scores were equivalent between groups within a 10% margin.

CONCLUSIONS

Non-technical skills assessment can be reliably taught in a highly scalable virtual format. Virtual NOTECHS training is a valuable tool for educational and quality improvement initiatives during the COVID-19 pandemic and for centers that lack ready access to onsite non-technical skills training expertise.

Resuming elective surgery after COVID-19: A simulation modelling framework for guiding the phased opening of operating rooms

OBJECTIVE

To develop a 2-stage discrete events simulation (DES) based framework for the evaluation of elective surgery cancellation strategies and resumption scenarios across multiple operational outcomes.

MATERIALS AND METHODS

Study data was derived from the data warehouse and domain knowledge on the operational process of the largest tertiary hospital in Singapore. 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 were extracted for the study. A clustering approach was used in stage 1 of the modelling framework to develop the groups of surgeries that followed distinctive postponement patterns. These clusters were then used as inputs for stage 2 where the DES model was used to evaluate alternative phased resumption strategies considering the outcomes of OR utilization, waiting times to surgeries and the time to clear the backlogs.

RESULTS

The tool enabled us to understand the elective postponement patterns during the COVID-19 partial lockdown period, and evaluate the best phased resumption strategy. Differences in the performance measures were evaluated based on 95% confidence intervals. The results indicate that two of the gradual phased resumption strategies provided lower peak OR and bed utilizations but required a longer time to return to BAU levels. Minimum peak bed demands could also be reduced by approximately 14 beds daily with the gradual resumption strategy, whilst the maximum peak bed demands by approximately 8.2 beds. Peak OR utilization could be reduced to 92% for gradual resumption as compared to a minimum peak of 94.2% with the full resumption strategy.

CONCLUSIONS

The 2-stage modelling framework coupled with a user-friendly visualization interface were key enablers for understanding the elective surgery postponement patterns during a partial lockdown phase. The DES model enabled the identification and evaluation of optimal phased resumption policies across multiple important operational outcome measures.

LAY ABSTRACT

During the height of the COVID-19 pandemic, most healthcare systems suspended their non-urgent elective surgery services. This strategy was undertaken as a means to expand surge capacity, through the preservation of structural resources (such as operating theaters, ICU beds, and ventilators), consumables (such as personal protective equipment and medications), and critical healthcare manpower. As a result, some patients had less-essential surgeries postponed due to the pandemic. As the first wave of the pandemic waned, there was an urgent need to quickly develop optimal strategies for the resumption of these surgeries. We developed a 2-stage discrete events simulation (DES) framework based on 34,025 unique cases over 43 operating rooms (ORs) and 18 surgical disciplines performed from 1 January 2019 to 31 May 2020 captured in the Singapore General Hospital (SGH) enterprise data warehouse. The outcomes evaluated were OR utilization, waiting times to surgeries and time to clear the backlogs. A user-friendly visualization interface was developed to enable decision makers to determine the most promising surgery resumption strategy across these outcomes. Hospitals globally can make use of the modelling framework to adapt to their own surgical systems to evaluate strategies for postponement and resumption of elective surgeries.

Cancer Survivors: What Are Their Information Seeking Behaviours?

This study aims to examine the information seeking behaviours and experiences of cancer survivors at various stages of the cancer survivorship trajectory in Singapore. Data was collected via a self-administered questionnaire from survivors diagnosed with the top 6 cancers in Singapore seen at the National Cancer Centre Singapore (NCCS). Cancer survivorship stages were categorized as newly diagnosed and on treatment (NT), completed treatment or cancer-free ≥ 5 years (CT) and had recurrence or second cancer (RS). Out of the 998 cancer survivors, 676 (68%) had searched for cancer information since their diagnosis. About 57% of the searchers did their most recent search in the past 6 months prior to the survey, with most of these survivors from the NT and RS groups. Around half of the searchers (55%) obtained cancer information from the internet. The most preferred source for cancer information was the internet (38%), followed by healthcare professionals (HCPs) (23%). About half (49%) obtained cancer information from their preferred source. Some information searchers (24%) did not do so, out of which about half used the internet to obtain information that they would have preferred to obtain from HCPs. The top 3 most commonly sought information was related to treatment, cancer and diet/nutrition. Half of the searchers were concerned with the quality of the information that they found. These information seeking behaviours and experiences were similar across cancer survivorship stages. Our study reveals that information seeking is prevalent across all survivorship stages. Patterns of information-seeking revealed a discrepancy between preferred and actual source.

