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Studies have shown that national-level initiatives to equip medical students with relevant digital competencies carry many benefits. Yet, few countries have outlined such competencies for clinical practice in the core medical school curriculum. This paper identifies current training gaps at the national level in digital competencies needed by students in the formal curricula of all three medical schools in Singapore from the perspectives of clinical educators and institutional leaders. It bears implications for countries that intend to implement standardized learning objectives for training in these digital competencies. Findings were drawn from in-depth interviews with 19 clinical educators and leaders of local medical schools. Participants were recruited using purposive sampling. Data were interpreted using qualitative thematic analysis. Thirteen of the participants were clinical educators while 6 were deans or vice deans of education from one of the three medical schools in Singapore. While the schools have introduced some relevant courses, they are not standardized nationally. Moreover, the school's niche areas have not been leveraged upon for training in digital competencies. Participants across all schools acknowledged that more formal training is needed in digital health, data management, and applying the principles of digital technologies. Participants also noted that the healthcare needs of the population, patient safety, and safe procedures in the utilization of digital healthcare technologies should be prioritized when determining the competencies needed by students. Additionally, participants highlighted the need for stronger collaboration among medical schools, and for a stronger link between current curriculum and clinical practice. The findings highlighted the need for better collaboration among medical schools in the sharing of educational resources and expertise. Furthermore, stronger collaborations with professional bodies and the healthcare system should be established to ensure that the goals and outcomes of medical education and the healthcare system are aligned. [ABSTRACT FROM AUTHOR]

Background: Emergency risk communication is a critical component in emergency planning and response. It has been recognised as significant for planning for and responding to public health emergencies. While there is a growing body of guidelines and frameworks on emergency risk communication, it remains a relatively new field. There has also been limited attention on how emergency risk communication is being performed in public health organisations, such as acute hospitals, and what the associated challenges are. This article seeks to examine the perception of crisis and emergency risk communication in an acute hospital in response to COVID-19 pandemic in Singapore and to identify its associated enablers and barriers.Methods: A 13-item Crisis and Emergency Risk Communication (CERC) Survey, based on the US Centers for Disease and Control (CDC) CERC framework, was developed and administered to hospital staff during February 24-28, 2020. The survey also included an open-ended question to solicit feedback on areas of CERC in need of improvement. Chi-square test was used for analysis of survey data. Thematic analysis was performed on qualitative feedback.Results: Of the 1154 participants who responded to the survey, most (94.1%) reported that regular hospital updates on COVID-19 were understandable and actionable. Many (92.5%) stated that accurate, concise and timely information helped to keep them safe. A majority (92.3%) of them were clear about the hospital's response to the COVID-19 situation, and 79.4% of the respondents reported that the hospital had been able to understand their challenges and address their concerns. Sociodemographic characteristics, such as occupation, age, marital status, work experience, gender, and staff's primary work location influenced the responses to hospital CERC. Local leaders within the hospital would need support to better communicate and translate hospital updates in response to COVID-19 to actionable plans for their staff. Better communication in executing resource utilization plans, expressing more empathy and care for their staff, and enhancing communication channels, such as through the use of secure text messaging rather than emails would be important.Conclusion: CERC is relevant and important in the hospital setting to managing COVID-19 and should be considered concurrently with hospital emergency response domains. [ABSTRACT FROM AUTHOR]

Objectives: To study clinical and patient reported outcomes for the Virtual Monitoring Clinic (VMC), a remote nurse‐led telemonitoring service for monitoring Rheumatoid Arthritis (RA) patients treated with disease‐modifying antirheumatic drugs (DMARDs). Methods: Patients with stable RA enrolled in the VMC were followed up prospectively. The primary outcomes evaluated at 1‐year follow‐up were: Disease Activity Score‐28 (DAS28), Routine Assessment of Patient Index Data 3 (RAPID3), and patient satisfaction assessed using an 11‐point Likert scale. Results: Of the 251 patients enrolled, 186 completed 1‐year of follow‐up. There was a 2.3% (n = 450) reduction in the annual workload from the rheumatology specialist outpatient clinic as a result of the VMC. Statistically significant improvement was seen in the mean patient satisfaction score (7.70‐8.16, P ≤ 0.001), with 61.5% of patients opting for the VMC alternating with rheumatology outpatient clinic visits as their preferred mode of follow‐up vis‐à‐vis standard care. There was a marginal increase in mean DAS28 and RAPID3 scores from 2.56 to 2.78 (P < 0.05) and 5.28 to 6.03 (P < 0.05), respectively. However, given that at 1‐year follow‐up more than half (72.0% and 63.4% based on DAS28 and RAPID3) of the patients' disease activity had improved or remained stable, and was in remission or low activity (73.1% and 53.2% based on DAS28 and RAPID3), the VMC seemed to maintain a stable RA disease activity for the majority of patients. Conclusions: The VMC is an effective and well‐accepted novel approach for the management of patients with stable RA. [ABSTRACT FROM AUTHOR]

