Arthralgia in midlife Singaporean women: the Integrated Women's Health Program (IWHP)

OBJECTIVE

Arthralgia is a common menopausal complaint in midlife women, and its causes remain unclear. We examined the prevalence of menopausal arthralgia with various factors including sleep quality, depression/anxiety, muscle strength and physical performance among midlife Singaporean women.

METHODS

The Integrated Women's Health Program (IWHP) comprised 1120 healthy, community-dwelling women of Chinese, Malay or Indian ethnicities (aged 45-69 years) attending well-women clinics at the National University Hospital, Singapore. Sociodemographic, menopausal, reproductive and health data were obtained with validated questionnaires. Muscle strength, physical performance and dual-energy X-ray absorptiometry were measured. Women with moderate to very severe symptoms using the Menopause Rating Scale were classified as having arthralgia. Multivariable logistic regression analyses examined risk factors for arthralgia.

RESULTS

One-third of the participants reported arthralgia, and 12.7%, 16.2% and 71.2% were in the premenopausal, perimenopausal and postmenopausal period, respectively. Menopausal symptoms, such as vaginal dryness (adjusted odds ratio [aOR]: 2.64, 95% confidence interval [CI]: 1.64, 4.24) and physical/mental exhaustion (aOR: 2.83, 95% CI: 1.79, 4.47), were independent risk factors for arthralgia. Poor muscle strength (aOR: 2.20, 95% CI: 1.29, 3.76), obesity (aOR: 1.94, 95% CI: 1.13, 3.32) and rheumatoid arthritis (aOR: 7.73, 95% CI: 4.47, 13.36) were also independently associated with arthralgia after adjustment for confounders.

CONCLUSIONS

Arthralgia in midlife Singaporean women was associated with menopausal symptoms of vaginal dryness and physical and mental exhaustion. Women with poor muscle strength were more likely to experience menopausal arthralgia.

The Impact of Exercise and Cognitive Stimulation Therapy on Intrinsic Capacity Composite Score in Pre-Frail Older Adults: A Pre-Post Intervention Study

Intrinsic capacity(IC) is a measure of physical, cognitive, vitality, psychological, and sensory abilities which determines functional ability. Decline in IC has been shown to accelerate the trajectory of frailty. We aim to show the impact of exercise (Ex) and cognitive stimulation therapy (CST) on (i) IC domains and composite score (ii) frailty and functional ability in pre-frail older adults. Secondary analysis of data from a pre-post intervention study of pre-frail older adults ≥ 65 years attending primary care clinic. Control (CON) and 2 intervention groups ((i) Ex 6 months (ii) CST 3 months with Ex 6 months (Ex+CST)) were recruited. Pre-frailty was determined using the FRAIL scale. Questionnaires (on demographics, functional ability, and depression) were administered and physical function assessment (gait speed (GS), short physical performance battery (SPPB) test, handgrip strength, five times sit-to-stand (5x-STS)) was conducted at 0, 3, 6 and 12 months. Four domains of IC were evaluated: locomotion (GS and 5x-STS), vitality (nutrition and muscle mass), cognition (MoCA and subjective cognitive decline) and psychological (depression and anxiety). Each domain was scored from 0 to 2 (no decline) with total IC score ranging from 0 to 8. 187 participants completed baseline and 3 months assessments, 109 (58.3%) were allocated to CON, 37 (19.8%) to Ex and 41 (21.9%) to Ex + CST groups. At 3 months, both Ex and Ex +CST showed improvement in IC composite scores, locomotion, and psychological domain scores but improvement in cognition domain only in Ex + CST group. At 6 months, there were improvements in total IC score, locomotion, vitality, and psychological domain in both Ex and Ex + CST groups. At 12 months, significant improvement was evident in total IC score for Ex and Ex+CST groups, vitality when fatigue (in addition to muscle mass and nutrition) was added and instrumental activities of daily living. Multidomain intervention incorporating exercise and CST resulted in significant improvement in IC composite scores, locomotion, vitality, cognition, and psychological domains.

Efficacy of Oral SERDs in the treatment of ER+, HER2 - metastatic breast cancer, a stratified analysis of the ESR1 wild type and mutant subgroups

BACKGROUND

Oral SERDs are a novel drug class that have been developed to counteract resistance due to ESR1 mutations. Several SERDs have emerged from phase 2 and 3 trials, with the FDA limiting approval for Elacestrant to patients with ESR1mt tumours despite PFS benefit in the overall population. However, questions remain on whether patients with ESR1wt tumours stand to benefit from oral SERDs.

PATIENTS AND METHODS

Manuscripts and conference presentations of Randomised Controlled Trials were extracted after a systematic search of Embase, PubMed and Cochrane from inception until January 21,2023. RCTs investigating the efficacy of oral SERDs versus endocrine therapy for ER positive, HER2 negative advanced breast cancer, and which reported the Kaplan Meier (KM) curves of PFS in the overall and ESR1 mutant (ESR1mt) population were selected. A graphical reconstructive algorithm was applied to estimate time-to-event outcomes from reported KM curves in all overall and ESR1mt cohorts. A bipartite matching algorithm, KMSubtraction, was used to derive survival data for unreported (ESR1wt) subgroups. An individual patient data (IPD) meta-analysis was then pursued, pooling data by ESR1 mutation status in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Guidelines for IPD.

RESULTS

The randomized clinical trials ACELERA, AMEERA-3, EMERALD and SERENA-2 were included, totalling 1290 patients. In the pooled analysis of the overall cohort, PFS benefit was observed with oral SERDs when compared with treatment of physicians choice (TPC) (HR 0.783, 95%CI 0.681-0.900, p<0.001). In the ESR1mt subgroup, oral SERDs demonstrated improved PFS (HR 0.557, 95%CI 0.440-0.705, p<0.001) compared to TPC. In the ESR1wt subgroup, oral SERDs demonstrated no significant PFS benefit (HR 0.944, 95%CI 0.783-1.138, p=0.543) when compared to TPC.

CONCLUSIONS

The results of this IPD meta-analysis suggests that PFS benefit in the overall population is mainly driven by the ESR1mt subgroup.

Comparison of transcatheter, minimally invasive and conventional surgical aortic valve replacement: a systematic review and network meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but long-term outcomes have yet to be comprehensively explored.

Purpose

To compare long-term mortality among three AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional surgical AVR (CAVR).

Methods

An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI to CAVR, and RCTs or propensity score-matched (PSM) studies comparing MIAVR to CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality was derived from graphical reconstruction of digitized Kaplan-Meier curves. Pairwise comparisons followed by network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk as well as transfemoral (TF-TAVI) patients.

Results

A total of 27 studies involving 16,554 patients were included. In the pairwise comparison of TAVI versus CAVR, TAVI showed superior mortality to CAVR until 39.5 months, beyond which there was no significant difference in longer term mortality. When restricted to TF-TAVI versus CAVR, consistent mortality benefit favoring TAVI was seen (shared-frailty hazard ratio [HR]=1.17, 95%CI=1.03-1.33, p=0.016). In the network meta-analysis involving majority PSM data, MIAVR was associated with significantly lower mortality than TAVI (HR=0.69, 95%CI=0.59-0.82) and CAVR (HR=0.68, 95%CI=0.58-0.80); this significant association was not seen when compared to TF-TAVI patients.

Conclusions

An initial short-medium term mortality benefit for TAVI over CAVR was noted but this benefit was attenuated over the longer term. In the subset of TF-TAVI patients, this long-term mortality benefit persisted, suggesting that non-TF techniques are associated with higher mortality. Amongst majority PSM data, MIAVR showed improved mortality compared to TAVI and CAVR but this was not seen in the TF-TAVI subset. This suggests that MIAVR may have a role in treating patients who are ineligible for TF-TAVI in experienced centers, and future RCTs are needed to conclusively validate this.

Comparison of risk of hyperkalemia between SGLT2 inhibitors and DPP4-inhibitors in patients with type 2 diabetes

Funding Acknowledgements

Type of funding sources: None.

Background

Hyperkalemia is a common complication and increases the risk of cardiac arrhythmias and mortality in patients with type 2 diabetes (T2DM), especially in those with diabetic nephropathy. We investigated the risk of hyperkalemia in patients initiated on SGLT2 inhibitors versus DPP-4 inhibitors among patients with T2DM.

Methods

This study included patients with T2DM who initiated on SGLT2 inhibitors or DPP-4 inhibitors between January 01, 2015 and December 31, 2019 from a territory-wide clinical registry in Hong Kong (Clinical Data Analysis and Reporting System [CDARS]). A multivariable cox proportional hazards analysis, adjusting for key confounders, was used to compare the risk of central laboratory-determined hyperkalemia (serum potassium ≥6.0mmol/L) and hypokalemia (serum potassium &lt;3.5mmol/L), respectively, between SGLT2 inhibitors and DPP-4 inhibitors.

