Assessing caregiver burden in advanced kidney disease: protocol for a systematic review of the measurement properties of instruments and tools.

INTRODUCTION: Caregiver burden is a significant issue in the care of patients with advanced kidney disease. Its assessment is crucial for evaluating the needs of caregivers and for the development of interventions to support them. Several instruments have been developed to measure caregiver burden in these patients. However, the measurement properties of these instruments have not been systematically reviewed. METHODS AND ANALYSIS: This systematic review will include a comprehensive search of databases including PubMed, CINAHL, Embase, Cochrane Library, SCOPUS and Web of Science by using keywords and MeSH terms to identify relevant studies starting from each database inception to 1 January 2024 and covering papers in English. The search strategy will combine relevant keywords and database-specific subject headings related to the following concepts: (1) caregivers, (2) burden, stress, distress, (3) chronic kidney disease, end-stage kidney disease, dialysis. Reference lists of eligible articles will also be hand searched. We will include quantitative and qualitative studies evaluating measurement properties of instruments assessing caregiver burden in caregivers of adult patients (aged ≥18 years). Data will be extracted from the selected studies and analysed using the COnsensus-based Standards for the selection of health Measurement INstruments checklist as the study quality assessment tool. Subsequently, the van der Vleuten utility index will be used to critique and categorise the instruments. A narrative that synthesises the utility of all instruments will be presented along with recommendations for the selection of instruments depending on specific clinical contexts. This systematic review will provide an overview of the measurement properties of available instruments, including discussion on reliability, validity and responsiveness. Results from the review may give rise to the subsequent development of most appropriate instrument that could be applied to the assessment of caregiver burden in advanced kidney disease. ETHICS AND DISSEMINATION: Ethics approval is not required as this study will merely synthesise data from published studies. The results will be disseminated through peer-reviewed publications as well as conference presentations. PROSPERO REGISTRATION NUMBER: CRD42023433906.

Developing an Artificial Intelligence-Driven Nudge Intervention to Improve Medication Adherence: A Human-Centred Design Approach.

To improve medication adherence, we co-developed a digital, artificial intelligence (AI)-driven nudge intervention with stakeholders (patients, providers, and technologists). We used a human-centred design approach to incorporate user needs in creating an AI-driven nudge tool. We report the findings of the first stage of a multi-phase project: understanding user needs and ideating solutions. We interviewed healthcare providers (n = 10) and patients (n = 10). Providers also rated example nudge interventions in a survey. Stakeholders felt the intervention could address existing deficits in medication adherence tracking and were optimistic about the solution. Participants identified flexibility of the intervention, including mode of delivery, intervention intensity, and the ability to stratify to user ability and needs, as critical success factors. Reminder nudges and provision of healthcare worker contact were rated highly by all. Conversely, patients perceived incentive-based nudges poorly. Finally, participants suggested that user burden could be minimised by leveraging existing software (rather than creating a new App) and simplifying or automating the data entry requirements where feasible. Stakeholder interviews generated in-depth data on the perspectives and requirements for the proposed solution. The participatory approach will enable us to incorporate user needs into the design and improve the utility of the intervention. Our findings show that an AI-driven nudge tool is an acceptable and appropriate solution, assuming it is flexible to user requirements.

Artificial intelligence in physical rehabilitation: A systematic review.