The aim of this study was to (1) translate the Gastrointestinal Tract Instrument (GIT) 2.0 from English to Chinese and (2) validate both versions in a multi-ethnic systemic sclerosis cohort in Singapore (SCORE). The English GIT2.0 was translated to Chinese using a standard forward-backward translation approach. Psychometric evaluation of the GIT2.0 included internal consistency reliability (using Cronbach's alpha), test-retest reliability (using intra-class correlation coefficient (ICC)), scale level factor analysis, and construct validity (using Spearman correlation) against the modified Scleroderma Health Assessment Questionnaire (S-HAQ) and the SF-36 v2. Most of the patients were females (88.6%) and Chinese (78.2%), with mean (SD) age of 51.0 (13.0) years and median disease duration of 4.5 years. We administered English ( n = 146) and Chinese ( n = 74) GIT2.0. The mean (SD) total GIT score was 0.29 (0.37). There was good internal consistency (Cronbach's alpha >0.70 for all subscales) and good test-retest reliability for the scale and all subscales (ICC 0.71-0.92) except for 'diarrhoea' (ICC = 0.54). Our hypothesised a priori construct validity was supported by moderate correlations between the total GIT score and S-HAQ GI subscale ( r = 0.446), and the social functioning subscale and SF36v2 role-social domain ( r = 0.337), and weak-to-moderate correlation between the emotional subscale and SF-36v2 role-emotional ( r = 0.295) and mental health ( r = 0.298) domains and mental component summary ( r = 0.356). Exploratory factor analysis of the seven subscales yielded a two-factor solution explaining 69.63% of the total variance. This study provides evidence for the reliability and validity of the English and Chinese GIT2.0 to be used in Singapore for research and routine practice. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To explore the feasibility of using SMS to conduct health surveys in patients with rheumatoid arthritis (RA). Methods: Using a two-way SMS system, we conducted a baseline survey using a short and a long quality of life instrument, with two follow-up administrations of the short survey among patients with RA on follow-up at the Singapore General Hospital (SGH). Our outcome variables were survey response rate, question response time, proportion of replies following the format instructions, and survey administration cost. Results: Among 85 participants (of 99 eligible patients approached), the response rate was 67% for the long survey, 80% for the short survey at baseline, and 74% and 70% at the first and second follow-ups, respectively. Survey response rate varied with the employment status of respondents. Approximately 78% of all replies followed the format instructions. All these replies were received within the stipulated 24-h timeline and half of them were received within 29min. Response time for the other 22% of replies that did not follow the format instructions was much longer. The average administration cost per survey was S$0.34 (equivalent of US$0.26). Conclusions: Two-way SMS is a promising tool to conduct short health surveys. Evidence for implementing long surveys over SMS is still weak. The post survey interviews with survey participants suggested that sequential delivery of survey questions coupled with SMS reminders in the interim, tailoring survey questions to individual health conditions, and providing feedback on individual survey results can potentially improve the response rate of such surveys. [Copyright &y& Elsevier]

Objective. How do we explain variations across nations in the incidence of political corruption? Recent theoretical work locates the causes for corruption in a combination of institutional conditions: monopoly power, little accountability, and wide discretion. This focus on the form of political institutions clarifies the micro- scale causes of political corruption, but it leaves unanswered questions about the macro-scale causes of corruption. Methods. This article addresses these questions about the macro scale through an analysis of perceived levels of corruption across nations. Results. Our work identifies poverty, large populations, and small public sectors as contextual causes of corruption. Historically-based differences in political cultures across broad geographical regions also affect the perceived incidence of corruption in nations. Conclusion. Further research should attempt to link micro-and macro-scale causes together in a single, multi-scalar model of corruption. [ABSTRACT FROM AUTHOR]

Background: CAR-T cell therapy represents a novel approach for the treatment of hematologic malignancies and solid tumors. However, its implementation is accompanied by the emergence of potentially life-threatening adverse events known as cytokine release syndrome (CRS). Given the escalating number of patients undergoing CAR-T therapy, there is an urgent need to develop predictive models for severe CRS occurrence to prevent it in advance. Currently, all existing models are based on decision trees whose accuracy is far from meeting our expectations, and there is a lack of deep learning models to predict the occurrence of severe CRS more accurately. Results: We propose PrCRS, a deep learning prediction model based on U-net and Transformer. Given the limited data available for CAR-T patients, we employ transfer learning using data from COVID-19 patients. The comprehensive evaluation demonstrates the superiority of the PrCRS model over other state-of-the-art methods for predicting CRS occurrence. We propose six models to forecast the probability of severe CRS for patients with one, two, and three days in advance. Additionally, we present a strategy to convert the model's output into actual probabilities of severe CRS and provide corresponding predictions. Conclusions: Based on our findings, PrCRS effectively predicts both the likelihood and timing of severe CRS in patients, thereby facilitating expedited and precise patient assessment, thus making a significant contribution to medical research. There is little research on applying deep learning algorithms to predict CRS, and our study fills this gap. This makes our research more novel and significant. Our code is publicly available at https://github.com/wzy38828201/PrCRS. The website of our prediction platform is: http://prediction.unicar-therapy.com/index-en.html. [ABSTRACT FROM AUTHOR]