Results

10193 new users of SGLT2 inhibitors were matched to 17305 new users of DPP-4 inhibitors. During the 2-year follow-up, there were 104 hyperkalemia events (incident rate [IR] = 5.17 per 1000 person-years) among SGLT2 inhibitors and 306 events (IR = 9.09 per 1000 person-years) among DPP-4 inhibitors, of which SGLT2 inhibitors were associated with a lower risk of incident hyperkalemia (Adjusted HR: 0.66 [95%CI 0.53-0.83], p&lt;0.001), compared to DPP-4 inhibitors. The incident hypokalemia was similar between SGLT2 inhibitors and DPP-4 inhibitors (Adjusted HR: 0.91 [95%CI 0.81-1.03], P=0.13).

Conclusion

SGLT2 inhibitors reduced incident hyperkalemia, but without increasing incident hypokalemia compared to DPP-4 inhibitors.

Impact of Exercise and Cognitive Stimulation Therapy on Physical Function, Cognition and Muscle Mass in Pre-Frail Older Adults in the Primary Care Setting: A Cluster Randomized Controlled Trial

OBJECTIVES

Multicomponent exercise program have shown to improve function and cognition in older adults but studies on pre-frail older adults in the primary care setting are limited. This study aimed i) to evaluate impact of 6 months exercise (Ex) versus complementary effect of 3 months of cognitive stimulation therapy (CST) to 6 months of Ex (Ex+CST) on physical function, muscle mass and cognition versus control group at 3, 6 and 12 months ii) inflammatory biomarkers such as Interleukin-6 (IL-6) and Tumor Necrosis Factor Alpha (TNF-α).

DESIGN

Cluster randomised control trial.

SETTING AND INTERVENTION

Pre-frail older adults ≥ 65 years attending primary care clinic. Two intervention groups i) Ex 6 months ii) CST 3 months with Ex 6 months.

MEASUREMENTS

At 0, 3, 6 and 12 months, questionnaires (on demographics, physical function, cognition, and depression) were administered and physical function assessment (gait speed, short physical performance battery (SPPB) test, handgrip strength, five times sit-to-stand (5x-STS)) was conducted. Muscle mass and its surrogates such as phase angle and body cell mass were measured using bioelectrical impedance analysis machine. Inflammatory biomarkers were measured at 0 and 3 months.

RESULTS

Data from 190 participants was analysed at 3 months (111 control, 37 Ex and 41 Ex+CST). At 3 months, significant improvement in cognition was seen only in the Ex+CST group whereas improvements in depression, gait speed, SPPB and 5x-STS were seen in both the Ex and Ex+CST groups. At 6 months, the Ex+CST group improved in cognition and depression whereas improvement in frailty and muscle mass indices were seen in both the interventions groups. At 12 months, both the interventions groups had better perceived health, gait speed and less decline in muscle mass compared with control groups. Both the Ex and Ex+CST had significant association with TNF-α at 3 months (β -2.71 (95% CI -4.80 - -0.62); p = 0.012 and β -1.74 (95% CI -3.43 - -0.06); p = 0.043 respectively).

CONCLUSION

Combined Ex+CST had significant improvement in cognition whereas the intervention groups improved in depression, physical function, muscle mass, frailty, perceived health and TNF-α levels. With growing evidence of the benefits of multicomponent interventions at primary care level, incorporating it into mainstream care with action plans on long-term sustainability and scalability should be a priority for every country.

Ablation therapies for paroxysmal atrial fibrillation: a systematic review and patient-level network meta-analysis

Background

Despite numerous promising trials, catheter ablation is still regarded as a second-line alternative to antiarrhythmic drugs (AAD) in the treatment of paroxysmal atrial fibrillation (PAF). There remains a role for a broad comparison of the effectiveness of various ablation therapies against each other, and versus AAD.

Purpose

To conduct a systematic review and network meta-analysis of ablation therapies and AAD in the treatment of PAF. Ablation therapies were hypothesized to be superior to AAD in preventing atrial fibrillation (AF) recurrence.

Methods

An electronic literature search was conducted to retrieve randomized controlled trials or propensity score-matched studies comparing freedom from AF recurrence among any combination of ablation modalities or AAD. Kaplan-Meier curves and risk tables for this outcome were graphically reconstructed to extract individual patient data (IPD). A Frequentist network meta-analysis (NMA) was performed using the derived hazard ratios (HRs) of each study to compare various ablation therapies and AAD. Two separate NMAs were also conducted with restricted mean survival time (RMST) analysis, using RMST absolute differences and ratios, in light of violation of the proportional-hazards assumption. Treatment strategies were ranked using P-scores. Pairwise comparisons were also performed between treatment pairs with three or more studies reporting direct comparisons.

Results

Across 24 studies comparing six ablation therapies, comprising 5274 patients, Frequentist NMA-derived HRs of AF recurrence compared to AAD were 0.35 (95% CI: 0.26–0.48) for cryoballoon ablation (CBA), 0.33 (95% CI: 0.25–0.45) for radiofrequency ablation (RFA), 0.21 (95% CI: 0.09–0.49) for combined CBA and RFA, 0.20 (95% CI: 0.11–0.39) for hot-balloon ablation (HBA), 0.44 (95% CI: 0.16–1.22) for laser-balloon ablation, and 0.33 (95% CI: 0.19–0.56) for pulmonary vein ablation catheter. RMST-based NMAs similarly showed a significant benefit of all ablation therapies over AAD in preventing AF recurrence. Although none of the HRs between pairs of ablation modalities were significant, P-scores for HBA and combined CBA and RFA were consistently higher than those of other treatments. Independent pairwise comparisons of RFA and CBA versus AAD were greatly in favor of ablation (shared-frailty HR=0.24, 95% CI: 0.19–0.31, p&lt;0.001; shared-frailty HR=0.44, 95% CI: 0.35–0.56, p&lt;0.001, respectively).

Conclusions

To our knowledge, this is the first network meta-analysis comparing a wide range of ablation therapies to AAD, synthesizing IPD from high-quality studies in three separate NMA models. The advantage of ablation therapies over AAD in preventing AF recurrence was consistently found across all three models. This strongly suggests that ablation should replace AAD as the first-line treatment for PAF in patients who are fit for the procedure. Moreover, the promising results of HBA underscore the need for more high-quality trials to be conducted.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 vaccine acceptance and hesitancy among primary healthcare workers in Singapore

Background

Factors affecting COVID-19 vaccine acceptance and hesitancy among primary healthcare workers (HCW) remain poorly understood. This study aims to identify factors associated with vaccine acceptance and hesitancy among HCW.

Methods

A multi-centre online cross-sectional survey was performed across 6 primary care clinics from May to June 2021, after completion of staff vaccination exercise. Demographics, profession, years working in healthcare, residential status, presence of chronic medical conditions, self-perceived risk of acquiring COVID-19 and previous influenza vaccination were collected. HCW who accepted vaccine were then asked to rank their top 5 reasons for vaccine acceptance; HCW who were vaccine hesitant had to complete the 15-item 5C scale on psychological antecedents of vaccination.

Results

Five hundred fifty seven out of 1182 eligible HCW responded (47.1%). Twenty nine were excluded due to contraindications. Among 528 respondents, vaccine acceptance rate was 94.9% (n = 501). There were no statistically significant differences in COVID-19 vaccine acceptance between sex, age, ethnicity, profession, number of years in healthcare, living alone, presence of chronic diseases, self-perceived risk or previous influenza vaccination. The top 3 reasons for COVID-19 vaccine acceptance ranked by 501 HCW were to protect their family and friends, protect themselves from COVID-19 and due to high risk of acquiring COVID-19 because of their jobs. HCW with suspected or confirmed COVID-19 exposure were 3.4 times more likely to rank ‘high risk at work’ as one of the top reasons for vaccine acceptance (χ² = 41.9, p < 0.001, OR = 3.38, 95%C.I. 2.32–4.93). High mean scores of ‘Calculation’ (5.79) and low scores for ‘Constraint’ (2.85) for 5C components among vaccine hesitant HCW (n = 27) highlighted that accessibility was not a concern; HCW took time to weigh vaccine benefits and consequences.

Conclusion

COVID-19 vaccine hesitancy is a minute issue among Singapore primary HCW, having achieved close to 95% acceptance rate. COVID-19 exposure risk influences vaccine acceptance; time is required for HCW to weigh benefits against the risks. Future studies can focus on settings with higher hesitancy rates, and acceptance of booster vaccinations with the emergence of delta and omicron variants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01693-z.

Clinical and Psychosocial Determinants of Patients with Tuberculosis/Human Immunodeficiency Virus Co-Infection: A Structural Equation Model Approach

Background

Tuberculosis (TB)/human immunodeficiency virus (HIV) co-infection is a complex mesh of physical and psychosocial disorders that require a multimodal and multifaceted approach for improved outcomes.