BACKGROUND: Physical disabilities become more common with advancing age. Rehabilitation restores function, maintaining independence for longer. However, the poor availability and accessibility of rehabilitation limits its clinical impact. Artificial Intelligence (AI) guided interventions have improved many domains of healthcare, but whether rehabilitation can benefit from AI remains unclear. METHODS: We conducted a systematic review of AI-supported physical rehabilitation technology tested in the clinical setting to understand: 1) availability of AI-supported physical rehabilitation technology; 2) its clinical effect; 3) and the barriers and facilitators to implementation. We searched in MEDLINE, EMBASE, CINAHL, Science Citation Index (Web of Science), CIRRIE (now NARIC), and OpenGrey. RESULTS: We identified 9054 articles and included 28 projects. AI solutions spanned five categories: App-based systems, robotic devices that replace function, robotic devices that restore function, gaming systems and wearables. We identified five randomised controlled trials (RCTs), which evaluated outcomes relating to physical function, activity, pain, and health-related quality of life. The clinical effects were inconsistent. Implementation barriers included technology literacy, reliability, and user fatigue. Enablers included greater access to rehabilitation programmes, remote monitoring of progress, reduction in manpower requirements and lower cost. CONCLUSION: Application of AI in physical rehabilitation is a growing field, but clinical effects have yet to be studied rigorously. Developers must strive to conduct robust clinical evaluations in the real-world setting and appraise post implementation experiences.

Predictors of frequency of 1-year readmission in adult patients with diabetes.

Diabetes mellitus (DM) is the third most common chronic condition associated with frequent hospital readmissions. Predictors of the number of readmissions within 1 year among patients with DM are less often studied compared with those of 30-day readmission. This study aims to identify predictors of number of readmissions within 1 year amongst adult patients with DM and compare different count regression models with respect to model fit. Data from 2008 to 2015 were extracted from the electronic medical records of the National University Hospital, Singapore. Inpatients aged ≥ 18 years at the time of index admission with a hospital stay > 24 h and survived until discharge were included. The zero-inflated negative binomial (ZINB) model was fitted and compared with three other count models (Poisson, zero-inflated Poisson and negative binomial) in terms of predicted probabilities, misclassification proportions and model fit. Adjusted for other variables in the model, the expected number of readmissions was 1.42 (95% confidence interval [CI] 1.07 to 1.90) for peripheral vascular disease, 1.60 (95% CI 1.34 to 1.92) for renal disease and 2.37 (95% CI 1.67 to 3.35) for Singapore residency. Number of emergency visits, number of drugs and age were other significant predictors, with length of stay fitted as a zero-inflated component. Model comparisons suggested that ZINB provides better prediction than the other three count models. The ZINB model identified five patient characteristics and two comorbidities associated with number of readmissions. It outperformed other count regression models but should be validated before clinical adoption.

Living with COPD: understanding patient experiences through the lens of photovoice.

BACKGROUND: Conventional quantitative or qualitative methodologies may not encompass the wide array of experiences of individuals living with Chronic Obstructive Pulmonary Disease (COPD). We used a novel approach - photovoice-to understand the impact of COPD on activities of daily living (ADLs) in a multicultural Asian country. METHODS: We recruited a purposive sample of eight patients from the outpatient clinics of the National University Health System, Singapore, between December 2020 and August 2021. We adopted a photovoice approach for data collection; participants were invited to take photos of how ADLs were impacted by COPD and attend a follow-up interview. An Interpretative Phenomenological Analysis method was used to analyze the data. Data saturation was reached by the seventh patient. RESULTS: COPD and the resulting breathlessness had a profound and diverse impact on our participants' lives. Living with COPD required substantial changes to how everyday tasks are performed, and participants learnt new strategies to deal with such tasks. A mixture of active and passive coping styles was evident. Feelings of frustration, anxiety and a sense of isolation were also reported. Contextual factors impacting ADLs included challenging climatic conditions and the local popularity of traditional or alternative medicine. CONCLUSION: The photovoice technique improved our understanding of the lived experiences of COPD patients and can benefit those who struggle to articulate their views by offering a different way to communicate beyond conventional interviewing.

Low Interfacial Resistance and Superior Suppression to Li-Dendrite Penetration Facilitated by Air-Stable and Mechanically Robust Al/Mg-Co-Doped Li-La-Zirconate as Electrolyte for Li-Based Solid-State Cells.