Chimeric antigen receptor T-cell (CAR-T) immunotherapy, a novel approach for treating blood cancer, is associated with the production of cytokine release syndrome (CRS), which poses significant safety concerns for patients. Currently, there is limited knowledge regarding CRS-related cytokines and the intricate relationship between cytokines and cells. Therefore, it is imperative to explore a reliable and efficient computational method to identify cytokines associated with CRS. In this study, we propose Meta-DHGNN, a directed and heterogeneous graph neural network analysis method based on meta-learning. The proposed method integrates both directed and heterogeneous algorithms, while the meta-learning module effectively addresses the issue of limited data availability. This approach enables comprehensive analysis of the cytokine network and accurate prediction of CRS-related cytokines. Firstly, to tackle the challenge posed by small datasets, a pre-training phase is conducted using the meta-learning module. Consequently, the directed algorithm constructs an adjacency matrix that accurately captures potential relationships in a more realistic manner. Ultimately, the heterogeneous algorithm employs meta-photographs and multi-head attention mechanisms to enhance the realism and accuracy of predicting cytokine information associated with positive labels. Our experimental verification on the dataset demonstrates that Meta-DHGNN achieves favorable outcomes. Furthermore, based on the predicted results, we have explored the multifaceted formation mechanism of CRS in CAR-T therapy from various perspectives and identified several cytokines, such as IFNG (IFN-γ), IFNA1, IFNB1, IFNA13, IFNA2, IFNAR1, IFNAR2, IFNGR1 and IFNGR2 that have been relatively overlooked in previous studies but potentially play pivotal roles. The significance of Meta-DHGNN lies in its ability to analyze directed and heterogeneous networks in biology effectively while also facilitating CRS risk prediction in CAR-T therapy. [ABSTRACT FROM AUTHOR]

Background: Emergency risk communication is a critical component in emergency planning and response. It has been recognised as significant for planning for and responding to public health emergencies. While there is a growing body of guidelines and frameworks on emergency risk communication, it remains a relatively new field. There has also been limited attention on how emergency risk communication is being performed in public health organisations, such as acute hospitals, and what the associated challenges are. This article seeks to examine the perception of crisis and emergency risk communication in an acute hospital in response to COVID-19 pandemic in Singapore and to identify its associated enablers and barriers. Methods: A 13-item Crisis and Emergency Risk Communication (CERC) Survey, based on the US Centers for Disease and Control (CDC) CERC framework, was developed and administered to hospital staff during February 24–28, 2020. The survey also included an open-ended question to solicit feedback on areas of CERC in need of improvement. Chi-square test was used for analysis of survey data. Thematic analysis was performed on qualitative feedback. Results: Of the 1154 participants who responded to the survey, most (94.1%) reported that regular hospital updates on COVID-19 were understandable and actionable. Many (92.5%) stated that accurate, concise and timely information helped to keep them safe. A majority (92.3%) of them were clear about the hospital's response to the COVID-19 situation, and 79.4% of the respondents reported that the hospital had been able to understand their challenges and address their concerns. Sociodemographic characteristics, such as occupation, age, marital status, work experience, gender, and staff's primary work location influenced the responses to hospital CERC. Local leaders within the hospital would need support to better communicate and translate hospital updates in response to COVID-19 to actionable plans for their staff. Better communication in executing resource utilization plans, expressing more empathy and care for their staff, and enhancing communication channels, such as through the use of secure text messaging rather than emails would be important. Conclusion: CERC is relevant and important in the hospital setting to managing COVID-19 and should be considered concurrently with hospital emergency response domains. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. • The surgical safety checklist acts as a defensive layer to prevent never events. • Shift the focus from checklist compliance to its local sociocultural context. • Use sociopsychological theories to understand surgical safety checklist practices. • Conformity vs. ritualism checklist practices when viewed from social deviance lens. • Activate safety voices and safety listening, and prioritize safety and thoroughness. [ABSTRACT FROM AUTHOR]