Aims

This study determined the treatment outcomes of patients with TB/HIV co-infection and the clinico-psychosocial predictors of the disease over a 10-year period in resource-limited settings.

Patients and Methods

This study reviewed the 10-year retrospective treatment outcomes of patients with TB/HIV co-infection in a tertiary centre. The data were retrieved from the TB treatment registers and analyzed with STATA 16.0. The effects of latent constructs of high clinical severity, stigmatization, and family stress/burden on treatment outcomes were evaluated using a structural equation model.

Results

Of the 1,321 who met the inclusion criteria, 1,193 had sufficient data. The mean age of the patients was 38.2 ± 16.7 years. The treatment adherence rate over the 10 years was 93.8% (±6.8%) but successful treatment outcome was 75.5% (±8.1%). Stigmatism of TB/HIV infections was experienced by adults and males (β = 0.972; P < 0.001 β = 0.674; P < 0.001, β = -0.770; P < 0.001, respectively), non-adherent to treatment (β = -0.460; P < 0.001) clinical severity of illness (β = 0.940; P < 0.001), and being HIV negative (β = -0.770; P < 0.001). Family Stress/Burden was strongly affected by both Death (β = 1.000; P < 0.001) and higher Stigmatism (β = 0.602; P < 0.001). Clinical severity of illness significantly influenced both Death and Unsatisfactory outcomes (β = 0.207; P < 0.001, β = 0.203; P < 0.05, respectively). Non-Adherence led to potentially unsatisfactory outcome.

Conclusion

TB/HIV co-infection is a complex psychosocial disorder that is significantly and negatively impacted by social determinants of the disease. A holistic approach to treatment intervention that addresses the latent factors of stigmatization, family stress/burden, and high clinical severity is key to achieving a successful treatment outcome.

Prevalence of IgE-mediated cow milk, egg, and peanut allergy in young Singapore children

Background

The rising prevalence of food allergy reported in the United States, UK, and Australia may be attributable to the rise in peanut allergy prevalence. The food allergy prevalence in other parts of the world such as Asia is, however, less well documented.

Objective

This study aimed to evaluate the prevalence of cow’s milk, egg, and peanut allergies in a general population of Singaporean children below 30 months of age.

Methods

A total of 4,115 children from the general population who attended well-baby visits between 2011 and 2015 completed standardized questionnaires to elicit a convincing history of food allergy to estimate the population prevalence of food allergies.

Results

The prevalence of a convincing history of cow’s milk allergy was 0.51% (95% confidence interval [CI], 0.3–0.7), hen’s egg allergy 1.43% (95% CI, 1.1–1.8), and peanut allergy 0.27% (95% CI, 0.12–0.42). Of the 15 of 59 children with a convincing history of hen’s egg allergy who consented, 12 (80%) had corroborative positive skin prick tests.

Conclusion

The prevalence of food allergy, in particular peanut allergy, in children below 2 years of age is lower in this South East Asian population than reported in Western cohorts. Further research should focus on deciphering differential risk factors for food allergy across different geographical locations.

Structured re-training to reduce peritonitis in a pediatric peritoneal dialysis program: a quality improvement intervention

BACKGROUND

Decline in skills and knowledge among patients and/or caregivers contributes to peritoneal-dialysis (PD)-related peritonitis. Re-training is important, but no guidelines exist. We describe the implementation of a structured re-training program to decrease peritonitis rates.

METHODS

This is a prospective quality improvement study involving pediatric patients on long-term home automated PD at National University Hospital, Singapore, between 2012 and 2018. With increasing peritonitis rates, systematic root cause analysis was performed, and based on the contributory factors identified, a structured re-training program was implemented from 2015. This was conducted in 5 cycles, each consisting of 4 modules (hand hygiene, exit site care, peritonitis, and PD troubleshooting).

RESULTS

Peritonitis rates were analyzed in 2 phases: Phase 1 (2012-2014) when no re-training was performed and Phase 2 (2016-2018) after re-training was instituted. Fifty-nine patients were included. Of these, 45 patients were in Phase 1, 32 in Phase 2, and 18 in both phases. Peritonitis rates decreased from 0.37 ± 0.67 episodes per patient-year in Phase 1 to 0.13 ± 0.32 episodes per patient-year in Phase 2. After adjusting for age at kidney failure onset, PD vintage, years of nursing experience, and the average patient-to-nurse ratio over the study period for each patient, the adjusted peritonitis rates decreased by 0.38 episodes per patient-year (95% CI, 0.09 to 0.67, p = 0.011) from Phase 1 to Phase 2.

CONCLUSION

Despite an improvement in staffing ratio, peritonitis rates only improved significantly after intensive structured re-training was instituted.

Low regulatory T-cells: A distinct immunological subgroup in minimal change nephrotic syndrome with early relapse following rituximab therapy

Rituximab is an important second line therapy in difficult nephrotic syndrome (NS), especially given toxicity of long-term glucocorticoid or calcineurin inhibitor (CNI) use. However, clinical response to rituximab is heterogenous. We hypothesized that this was underpinned by immunological differences amongst patients with NS. We recruited a cohort of 18 subjects with glucocorticoid-dependent or glucocorticoid-resistant childhood-onset minimal change NS who received rituximab either due to CNI nephrotoxicity, or due to persistent glucocorticoid toxicity with inadequate response to cyclophosphamide or CNIs. Immunological subsets, T-cell activation assays and plasma cytokines were measured at baseline and 6-months post-rituximab. Time to relapse was bifurcated: 56% relapsed within one year ("early relapse"), while the other 44% entered remission mainly lasting ≥3 years ("sustained remission"). At baseline, early relapse compared to sustained remission group had lower regulatory T-cells (Tregs) [2.94 (2.25, 3.33)% vs 6.48 (5.08, 7.24)%, P<0.001], PMA-stimulated IL-2 [0.03 (0, 1.85)% vs 4.78 (0.90, 9.18)%, P=0.014] and IFNγ [2.22 (0.18, 6.89)% vs 9.47 (2.72, 17.0)%, P=0.035] levels. Lower baseline Treg strongly predicted early relapse (ROC-AUC 0.99, 95% CI 0.97-1.00, P<0.001). There were no differences in baseline plasma cytokine levels. Following rituximab, there was significant downregulation of Th2 cytokines in sustained remission group (P=0.038). In particular, IL-13 showed a significant decrease in sustained remission group [-0.56 (-0.64, -0.35)pg/ml, P=0.007)], but not in the early relapse group. In conclusion, early relapse following rituximab is associated with baseline reductions in Treg and T-cell hyporesponsiveness, which suggest chronic T-cell activation and may be useful predictive biomarkers. Sustained remission, on the other hand, is associated with downregulation of Th2 cytokines following rituximab.

Slow Gait, Subjective Cognitive Decline and Motoric Cognitive RISK Syndrome: Prevalence and Associated Factors in Community Dwelling Older Adults

BACKGROUND

Motoric Cognitive Risk Syndrome (MCR), slow gait speed (SG) and subjective cognitive decline (SCD) are known to be harbingers of dementia. MCR is known to be associated with a 3-fold increased risk of future dementia, while SG can precede cognitive impairment.

OBJECTIVE

We aim to determine the prevalence and demographics of MCR, slow gait alone (SG-A) and subjective cognitive decline alone (SCD-A) in community-dwelling older adults and association with physical, functional, cognition and psychosocial factors.

METHODS

A total of 509 participants were classified into four groups according to presence of SG and/or SCD. Multinomial logistic regression was used to identify the factors associated with SG-A, SCD-A and MCR.

RESULTS

The prevalence of MCR was 13.6%, SG-A 13.0% and SCD-A 35.0%. Prevalence of MCR doubled every decade in females with 27.7% of female ≥ 80 years old had MCR. Almost 4 in 10 had no SG or SCD (SG+SCD negative). MCR and SG-A groups were significantly older, had higher body mass index (BMI), lower education, lower global cognition scores especially in non-memory domains, higher prevalence of low grip strength and lower short physical performance battery scores than those with SCD-A and SG+SCD negative. In addition, the SG-A group had significantly higher prevalence of multi-morbidity and diabetes. The prevalence of pain, depression, frailty, social isolation and activity of daily living impairment were significantly higher in MCR. The global cognitive and functional scores for those with SCD-A were comparable to the SG+SCD negative group. The Malay ethnic group had the lowest prevalence of SCD but highest prevalence of SG. After adjusting for confounding factors, age, BMI, frailty status, instrumental activity of daily living, depression and pain remained significantly associated with MCR. For SG-A, age, BMI, education and number of chronic diseases remained significant.

