Evaluating Quality-of-Life, Length of Stay and Cost-Effectiveness of a Front-Door Geriatrics Program: An Exploratory Proof-of-Concept Study.

BACKGROUND: The Emergency Department Interventions for Frailty (EDIFY) program was developed to deliver early geriatric specialist interventions at the Emergency Department (ED). EDIFY has been successful in reducing acute admissions among older adults. OBJECTIVES: We aimed to examine the effectiveness of EDIFY in improving health-related quality-of-life (HRQOL) and length of stay (LOS), and evaluate EDIFY's cost-effectiveness. DESIGN: A quasi-experiment study. SETTING: The ED of a 1700-bed tertiary hospital. PARTICIPANTS: Patients (≥85 years) pending acute hospital admission and screened by the EDIFY team to be potentially suitable for discharge or transfer to low-acuity care areas. INTERVENTION: EDIFY versus standard-care. MEASUREMENTS: Data on demographics, comorbidities, premorbid function, and frailty status were gathered. HRQOL was measured using EQ-5D-5L over 6 months. We used a crosswalk methodology to compute Singapore-specific index scores from EQ-5D-5L responses and calculated quality-adjusted life-years (QALYs) gained. LOS and bills in Singapore-dollars (SGD) before subsidy from ED attendances (including admissions, if applicable) were obtained. We estimated average programmatic EDIFY cost and performed multiple imputation (MI) for missing data. QALYs gained, LOS and cost were compared. Potential uncertainties were also examined. RESULTS: Among 100 participants (EDIFY=43; standard-care=57), 61 provided complete data. For complete cases, there were significant QALYs gained at 3-month (coefficient=0.032, p=0.004) and overall (coefficient=0.096, p=0.002) for EDIFY, whilst treatment cost was similar between-groups. For MI, we observed only overall QALYs gained for EDIFY (coefficient=0.102, p=0.001). EDIFY reduced LOS by 17% (Incident risk ratio=0.83, p=0.015). In a deterministic sensitivity analysis, EDIFY's cost-threshold was SGD$2,500, and main conclusions were consistent in other uncertainty scenarios. Mean bills were: EDIFY=SGD$4562.70; standard-care=SGD$5530.90. EDIFY's average programmatic cost approximated SGD$469.30. CONCLUSIONS: This exploratory proof-of-concept study found that EDIFY benefits QALYs and LOS, with equivalent cost, and is potentially cost-effective. The program has now been established as standard-care for older adults attending the ED at our center.

Bendamustine is safe and effective for lymphodepletion before tisagenlecleucel in patients with refractory or relapsed large B-cell lymphomas.

BACKGROUND: Anti-CD19 chimeric antigen receptor T-cell immunotherapy (CAR-T) is now a standard treatment of relapsed or refractory B-cell non-Hodgkin lymphomas; however, a significant portion of patients do not respond to CAR-T and/or experience toxicities. Lymphodepleting chemotherapy is a critical component of CAR-T that enhances CAR-T-cell engraftment, expansion, cytotoxicity, and persistence. We hypothesized that the lymphodepletion regimen might affect the safety and efficacy of CAR-T. PATIENTS AND METHODS: We compared the safety and efficacy of lymphodepletion using either fludarabine/cyclophosphamide (n = 42) or bendamustine (n = 90) before tisagenlecleucel in two cohorts of patients with relapsed or refractory large B-cell lymphomas treated consecutively at three academic institutions in the United States (University of Pennsylvania, n = 90; Oregon Health & Science University, n = 35) and Europe (University of Vienna, n = 7). Response was assessed using the Lugano 2014 criteria and toxicities were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and, when possible, the American Society for Transplantation and Cellular Therapy (ASTCT) consensus grading. RESULTS: Fludarabine/cyclophosphamide led to more profound lymphocytopenia after tisagenlecleucel infusion compared with bendamustine, although the efficacy of tisagenlecleucel was similar between the two groups. We observed significant differences, however, in the frequency and severity of adverse events. In particular, patients treated with bendamustine had lower rates of cytokine release syndrome and neurotoxicity. In addition, higher rates of hematological toxicities were observed in patients receiving fludarabine/cyclophosphamide. Bendamustine-treated patients had higher nadir neutrophil counts, hemoglobin levels, and platelet counts, as well as a shorter time to blood count recovery, and received fewer platelet and red cell transfusions. Fewer episodes of infection, neutropenic fever, and post-infusion hospitalization were observed in the bendamustine cohort compared with patients receiving fludarabine/cyclophosphamide. CONCLUSIONS: Bendamustine for lymphodepletion before tisagenlecleucel has efficacy similar to fludarabine/cyclophosphamide with reduced toxicities, including cytokine release syndrome, neurotoxicity, infectious and hematological toxicities, as well as reduced hospital utilization.