In the context of usage as a solid electrolyte (SE) for Li-based solid-state cells, the interfacial characteristics of Li-La-zirconate (LLZO) with the electrodes and the mechanical properties of LLZO influence the overall impedance and stability. In this regard, the newly developed air-stable Al/Mg-co-doped LLZO has been found to possess greater resistance to crack propagation (by ∼31%) and fracture stress (by ∼52%), along with elevated hardness and stiffness, as compared to simply Al-doped LLZO. Furthermore, as directly visualized via cross-section electron microscopy at the Li/LLZO interfaces, the air-stability, along with mechanical robustness of Al/Mg-co-doped LLZO, facilitates the complete absence of impurity phase and cracks at the Li/LLZO interface, unlike for the simply Al-doped LLZO. These result in a very low area specific resistance for the Li/"Al/Mg-co-doped LLZO" interface of ∼9 Ω cm2, which is ∼3 times lower than that at the Li/"Al-doped LLZO" interface and is also among the lowest reported to date for Li/LLZO interfaces, that too sans any surface/interfacial coating/engineering. Galvanostatic Li-plating/stripping cycles indicate that the critical current density toward initiating Li-dendrite nucleation/propagation is higher in the case of Al/Mg-co-doped LLZO SE, viz., ∼0.45 mA/cm2, than for the Al-doped counterpart (viz., ∼0.25 mA/cm2). Furthermore, Li-stripping/plating cycles @ 0.1 mA/cm2 have revealed outstanding stability of polarization voltage up to at least 100 cycles upon using Al/Mg-codoped LLZO as the SE, in contrast to the instability right from the 36th cycle onward with the Al-doped LLZO. This indicates superior suppression toward Li-dendrite nucleation/propagation by the Al/Mg-codoped LLZO, unlike by Al-doped LLZO, as also directly visualized via cross-section electron microscopy post-cycling. The air-stability induced a clean Li/LLZO interface (viz., good contact), which, together with the mechanical robustness of Al/Mg-codoped LLZO, resulted in the very low interfacial resistance and excellent suppression toward Li-dendrite nucleation/propagation, leading to high CCD and very stable long-term Li-stripping/plating. Overall, in addition to highlighting the notable advantages offered by the Al/Mg-co-doped LLZO solid electrolyte, the insights obtained as part of this work are expected to lead to the successful and facile development of high-performance solid-state Li-based cells.

Facile and Scalable Development of High-Performance Carbon-Free Tin-Based Anodes for Sodium-Ion Batteries.

Tin (Sn)-based anodes for sodium (Na)-ion batteries possess higher Na-storage capacity and better safety aspects compared to hard carbon -based anodes but suffer from poor cyclic stability due to volume expansion/contraction and concomitant loss in mechanical integrity during sodiation/desodiation. To address this, the usage of nanoscaled electrode-active particles and nanoscaled-carbon-based buffers has been explored, but with compromises with the tap density, accrued irreversible surface reactions, overall capacity (for "inactive" carbon), and adoption of non-scalable/complex preparation routes. Against this backdrop, anode-active "layered" bismuth (Bi) has been incorporated with Sn via a facile-cum-scalable mechanical-milling approach, leading to individual electrode-active particles being composed of well-dispersed Sn and Bi phases. The optimized carbon-free Sn-Bi compositions, benefiting from the combined effects of "buffering" action and faster Na transport of Bi, to go with the greater Na-storage capacity and lower operating potential of Sn, exhibit excellent cyclic stability (viz., ∼83-92% capacity retention after 200 cycles at 1C) and rate capability (viz., no capacity drop from C/5 to 2C, with only ∼25% drop at 5C), despite having fairly coarse particles (∼5-10 µm). As proven by operando synchrotron X-ray diffraction and stress measurements, the sequential sodiation/desodiation of the components and, concomitantly, stress build-ups at different potentials provide "buffering" action even for such "active-active" Sn-Bi compositions. Furthermore, the overall stress development upon sodiation of Bi has been found to be significantly lower than that of Sn (by a factor of ∼3.8), which renders Bi promising as a "buffer" material, in general. Dissemination of such complex interplay between electrode-active components during electrochemical cycling also paves the way for the development of high-performance, safe, and scalable "alloying-reaction"-based anode materials for Na-ion batteries and beyond, sans the need for ultrafine/nanoscaled electrode particles or "inactive" nanoscaled-carbon-based "buffer" materials.