Healthcare worker stress, anxiety and burnout during the COVID-19 pandemic in Singapore: A 6-month multi-centre prospective study

Aim

The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout.

Method

A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale).

Results

The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout.

Conclusions

Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

Design and Multicenter Clinical Validation of a 3-Dimensionally Printed Nasopharyngeal Swab for SARS-CoV-2 Testing

Importance

Three-dimensionally printed nasopharyngeal swabs (3DP swabs) have been used to mitigate swab shortages during the coronavirus disease 2019 (COVID-19) pandemic. Clinical validation for diagnostic accuracy and consistency, as well as patient acceptability, is crucial to evaluate the swab's performance.

Objective

To determine the accuracy and acceptability of the 3DP swab for identifying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Design, Setting, and Participants

A diagnostic study was conducted from May to July 2020 at 2 tertiary care centers in Singapore with different reference swabs (FLOQSwab [COPAN Diagnostics] or Dacron swab [Deltalab]) and swab processing techniques (wet or dry) to evaluate the performance of the 3DP swab compared with traditional, standard-of-care nasopharyngeal swabs used in health care institutions. The participants were patients with COVID-19 in the first 2 weeks of illness and controls with acute respiratory illness with negative test results for SARS-CoV-2. Paired nasopharyngeal swabs were obtained from the same nostril and tested for SARS-CoV-2 by reverse-transcriptase polymerase chain reaction. The sequence of swabs was randomized based on odd and even participant numbers.

Main Outcomes and Measures

Primary outcome measures were overall agreement (OA), positive percentage agreement (PPA), and negative percentage agreement of the 3DP swab compared with reference swabs. Secondary outcome measures were the correlation of cycle threshold (Ct) values of both swabs.

Results

The mean (SD) age of participants was 45.4 (13.1) years, and most participants were men (87 of 89 [97.8%]), in keeping with the epidemiology of the COVID-19 pandemic in Singapore. A total of 79 patients with COVID-19 and 10 controls were recruited. Among the patients with COVID-19, the overall agreement and PPA of the 3DP swab was 91.1% and 93.5%, respectively, compared with reference swabs. The PPA was 100% for patients with COVID-19 who were tested within the first week of illness. All controls tested negative. The reverse-transcriptase polymerase chain reaction Ct values for the ORF1ab and E-gene targets showed a strong correlation (intraclass correlations coefficient, 0.869-0.920) between the 3DP and reference swab on independent testing at each institution despite differences in sample processing. Discordant results for both gene targets were observed only at high Ct values.

Conclusions and Relevance

In this diagnostic study of 79 patients with COVID-19 and 10 controls, the 3DP swab performed accurately and consistently across health care institutions and could help mitigate strained resources in the escalating COVID-19 pandemic.

Improvement in quality of life among Sri Lankan patients with haemorrhoids after invasive treatment: a longitudinal observational study

Background

Haemorrhoids is a common chronic disease that can significantly impact patients’ quality of life. Yet, few studies have evaluated health-related quality of life (HRQoL) of patients with haemorrhoids before and after treatment. This study investigated the HRQoL of patients with haemorrhoids before and after treatment and the change in HRQoL from baseline.