Malnutrition among patients admitted to the subacute geriatric ward during the COVID-19 pandemic era: A cross-sectional study in a tertiary hospital in Malaysia.

BACKGROUND: Acute illness and hospitalisation detriment the nutritional status of older patients. This study aimed to describe the prevalence of malnutrition, characteristics and in-hospital outcomes associated with malnutrition, and nutritional management among patients who were admitted to the Subacute Geriatric Ward. METHODS: This is a retrospective study of older patients (age ≥ 60) who were admitted to the Subacute Geriatric Ward of Kuala Lumpur Hospital from 1 March 2021 to 31 May 2021. Malnutrition was identified using the Mini Nutritional Assessment-Short Form (MNA-SF). The in-hospital outcomes evaluated were hospital-associated complications, namely delirium, functional decline, incontinence, inpatient falls, inpatient pressure injuries, hospital-acquired infection, institutionalisation, and inpatient mortality. RESULTS: Seventy-three patients were included (mean age 74.7, female 58.9%), of which 28 (38.4%) and 27 (37.0%) were malnourished and at risk of malnutrition, respectively. Poorer nutritional status was associated with increased age, comorbidity burden, frailty, immobility, impaired basic activities of daily living, history of falls, cognitive impairment, incontinence, and arthritis. About 71.2% and 60.3% of patients were offered dietitian review and oral nutritional supplements, respectively. The in-hospital outcome rates were higher among malnourished patients, but the differences were not statistically significant. However, multiple hospital-associated complications were more common with poorer nutritional status (p = 0.018). CONCLUSION: Hospital malnutrition is prevalent among older patients, and unidentified malnutrition is not justified due to its association with multiple adverse outcomes.

The SINgapore GERiatric Intervention Study to Reduce Cognitive Decline and Physical Frailty (SINGER): Study Design and Protocol.

BACKGROUND: The SINgapore GERiatric intervention study to reduce cognitive decline and physical frailty (SINGER) randomised controlled trial (RCT) uses a multidomain lifestyle interventions approach, shown to be effective by the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) trial, to delay cognitive decline. OBJECTIVE: To investigate the efficacy and safety of the SINGER multidomain lifestyle interventions in older adults at risk for dementia to delay cognitive decline. PARTICIPANTS: 1200 participants between 60-77 years old, with Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) dementia risk score ≥6, fulfilling at least one of the following LIBRA index for diet, cognitive activity, physical activity and a Montreal Cognitive Assessment (MoCA) score ≥18, ≤27 points, will be recruited across Singapore. METHODS: SINGER is a 2-year multi-site RCT consisting of multidomain interventions: dietary advice, exercise, cognitive training, and vascular risk factors management. Participants will be randomised into either the Self-Guided Intervention (SGI; general lifestyle and health information and resources) or Structured Lifestyle Intervention (SLI) group. The SLI comprises diet training (6 group and 3 individual sessions over 12 months); exercise (supervised: 1-hour twice weekly for 6 months, unsupervised: 2-3/week for the rest of the study duration); cognitive sessions (15-30 minutes/session, 3/week for 6 months, together with 10 workshops in 24 months). Vascular management takes place every 3-6 months or otherwise as specified by study physicians. The primary outcome is global cognition measured using the modified Neuropsychological Battery assessing performance in various domains, such as episodic memory, executive function and processing speed. Secondary outcome measures include: domain-specific cognition and function, imaging evidence of brain and retinal changes, incidence and progression of chronic diseases, blood biomarkers, quality of life, mental health and cost-benefit analysis. CONCLUSIONS: SINGER is part of the Worldwide-FINGERS international network, which is at the forefront of harmonizing approaches to effective non-pharmacological interventions in delaying cognitive decline in older adults at risk of dementia. By establishing the efficacy of multidomain interventions in preventing cognitive decline, SINGER aims to implement the findings into public health and clinical practices by informing policy makers, and guiding the design of community- and individual-level health promotion initiatives.