Readiness for transfer: a mixed-methods study on ICU transfers of care.

OBJECTIVE: Past studies on intensive care unit (ICU) patient transfers compare the efficacy of using standardised checklists against unstructured communications. Less studied are the experiences of clinicians in enacting bidirectional (send/receive) transfers. This study reports on the differences in protocols and data elements between receiving and sending transfers in the ICU, and the elements constituting readiness for transfer. METHODS: Mixed-methods study of a 574-bed general hospital in Singapore with a 74-bed ICU for surgical and medical patients. Six focus group discussions (FGDs) with 34 clinicians comprising 15 residents and 19 nurses, followed by a structured questionnaire survey of 140 clinicians comprising 21 doctors and 119 nurses. FGD transcripts were analysed according to the standard qualitative research guidelines. Survey data were analysed using Student's t-test with Bonferroni corrections. RESULTS: General ward (GW) clinicians are more likely to receive ICU patients with complete discharge summaries while ICU clinicians receiving GW patients get significantly less data. Emergency department (ED), GW and operating theatre physicians accompany their patients to the ICU while ICU nurses accompany their patients to the GW. Not all units, such as the ED, experience bidirectional transfers. CONCLUSION: The protocols and supporting data elements of an ICU transfer vary by the type of transfer and transferring unit. Readiness for transfer means that sending unit protocols affirmatively consider the needs of the receiving unit's data needs and resource constraints.

Feasibility analysis of a novel non-invasive ultrasonographic method for the measurement of intra-abdominal pressure in the intensive care unit.

Increased intra-abdominal pressure (IAP) is an important vital sign in critically ill patients and has a negative impact on morbidity and mortality. This study aimed to validate a novel non-invasive ultrasonographic approach to IAP measurement against the gold standard intra-bladder pressure (IBP) method. We conducted a prospective observational study in an adult medical ICU of a university hospital. IAP measurements using ultrasonography by two independent operators, with different experience levels (experienced, IAPUS1; inexperienced, IAPUS2), were compared with the gold standard IBP method performed by a third blinded operator. For the ultrasonographic method, decremental external pressure was applied on the anterior abdominal wall using a bottle filled with decreasing volumes of water. Ultrasonography looked at peritoneal rebound upon brisk withdrawal of the external pressure. The loss of peritoneal rebound was identified as the point where IAP was equal to or above the applied external pressure. Twenty-one patients underwent 74 IAP readings (range 2-15 mmHg). The number of readings per patient was 3.5 ± 2.5, and the abdominal wall thickness was 24.6 ± 13.1 mm. Bland and Altman's analysis showed a bias (0.39 and 0.61 mmHg) and precision (1.38 and 1.51 mmHg) for the comparison of IAPUS1 and IAPUS2 and vs. IBP, respectively with small limits of agreement that were in line with the research guidelines of the Abdominal Compartment Society (WSACS). Our novel ultrasound-based IAP method displayed good correlation and agreement between IAP and IBP at levels up to 15 mmHg and is an excellent solution for quick decision-making in critically ill patients.

Na2ZrFe(PO4)3─A Rhombohedral NASICON-Structured Material: Synthesis, Structure and Na-Intercalation Behavior.