This pilot study explores the relationship between nocturnal hypoglycemia (NH) and subjective sleep quality in people with type 1 diabetes (T1D). Twenty-seven adults with T1D wore a Freestyle Libre Pro CGM and recorded subjective sleep quality daily, as assessed by a single Likert scale question. Frequency, duration, area under the curve (AUC) of NH (00:00–06:00) defined as sensor glucose below threshold (< 3.9 mmol/L; < 3 mmol/L) for ≥ 15 min, nocturnal mean glucose, Time in Range (3.9–10 mmol/L), and coefficient of variation were calculated. Twenty-seven adults, 18 (66.7%) women, with median (IQR) age of 27 (26, 32) years and HbA1c of 7.6 (7.1, 8.1) participated. Nights with NH < 3.9 mmol/L resulted in a lower (worse) sleep score than nights without NH [Mean (SD): 3.3 (1.2) vs 3.5 (1.0), p = 0.03). A higher frequency and longer duration but not AUC [adjusted OR (95% CI) 0.52 (0.38, 0.72), 0.961 (0.932, 0.991), 0.999 (0.998, 1.001) respectively)], of NH < 3.9 mmol/L, were associated with a lower sleep score. NH < 3.0 mmol/L metrics were not associated with sleep quality. Recurrent NH < 3.9 mmol/L, rather than prolonged NH < 3.0 mmol/L, seems associated with subjective sleep quality, implying that those with the highest burden of NH are likely unaware of it. [ABSTRACT FROM AUTHOR]

Objectives: To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans - physical functioning, social relationships, and positive mindset.Methods: We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n = 134 participants) and item(n = 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were "binned" and "winnowed" by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews.Results: Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset).Conclusions: We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively. [ABSTRACT FROM AUTHOR]

Health-related quality of life (HRQOL) instruments are sometimes used without explicit understanding of which HRQOL domains are important to a given population. In this study, we sought to elicit an importance hierarchy among 27 HRQOL domains (derived from the general population) via a best-worst scaling survey of the population in Singapore, and to determine whether these domains were consistently valued across gender, age, ethnicity, and presence of chronic illnesses. We conducted a community-based study that sampled participants with quotas for gender, ethnicity, age, presence of chronic illness, and interview language. For the best-worst scaling exercise, we constructed comparison sets according to a balanced incomplete block design resulting in 13 sets of questions, each with nine choice tasks. Each task involved three HRQOL domains from which participants identified the most and least important domain. We performed a standard analysis of best-worst object scaling design (Case 1) using simple summary statistics; 603 residents participated in the survey. The three most important domains of health were: “the ability to take care of self without help from others” (best-worst score (BWS): 636), “healing and resistance to illness” (BWS: 461), and “having good relationships with family, friends, and others” (BWS: 373). The 10 top-ranked domains included physical, mental, and social health. The three least important domains were: “having a satisfying sex life” (BWS: -803), “having normal physical appearance” (BWS: -461), and “interacting with others (talking, shared activities, etc.)” (BWS: -444). Generally, top-ranked domains were consistently valued across gender, age, ethnicity, and presence of chronic illness. We conclude that the 10 top-ranked domains reflect physical, mental, and social dimensions of well-being suggesting that the sampled population’s views on health are consistent with the World Health Organization’s definition of health, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. [ABSTRACT FROM AUTHOR]

Aim: Neonatal jaundice is an important and prevalent condition that can cause kernicterus and mortality. This study validated a smartphone‐based screening application (Biliscan) in detecting neonatal jaundice. Methods: A cross‐sectional prospective study was conducted at the neonatal unit in a tertiary teaching hospital between August 2020 and October 2021. All babies born at the gestation of 35 weeks and above with clinical jaundice or are recommended for screening of jaundice within 21 days of post‐natal age were recruited. Using Biliscan, images of the babies' skin over the sternum were taken against a standard colour card. The application uses feature extraction and machine learning regression to estimate the bilirubin level. Independent Biliscan bilirubin estimates (BsB) were made and compared with total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) levels. Bland Altman plots were used to establish the agreement between BsB and TSB, as well as TcB, using the clinically acceptable limits of agreement of ±35 μmol/L, which were defined a priori. Pearson correlation coefficient was assessed to establish the strength of the relationship between BsB versus TSB and TcB. Diagnostic accuracy was assessed through receiver operating characteristic curve analysis. Results: Sixty‐one paired TSB‐BsB and 85 paired TcB‐BsB measurements were obtained. Bland Altman plot for the entire group showed that 54% (33/61) of the pairs of TSB and BsB readings and 66% (56/85) of the pairs of TcB and BsB readings were within the maximum clinically acceptable difference of 35 μmol/L. Pearson r for BsB versus TSB and TcB was 0.54 (P < 0.001) and 0.66 (P < 0.001) respectively. Compared with TSB, the recommended gold standard measure for jaundice, Biliscan has a sensitivity of 76.92% and specificity of 70.83% for jaundice requiring phototherapy. The positive and negative predictive values in term infants were 93.3% and 36.9%, respectively. Conclusion: Our results suggest that there is moderate correlation and mediocre agreement between BsB and TSB, as well as TcB. Improvement to the application algorithm and further studies that include a larger population, and a wider range of bilirubin values are necessary before the tool may be considered for use in screening of jaundice in newborns. [ABSTRACT FROM AUTHOR]

