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Background: Little is known about optimization of electronic health records (EHR) systems in the hospital setting while adoption of EHR systems continues in the United States. Objective: To understand optimization processes of EHR systems undertaken in leading healthcare organizations in the United States. Methods: Informed by grounded theory approach, a qualitative study was undertaken that involved 11 in-depth interviews and a focus group with the EHR experts from the high performing healthcare organizations across the United States. Results: The study describes EHR optimization processes characterized by prioritizing exponentially increasing requests with predominant focus on improving efficiency of EHR, building optimization teams or advisory groups, and standardization. The study discusses 16 types of optimization that interdependently produced 16 results along with identifying 11 barriers and 20 facilitators to optimization. Conclusion: The study describes overall experiences of optimizing electronic health records in select high performing healthcare organizations in the US. The findings highlight the importance of optimizing the EHR after, and even before, go-live and dedicating resources exclusively for optimization.

Introduction: Tuberculosis (TB) remains endemic in Singapore. Singapore’s clinical practice guidelines for the management of tuberculosis were first published in 2016. Since then, there have been major new advances in the clinical management of TB, ranging from diagnostics to new drugs and treatment regimens. The National TB Programme convened a multidisciplinary panel to update guidelines for the clinical management of drug-susceptible TB infection and disease in Singapore, contextualising current evidence for local practice. Method: Following the ADAPTE framework, the panel systematically reviewed, scored and synthesised English-language national and international TB clinical guidelines published from 2016, adapting recommendations for a prioritised list of clinical decisions. For questions related to more recent advances, an additional primary literature review was conducted via a targeted search approach. A 2-round modified Delphi process was implemented to achieve consensus for each recommendation, with a final round of edits after consultation with external stakeholders. Results: Recommendations for 25 clinical questions spanning screening, diagnosis, selection of drug regimen, monitoring and follow-up of TB infection and disease were formulated. The availability of results from recent clinical trials led to the inclusion of shorter treatment regimens for TB infection and disease, as well as consensus positions on the role of newer technologies, such as computer-aided detection-artificial intelligence products for radiological screening of TB disease, next-generation sequencing for drug-susceptibility testing, and video observation of treatment. Conclusion: The panel updated recommendations on the management of drug-susceptible TB infection and disease in Singapore.

Background: Early implant placement combined with simultaneous contour augmentation was able to rebuild stable facial hard-tissue and soft-tissue contours that were esthetically pleasing. The purpose of this study was to evaluate the clinical esthetic outcome, when two different bone grafting materials were used.Methods: Forty-eight patients were randomly assigned into two groups. In the control group, autogenous bone was used to cover the exposed implant surface then a layer of deproteinized bovine bone mineral (DBBM) was added. This graft combination was then combined with a collagen membrane. In the test group, the exposed implant surface was covered with a layer of freeze-dried bone allograft (FDBA) in combination with the collagen membrane. Modified plaque index (mPI), modified sulcular bleeding index (mSBI), probing depth (PD), keratinized mucosa (KM), implant crown length (IC), distance from the implant shoulder radiographic bone-to-implant contact (DIB), pink esthetic score (PES), and white esthetic score (WES) were measured at 12-months post implant loading.Results: All 48 implants were clinically successful, and no significant differences were observed in mPI, mSBI, PD, KM, IC, DIB, PES, and WES at 1-year implant loading. The mean mucosal recessions of test and control group were unchanged, 0 and -0.02 mm, respectively. The mean DIB were -0.32 and -0.21 mm in test and control implants, respectively. The mean totals of PES/WES were 15.29 and 15.33 for the test and control groups, respectively, with no significant difference between groups.Conclusion: This study demonstrated that autogenous bone plus DBBM and FDBA each combined with a collagen membrane both resulted in stable clinical and esthetic outcomes in early implant placement with contour augmentation after 1 year. [ABSTRACT FROM AUTHOR]

Herpes zoster (HZ) causes significant morbidity, particularly in older adults. With the advent of a recombinant zoster vaccine, HZ is potentially preventable. However, data on HZ burden and healthcare utilization in primary care populations remains scarce. This study described the prevalence and healthcare utilization in managing HZ in a developed community. A retrospective database review was conducted across a cluster of 8 public primary care clinics in urban Singapore. Data of multi-ethnic Asian patients with a diagnosis code of “herpes zoster” from 2018 to 2020 was extracted from their electronic medical records. Socio-demographic, clinical, visitation, medical leave, prescription, and referral data were analyzed. A total of 2,987 out of 737,868 individuals were diagnosed with HZ over 3 years. The mean age was 59.9 (SD + 15.5) years; 49.2% were male; 78.5% Chinese, 12.2% Malay, and 4.1% Indian. The prevalence was 221, 224, 203 per 100,000 persons in 2018, 2019, and 2020, respectively. The 70 to 79-year age group had the highest prevalence (829/100,000) across 3 years. Oral acyclovir (median daily dose 4,000 mg; median duration 7 days) and topical acyclovir were prescribed in 71.6 and 47.6%, respectively. Analgesia prescribed were gabapentin (41.0%), paracetamol combinations (30.1%), oral NSAIDs (23.7%), opioids (6.0%), and tricyclic antidepressants (1.9%). Most individuals consulted only once (84.3%); 32.7% of them required medical leave and 5.6% had more than 7 days of absenteeism. HZ-related referrals to the hospital were required in 8.9% (4.9% emergency, 2.8% ophthalmology). The findings of this study suggest a need for HZ vaccination among older age groups. Visitation and referral rates were low. The use of topical acyclovir was uncovered, and further research should evaluate the underlying reasons, benefits, and harms of such practice. The use of analgesia combinations may be explored further.