SARC-F at the Emergency Department: Diagnostic Performance for Frailty and Predictive Performance for Reattendances and Acute Hospitalizations.

OBJECTIVES: Sarcopenia is associated with adverse health outcomes including mortality, functional loss, falls, and poorer quality of life. However, the value of screening sarcopenia at the Emergency Department (ED) remains unclear. We aimed to examine the SARC-F questionnaire for its (1) diagnostic ability in identifying frailty, and (2) predictive ability for adverse health outcomes. DESIGN: A secondary analysis of a quasi-experimental study. SETTING: An ED within a 1700-bed tertiary hospital. PARTICIPANTS: ED patients aged ≥85 years (mean age 90.0 years) recruited into the Emergency Department Interventions of Frailty (EDIFY) study. MEASUREMENTS: Data of demographics, premorbid function, frailty status [Frailty Index (FI), Clinical Frailty Scale (CFS), FRAIL], comorbidities, medications, and cognitive status were gathered. We also captured outcomes of mortality, acute hospitalization, and ED reattendance at 1-, 3-, and 6-month. We then compared area under the operating characteristic curves (AUCs) for the abovementioned measures against the FI (reference) for diagnosis of frailty. Lastly, we performed univariate analyses and logistic regression to compare SARC-F and other measures against the adverse outcomes of interest. RESULTS: Amongst the various instruments, the SARC-F (AUC 0.92, 95% Confidence Interval (CI) 0.86-0.98, P<0.001; Sensitivity 79.0%, and Specificity 88.9%) performed best for frailty detection as defined by FI. Optimal cutoff was ≥3 (Sensitivity 91.4%, Specificity 83.3%, and Negative Predictive Value 68.2%). Only SARC-F was predictive of acute hospitalization [Adjusted Odds Ratio (OR) 4.00, 95% CI 1.47-10.94, P=0.007] and ED-reattendance [Adjusted OR 3.29, 95% CI 1.26-8.56, P=0.015] at 3-month. CONCLUSIONS: The SARC-F demonstrated excellent diagnostic ability for frailty detection and predictive validity for ED reattendance and acute hospitalization at 3 months. Lowering cutoff score to ≥3 may improve case-finding at the ED to facilitate early identification and management of sarcopenia. Further studies are required to validate the diagnostic and predictive performance of SARC-F at ED settings.

High flow nasal cannula in asthmatic children with suspected COVID-19 / Cânula nasal de alto fluxo em crianças asmáticas com suspeita de COVID-19

Abstract Introduction: The use of a high-flow nasal cannula as an alternative treatment for acute respiratory failure can reduce the need for invasive mechanical ventilation and the duration of hospital stays. Objective: The present study aimed to describe the use of a high-flow nasal cannula in pediatric asthmatic patients with acute respiratory failure and suspected COVID-19. Methods: To carry out this research, data were collected from medical records, including three patients with asthma diagnoses. The variables studied were: personal data (name, age in months, sex, weight, and color), clinical data (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest, and laboratory radiography (arterial blood gases and reverse-transcriptase polymerase chain reaction). Clinical data were compared before and after using a high-flow nasal cannula. Results: After the application of the therapy, a gradual improvement in heart, respiratory rate, PaO2/FiO2 ratio, and the Pediatric Respiratory Assessment Measure score was observed. Conclusion: The simple and quick use of a high-flow nasal cannula in pediatric patients with asthma can be safe and efficient in improving their respiratory condition and reducing the need for intubation.