Interprofessional collaboration (IPC) is key to ensuring safe quality care for patients. However, IPC intervention outcomes are variable, leading to calls for systems theories to understand complex interactions in healthcare. Using networked ecological systems theory (NEST), we aimed to uncover facilitators and barriers impacting the interactions between nurses and physicians in a specialty healthcare center. A qualitative study involving 55 non-participant observations and 17 individual semi-structured interviews was conducted at the National Neuroscience Institute of Singapore from April 2019 to March 2021. Template analysis was used to analyze the data. The most important IPC facilitators were exosystemic institutional support and physicians' willingness to engage in IPC in the microsystems that together enabled the establishment of disease-based outpatient programs fostering patient-centered interactions among different healthcare professionals (HCP). We also found that patient-, disease-, and systems-related knowledge played an important role in facilitating IPC. Macrosystemic entrenchments such as intraprofessional composition of ward rounds emerged as a significant barrier. However, microsystemic efforts such as chat groups connecting all HCP involved in the care of the patients in the wards have fostered IPC. Although still preliminary, these findings suggest NEST can be useful to inform systematic interventions to improve IPC. [ABSTRACT FROM AUTHOR]

Hypoglycaemia leads to significant morbidity and impacts negatively on quality-of-life, especially in elderly people with increased frailty. The aims of this study were to determine the prevalence of low interstitial fluid glucose (IFG) in patients with tightly controlled type 2 diabetes (T2D), and to evaluate whether there were differences in burden of low IFG between sulphonylurea and insulin treated groups. A Freestyle Libre-Pro sensor was used for sampling of the IFG continuously. Patients were blinded to the IFG levels. The sensor was returned to the investigators after a 2-week period and the data were downloaded for analysis. There was a total of 69 patients (median age 72 years (IQR = 69–74)) − 40 were sulfonylurea-treated and 29 insulin-treated. In total, 781 low sensor glucose events (<4.0 mmol/L) were detected, of which 254 were very low sensor glucose events (<2.8 mmol/L). Twenty-six out of 29 insulin-treated (89.6%) and 36 out of 40 sulphonylurea-treated patients (90%) contributed to the 781 events of low sensor glucose. Twenty out of 29 insulin-treated (69%) and 26 out of 40 sulphonylurea-treated patients (65.0%) contributed to the 254 very low sensor glucose events. Only 9% of all events were identified by patients. Nocturnal events represented 55.8% of low sensor glucose events and 61.0% of very low sensor glucose events. At a cut-off of <2.8 mmol/L, it was found that the insulin group had a significantly greater number of such events as compared to the sulfonylurea group. This study demonstrates that elderly patients with tightly-controlled T2D have a significant number of low sensor glucose events which go by undetected. [ABSTRACT FROM AUTHOR]

Introduction/objectives: To address the diagnostic delay in axial spondyloarthritis (axSpA), we have cross-culturally adapted the Hamilton axSpA questionnaire, a self-administered screening questionnaire, in the Singapore population. In this study, we compared the performance of various scoring methods for this questionnaire in detecting axSpA. Method: The questionnaire was self-administered by eligible subjects. Scoring methods included method A, the original questionnaire scoring, and methods B–E, scoring developed based on the Assessment of SpondyloArthritis International Society (ASAS) criteria for inflammatory back pain (IBP) and the referral, classification and both referral and classification of axSpA, respectively. The reference standard was diagnosis by a rheumatologist. Since the ASAS criteria-based scoring methods were mainly based on clinical axSpA features, self-report and rheumatologist-assessment of clinical axSpA features were also compared in subjects with axSpA. Results: Of 1418 subjects (age: 54 ± 14 years, female: 73%) recruited, 46 were diagnosed with axSpA by a rheumatologist. Sensitivities of methods A–E were 35%, 61%, 63%, 48% and 83%, respectively. Self-report of clinical axSpA features exceeded rheumatologist-assessment for arthritis (83 vs 26%), good response to NSAIDs (37 vs 30%), enthesitis (35 vs 30%), dactylitis (20 vs 2%) and family history for axSpA (13 vs 4%). The reverse was true for IBP (41 vs 63%) and uveitis (4 vs 15%). Conclusions: A self-administered questionnaire using the ASAS referral and classification criteria-based scoring yielded relatively high sensitivity in detecting axSpA in subjects newly referred to rheumatology clinics. This supports its evaluation as a screening and referral tool in the general population in future studies. Key Points • A self-administered questionnaire could be used as a screening and referral tool. • ASAS referral and classification criteria-based scoring yielded relatively high sensitivity. • Inaccurate perception of clinical axSpA features was observed in axSpA patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Individuals with diabetes mellitus (DM) may be susceptible to non-steroidal anti-inflammatory drug (NSAID)-induced acute kidney injury (AKI) but data on NSAID-related adverse renal events is sparse. OBJECTIVE: We aimed to evaluate the risk of acute kidney injury and/or hyperkalemia after systemic NSAID among individuals with DM and diabetic chronic kidney disease (CKD). METHODS: Retrospective cohort study of 3896 adults with DM with incident prescriptions between July 2015 and December 2017 from Singapore General Hospital and SingHealth Polyclinics. Laboratory, hospitalization and medication data were retrieved from electronic medical records. The primary outcome was the incidence of AKI and/ or hyperkalemia within 30 days after prescription. RESULTS: AKI and/or hyperkalemia occurred in 13.5% of all DM and 15.8% of diabetic CKD. The association between systemic NSAID >14 days and 30-day risk of AKI and/or hyperkalemia failed to reach statistical significance in unselected DM (adjusted OR 1.62, 95% CI 0.99–2.65, p = 0.05) and diabetic CKD (adjusted OR 0.64, 95% CI 0.15–2.82, p = 0.64), but the odds of AKI and/or hyperkalemia were markedly and significantly increased when NSAID was prescribed with renin-angiotensin-aldosterone system (RAAS) blocker (adjusted OR 4.17, 95% CI 1.74–9.98, p = 0.001) or diuretic (adjusted OR 3.31, 95% CI 1.09–10.08, p = 0.04) and in the absence of diabetic CKD (adjusted OR 1.98, 95% CI 1.16–3.36, p = 0.01). CONCLUSION: NSAID prescription >14 days in individuals with DM with concurrent RAAS blockers or diuretics was associated with higher 30-day risk of AKI and/or hyperkalemia. [ABSTRACT FROM AUTHOR]