Active bone-conducting hearing devices (aBCHD; e.g., MEDEL Bonebridge® (BB)) and active middle ear implants (aMEI; e.g., MEDEL Vibrant Soundbridge® (VSB)) use radio frequency transmission to send information from an external microphone and sound processor to an internally implanted transducer. These devices potentially have an advantage over devices with percutaneous links because the skin is closed over the implantable components, which should reduce the risk of skin problems and infection. On the other hand, surgical procedures are more complex, with a greater risk of damage due to surgery. The objectives of this research were to quantify the reliability and long-term survival of MEDEL VSB and BB devices, determine the adverse and serious adverse device-related complications, and consider associated causes. A multi-center observational retrospective and prospective study was conducted at eleven auditory implant centers in the United Kingdom. Data was collected using a surgical questionnaire and audiological reports. Data were obtained from patient notes or from prospective cases that had a minimum follow-up of one year post-implant. Consecutive patient records were reviewed. Datasets from 109 BB and 163 VSB were reviewed. Of these, 205 were retrospective case note reviews, and 67 were prospective cases. The mean follow-up was 4 and 6 years, respectively, for BB and VSB. Kaplan–Meier Survival analyses indicated that the BB survival was 97% and 93.3% at 1 and 5 years, respectively, and the VSB was 92.1% and 87% at the same time points. This is a large cohort study for the field and has indicated that BB and VSB are safe interventions. Care should be taken to monitor magnet strength in the first few months. For the majority of device-related effects, there was no apparent association with etiology. However, an interesting pattern emerged for individuals who exhibited an inflammatory response, e.g., adhesions or device extrusion, and those with a history of chronic suppurative otitis media. This should be considered in future work and is not surprising given that many VSB recipients have a complicated hearing history, often associated with otitis media.

Objective To examine factors contributing to the low COVID-19 infectivity rate among healthcare workers in SingHealth Polyclinics (SHP), Singapore, from February to July 2020.Design Retrospective description, analysis and discussion of the factors and their contribution.Setting Single-institution study.Methods We describe and discuss the healthcare policies, infrastructure, people and processes contributing to the low COVID-19 infectivity rate in SHP.There were 1212 full-time and 198 contract staff. Of these, 171 SHP employees also supported the work in dormitories, isolation and community care facilities. During the review period, healthcare workers (HCWs) in SHP managed about 867 076 patient attendances, including 63 503 for upper respiratory tract infections, across its cluster of eight polyclinics. 29 642 swabs for COVID-19 were performed in SHP, with 126 positive results. 395 swabs were carried out in the dormitories and 59 were positive. Despite the high exposure, only two SHP staff were infected with COVID-19. Both have recovered well.Results Provision of adequate personal protection equipment, zonal segregation of high-risk patients, reduction in physical patient visits, effective staff communication, implementation of self-declared temperature monitoring and the maintenance of sustainable workload and work hours of HCWs contributed to the mitigation of COVID-19 infection risk among our staff.Conclusions Until the widespread uptake of safe and effective vaccines against COVID-19, these measures are important in protecting HCWs. They are also important when managing future pandemics of similar nature to COVID-19.

Background: The Vibrant Soundbridge middle ear implant and the Bonebridge bone conducting hearing device are hearing implants that use radio frequency transmission to send information from the sound processor to the internal transducer. This reduces the risk of skin problems and infection but requires a more involved surgical procedure than competitor skin penetrating devices. It is not known whether more complex surgery will lead to additional complications. There is little information available on the reliability of these systems and adverse medical or surgical events. The primary research question is to determine the reliability and complication rate for the Vibrant Soundbridge and Bonebridge. The secondary research question explores changes in quality of life following implantation of the devices. The tertiary research question looks at effectiveness via changes in auditory performance. Method: The study was designed based on a combination of a literature search, two clinician focus groups and expert review.A multi-centre longitudinal observational study was designed. There are three study groups, two will have been implanted prior to the start of the study and one group, the prospective group, will be implanted after initiation of the study. Outcomes are surgical questionnaires, measures of quality of life, user satisfaction and speech perception tests in quiet and in noise. Conclusion: This is the first multi-centre study to look at these interventions and includes follow up over time to understand effectiveness, reliability, quality of life and complications. Keywords: Bone conducting device, Bonebridge, Soundbridge, Middle ear implant, Implant registry, Quality of life

Wavefront sensing and control are important for enabling one of the key advantages of using large apertures, namely higher angular resolution. Pyramid wavefront sensors are becoming commonplace in new instrument designs owing to their superior sensitivity. However, one remaining roadblock to their widespread use is the fabrication of the pyramidal optic. This complex optic is challenging to fabricate due to the pyramid tip, where four planes need to intersect at a single point. Thus far, only a handful of these have been produced due to the low yields and long lead times. To address this, we present an alternative implementation of the pyramid wavefront sensor which relies instead on two roof prisms. Such prisms are easy and inexpensive to source. We demonstrate the successful operation of the roof prism pyramid wavefront sensor on an 8 m class telescope, at visible and near-infrared wavelengths, for the first time using a SAPHIRA HgCdTe detector without modulation for a laboratory demonstration, and elucidate how this sensor can be used more widely on wavefront control test benches and instruments. [ABSTRACT FROM AUTHOR]

Subclinical thyroid disorders are commonly encountered in the primary care setting. This article aims to review the latest evidence and guidelines pertaining to the management of subclinical hypo- and hyperthyroidism, in particular the important decision of when treatment should be considered.