Methods

A prospective observational study of patients with haemorrhoids was conducted at two public hospitals in Kandy, Sri Lanka. Two questionnaires assessing symptom severity and haemorrhoid-specific QoL were administered at initial consultation and at 4- and 8-week follow-ups after treatment (sclerotherapy, rubber band ligation (RBL), haemorrhoidectomy or evacuation of haematoma). The primary outcome was the least squares (LS) change of HRQoL score from baseline, measured using the Short Health Scale adapted for Haemorrhoidal Disease (4 domains: symptom load, interference with daily activities, concern, general well-being).

Results

In 48 patients selected for this study, LS mean change from baseline showed significant improvement in HRQoL across all domains and total Short Health Scale adapted for Haemorrhoidal Disease score at 4- and 8-week follow-ups (P < 0.001). Difference in LS mean change from baseline also showed continued improvement of HRQoL from week 4 to week 8 (P < 0.010). ‘Concern’ showed greatest improvement at 4 and 8 weeks (P < 0.001). Averaged LS mean changes from baseline showed RBL had greater improvement of HRQoL compared with sclerotherapy (P = 0.004).

Conclusion

Patients with haemorrhoids had improved HRQoL after invasive treatment. Haemorrhoid-specific QoL is an important component of the extent of disease and can serve as an aid to guide treatment, assess outcomes and monitor disease.

Stressors and coping strategies of migrant workers diagnosed with COVID-19 in Singapore: a qualitative study

INTRODUCTION

The health, psychological and socioeconomic vulnerabilities of low-wage migrant workers have been magnified in the COVID-19 pandemic, especially in high-income receiving countries such as Singapore. We aimed to understand migrant worker concerns and coping strategies during the COVID-19 pandemic to address these during the crisis and inform on comprehensive support needed after the crisis.

METHODS

In-depth semi-structured interviews were carried out with migrant workers diagnosed with COVID-19. The participants were recruited from a COVID-19 mass quarantine facility in Singapore through a purposive sampling approach. Interviews were transcribed verbatim and thematic analysis performed to derive themes in their collective experience during the crisis.

RESULTS

Three theme categories were derived from 27 interviews: migrant worker concerns during COVID-19, coping during COVID-19 and priorities after COVID-19. Major stressors in the crisis included the inability to continue providing for their families when work is disrupted, their susceptibility to infection in crowded dormitories, the shock of receiving the COVID-19 diagnosis while asymptomatic, as well as the isolating conditions of the quarantine environment. The workers coped by keeping in contact with their families, accessing healthcare, keeping updated with the news and continuing to practise their faith and religion. They looked forward to a return to normalcy after the crisis with keeping healthy and having access to healthcare as new priorities.

CONCLUSION

We identified coping strategies employed by the workers in quarantine, many of which were made possible through the considered design of care and service delivery in mass quarantine facilities in Singapore. These can be adopted in the set-up of other mass quarantine facilities around the world to support the health and mental well-being of those quarantined. Our findings highlight the importance of targeted policy intervention for migrant workers, in areas such as housing and working environments, equitable access to healthcare, and social protection during and after this crisis.

Factors associated with returning to work in head and neck cancer survivors in Singapore: A preliminary exploratory mixed-methods approach study

BACKGROUND

Little is known about return-to-work (RTW) among Asian head and neck cancer (HNC) survivors. We investigated the prevalence and factors associated with RTW among HNC patients with in Singapore.

METHODS

In this cross-sectional mixed-methods study, 80 HNC patients, who had been working prior to diagnosis, completed questionnaires and 15 participated in qualitative interviews to explore perceived barriers and facilitators of RTW. Multivariate logistic regression was used to evaluate factors associated with not-returning-to-work (NRTW) within 6 months of treatment completion.

RESULTS

Thirty-five participants reported NRTW 43.8%. Multivariable analysis showed that patients with advanced stage (III-IV) cancer (odds ratios [OR] = 4.51, 95% confidence intervals [CI]: 1.15-13.28, p = 0.006), multi-modality treatment (OR = 4.62, 95% CI: 1.38-15.52, p = 0.013), and pink-collar jobs (OR = 9.30, 95% CI: 1.70-50.83, p = 0.010) had higher odds of NRTW.