Background and Aim: The coronavirus disease 2019 pandemic has impacted gastroenterology practices worldwide; however, its protracted effects within Southeast Asia were unknown. The primary aim of the study was to determine the impact of the pandemic on clinical demands including burnout among gastroenterologists within the region. The secondary aim was to identify risk factors for burnout and determine regional stressors. Methods: This was a mixed‐methods study. Gastroenterologists were surveyed electronically between September 1 and December 7, 2020, via gastroenterology and endoscopy societies of Brunei, Indonesia, Malaysia, Philippines, Singapore, and Thailand. Quantitative and qualitative data were collected. The 22‐item Maslach Burnout Inventory‐Human Services Survey (MBI‐HSS) was used to detect burnout. Quantitative data were non‐parametric; non‐parametric methods were used for statistical comparisons. Logistic regression was used to determine risk factors for burnout. Content analysis method was used to analyze qualitative data. Ethical approval was obtained. Results: A total of 73.0% reported that they were still significantly affected by the pandemic. Of these, 40.5% reported increased workload and 59.5% decreased workload. Statistically significant differences in weekly working hours, endoscopy, and inpatient volumes were present. No differences were observed in outpatient volumes, likely because of telemedicine. Burnout was common; however, 50.1% of gastroenterologists were unaware of or did not have access to mental health support. This, as well as depression, being a trainee, and public sector work, increased burnout risk significantly. Conclusion: The effects of the pandemic are multifaceted, and burnout is common among Southeast Asian gastroenterologists. Safeguards for mental health are suboptimal, and improvements are urgently needed. [ABSTRACT FROM AUTHOR]

Objectives: Early detection of autoimmune rheumatic diseases is crucial given their high morbidity and mortality and short window of opportunity to improve patient outcomes. Self-administered screening questionnaires such as the connective tissue disease screening questionnaire (CSQ) have been shown to promote early detection of autoimmune rheumatic diseases. However, optimal scoring of screening questionnaires may differ with prevalence of clinical features and changes in classification criteria. We compared the performance of 3 scoring methods for the CSQ for early detection of autoimmune rheumatic diseases in a multi-ethnic Asian population. Methods: Patients who were newly referred for evaluation of possible autoimmune rheumatic diseases were invited to answer the cross-culturally adapted CSQ. Detection of autoimmune rheumatic diseases using 1) the original CSQ scoring, 2) a modified CSQ scoring and 3) a scoring based on current classification criteria, were compared to classification of autoimmune rheumatic diseases by classification criteria. Results: Of 819 participants, 85 were classified as having autoimmune rheumatic diseases screened for by the adapted CSQ. The original CSQ scoring yielded relatively lower sensitivities in detecting both any and individual autoimmune rheumatic diseases (67% and 20-57%, respectively) compared to the modified CSQ scoring (81% and 60-73%, respectively) and the scoring based on current classification criteria (89% and 50-88%, respectively). Conclusion: The adapted CSQ with the classification criteria-based scoring achieved relatively high sensitivities in detecting autoimmune rheumatic diseases, suggesting this could be employed as the first step in population screening. [ABSTRACT FROM AUTHOR]