A NASICON-structured earth-abundant mixed transition metal (TM) containing Na-TM-phosphate, viz., Na2ZrFe(PO4)3, has been prepared via a sol-gel route using a low-cost Fe3+-based precursor. The as-prepared material crystallizes in the desired rhombohedral NASICON structure (space group: R3̅c) at room temperature. Synchrotron X-ray diffraction (XRD), transmission electron microscopy, X-ray absorption spectroscopy, etc., have been performed to determine the crystal structure, associated details, composition, and electronic structures. In light of the structural features, as one of the possible functionalities of Na2FeZr(PO4)3, Na-intercalation/deintercalation has been examined, which indicates the occurrence of reversible electrochemical Na-insertion/extraction via Fe2+/Fe3+ redox at an average potential of ∼2.5 V. The electrochemical data and direct evidences from operando synchrotron XRD indicate that the rhombohedral structure is preserved during Na-insertion/extraction, albeit within a certain range of Na-content (i.e., ∼2-3 p.f.u.), beyond which rhombohedral → monoclinic transformation takes place. Within this range, Na-insertion/extraction takes place via solid-solution pathway, resulting in outstanding cyclic stability, higher Na-diffusivity, and good rate-capability. To the best of the authors' knowledge, this represents the first in-depth structural, compositional, and electrochemical studies with Na2ZrFe(PO4)3, along with the interplay between those, which provide insights into the design of similar low-cost materials for various applications, including sustainable electrochemical energy storage systems.

Development of a high-rate-capable O3-structured 'layered' Na transition metal oxide by tuning the cation-oxygen bond covalency.

By developing a high-rate-capable O3-structured Na(Li0.05Ni0.3Si0.05Ti0.45Cu0.1Mg0.05)O2-based cathode material for Na-ion batteries, wherein partial substitution of more electronegative Si4+ for Ti4+ in the transition metal layer has weakened-cum-lengthened the Na-O bond, enlarged the 'inter-slab' spacing and, thus, enhanced the Na-transport kinetics, a design criterion has been laid-out in the above context.

Correction: Expanding the utility of the ROX index among patients with acute hypoxemic respiratory failure.

[This corrects the article DOI: 10.1371/journal.pone.0261234.].

Understanding the Effects of Tetrahedral Site Occupancy by the Zn Dopant in Li-NMCs toward High-Voltage Compositional-Structural-Mechanical Stability via Operando and 3D Atom Probe Tomography Studies.

Ni-containing "layered"/cation-ordered LiTMO2s (TM = transition metal) suffer from Ni-migration to the Li-layer at the unit cell level, concomitant transformation to a spinel/rock salt structure, hindrance toward Li-transport, and, thus, fading in Li-storage capacity during electrochemical cycling (i.e., repeated delithiation/lithiation), especially upon deep delithiation (i.e., going to high states-of-charge). Against this backdrop, our previously reported work [ACS Appl. Mater. Interfaces 2021, 13, 25836-25849] revealed a new concept toward blocking the Ni-migration pathway by placing Zn2+ (which lacks octahedral site preference) in the tetrahedral site of the Li-layer, which, otherwise, serves as an intermediate site for the Ni-migration to the Li-layer. This, nearly completely, suppressed the Ni-migration, despite being deep delithiated up to a potential of 4.7 V (vs Li/Li+) and, thus, resulted in significant improvement in the high-voltage cyclic stability. In this regard, by way of conducting operando synchrotron X-ray diffraction, operando stress measurements, and 3D atom probe tomography, the present work throws deeper insights into the effects of such Zn-doping toward enhancing the structural-mechanical-compositional integrity of Li-NMCs upon being subjected to deep delithiation. These studies, as reported here, have provided direct lines of evidence toward notable suppression of the variations of lattice parameters of Li-NMCs, including complete prevention of the detrimental "c-axis collapse" at high states-of-charges and concomitant slower-cum-lower electrode stress development, in the presence of the Zn-dopant. Furthermore, the Zn-dopant has been found to also prevent the formation of Ni-enriched regions at the nanoscaled levels in Li-NMCs (i.e., Li/Ni-segregation or "structural densification") even upon being subjected to 100 charge/discharge cycles involving deep delithiation (i.e., up to 4.7 V). Such detailed insights based on direct/real-time lines of evidence, which reveal important correlations between the suppression of Ni-migration and high-voltage compositional-structural-mechanical stability, hold immense significance toward the development of high capacity and stable "layered" Li-TM-oxide based cathode materials for the next-generation Li-ion batteries.