CONCLUSION

The factors associated with employment after HNC treatment are complex. Identification of key modifiable factors may lead to improved RTW outcomes.

Prevalence of olfactory and taste dysfunction in COVID-19 patients: a community care facility study

Purpose

We aim to study the prevalence of olfactory and taste dysfunction (OTD) in subjects residing in a Community Care Facility (CCF), a center unique to Singapore that is dedicated to isolate foreign workers with COVID-19 infection who have mild disease with minimal or no symptoms.

Methods

This is a cross-sectional study analyzing data prospectively collected from COVID-19-positive subjects who were admitted into a single-center Singapore EXPO CCF from 1st May 2020 to 1st July 2020. The following variables were collected: age, gender, ethnicity, anosmia, ageusia and acute respiratory infection (ARI) symptoms. Symptoms of anosmia and ageusia were self-declared via a mandatory questionnaire administered on admission.

Results

A total of 1983 subjects were included. The overall prevalence of anosmia and ageusia is 3.0% and 2.6%, respectively. 58% of anosmic subjects have co-existent ageusia and 72.6% of anosmic subjects have no concurrent sinonasal symptoms. OTD is less likely to present in subjects who are asymptomatic for ARI, compared to those symptomatic for ARI (anosmia: 2.0% versus 4.4% p = 0.002; ageusia: 1.6% versus 4.2% p < 0.001). There is a difference in the prevalence of OTD between the different ethnic groups (Indian, Chinese, Bangladeshi and Others), with Chinese and Bangladeshi reporting a higher prevalence (p < 0.043)

Conclusion

The true prevalence of OTD in COVID-19-positive subjects may be low with aggressive screening of all subjects, including those asymptomatic for ARI.

Improvement in quality of life with treatment of chronic venous disease: A longitudinal observational study in Kandy, Sri Lanka

OBJECTIVE

This study assessed the improvement in Quality of Life (QoL) of Chronic Venous Disease (CVD) patients in Sri Lanka following treatment.

METHODS

This was a prospective observational study of 58 newly or previously diagnosed CVD patients. QoL was assessed by the 14-item ChronIc Venous dIsease quality of life Questionnaire (CIVIQ-14) at 4 and 8 weeks after treatment.

RESULTS

At 8 weeks, the improvement in Global score from baseline was greatest in the surgical group with adjusted least squares mean of 23.5 (p < 0.001) followed by the non-surgical group at 13.3 (p < 0.001). There was no significant improvement in the no-treatment group at 0.333 (p = 0.950). Similar results were obtained for Pain and Physical domain scores at 8 weeks. Likewise, at 4 weeks, Global score and Pain and Physical domain scores showed significant improvement in the surgical and non-surgical groups (all p < 0.001) only.

CONCLUSION

Both surgical and non-surgical treatments improved QoL of CVD patients.

A survey of anxiety and burnout in the radiology workforce of a tertiary hospital during the COVID-19 pandemic

Introduction

We aimed to study anxiety and burnout among Division of Radiological Sciences (RADSC) staff during the COVID‐19 pandemic and identify potential risk and protective factors. These outcomes were compared with non‐RADSC staff.

Methods

A cross‐sectional online study was conducted between 12 March and 20 July 2020 in the largest public tertiary hospital receiving COVID‐19 cases. Burnout and anxiety were assessed with the Physician Work‐Life Scale and the Generalized Anxiety Disorder‐7 Scale, respectively. Workplace factors were examined as potential risk and protective factors using multivariable ordinary least squares regression analyses, adjusting for pertinent demographic characteristics.