Resumo Introdução: A utilização da cânula nasal de alto fluxo como alternativa de tratamento para a insuficiência respiratória aguda pode diminuir a necessidade de utilização de ventilação mecânica invasiva e reduzir os dias de internamento. Objetivo: Descrever a utilização da cânula nasal de alto fluxo em pacientes pediátricos asmáticos com insuficiência respiratória aguda e suspeita de COVID-19. Métodos: Para a realização dessa pesquisa foram coletados dados de prontuários, sendo três pacientes com diagnóstico de asma incluídos. As variáveis estudadas foram: dados pessoais (nome, idade em meses, sexo, peso e cor) e clínicos (exame físico, PRAM Escore, frequência respiratória, frequência cardíaca, e saturação periférica de oxigênio), diagnóstico, história da moléstia atual, radiografia de tórax e exames laboratoriais (gasometria arterial e Reverse-Transcriptase Polymerase Chain Reaction). Foram comparados dados clínicos antes e após a utilização da cânula nasal de alto fluxo. Resultados: Após a aplicação da terapia foi possível observar melhora gradativa da frequência cardíaca e respiratória, relação PaO2/FiO2 e do escore Pediatric Respiratory Assessment Measure. Conclusão: A utilização simples e rápida da cânula nasal de alto fluxo em pacientes pediátricos com asma pode ser segura e eficiente para melhora do quadro respiratório, diminuindo a necessidade de intubação.

Properties of Macroalgae Biopolymer Films Reinforcement with Polysaccharide Microfibre.

Developing robust and biodegradable biopolymer films based on macroalgae is a challenging task because of its inadequate mechanical strength and poor moisture barrier attribute to its hydrophilic nature. A promising and sustainable approach to overcome this challenge is to reinforce the biopolymer film with polysaccharide microfibre (microcrystalline cellulose) derived from Gigantochloa levis bamboo (GL-MCC). Eucheuma cottonii macroalgae were used for the development of biopolymer films without further extraction and purification, which was considered economical and easy. The mechanical, water contact angle (WCA), water absorption capacity (WSC), and thermal behaviour of macroalgae-based biopolymer films revealed that the inclusions of GL-MCC significantly enhanced the durability, moisture barrier, and thermal stability of the biopolymer films. The enhancement is ascribed to the interaction between macroalgae and GL-MCC due to high compatibility. Moreover, the incorporation of GL-MCC successfully increased the rigidity of the macroalgae-based biopolymer films against microorganism and moisture attack, but remain biodegradable and environmental-friendly. The developed biodegradable macroalgae/GL-MCC biopolymer films can potentially be used as packaging materials.

Procuras não urgentes a um pronto-socorro hospitalar pediátrico: perspectivas dos usuários / Nonurgent visits to a pediatric hospital emergency department: users' perspectives

Causas não urgentes são frequentes entre os pacientes nos prontos-socorros (PS) pediátricos, com consequências aos pacientes, aos profissionais e ao sistema. Este estudo objetiva descrever as procuras não urgentes a um PS de hospital de referência pediátrico, sendo um estudo observacional descritivo. Dos 168 participantes, 63% haviam procurado previamente outros serviços de saúde. O principal motivo citado como razão de procura foi "ter o hospital como referência de resolutividade e confiança". A maioria (68%) dos entrevistados classificaram os quadros como urgências. Enquanto 63% disseram não ter recebido orientações sobre sinais de alarme na criança, 83% não haviam recebido informações sobre diferenças entre os níveis de atenção em saúde. Assim, foi demonstrada que a compreensão das razões de procura ao PS deve ser avaliada conjuntamente ao contexto social, de educação e de acesso à saúde dos usuários. (AU)

Nonurgent causes have been frequent in pediatric emergency departments (ED), leading to consequences for patients, professionals and the system. This study aimed to describe nonurgent pediatric visits to an ED of a reference pediatric hospital, as an observational descriptive study. Of 168 participants, 63% had sought prior care before going to the ED. The main reason cited for the search of the ED was "to have the hospital as a reference of problem-solving capacity and trust". Most caregivers (68%) assessed their child's current condition as an urgency. While 63% reported not having received information about alarming symptoms in children, 83% did not receive information about the differences among levels of health care. The results showed that understanding the reasons to ED search should be analyzed in conjunction with the users' social, educational, and of health system access context. (AU)

Enhancement in the Physico-Mechanical Functions of Seaweed Biopolymer Film via Embedding Fillers for Plasticulture Application-A Comparison with Conventional Biodegradable Mulch Film.