CONCLUSION

Both MCR and SG-A are associated with global cognitive decline especially in the non-memory domains and lower functional scores. Gait speed is a good predictor of negative outcomes and should be considered as the 'sixth' vital sign. Long term prospective studies are needed to evaluate: i) the conversion to dementia in different ethnic groups and ii) effect of targeted physical and / or dual task exercise on delaying the conversion to dementia and / or improvement in physical measures and reduction of disability.

Practicality and Reliability of Self Vs Administered Rapid Geriatric Assessment Mobile App

OBJECTIVES

To develop and cross-validate self-administered Rapid Geriatric Assessment (SA-RGA) app against administered Rapid Geriatric Assessment (A-RGA) to identify seniors with geriatric syndromes such as frailty, sarcopenia, and anorexia of ageing who may benefit from targeted intervention.

DESIGN

Prospective observational study.

SETTING

Primary Care and Community.

PARTICIPANTS

A-RGA and SA-RGA app were administered to older adults ≥ 60 years old from December 2020 to April 2021.

MEASUREMENTS

The RGA app screens for frailty (FRAIL), sarcopenia (SARC-F), anorexia of aging (SNAQ) and cognition (Rapid Cognitive Screen) with assisted management pathway. Patient Health Questionnaire 9 is administered for those who score positive for fatigue. The diagnostic performance of SA-RGA was compared against A-RGA as a reference by calculating the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and positive likelihood ratio (+LR).

RESULTS

123 participants with a mean age of 71 ± 5.9 years completed both the SA-RGA and A-RGA. Questions on fatigue, 5 or more illnesses, loss of weight and falls in the past year performed better with high sensitivity, specificity, NPV and +LR than self-functional assessment where SA-RGA participants reported lower prevalence on the FRAIL scale aerobic and resistance components, and higher prevalence on the SARC-F strength and rising from a chair components.

CONCLUSION

The SA-RGA app performed well in certain domains such as assessment for weight loss, falls, number of chronic illness and fatigue. Self-functional assessment can be improved further by removing ambiguity in wordings such as "some" or "a lot" and replacing it with functional difficulty scale. SA-RGA has the potential to be incorporated in the eHEALTH platforms worldwide for early identifications of older adults at risk and to reduce health inequalities, at the same time building community resilience in the era of Covid-19 pandemic.

Outcomes of Gas-Forming Pyogenic Liver Abscess Are Comparable to Non-Gas-Forming Pyogenic Liver Abscess in the Era of Multi-Modal Care: A Propensity Score Matched Study

Background: Gas-forming pyogenic liver abscess (GFPLA) occurs in 7%-24% of all PLAs and has been associated traditionally with high mortality rates. Studies have suggested that the use of a proactive approach of prompt resuscitation, parenteral antibiotic agents, percutaneous drainage, and a dedicated multi-disciplinary team may improve clinical outcomes. Hence, we aim to investigate whether the clinical outcomes of PLA are determined by gas formation. Methods: This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes mellitus, presence of septic shock, hemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Baseline demographics, clinical profile, and peri-operative data were compared. Results: There were 213 patients who had PLA: 41 (19.2%) patients had GFPLA and 172 (80.8%) patients had non-GFPLA. The PSM analysis resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Median duration of parenteral antibiotic agents was significantly lower in the GFPLA group (9.5 d vs. 14 d, p = 0.044), but median total duration of antibiotic use was comparable (GFPLA 39 d vs. non-GFPLA 37 d, p = 0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs. 15, p = 0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36 (72.2%) vs. 47/72 (65.3%), respectively, p = 0.467) and in-hospital all-cause death (4/36 (11.1%) vs. 7 (9.7%), p = 0.822) Conclusions: Outcomes of GFPLA are comparable to those of non-GFPLA in the era of multi-modal care.

HbA1c variability, in addition to mean HbA1c, predicts incident hip fractures in Chinese people with type 2 diabetes

Type 2 diabetes is associated with an increased risk of hip fractures. We hypothesize that long-term glycemic variability predicts incident hip fractures. We demonstrated that HbA1c variability predicted incident hip fractures independent of mean HbA1c, suggesting the potential benefits of minimizing glycemic variability in addition to optimizing mean glycemia for bone health.

INTRODUCTION

Type 2 diabetes is associated with an increased risk of hip fractures, and a linear relationship between HbA1c levels and hip fracture incidence has been observed. We hypothesize that HbA1c variability also predicts incident hip fractures in type 2 diabetes.

METHODS

Chinese individuals with type 2 diabetes aged ≥ 60 years were identified from electronic health records in Hong Kong between 2008 and 2012 and observed for incident hip fractures. Hip fracture was defined by the International Classification of Diseases (Ninth Revision) code 820. HbA1c variability was determined using standard deviation, adjusted standard deviation, and coefficient of variation of HbA1c measurements in the 5 years preceding the entry date. Multivariable Cox regression analysis was used to evaluate associations between HbA1c variability and incident hip fractures.

RESULTS

A total of 83,282 participants were included. Their mean age was 71.3 ± 7.5 years, duration of diabetes 11.7 ± 7.7 years, baseline HbA1c 56.6 ± 13.5 mmol/mol (7.33 ± 1.23%), and median follow-up 6.8 years. All indices of HbA1c variability were significant independent predictors of incident hip fractures, with an adjusted hazard ratio of up to 1.29 (all p < 0.001), and remained to be independent predictors across groups of different intensity of glycemic control. Mean HbA1c ≥ 64 mmol/mol (8.0%) was associated with a 25% increase in incident hip fractures compared with mean HbA1c < 53 mmol/mol (7.0%).

CONCLUSION

HbA1c variability is an independent positive predictor of hip fracture in type 2 diabetes, across the spectrum of varying degree of glycemic control, while a high HbA1c is also not advisable from the perspective of bone health.

Impact of formulary interventions on the minimum inhibitory concentration of methicillin-resistant Staphylococcus aureus to mupirocin, chlorhexidine, and octenidine in a Singapore tertiary institution

Methicillin-resistant Staphylococcus aureus (MRSA) decolonization is an effective measure to prevent clinical infection but resistance is a concern. We aim to evaluate the impact of mupirocin (MUP) ointment formulary removal, plateauing use of chlorhexidine gluconate (CHG), and hospital-wide introduction of octenidine (OCT)-based products on the minimum inhibitory concentration (MIC) of MRSA to MUP, CHG, and OCT in our hospital. A prevalence study was conducted at three time points (TP) on consecutive MRSA screening isolates to evaluate for their MICs to MUP, CHG, and OCT using broth microdilution sensititre plates and detection of the ileS-2 gene encoding high-level MUP resistance in 2013 (pre-intervention TP1; n = 160), 2016 (early post-intervention TP2; n = 99) and 2017 (late post-intervention TP3; n = 76). Statistical analyses were performed using Chi square test with reference from TP1. There was a significant improvement in MUP susceptibility (MIC < 4 mcg/ml) from 71.9% (TP1) to 86.9% (TP2; p = 0.006) to 88.2% (TP3; p = 0.007). The prevalence of MUP high-level resistance (MIC > 256 mcg/ml) reduced from 25.0% (TP1) to 12.1% (TP2; p = 0.014) to 5.3% (TP3; p = 0.001). Likewise, the prevalence of isolates harboring the ileS-2 gene decreased from 28.1% (TP1) to 18.2% (TP2; p = 0.072) to 9.2% (TP3; p = 0.002). OCT MIC range remains stable at 0.5 to 1 mcg/ml across all three TPs. The proportion of isolates with reduced CHG susceptibility (MIC ≥ 4 mcg/ml) increased over the three TPs from 23.1 to 27.2% (p = 0.45) to 42.1% (p = 0.003). Active formulary regulations have an impact on the resistance profile of MRSA and can be used as a strategy to preserve the MRSA decolonization armamentarium.

SLEEP-GOAL: A multicenter success criteria outcome study on 302 obstructive sleep apnoea (OSA) patients

OBJECTIVE

To demonstrate SLEEP-GOAL as a more holistic and comprehensive success criterion for Obstructive Sleep Apnoea (OSA) treatment.

METHODS

A prospective 7-country clinical trial of 302 OSA patients, who met the selection criteria, and underwent nose, palate and/or tongue surgery. Pre- and post-operative data were recorded and analysed based on both the Sher criteria (apnoea hypopnea index, AHI reduction 50% and <20) and the SLEEP-GOAL.