Results

RADSC staff (n = 180) and non‐RADSC staff (n = 1458) demonstrated moderate‐to‐severe anxiety rates of 6.7 and 13.2 % and burnout rates of 17.8 and 23.9 %, respectively. RADSC staff reported significantly lower anxiety (mean ± SD: 4.0 ± 3.7 vs 4.9 ± 4.5; P‐value < 0.05), burnout (mean ± SD: 1.9 ± 0.7 vs 2.1 ± 0.8; P‐value < 0.01), increased teamwork (82.2% vs 74.1%; P‐value < 0.05) and fewer night shifts (36.7% vs 41.1%; P‐value < 0.01). Among RADSC staff, higher job dedication was associated with lower anxiety (b (95% CI) = −0.28 (−0.45, −0.11)) and burnout (b (95% CI) = −0.07 (−0.11,‐0.04)), while longer than usual working hours was associated with increased anxiety (b (95% CI) = 1.42 (0.36, 2.45)) and burnout (b (95% CI) = 0.28 (0.09, 0.48)).

Conclusions

A proportion of RADSC staff reported significant burnout and anxiety, although less compared to the larger hospital cohort. Measures to prevent longer than usual work hours and increase feelings of enthusiasm and pride in one’s job may further reduce the prevalence of anxiety problems and burnout in radiology departments.

Managing COVID-19 in a Novel, Rapidly Deployable Community Isolation Quarantine Facility

Singapore is one of the most densely populated small island-states in the world. During the coronavirus disease 2019 (COVID-19) pandemic, Singapore implemented large-scale institutional isolation units called Community Care Facilities (CCFs) to combat the outbreak in the community by housing low-risk COVID-19 patients from April to August 2020. The CCFs were created rapidly by converting existing public spaces and used a protocolized system, augmented by telemedicine to enable a low health care worker-patient ratio (98 health care workers for 3200 beds), to operate these unique facilities. In the first month, a total of 3758 patients were admitted to 4 halls, 4929 in-house medical consults occurred, 136 patients were transferred to a hospital, 1 patient died 2 weeks after discharge, and no health care workers became infected. This article shares the authors' experience in operating these massive-scale isolation facilities while prioritizing safety for all and ensuring holistic patient care in the face of a public health crisis and lean health care resources.

Early Outcomes of a National Cancer Center's Strategy Against COVID-19 Executed Through a Disease Outbreak Response Taskforce

PURPOSE

We present the strategy of a comprehensive cancer center organized to make operations pandemic proof and achieve continuity of cancer care during the COVID-19 pandemic.

METHODS

Disease Outbreak Response (DORS) measures implemented at our center and its satellite clinics included strict infection prevention, manpower preservation, prudent resource allocation, and adaptation of standard-of-care treatments. Critical day-to-day clinical operations, number of persons screened before entry, staff temperature monitoring, and personal protection equipment stockpile were reviewed as a dashboard at daily DORS taskforce huddles. Polymerase chain reaction swab tests performed for patients and staff who met defined criteria for testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were tracked. Descriptive statistics of outpatient attendances and treatment caseloads from February 3 to May 23, 2020, were compared with the corresponding period in 2019.

RESULTS

We performed COVID-19 swabs for 80 patients and 93 staff, detecting three cancer patients with community-acquired COVID-19 infections with no nosocomial transmission. Patients who required chemotherapy, radiotherapy, or surgery and patients who are on maintenance treatment continued to receive timely treatment without disruption. The number of intravenous chemotherapy treatments was maintained at 97.8% compared with 2019, whereas that of weekly radiotherapy treatments remained stable since December 2019. All cancer-related surgeries proceeded without delay, with a 0.3% increase in workload. Surveillance follow-ups were conducted via teleconsultation, accounting for a 30.7% decrease in total face-to-face clinic consultations.

CONCLUSION

Through the coordinated efforts of a DORS taskforce, it is possible to avoid nosocomial SARS-CoV-2 transmissions among patients and staff without compromising on care delivery at a national cancer center.