Faceted Antimony Particles with Interiors Reinforced with Reduced Graphene Oxide as High-Performance Anode Material for Sodium-Ion Batteries.

The attainment of "true reinforcement" in a composite and harnessing of the associated beneficial effects have been demonstrated here through the development of faceted crystalline Sb particles having the interiors reinforced with reduced graphene oxide (rGO). Such a unique and "near-ideal" micro/nanocomposite architecture has been achieved via a facile/cost-effective route by facilitating heterogeneous nucleation/growth of Sb-oxide particles on/around dispersed rGO sheets upon incorporation of the same directly into the precursor suspension, followed by the reduction of Sb-oxide to Sb, in intimate contact with the rGO, during the subsequent single heat-treatment step. As a potential anode material for Na-ion batteries, the as-developed Sb/rGO composite exhibits a reversible Na-storage capacity of ∼550 mAh/g (@ 0.2 A/g) and a fairly high first cycle Coulombic efficiency (CE) of ∼79%, with the good reversibility being attributed to the coarse particle size of Sb and encompassing of rGO sheets inside the Sb particles. Furthermore, despite the coarse particle size, the Sb/rGO-based electrode exhibits outstanding cyclic stability, with negligible capacity fade up to 150 cycles (viz., ∼97% capacity retention), and rate capability, with >86% capacity being obtained upon raising the current density from 0.1 to 2 A/g, resulting in a capacity of ∼490 mAh/g, even at 2 A/g.

Continuing chronic care services during a pandemic: results of a mixed-method study.

BACKGROUND: Patients with chronic diseases have seen unprecedented changes to healthcare practices since the emergence of COVID-19. Traditional 'on-site' clinics have had to innovate to continue services. Whether these changes are acceptable to patients and are effective for care continuation are largely unreported. METHODS: We evaluated the effectiveness of care provision at a re-structured chronic care clinic and elicited the patient experiences of care and self-management. We conducted a convergent, parallel, mixed-methods study. Adult patients attending a chronic care clinic were included. We extracted data from 4,849 clinic visits before and during the COVID-19 pandemic, including operational metrics and attendee profile. We also conducted fifteen interviews with patients from the same clinic using a semi-structured interview guide. RESULTS: Re-structuring the chronic clinic, including the introduction of teleconsultations, home-delivery of prescriptions and use of community-based phlebotomy services, served to maintain continuity of care while adhering to COVID-19 containment measures. Qualitatively, five themes emerged. Patients were able to adjust to healthcare practice changes and adapt their own lifestyles, although poor self-management practices were adopted. While most were apprehensive about attending the clinic, they valued ongoing care access and were reassured by the on-site containment measures. CONCLUSIONS: Continuation of routine services is desired by patients and can be achieved through the adoption of containment measures, by greater collaboration with community partners, and the use of technology. Patients adapted to service changes, but poor self-management was evident. To prevent chronic disease relapse, services must strive to innovate rather than suspend services during pandemics.

Personalised Dosing Using the CURATE.AI Algorithm: Protocol for a Feasibility Study in Patients with Hypertension and Type II Diabetes Mellitus.