RESULTS

There were 229 males and 73 females, mean age of 42.4±17.3 years, mean BMI 27.9±4.2. The mean VAS score improved from 7.7±1.4 to 2.5±1.7 (p<0.05), mean Epworth score (ESS) improved from 12.2±4.6 to 4.9±2.8 (p<0.05), mean body mass index (BMI) decreased from 27.9±4.2 to 26.1±3.7 (p>0.05), gross weight decreased from 81.9±14.3kg to 76.6±13.3kg. The mean AHI decreased 33.4±18.9 to 14.6±11.0 (p<0.05), mean lowest oxygen saturation (LSAT) improved 79.4±9.2% to 86.9±5.9% (p<0.05), and mean duration of oxygen <90% decreased from 32.6±8.9 minutes to 7.3±2.1 minutes (p<0.05). The overall success rate (302 patients) based on the Sher criteria was 66.2%. Crosstabulation of respective major/minor criteria fulfilment, based on fulfilment of two major and two minor or better, the success rate (based on SLEEP-GOAL) was 69.8%. Based solely on the Sher criteria, 63 patients who had significant blood pressure reduction, 29 patients who had BMI reduction and 66 patients who had clinically significant decrease in duration of oxygen <90% would have been misclassified as "failures".

CONCLUSION

AHI as a single parameter is unreliable. Assessing true success outcomes of OSA treatment, requires comprehensive and holistic parameters, reflecting true end-organ injury/function; the SLEEP-GOAL meets these requirements.

Internalized stigma, disclosure and self-esteem among psychiatric patients in a general hospital outpatient clinic

OBJECTIVE

Psychiatric patients often experience internalized stigma. This occurs when persons accept the negative attitudes of others towards them, then internalize and apply these beliefs to themselves. We assess the effects of internalized stigma on illness disclosure and on self-esteem in psychiatric outpatients, hypothesizing that internalized stigma is more pronounced in psychiatric patients than in medical patient controls and that internalized stigma is associated with avoidance of disclosure, as well as reduced self-esteem.

METHODS

Psychiatric and medical outpatients were randomly selected to participate in the study, conducted at a general hospital specialist outpatient clinic.

RESULTS

Psychiatric patients demonstrated significantly lower self-esteem than controls. Internalized stigma was the highest for singles, and the lowest among married and older patients. Among psychiatric patients, a higher internalized stigma was significantly associated with experienced discrimination and with lower levels of self-esteem. Those who avoided disclosure had significantly higher internalized stigma than those who self-disclosed.

CONCLUSION

The results confirmed our study hypotheses. Marriage and older age seemed to confer a protective effect on self-esteem.

Improving Influenza Vaccination Coverage Among Patients With COPD: A Pilot Project

Background and objective

Guidelines for chronic obstructive pulmonary disease (COPD) advocate regular influenza vaccination, which has been shown to reduce exacerbations. However, influenza vaccination rates remain low. This quality improvement project was initiated to help improve influenza vaccination rates in a tertiary hospital.

Methods

All patients with COPD in the airway program (TAP) in the National University Hospital at the end of 2013 were recruited. The interventions were implemented in 2014; thus, population was stratified into the pre-intervention group and post-intervention group. Those who died in 2014 were excluded. They were (1) patient education posters in the clinics on the need for regular influenza vaccination, (2) direct interventions by physicians, and (3) intervention by the nurses when vaccinations were neglected. Physicians were made aware of previous vaccination rates, vaccination card reminders were placed in the clinics, and a new electronic healthcare record system (EHR) was implemented. The patients were followed up till the end of 2015 or until death. When an influenza vaccination was administered, the patients were asked which of the interventions led to the vaccination. A questionnaire was delivered to the physicians to determine the interventions that led to any change in vaccination prescription practices.

Results

The pre-intervention influenza vaccination rate was low at 47.7%. The post-intervention influenza vaccination rate improved to 80.7% with the multi-pronged approach. Physicians initiated the majority of vaccinations (87.9%), while nurses helped intervene in a further 12.1%. Physicians’ vaccination prescription practices changed as a result of self-awareness of low vaccination rates, vaccination card reminders, and the new EHR. Patient education made minimal impact.

Conclusion

This project demonstrates that with regular audits to track progress and several easy-to-implement interventions, improving influenza vaccination rates is an achievable goal.

Family medicine vocational training and career satisfaction in Hong Kong

BACKGROUND

Postgraduate vocational training in family medicine (FM) is essential for physicians to build capacity and develop quality primary care. Inadequate standards in training and curriculum development can contribute to poor recruitment and retention of doctors in primary care. This study aimed to investigate: 1) the satisfaction level of doctors regarding vocational training in family medicine and associated demographics; and 2) the satisfaction level of doctors regarding their family medicine career and associated factors.

METHOD

This is a cross sectional study of all family medicine physicians across all government-funded primary care clinics (GOPCs). The study questionnaire consisted of items from a standardized and validated physician survey named the Physician Worklife Survey (PWS) (Konrad et al., Med Care, 1999). We selected three scales (7 items) relating to global job satisfaction, global career satisfaction and global specialty (family medicine) satisfaction with additional items on training and demographics. All significant variables in bivariate analyses were further examined using stepwise logistic regression.

RESULTS

Out of 424 eligible family medicine physicians, 368 physicians successfully completed the questionnaire. The response rate was 86.8%. Most participants were male (52.6%), were aged between 35 and 44 years (55.5%), were FM specialists (42.4%), graduated locally (86.2%), and had postgraduate qualifications. Eighty-two percent (82%) of participants were satisfied with their training. Having autonomy and protected time for training were associated with satisfaction with FM training. Satisfaction with family medicine as a career was correlated with physicians' satisfaction with their current job. Doctors who did not enroll in training (p < 0.001) and physicians who were older (p = 0.023) were significantly less satisfied. Stepwise multivariate regression showed that doctors who subjectively believed their training as "broad and in depth' had higher career satisfaction (p < 0.001).

CONCLUSION

Overall, the satisfaction level of physicians on current family medicine training in Hong Kong was high. Having autonomy and protected time for training is associated with higher training satisfaction levels. Perceiving FM training as "broad and in-depth" is associated with higher family medicine career satisfaction.

Teachers' role in identifying young children at risk for developmental delay and disabilities: Usefulness of the Parents Evaluation of Developmental Status tool

BACKGROUND

Identifying children with developmental delays and disabilities more effectively will require the participation of others such as preschool teachers who often have extended contact with the child in their first few years. We wished to determine how preschool teachers' reports of concerns compared with norming data from the Parents Evaluation of Developmental Status (PEDS).

METHODS

A total of 1,357 English responses from teachers of nine preschool centres were analyzed and matched with expected rates of concerns from the U.S. norming sample.

RESULTS

The preschool teachers' reporting of rates of concerns fell within the range of scores reported in norming studies from parent reports in the United States. Teachers were most concerned about children's language and behaviours.

CONCLUSIONS

The preschool teacher reports of concerns are similar to expected parents PEDS ratings in the United States. Preschool teachers can screen children's development. There may be a role for the PEDS to be used as a developmental screener by preschool teachers for monitoring of developmental status. Further studies on the PEDS are recommended in the Singapore context.

Mental Health Literacy in Cancer Outpatients in Singapore

OBJECTIVE

We aimed to evaluate the prevalence of depressive and anxiety symptoms and mental health literacy (MHL) in outpatients with or without cancer in Singapore.

METHODS

Oncology outpatients and outpatients without cancer (controls) were assessed for severity of anxiety and depressive symptoms (using the Hospital Anxiety and Depression Scale) and MHL regarding major depressive disorder and generalised anxiety disorder in terms of diagnosis, aetiology, treatment, and attitudes toward mental health services.

RESULTS

A total of 89 oncology outpatients and 61 controls were recruited. Those with primary and secondary education had significantly lower MHL scores than those with university education (p = 0.001). Oncology outpatients and controls were comparable in terms of anxiety (13.5% vs 9.8%, p = 0.5), depression (2.2% vs 1.6%, p > 0.99), and total MHL score (7.94 vs 9.13, p = 0.102).

CONCLUSIONS

MHL is comparable between oncology outpatients and controls and is positively associated with education level.

Predictors of difficulty in intubation in patients with obstructive sleep apnoea

OBJECTIVE

To evaluate predictors of difficult intubation in patients with obstructive sleep apnoea (OSA).

METHODOLOGY

Prospective series of 405 OSA patients (350 males/55 females) who had upper airway surgery. Procedures included functional endoscopic sinus surgery, septoplasty, turbinate reduction, palate/tonsil surgery, and/or tongue base surgery. Intubation difficulty (ID) was assessed using Mallampati grade, Laryngoscopic grade (Cormack and Lehane), and clinical parameters including BMI, neck circumference, thyromental distance, jaw adequacy, neck movements and glidescope grading.