Pairing a prognostic target with potential therapeutic strategy for head and neck cancer

OBJECTIVES

We have previously identified and validated a panel of molecular prognostic markers (ATP13A3, SSR3, and ANO1) for Head and Neck Squamous Cell Carcinoma (HNSCC). The aim of this study was to investigate the consequence of ATP13A3 dysregulation on signaling pathways, to aid in formulating a therapeutic strategy targeting ATP13A3-overexpressing HNSCC.

MATERIALS AND METHODS

Gene Set Enrichment Analysis (GSEA) was performed on HNSCC microarray expression data (Internal local dataset [n = 92], TCGA [n = 232], EMBL [n = 81]) to identify pathways associated with high expression of ATP13A3. Validation was performed using immunohistochemistry (IHC) on tissue microarrays (TMAs) of head and neck cancers (n = 333), staining for ATP13A3 and phosphorylated Aurora kinase A (phospho-T288). Short interfering RNA was used to knockdown ATP13A3 expression in patient derived HNSCC cell lines. Protein expression of ATP13A3 and Aurora kinase A was then assessed by immunoblotting.

RESULTS

GSEA identified Aurora kinase pathway to be associated with high expression of ATP13A3 (p = 0.026). The Aurora kinase pathway was also associated with a trend towards poor prognosis and tumor aggressiveness (p = 0.086, 0.094, respectively). Furthermore, the immunohistochemical staining results revealed a significant association between Aurora kinase activity and high ATP13A3 expression (p < 0.001). Knockdown of ATP13A3 in human head and neck cell lines showed decrease in Aurora kinase A levels.

CONCLUSION

Tumors with high ATP13A3 are associated with high Aurora kinase activity. This suggests a potential therapeutic role of Aurora kinase inhibitors in a subset of poor prognosis HNSCC patients with overexpression of ATP13A3.

Determining the Concerns of Breast Cancer Survivors to Inform Practice

OBJECTIVE

Breast cancer is the most common cancer in women across all ethnicities, accounting for almost one in three incident cancers in female, and the leading cause of mortality in Singapore. Literature reveals that survivors of breast cancer have many concerns, and these concerns can linger on for decades. The primary aim of this secondary analysis was to establish the concerns of breast cancer survivors and use the data to inform practice.

METHODS

The present report was part of a bigger data designed to evaluate the concerns of cancer survivors (top six cancers) across the survivorship trajectory. Data of 438 breast cancer survivors were derived from a cross-sectional survey of the self-reported concerns of 1107 cancer survivors, using the questionnaire adopted from the Mayo Clinic Cancer Centre's Cancer Survivors Survey of Needs. Logistic regression models were fitted to estimate the odds ratios to assess the association of various variables with the presence of ≥1 concerned or very concerned issue among patients. Linear regression models were fitted to identify the variables associated with quality of life (QOL).

RESULTS

A total of 438 breast cancer survivors responded to this survey. The top five concerns were cancer treatment and recurrence risk (55.5%), followed by fear of recurrence (FOR) (54.6%), long-term effects of treatment (53.4%), osteoporosis/bone health (39.0%), and keeping primary care physicians informed (37.4%). Cancer treatment and recurrence risk, FOR, and long-term treatment effects were among the top concerns across the survivorship trajectory. The mean QOL was 7.5 on a scale of 0-10.

CONCLUSIONS

Irrespective of the cancer trajectory, survivors of breast cancer have serious concerns that warrant attention. Designing patient care delivery that addresses these concerns identified is critical in assisting them in their coping process and enhancing their QOL.

Development of an enhanced acute care surgery service in response to the COVID-19 global pandemic

BACKGROUND

As the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions.

METHODS

An enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed.

RESULTS

There were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised.

CONCLUSION

In healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.