Objective: To cross‐culturally adapt the Hamilton axial spondyloarthritis (axial SpA) screening questionnaire and develop a Chinese version for use in a multi‐ethnic Asian population in Singapore. Methods: Consenting participants newly referred from primary care to a rheumatology specialist outpatient clinic for evaluation of possible axial SpA were studied. The original axial SpA questionnaire was revised based on inputs from cognitive debriefing interviews (CDIs) and discussions with an expert panel of rheumatologists and the developer. Forward and back translations of the adapted English version were also reviewed by the expert panel and the developer. The common translation produced was tested in CDIs with Chinese‐speaking participants. Adapted English and Chinese versions were pilot‐tested in a separate group of similar participants. Results: Participants were recruited for English (n = 25) and Chinese CDIs (n = 15, relatively older and less frequently presented with axial SpA symptoms), respectively. Alternative terms and explanatory notes were added to difficult medical terms to improve the understandability of the adapted English version. English medical terms were retained in the Chinese version. Pilot‐testing of the adapted axial SpA questionnaire was performed on 116 participants, all of whom reported ease of comprehension with both adapted versions. Only one participant was diagnosed with axial SpA, who also scored positive on the adapted axial SpA questionnaire. Conclusion: The adapted axial SpA questionnaire demonstrated good sensitivity in the pilot‐testing and appears to be a promising tool for facilitating early identification of axial SpA cases in the multi‐ethnic Asian population. [ABSTRACT FROM AUTHOR]

Objectives: To cross-culturally adapt the Connective Tissue Disease (CTD) Screening Questionnaire (CSQ) in a multi-ethnic Asian population in Singapore. Methods: An expert panel of accredited rheumatologists evaluated the content validity of the original CSQ. Consenting participants newly referred from primary care to a rheumatology specialist outpatient clinic for evaluation of possible CTDs were studied. Cognitive debriefing interviews (CDIs) using the original CSQ were conducted with English-speaking participants, with modifications made based on their inputs and in discussion with a second expert panel (rheumatologists and the CSQ developers). Forward and back translations of the adapted English version were reviewed by the second expert panel. The common translation produced was tested in CDIs with Chinese-speaking participants. Adapted English and Chinese versions were pilot tested in a separate group of newly referred patients. Results: Content validity of the original CSQ was confirmed by the expert panel. A total of 30 and 15 participants were recruited for English and Chinese CDIs, respectively. Alternative terms and explanatory notes were added to difficult medical terms in the adapted English CSQ. A further explanatory note was added to one difficult item, and English medical terms were retained in the Chinese version. Pilot testing of the adapted CSQ was performed on 116 participants, which exhibited an overall sensitivity and specificity of 71% and 58%, respectively, in identifying CTDs. Conclusions: The adapted CSQ demonstrated satisfactory sensitivity in the pilot testing and appears to be a promising tool for facilitating early identification of CTDs in the multi-ethnic Asian population. Key Points: • Early identification and management of patients with CTDs is crucial given their high disease burden and short "windows of opportunity." • High reliability and validity of original CSQ and its cross-culturally adapted versions have been reported; however, the CSQ has not been validated in Southeast Asia where CTDs are associated with higher morbidity and mortality compared to other countries. • Our cross-culturally adapted CSQ demonstrated satisfactory sensitivity in identifying CTDs in the multi-ethnic Asian population. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the 1-year short-term mortality rate following hospital admissions with severe hypoglycemia. This study aimed to determine the factors associated with increased 1-year mortality rate following hospitalization in diabetes patients admitted with severe hypoglycemia to the Singapore General Hospital.Methods: Clinical, biochemical, and 1-year mortality data from diabetes patients who were admitted with severe hypoglycemia in the year 2014 were extracted from institutional medical records. Patients who passed away during the episode of admissions with severe hypoglycemia were excluded from the analysis. The clinical and biochemical factors between patients who survived and those who did not survive within 1 year following admission were compared using logistic regression analysis.Results: Three hundred and four patients (181 female and 123 male) were admitted with severe hypoglycemia in 2014, and the mean capillary blood glucose on admission was 2.3 ± 0.7 mmol/L. Sixty-three (20.7%) patients died within 1-year post-discharge from the hospital. Compared with patients who survived 1-year post-discharge from the hospital, non-survivors were older (69.3 ± 11.0 vs 75.5 ± 11.2 years, p < .001), had longer lengths of stay (LOS) (5.0 ± 7.4 vs 9.0 ± 12.8 days, p = .02), and had a higher Charlson Comorbidity Index (CCI) (4.1 ± 1.9 vs 5.9 ± 2.4, p < .001). Factors associated with increased 1-year mortality risk were age (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.03-1.09, p < .01), LOS in hospital (OR = 1.01; 95% CI = 1.01-1.08, p < .01), and CCI (OR = 1.51; 95% CI = 1.31-1.75, p < .01), respectively.Conclusions: Older diabetes patients with more comorbidities and longer LOS were at increased risk of dying within a year of discharge after hospitalization with severe hypoglycemia. Admission with severe hypoglycemia has important prognostic implications. Healthcare professionals should address hypoglycemia and other health issues during the hospital admissions. [ABSTRACT FROM AUTHOR]