RESULTS

Mean age was 41.6 years old; mean BMI 26.6; mean neck circumference 44.5cm; mean Apnea Hypopnea Index (AHI) was 25.0; and mean LSAT 82%. The various laryngeal grades (based on Cormack and Lehane), grade 1 - 53 patients (12.9%), grade 2A - 127 patients (31.0%), grade 2B - 125 patients (30.5%), grade 3 - 93 patients (22.7%) and grade 4 - seven patients (1.7%); hence, 24.4% had difficulties in intubation. Parameters that adversely affected intubation were, age of the patient, opening of mouth, retrognathia, overbite, overjet, limited neck extension, thyromental distance, Mallampati grade, and macroglossia (p<0.001). Body mass index (BMI) (p=0.087), neck circumference (p=0.645), neck aches (p=0.728), jaw aches (p=0.417), tonsil size (p=0.048), and AHI (p=0.047) had poor correlation with intubation. BMI-adjusted for Asians and Caucasians, showed that Asians were more likely to have difficulties in intubation (adjusted OR = 4.6 (95%Confidence Interval: 1.05 to 20.06) (p=0.043), compared to the Caucasian group.

CONCLUSION

This study illustrates that difficult intubation can be predicted pre-surgery in order to avert any anaesthetic morbidity.

Epidemiology and prognostic factors for mycosis fungoides and Sézary syndrome in a multi-ethnic Asian cohort: a 12-year review

BACKGROUND

Limited information exists regarding survival of Asian patients with mycosis fungoides (MF) and Sézary syndrome (SS).

OBJECTIVE

To evaluate the epidemiology, outcome and prognostic factors of these patients.

METHODS

A retrospective review of MF/SS cases diagnosed from 2000 to 2011 at a tertiary referral dermatology centre in Singapore was performed.

RESULTS

Of 246 patients, 63% were male and the median age at diagnosis was 49 years. 73.2% were Chinese, 12.6% Indian, 6.9% Malay and 7.3% Caucasian. A total of 239 patients (97.2%) had MF and seven had SS. Median follow-up duration was 6.3 years, and median duration of symptoms at diagnosis was 13 months. For patients with MF, the majority had early disease (92.8% stage IA-IIA). 3.8% were stage IIB, 1.7% stage III and 1.7% stage IV. Complete response to treatment occurred in 78.2%, partial response in 9.6%, persistent but non-progressive disease in 10.0% and disease progression in 4.1% of patients. Large cell transformation occurred in 4.1% of patients. Mean overall survival during this study was 12.7 years, with death occurring in 2.5% of patients (all ≥stage IIB at diagnosis). For patients with SS, 71.4% presented with stage IVA disease, 28.6% stage IVB. Complete response to treatment occurred in 14.2%, persistent but non-progressive disease in 28.6% and disease progression in 57.2% of patients. Mean overall survival was 3.3 years within this study, with death occurring in 42.9% of SS patients. Prognostic factors associated with favourable recurrence-free survival were male gender (P = 0.008), early disease stage (T1) at diagnosis (P < 0.001) and absence of maintenance treatment after remission (P = 0.01).

CONCLUSION

Compared to Caucasian and East Asian cohorts, MF in South-East Asians was diagnosed at a younger age and associated with lower mortality, largely due to greater prevalence of hypopigmented MF.

Roux-en-Y or Billroth II Reconstruction After Radical Distal Gastrectomy for Gastric Cancer: A Multicenter Randomized Controlled Trial

OBJECTIVE

The aim of the study was to compare the clinical symptoms between Billroth II (B-II) and Roux-en-Y (R-Y) reconstruction after distal subtotal gastrectomy (DG) for gastric cancer.

BACKGROUND

Surgery is the mainstay of curative treatment for gastric cancer. The technique for reconstruction after DG remains controversial. Both B-II and R-Y are popular methods.

METHODS

This is a prospective multicenter randomized controlled trial. From October 2008 to October 2014, 162 patients who underwent DG were randomly allocated to B-II (n = 81) and R-Y (n = 81) groups. The primary endpoint is Gastrointestinal (GI) Symptoms Score 1 year after surgery. We also compared the nutritional status, extent of gastritis on endoscopy, and quality of life after surgery between the 2 procedures at 1 year.

RESULTS

Operative time was significantly shorter for B-II than for R-Y [mean difference 21.5 minutes, 95% confidence interval (95% CI) 3.8-39.3, P = 0.019]. The B-II and R-Y groups had a peri-operative morbidity of 28.4% and 33.8%, respectively (P = 0.500) and a 30-day mortality of 2.5% and 1.2%, respectively (P = 0.500). GI symptoms score did not differ between R-Y versus B-II reconstruction (mean difference -0.45, 95% CI -1.21 to 0.31, P = 0.232). R-Y resulted in a lower median endoscopic grade for gastritis versus B-II (mean difference -1.32, 95% CI -1.67 to -0.98, P < 0.001). We noted no difference in nutritional status (R-Y versus B-II mean difference -0.31, 95% CI -3.27 to 2.65, P = 0.837) and quality of life at 1 year between the 2 groups too.

CONCLUSION

Although BII is associated with a higher incidence of heartburn symptom and higher median endoscopic grade for gastritis, BII and RY are similar in terms of overall GI symptom score and nutritional status at 1 year after distal gastrectomy.

Comparison of the Re-usable LMA Classic™ and Two Single-use Laryngeal Masks (LMA Unique™ and SoftSeal™) in Airway Management by Novice Personnel

In a single-blind randomized trial, three types of laryngeal masks: the reusable LMA Classic™, the single-use LMA Unique™ and SoftSeal™ were inserted by novice medical officers in anaesthesia. Five successive attempts were undertaken with each mask type. The order of the mask type insertion was randomly selected. Mean (SD) insertion times for LMA Classic™, LMA Unique™ and Soft Seal™ were 32.9 (12.3), 39.6 (23.4) and 49.4 (50.4) seconds respectively. Differences were only significant between LMA Classic™ and SoftSeal™ (P=0.012). There were no significant differences in first attempt success rates (LMA Classic™ 80%, LMA Unique™ 77% and SoftSeal™ 62%). The SoftSeal™ was most frequently associated with blood on the mask (32%) compared to the LMA Unique™(9%) and LMA Classic™ (6%). Sore throat was experienced in 14% of patients in the LMA Unique™ group versus 41% and 42% in the LMA Classic™ and SoftSeal™ groups respectively. Mean±SD oropharyngeal leak pressure was significantly higher in the SoftSeal™ (21±6 cmH2O) compared to the LMA Classic™ (17±7 cmH2O) and LMA Unique™ (16±6 cmH2O).

Novice medical doctors can be taught to insert disposable laryngeal masks. The SoftSeal™ took longer to insert, which resulted in a higher incidence of blood on the mask, but success rates did not differ. The LMA Unique™ was associated with the lowest incidence of sore throat in the immediate postoperative period. A higher oropharyngeal leak pressure with the SoftSeal™ may indicate improved airway seal and protection against aspiration.

Indoor environmental quality, occupant satisfaction, and acute building-related health symptoms in Green Mark-certified compared with non-certified office buildings

Indoor environmental quality (IEQ) has become an important component of green building certification schemes. While green buildings are expected to provide enhanced IEQ, higher occupant satisfaction, and less risks of occupant health when compared with non-green buildings, the literature suggests inconsistent evidence due to diverse research design, small sample size, and weak statistical analysis. This study compared several outcomes pertinent to IEQ performance in green and non-green office buildings in Singapore. Adopting a cross-sectional study design, objective measurements were taken in eight green and six non-green buildings, and satisfaction and acute health symptom risks of 367 occupants were obtained. Green buildings exhibited lower concentration of PM2.5, bacteria, and fungi and maintained temperature and humidity more consistently compared to non-green counterparts. The mean ratings for satisfaction with temperature, humidity, lighting level, air quality, and indoor environment were higher in green buildings (with statistical significance P < 0.05). There was statistically significant reduction in risk of occupants having headache, unusual fatigue, and irritated skin in green buildings. Although matching of buildings and occupant characteristics, survey participation bias, and sampling duration (a 1-week snapshot) of IEQ monitoring remain as limitations, this study offered positive association of green buildings with qualitatively and quantitatively measured performance of IEQ.

Development of a Brief Caregiver-centric Screening Tool to Identify Risk of Depression among Caregivers of Hospitalized Older Adults

OBJECTIVES

Caregivers of hospitalized older adults experience elevated levels of stress and are at risk of poor health outcomes. There is a lack of screening tools based on self-reported caregiver variables incorporating both protective and risk factors, for early identification of at-risk caregivers. This study reports the development of a caregiver-centric screening tool to identify risk of depression at admission and predicts 3-month risk of depression and quality of life amongst caregivers of older adults with an unplanned admission.

DESIGN, SETTING AND PARTICIPANTS

This prospective cohort study was conducted in the medical wards of a tertiary-care hospital from July 2015 to May 2017. We recruited family caregivers of patients aged 65 years and above who fulfilled the following criteria: a) unplanned admission, b) not residing in nursing homes; and c) requiring assistance in activities of daily living.