Implementing the Biodesign Process for Medical Device Innovation in Head and Neck Surgery

Introduction. The Stanford Biodesign process is a needs-driven approach to innovation which begins in the clinical setting and environment and is championed by practicing clinicians and surgeons. Here, our team applied the Stanford Biodesign process through clinical immersion to identify potential unmet clinical needs in the field of head and neck surgery, brainstormed and prototyped solutions to solve the top unmet need, and developed a commercialized medical device. Methods. The team underwent the 3 phases of the Biodesign process: identify, invent, and implement. The team underwent clinical immersion and followed head and neck surgeons from the Department of Head and Neck Surgery for a duration of 1 month. The needs identified were then filtered through a structured process using predefined filters, and a top need was chosen. After multiple rounds of brainstorming and prototyping, a final concept was developed. Results. The team collected 111 unmet needs and designed the in vivo surgical lighting concept that eventually led to the development of the KLARO™ in vivo surgical lighting device with a commercial partner. KLARO™ is a fully flexible 4.6-mm diameter light-emitting diode light strip that is freely bendable to be safely placed into deep cavities during open surgeries. Conclusion. The Biodesign process provides a standardized way to turn these needs into solution to advance the field of head and neck surgery and improve the outcome of patients.

Caregivers of cancer patients: what are their information-seeking behaviours and resource preferences?

Cancer impacts not only the patient but also the family members who share the distressing trajectory of the patient. The literature indicates that caregivers have many unmet information needs while providing care and support to the cancer patients, and caregivers have to resort to seeking information to supplement their information needs. This study aims to establish the prevalence of health-information-seeking behaviours among caregivers of cancer patients as a means of ascertaining if their information needs have been met and their information source and resource preference. Data were obtained via a self-reported questionnaire from caregivers of cancer patients at the National Cancer Centre Singapore between 10 September and 7 December 2018. A total of 986 caregivers responded of which 180 (18%) caregivers did not undertake information search and the common reasons were ‘trust healthcare professionals’ (HCPs) more than other sources (64%), and ‘HCPs provide enough information’ (59%). Among the 795 caregivers who have searched for cancer information, about half of these caregivers (54%) have searched information on the Internet and another 15% have obtained their information from HCPs in their most recent search. A total of 371 (47%) caregivers have used their preferred source of information to conduct their most recent information search. The top three most commonly sought information was treatment (35.6%), disease (35.6%) and side effects (26.5%). Almost half (46%) of these caregivers was concerned about the quality of information they have found on the Internet. Our study supports that information-seeking is prevalent amongst caregivers of cancer patients and reveals the prevalence of Internet use and the concerns associated with its use. Patterns of information-seeking revealed a discrepancy between preferred and actual source. The results also suggest that HCPs play a significant role in the information-seeking behaviours of caregivers of cancer patients.

Adherence of head and neck squamous cell carcinoma patients to tumor board recommendations

BACKGROUND

Multidisciplinary team (MDT) meetings or tumor boards (TBs) are fundamental components of cancer treatment. Although their primary function is improved outcomes, this aspect is often underreported. The main objective of this study was to analyze the outcomes of patients with head and neck squamous cell carcinoma (HNSCC) discussed at TBs, and to compare the effect of adherence and nonadherence to recommended treatment plans on outcomes.

METHODS

Retrospective data analysis was conducted of HNSCC patients those who were adherent and nonadherent to TB therapy recommendations during 2008-2009 at a comprehensive cancer center. Fisher's exact test and t test were used for group-wise comparison, and Kaplan-Meier and logistic regression models, for survival analysis and determination of the contributing factors to nonadherence.

RESULTS

Comprehensive Treatment plans were recommended by TBs in 293 HNSCC patients with curative intent. Seventy-two patients were excluded based on the selection criteria. Among the remaining 221 patients, 172 (77.9%) were adherent to TB recommendations, while 49 (22.1%) failed to comply. Patient (n = 36; 73.5%), clinician (n = 2; 4.1%), and disease-related (n = 11; 22.4%) factors were significant contributors to nonadherence. Mean (±standard deviation (SD)) survival time was 55.6 ± 2.32 and 29.1 ± 4 months in the adherent and nonadherent groups, (P < .0001, respectively). Multivariate analyses showed that gender, ethnicity, higher T-stage, and multimodal treatment were associated with nonadherence.