The increasing focus of healthcare systems worldwide on long-term care highlights the need for culturally sensitive Health-Related Quality of Life instruments to accurately capture perceived health of various populations. Such instruments require a contextualized conceptual framework of health domains, which is lacking in some socio-cultural contexts. We developed a comprehensive and culturally sensitive conceptual framework of health domains relevant to the Singaporean population. We recruited Singaporeans/ permanent residents, English/ Chinese-speaking, with/ without chronic illnesses to participate in focus group discussions (FGDs) and in-depth interviews (IDIs). We elicited health areas participants perceived to be important for them to be happy and satisfied with life. To encourage spontaneous emergence of themes, we did not specify any aspect beyond the broad domains of Physical, Mental, and Social health so as not to limit the emergence of new themes. Themes from the transcripts were distilled through open coding (two independent coders), then classified into more abstract domains (each transcript coded independently by two coders from a pool of six coders). From October 2013 to August 2014, 121 members of the general public participated in 18 FGDs and 13 IDIs (44.6% males, mean age: 53.3 years 77% Chinese, 9% Malay, 12% Indian, 63% with chronic illness) while 13 healthcare workers participated as patient-proxies in three FGDs. Thematic analysis identified 27 domains. The 15 physical domains included physical appearance, energy, physical fitness, and health and resistance to illness. The nine mental domains included emotions, self-esteem, and personal freedom. The three social domains were social contact, social relationships, and social roles. This conceptual framework reflected physical, mental, and social dimensions of well-being, suggesting that the Singapore population’s views on health support the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. [ABSTRACT FROM AUTHOR]

Background: Inpatients hypoglycemia has adverse impacts on patient outcomes and healthcare resources use. While recurrent hypoglycemia is largely preventable, limited studies were done within the Asia-Pacific context. We sought to determine whether temporal distributions of hypoglycemia exist between insulin and/or sulfonylureas (SU) treated patients and identify predictors of recurrent hypoglycemia at a tertiary medical center in Singapore. Methods: We analyzed data of 420 hypoglycemic episodes (capillary blood glucose (CBG) ≤ 70mg/dL) in 207 diabetes patients at general medical wards over a 2-month period from 1st May 2017. This was analyzed by 4 time frames coincided with blood glucose monitoring times. Time periods associated with hypoglycemia were compared using the Chi-square test. Multivariate logistic regression estimated risk factors of recurrent hypoglycemia. Results: Most frequent hypoglycemia episodes occurred between 04:00 and 09:59 (41.7%). Greater frequency was seen in insulin- and SU-treated than insulin-treated patients between 04:00 to 09:59 (58.3% vs.37.9% of readings for respective treatments, p<0.05). It was also more frequent in insulin-treated than SU-treated patients between 10:00 to 15:59 (19.2% vs. 10.9%, p<0.05). Nearly a third of patients had recurrent hypoglycemia (32.9%). Longer length of stay, treated with premixed insulin, age < 65 years, HbA1C > 7% and repeated CBG checking > 30 minutes interval emerged as predictors of recurrent hypoglycemia with odds ratio of 1.07 (95% CI 1.03-1.11), 8.07 (95% CI 2.82-23.08), 3.71 (95% CI 1.59-8.65), 3.12 (95% CI 1.26-7.74) and 3.54 (95% CI 1.59-7.91), respectively. Conclusions: Hypoglycemic episodes were more frequent in the early hours of the day in insulin and SU-treated inpatients. This may have implications for the continuing use of SU at inpatients. Recurrent hypoglycemia can be prevented by developing strategies targeting the modifiable iatrogenic risk factors. Disclosure: P. Lim: None. S. Goh: None. Y. Bee: None. X. Xin: None. L. Ang: None. N.A. Salleha: None. M.M. Teh: None. [ABSTRACT FROM AUTHOR]

Background: Social relationships (SR) is an important domain of health-related quality of life. We developed and calibrated a novel item bank to measure SR in Singapore, a multi-ethnic city in Southeast Asia.Methods: We developed an initial candidate pool of 51 items from focus groups, individual in-depth interviews and existing instruments that had been developed and/or validated for use in Singapore. We administered all items in English to a multi-stage sample of subjects, stratified for age and gender, with and without medical conditions, recruited from community and hospital settings. We calibrated their responses using Samejima's Graded Response Model (SGRM). We evaluated a final 30-item bank with respect to Item Response Theory (IRT) model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity.Results: Among 503 participants (47.7% male, 41.4% above 50 years old, 34.0% Chinese, 33.6% Malay and 32.4% Indian), bi-factor model analyses supported essential unidimensionality: explained common variance of the general factor was 0.805 and omega hierarchical was 0.98. Local independence was deemed acceptable: the average absolute residual correlations were < 0.06 and 1.8% of the total item-pair residuals were flagged for local dependence. The overall SGRM model fit was adequate (p = 0.146). Five items exhibited DIF with respect to age, ethnicity and education, but were retained without modification of scores because they measured important aspects of SR. The SR scores correlated in the hypothesized direction with a self-reported measure of global health (Spearman's rho = - 0.28, p < 0.001).Conclusion: The 30-item SR item bank has shown acceptable psychometric properties. Future studies to evaluate the validity of SR scores when items are administered adaptively are needed. [ABSTRACT FROM AUTHOR]