MEASUREMENTS

We examined 11 candidate caregiver variables (mastery, burden and nine demographic variables). Risk of depression (score ≥8 on Hospital Anxiety and Depression Scale (HADS-D) depression subscale) was the primary outcome, and was assessed during the index admission. Logistic regression models were used to identify risk factors and risk scores (weights). The total risk scores were then stratified into three risk levels. Predictive validity of the screening tool was assessed using 3-months post-discharge risk of depression and health-related quality of life (HRQoL).

RESULTS

The study included 274 caregiver-patient dyads. The mean (SD) age of the caregivers was 59 (10) years with 33.6% caregivers screening positive for risk of depression. The final model comprised three caregiver variables: mastery, burden and education. The total risk scores ranged from 0 to 6 and showed good discrimination (AUC:0.82, 95% CI: 0.77 to 0.87). Caregivers were classified into low-risk (0-1 points), intermediate-risk (2-4 points), and high-risk (5-6 points) groups, with corresponding rates of risk of depression (HADS-D≥8) of 10.7%, 44.6% and 73.3%, during admission. Relative risk rates of the intermediate- and high- risk group using the low-risk group as reference were 4.16 and 6.84 respectively. At 3-months post-discharge, the rates of caregivers at risk of depression or having poor HRQoL also increased corresponding to the three risk levels as per baseline, supporting the predictive validity of the tool.

CONCLUSIONS/IMPLICATIONS

The caregiver-centric tool is a novel, practical, self-administered, relatively brief caregiver-centric instrument that can be used for rapid screening and stratification of caregivers at risk of depression. Uniquely, the tool comprised of assessment of protective factor (mastery) in addition to risk factors to provide a holistic assessment of the caregiver. It can be incorporated as part of older adults' admission evaluation so that prompt intervention can be rendered to their at-risk caregivers.

Impact of acute stress on itch sensation and scratching behaviour in patients with atopic dermatitis and healthy controls

BACKGROUND

Patients with atopic dermatitis (AD) often report that stress aggravates their itch. However, no study has investigated if and how acute stress influences itch sensation and scratching behaviour in these patients.

OBJECTIVES

We evaluated the impact of acute stress on experimentally induced cowhage itch perception and scratching behaviour in 16 healthy subjects and 15 patients with AD.

METHODS

The Trier Social Stress Test (TSST) was used to induce acute stress. The itch sensation, provoked by applying cowhage to the forearms, and off-site scratching behaviour (not directed at the cowhage application site) were compared before and after performing the TSST or the control condition (watching a video of landscape scenes).

RESULTS

In patients with AD, stress induced by TSST caused a significant reduction of cowhage-evoked itch but significantly increased off-site scratching behaviour. Such changes in itch perception and scratching behaviour were not observed in healthy controls. In addition, a significant positive correlation was noted between stress induced by TSST and clinical severity of eczema.

CONCLUSIONS

We speculate that psychological stress increases spontaneous scratching in patients with AD, which may enhance the vicious cycle of itching and scratching, resulting in aggravation of the skin eczema. These results provide new insights on the mechanism of acute stress-related exacerbation of itch in patients with AD.

Early initiation and regular breast milk expression reduces risk of lactogenesis II delay in at-risk Singaporean mothers in a randomised trial

INTRODUCTION

Lactogenesis II (LaII) failure can be prevented in at-risk mothers with simple proactive interventions. In a randomised trial, we investigated the efficacy of early and regular breast milk expression in establishing LaII, using an electric double-breast pump.

METHODS

Mothers with uncomplicated singleton deliveries were randomised to intervention (n = 31) or control (n = 29) groups. The former commenced breast milk expression with an electric pump within one hour of delivery and maintained regular expression with direct breastfeeding. Control mothers directly breastfed without regular pump expression. Expressed milk volumes were analysed for citrate, lactose, sodium and protein.

RESULTS

Median time of LaII was Day 3 (interquartile range [IQR] 1 day) with intervention and on Day 4 (IQR 1 day) among controls (p = 0.03). Biochemical steady-state concentrations were achieved around early Day 4 (sodium, total protein) and Days 4-5 (citrate, lactose). Sodium, protein and lactose levels were similar in both groups over seven days, at 5.80 mM, 0.68 mM and -13.38 mM, respectively. Mean daily milk volume with intervention was 73.9 mL on Day 3 and 225.2 mL on Day 7, greater than controls (25.4 mL on Day 3 and 69.2 mL on Day 7; p < 0.2). Mean infant weights were similar on Day 8 at 3,477 g with intervention and 3,479 g among controls.

CONCLUSION

LaII is established by postnatal Day 3 with early initiation of regular breast milk expression, a useful intervention for mothers at risk of early-onset breastfeeding failure.

Preoperative Red Cell Distribution Width and 30-day mortality in older patients undergoing non-cardiac surgery: a retrospective cohort observational study

Increased red cell distribution width (RDW) is associated with poorer outcomes in various patient populations. We investigated the association between preoperative RDW and anaemia on 30-day postoperative mortality among elderly patients undergoing non-cardiac surgery. Medical records of 24,579 patients aged 65 and older who underwent surgery under anaesthesia between 1 January 2012 and 31 October 2016 were retrospectively analysed. Patients who died within 30 days had higher median RDW (15.0%) than those who were alive (13.4%). Based on multivariate logistic regression, in our cohort of elderly patients undergoing non-cardiac surgery, moderate/severe preoperative anaemia (aOR 1.61, p = 0.04) and high preoperative RDW levels in the 3rd quartile (>13.4% and ≤14.3%) and 4th quartile (>14.3%) were significantly associated with increased odds of 30-day mortality - (aOR 2.12, p = 0.02) and (aOR 2.85, p = 0.001) respectively, after adjusting for the effects of transfusion, surgical severity, priority of surgery, and comorbidities. Patients with high RDW, defined as >15.7% (90th centile), and preoperative anaemia have higher odds of 30-day mortality compared to patients with anaemia and normal RDW. Thus, preoperative RDW independently increases risk of 30-day postoperative mortality, and future risk stratification strategies should include RDW as a factor.

Endobronchial valve for treatment of persistent air leak complicating spontaneous pneumothorax

INTRODUCTION

Endobronchial one-way valves have been proposed as treatment for persistent air leak complicating spontaneous pneumothorax in which surgical intervention is not feasible. However, published data on efficacy, safety, and factors associated with success are scanty.

METHODS

This is a retrospective study of 37 patients at a general hospital from 2008 to 2016. The impact of endobronchial valve implantation on the time to air-leak cessation after bronchoscopy was evaluated.

RESULTS

The median patient age was 71 years. The majority of patients were males (92%), were ever-smokers (83%), had at least one co-morbidity (97%), and had secondary spontaneous pneumothorax (89%). Nineteen patients (51%) had a mean of 2.6 endobronchial valves implanted (range, 1-6). The air leak ceased within 72 hours for only eight patients (22% of the complete cohort), with immediate air-leak cessation after completion of endobronchial valve implantation. All six successful cases that had computed tomographic data of the thorax were shown to have bilateral intact interlobar fissures. The median (interquartile range) Charlson co-morbidity index was 1 (0.25-1) and 2 (1-3) for the success group and failure group, respectively (P=0.029). All patients in the no-endobronchial valve group survived, whereas three patients in the endobronchial valve group died within 30 days of endobronchial valve implantation.

CONCLUSION

Only a small proportion of cases of endobronchial valve implantation for air leak complicating pneumothorax had unequivocal success. Intact bilateral interlobar fissures appear to be a necessary, though not sufficient, condition for success. Patients with fewer medical co-morbidities and immediate air-leak cessation after endobronchial valve implantation have a higher likelihood of success.

Biological false-positive venereal disease research laboratory test in cerebrospinal fluid in the diagnosis of neurosyphilis - a case-control study

BACKGROUND

There is no clear consensus on the diagnosis of neurosyphilis. The Venereal Disease Research Laboratory (VDRL) test from cerebrospinal fluid (CSF) has traditionally been considered the gold standard for diagnosing neurosyphilis but is widely known to be insensitive.

OBJECTIVE

In this study, we compared the clinical and laboratory characteristics of true-positive VDRL-CSF cases with biological false-positive VDRL-CSF cases.

METHODS

We retrospectively identified cases of true and false-positive VDRL-CSF across a 3-year period received by the Immunology and Serology Laboratory, Singapore General Hospital. A biological false-positive VDRL-CSF is defined as a reactive VDRL-CSF with a non-reactive Treponema pallidum particle agglutination (TPPA)-CSF and/or negative Line Immuno Assay (LIA)-CSF IgG. A true-positive VDRL-CSF is a reactive VDRL-CSF with a concordant reactive TPPA-CSF and/or positive LIA-CSF IgG.