CONCLUSION

Adherence to TB recommendations improved overall survival, reflecting the importance of interdisciplinary expertise in contemporary cancer treatment. Early identification and intervention is crucial in "at risk" patients to prevent subsequent drop-out from optimal cancer care.

A qualitative approach in determining the patient-centered information and supportive care needs of cancer patients in Singapore

OBJECTIVES

To qualitatively interpret the information and supportive care needs perceived by cancer patients undergoing treatment in order to get a deeper appreciation of patients' needs and concerns. The intended outcome is to provide baseline knowledge for improving patient-centred strategies to better meet the information and supportive needs of patients.

DESIGN

A qualitative research approach, based on conventional content analysis, was used throughout the research process. The three open-ended questions obtained from a previous quantitative study guided the researchers to explore the information and supportive care needs of patients. Data from patients' responses were analysed and coded in themes.

PARTICIPANTS AND SETTING

Patients attending the Ambulatory Treatment Unit of the National Cancer Centre Singapore were invited to participate in the study. We determined from these subjects the type of information that cancer patients need, and to measure the extent to which these information needs are met by measuring patients' level of satisfaction. Included in the quantitative study were three open-ended questions designed to gain a deeper understanding of their needs and concerns. All subjects were aged 21 years and above and able to understand and communicate in English/Mandarin. They were also aware of their diagnosis, they were not cognitively impaired and were not at the end-of-life situation.

RESULTS

A variety of information and supportive care needs were identified, and three specific areas of concerns were identified: (1) psychosocial and supportive care needs, (2) information needs and (3) information delivery by professionals.

CONCLUSION

The information and supportive care needs expressed were consistent with issues of cancer patients undergoing treatment. The strategies to improve patients' coping abilities through patient-centred care are discussed. Further studies assessing the barriers of information provision by healthcare professionals should provide more detailed knowledge about unmet information needs.

A cellular and proteomic approach to assess proteins extracted from cryopreserved human amnion in the cultivation of corneal stromal keratocytes for stromal cell therapy

Background

Human corneal stromal keratocytes propagated in culture media supplemented with human amnion extract (AME) can correct early corneal haze in an animal model. Clinical application of cultivated keratocytes is limited by infectious disease screening before amnion products can be used in humans. It remains unclear if AME from cryopreserved versus fresh human amnion can support human keratocyte propagation, and which components of the extract promote keratocyte growth.

Methods

Three placentas were collected for the preparation of fresh and cryopreserved amnion tissues followed by homogenization and protein extraction. AME protein profiles were studied using isobaric tagging for relative and absolute quantitation (iTRAQ) proteomics. Enriched gene ontology (GO) terms and functional classes were identified. Primary human keratocytes from 4 donor corneas were cultured in media supplemented with fresh AME (F-AME) or cryopreserved AME (C-AME). Cell viability, proliferation and keratocyte marker expression were examined by confocal immunofluorescence and flow cytometry.

Results

AME proteomics revealed 1385 proteins with similar expression levels (between 0.5- and 2-fold) between F- and C-AME, while 286 proteins were reduced (less than 0.5-fold) in C-AME. Enriched GO term and biological pathway analysis showed that those proteins with comparable expression between F-AME and C-AME were involved in cell metabolism, epithelial-mesenchymal transition, focal adhesion, cell-extracellular matrix interaction, cell stress regulation and complement cascades. Human corneal stromal keratocytes cultured with F-AME or C-AME showed similar morphology and viability, while cell proliferation was mildly suppressed with C-AME (P > 0.05). Expression of aldehyde dehydrogenase 3A1 (ALDH3A1) and CD34 was similar in both cultures.

Conclusion

AME from cryopreserved amnion had limited influence on keratocyte culture. It is feasible to use protein extract from cryopreserved amnion to propagate human keratocytes for potential translational applications.