Chronic diseases typically require long-term management through healthy lifestyle practices and pharmacological intervention. Although efficacious treatments exist, disease control is often sub-optimal leading to chronic disease-related sequela. Poor disease control can partially be explained by the 'one size fits all' pharmacological approach. Precision medicine aims to tailor treatments to the individual. CURATE.AI is a dosing optimisation platform that considers individual factors to improve the precision of drug therapies. CURATE.AI has been validated in other therapeutic areas, such as cancer, but has yet to be applied in chronic disease care. We will evaluate the CURATE.AI system through a single-arm feasibility study (n = 20 hypertensives and n = 20 type II diabetics). Dosing decisions will be based on CURATE.AI recommendations. We will prospectively collect clinical and qualitative data and report on the clinical effect, implementation challenges, and acceptability of using CURATE.AI. In addition, we will explore how to enhance the algorithm further using retrospective patient data. For example, the inclusion of other variables, the simultaneous optimisation of multiple drugs, and the incorporation of other artificial intelligence algorithms. Overall, this project aims to understand the feasibility of using CURATE.AI in clinical practice. Barriers and enablers to CURATE.AI will be identified to inform the system's future development.

Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore.

INTRODUCTION: To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. METHODS: This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. RESULTS: Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. CONCLUSION: The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.

Predicting and Validating 30-day Hospital Readmission in Adults With Diabetes Whose Index Admission Is Diabetes-related.

OBJECTIVE: The primary objective is to develop a prediction model of 30-day hospital readmission among adults with diabetes mellitus (DM) whose index admission was DM-related. The secondary aims are to internally and externally validate the prediction model and compare its performance with 2 existing models. RESEARCH DESIGN AND SETTING: Data of inpatients aged ≥ 18 years from 2008 to 2015 were extracted from the electronic medical record system of the National University Hospital, Singapore. Unplanned readmission within 30 days was calculated from the discharge date of the index hospitalization. Multivariable logistic regression and 10-fold cross-validation were performed. For external validation, simulations based on prevalence of 30-day readmission, and the regression coefficients provided by referenced papers were conducted. RESULTS: Eleven percent of 2355 patients reported 30-day readmission. The prediction model included 4 predictors: length of stay, ischemic heart disease, peripheral vascular disease, and number of drugs. C-statistics for the prediction model and 10-fold cross-validation were 0.68 (95% CI 0.66, 0.70) and 0.67 (95% CI 0.63 to 0.70), respectively. Those for the 3 simulated external validation data sets ranged from 0.64 to 0.68. CONCLUSION: The prediction model performs well with good internal and external validity for identifying patients with DM at risk of unplanned 30-day readmission.

Expanding the utility of the ROX index among patients with acute hypoxemic respiratory failure.

BACKGROUND: Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in increased mortality. The ROX index has been validated to predict HFNC failure among pneumonia patients with acute hypoxemic respiratory failure (AHRF), but little information is available for non-pneumonia causes. In this study, we validate the ROX index among AHRF patients due to both pneumonia or non-pneumonia causes, focusing on early prediction. METHODS: This was a retrospective observational study in eight Singapore intensive care units from 1 January 2015 to 30 September 2017. All patients >18 years who were treated with HFNC for AHRF were eligible and recruited. Clinical parameters and arterial blood gas values at HFNC initiation and one hour were recorded. HFNC failure was defined as requiring intubation post-HFNC initiation. RESULTS: HFNC was used in 483 patients with 185 (38.3%) failing HFNC. Among pneumonia patients, the ROX index was most discriminatory in pneumonia patients one hour after HFNC initiation [AUC 0.71 (95% CI 0.64-0.79)], with a threshold value of <6.06 at one hour predicting HFNC failure (sensitivity 51%, specificity 80%, positive predictive value 61%, negative predictive value 73%). The discriminatory power remained moderate among pneumonia patients upon HFNC initiation [AUC 0.65 (95% CI 0.57-0.72)], non-pneumonia patients at HFNC initiation [AUC 0.62 (95% CI 0.55-0.69)] and one hour later [AUC 0.63 (95% CI 0.56-0.70)]. CONCLUSION: The ROX index demonstrated moderate discriminatory power among patients with either pneumonia or non-pneumonia-related AHRF at HFNC initiation and one hour later.