RESULTS

During the study period, a total of 1254 specimens underwent VDRL-CSF examination. Amongst these, 60 specimens from 53 patients tested positive for VDRL-CSF. Of the 53 patients, 42 (79.2%) were true-positive cases and 11 (20.8%) were false-positive cases. In our setting, a positive non-treponemal serology has 97.6% sensitivity, 100% specificity, 100% positive predictive value and 91.7% negative predictive value for a true-positive VDRL-CSF based on our laboratory definition. HIV seropositivity was an independent predictor of a true-positive VDRL-CSF.

CONCLUSION

Biological false-positive VDRL-CSF is common in a setting where patients are tested without first establishing a serological diagnosis of syphilis. Serological testing should be performed prior to CSF evaluation for neurosyphilis.

Food allergy and allergic rhinitis in 435 asian patients - A descriptive review

OBJECTIVE

To describe the prevalence of food allergy in Asian patients with allergic rhinitis.

STUDY DESIGN

A non-randomized prospectively collected patients over a three year period, with complaints of nose congestion, rhinorrhea and/or nasal discharge.

RESULTS

There were 435 patients enrolled, 213 children and 222 adults. The children group had a high prevalence of allergen specific IgE to Dermatophagoides pteryonysinus (70%), Dermatophagoides farina (69%), and Blomia tropicalis (55%); followed by dogs (32%), cats (19%) and cockroaches (19%). In the children food allergy category, the top three allergens were egg white (54%), milk (31%) and soya bean (13%). The adult group had results of Dermatophagoides pteryonysinus (71%), Dermatophagoides farina (72%), and Blomia tropicalis (59%); the adult food allergy category, the top 3 allergens were egg white (13%), milk (6%) and soya bean (5%). There was a statistically significant difference in the child and adult group for Dust, D. pteryonysinus, D. farina, B.tropicalis, egg white, wheat, gluten and soya bean. In the age specific child groups, there was an increased in egg food allergy levels, with a peak at the age of five-nine years old and decreasing thereafter (p=0.04). In the children group, the mean Total Nasal Symptom Score (TNSS) was 10.3 (range of 7 to 13); the adult group was similar, with a mean TNSS of 9.8 (range 5 to 12).

CONCLUSION

The prevalence of food allergy in paediatric patients with allergic rhinitis is fairly high and should be considered when treating these children.

Patient Satisfaction Is Linked to Nursing Workload in a Singapore Hospital

No studies have examined the association between patient satisfaction and the allocation of nursing care hours using a workload management system. The aim of this study is to examine the correlation between inpatients’ perceived satisfaction with nursing care and nursing workload management in a Singapore hospital. A secondary data analysis was performed based on the results of 270 patients’ perceived satisfaction measured by the Revised Humane Caring Scale and nursing workload management data extracted from the TrendCare Patient Acuity System. Data were collected from March to October 2013. There were weak positive ( rs = .212 to rs = .120) and negative ( rs = −.120 to rs = −.196) correlations between patient satisfaction and nursing workload. Nursing leaders should build positive work environment through maximizing efficient resource allocation and adequate staffing to deliver safe patient care. Future studies could involve other patient outcomes such as incidences of fall and pressure ulcer.

Use of an Industrial Tungsten Carbide Drill in the Treatment of a Complex Fracture in a Patient with Severe Osteopetrosis: A Case Report

The treatment of fractures in osteopetrosis can be complicated and difficult. We describe the use of an industrial grade tungsten carbide drill bit in the treatment of one of these complex fractures. An industrial grade tungsten carbide drill bit was used to fashion a medullary canal in the surgical treatment of a left peri-implant fracture of the neck of femur in a patient with osteopetrosis. The patient was successfully treated with a hemiarthroplasty with good functional outcomes. A tungsten carbide drill bit serves as an effective and safe option in the treatment of osteopetrotic femoral neck fractures.

Attitudes toward utility, effects and side effects of treatment for anxiety and depression

OBJECTIVES

Negative perceptions about psychiatric treatment are likely to affect treatment adherence. We compared attitudes of patients with psychiatric illness and those of medical patients towards psychiatric treatment.

METHODS

Both patients with psychiatric illness and medical patients (controls) were shown a printed copy of two vignettes depicting major depression and generalized anxiety disorder. They were asked for their perceptions on the utility, effects and possible side effects of psychiatric medications, as well as the utility of psychotherapy in treating major depression and generalized anxiety disorder. Responses between psychiatric patients and medical patients were compared using appropriate statistical tests, including logistic regression.

RESULTS

Patients with psychiatric illness were more likely than medical patients to endorse the utility of medications in treating major depression and generalized anxiety disorder (p<0.001). Those with psychiatric illness were more likely to endorse the utility of psychotherapy in treating major depression (p=0.004). Both groups of patients were of the view that psychotherapy would benefit generalized anxiety disorder. Older and lesser educated patients held negative beliefs about medications.

CONCLUSIONS

While patients with psychiatric illnesses endorsed favourable attitudes toward medications (p<0.001), the older and lesser educated were more likely to hold negative views (p<0.05). Psychoeducation should be tailored to the needs of older and lesser educated patients.

A vegetable, fruit, and white rice dietary pattern during pregnancy is associated with a lower risk of preterm birth and larger birth size in a multiethnic Asian cohort: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort study

BACKGROUND

Maternal dietary patterns during pregnancy have been shown to influence infant birth outcomes. However, to our knowledge, only a few studies have examined the associations in Asian populations.

OBJECTIVE

We characterized maternal dietary patterns in Asian pregnant women and examined their associations with the risk of preterm birth and offspring birth size.

DESIGN

At 26-28 wk of gestation, 24-h recalls and 3-d food diaries were collected from the women in the Growing Up in Singapore Towards healthy Outcomes mother-offspring cohort. Dietary patterns were derived from exploratory factor analysis. Gestational age was determined by a dating ultrasound scan in the first trimester, and infant birth anthropometric measurements were obtained from hospital records. Associations were assessed by logistic and linear regressions with adjustment for confounding factors.

RESULTS

Three maternal dietary patterns were identified: vegetable, fruit, and white rice (VFR); seafood and noodle (SfN); and pasta, cheese, and processed meat (PCP). Of 923 infants, 7.6% were born preterm, 13.4% were born small for gestational age, and 14.7% were born large for gestational age. A greater adherence to the VFR pattern (per SD increase in VFR score) was associated with a lower risk of preterm births (OR: 0.67; 95% CI: 0.50, 0.91), higher ponderal index (β: 0.26 kg/m³; 95% CI: 0.06, 0.45 kg/m³), and increased risk of a large-for-gestational-age birth (RR: 1.31; 95% CI: 1.06, 1.62). No associations were observed for the SfN and PCP patterns in relation to birth outcomes.

CONCLUSIONS

The VFR pattern is associated with a lower incidence of preterm birth and with larger birth size in an Asian population. The findings related to larger birth size warrant further confirmation in independent studies. This trial was registered at clinicaltrials.gov as NCT01174875.

A Single Dose-Escalation Study to Evaluate the Safety and Pharmacokinetics of Orally Administered Des-Aspartate Angiotensin I in Healthy Subjects

Des-aspartate-angiotensin I (DAA-I) is an endogenous angiotensin peptide and a prototype angiotensin receptor agonist (ARA). It acts on the angiotensin AT₁ receptor and antagonises the deleterious actions of angiotensin II. DAA-I attenuates animal models of human disease in which angiotensin II has been implicated, such as cardiac hypertrophy, neointima formation, arteriosclerosis, renal failure, post-infarction injuries, diabetes, viral infection, chemical-induced inflammation, heat stroke, cancer, and gamma radiation lethality. DAA-I crosses Caco-2 cells and is effective at sub-nanomolar concentrations. These two properties are responsible for its oral efficacy. A single dose-escalation study was conducted to evaluate the safety, tolerability and pharmacokinetics of orally administered DAA-I in 18 healthy subjects. DAA-I was safe and well tolerated by the subjects, who were administered either 0.08, 0.70 or 1.50 mg/kg of the compound. The heart rate and systolic and diastolic blood pressures determined at each post-dose measurement remained within the clinically acceptable range. Across all cohorts, DAA-I had no substantial effect on blood pressures compared with placebo. Electrocardiographs (ECGs) were normal, and none of the subjects complained of chest discomfort. All clinical laboratory tests obtained before and after DAA-I and placebo treatment were normal. Pharmacokinetic analysis over a 12-h period following DAA-I administration did not show any increase of its level beyond basal concentration. This is in line with studies showing that intravenously administered DAA-I is rapidly metabolized and has a short half-life. We postulate that, during its short systemic sojourn, DAA-I exerts its actions via biased agonism on the angiotensin AT₁ receptor.

The ClinicalTrial.gov assignment number for this study is NCT02666196.