This study aimed to compare the performance of fabricated microbially induced precipitated calcium carbonate⁻ (MB⁻CaCO3) based red seaweed (Kappaphycus alvarezii) bio-polymer film and commercial calcium carbonate⁻ (C⁻CaCO3) based red seaweed bio-film with the conventional biodegradable mulch film. To the best of our knowledge, there has been limited research on the application of commercial CaCO3 (C⁻CaCO3) and microbially induced CaCO3 (MB⁻CaCO3) as fillers for the preparation of films from seaweed bio-polymer and comparison with biodegradable commercial plasticulture packaging. The results revealed that the mechanical, contact angle, and biodegradability properties of the polymer composite films incorporated with C⁻CaCO3 and MB⁻CaCO3 fillers were comparable or even superior than the conventional biodegradable mulch film. The seaweed polymer film incorporated with MB⁻CaCO3 showed the highest contact angle of 100.94°, whereas conventional biodegradable mulch film showed a contact angle of 90.25°. The enhanced contact angle of MB⁻CaCO3 resulted in high barrier properties, which is highly desired in the current scenario for plasticulture packaging application. The water vapor permeability of MB⁻CaCO3 based seaweed films was low (2.05 ± 1.06 g·m/m²·s·Pa) when compared to conventional mulch film (2.68 ± 0.35 g·m/m²·s·Pa), which makes the fabricated film an ideal candidate for plasticulture application. The highest tensile strength (TS) was achieved by seaweed-based film filled with commercial CaCO3 (84.92% higher than conventional mulch film). SEM images of the fractured surfaces of the fabricated films revealed the strong interaction between seaweed and fillers. Furthermore, composite films incorporated with MB⁻CaCO3 promote brighter film, better water barrier, hydrophobicity, and biodegradability compared to C⁻CaCO3 based seaweed polymer film and conventional mulch film. From this demonstrated work, it can be concluded that the fabricated MB⁻CaCO3 based seaweed biopolymer film will be a promising candidate for plasticulture and agricultural application.

Impulse oscillometry in the assessment of children's lung function.

PURPOSE: To review available evidence in the literature on impulse oscillometry in the assessment of lung function in children with respiratory diseases, especially asthma. DATA COLLECTION: Research in the Medline, PubMed, and Lilacs databases, with the keywords forced oscillation, impulse oscillometry, asthma and impulse oscillometry. RESULTS: The Impulse Oscillometry System (IOS) allows the measurement of resistance and reactance of airways and is used as a diagnostic resource. A significant association between the findings of the IOS and those of spirometry is observed. In asthma, the IOS has already been used to assess the bronchodilator response and the therapeutic response to different drugs and has shown to be a sensitive technique to evaluate disease control. There are limitations to this assessment, such as children with attention deficit and in some cases it is difficult to interpret the results from a clinical point of view. CONCLUSION: The IOS is a useful tool for the measurement of the lung function of children. It is an easy test, although its interpretation is not straightforward.

Age-related macular degeneration and mortality: the Melbourne Collaborative Cohort Study.

AimsTo assess associations between features of age-related macular degeneration (AMD) and mortality.MethodsA total of 21 129 participants from the Melbourne Collaborative Cohort Study aged 47-85 years (60% female) were assessed for AMD (2003-2007). Mortality data to December 31, 2012 were obtained through linkage with the National Death Index. Associations were assessed using Cox regression, adjusting for age, sex, smoking, region of birth, education, physical activity, diet and alcohol.ResultsLate AMD was identified in 122 (0.6%) participants, including those with choroidal neovascularisation (n=55, 0.3%), geographic atrophy (n=87, 0.4%) and reticular pseudodrusen (n=87, 0.4%). After a median follow-up period of 8.1 years, 1669 (8%) participants had died, including those from cardiovascular diseases (386), tobacco-related cancers (179), and neurodegenerative disease (157). There was evidence of an increased rate of all-cause mortality for those with choroidal neovascularisation (Hazard Ratio (HR) 1.71 95% CI 1.06-2.76) and geographic atrophy (HR 1.46 95% CI 0.99-2.16). Choroidal neovascularisation was also associated with an increased rate of cardiovascular mortality (HR 3.16 95% CI 1.62-6.15) and geographic atrophy was associated with an increased rate of death from tobacco-related cancer (HR 2.86 95% CI 1.15-7.09). Weak evidence was also present for an association between choroidal neovascularisation and death from neurodegenerative disease (HR 2.49 95% CI 0.79-7.85). Neither reticular pseudodrusen nor the earlier stages of AMD were associated with mortality.ConclusionsLate AMD is associated with an increased rate of all-cause mortality. Choroidal neovascularisation and geographic atrophy were associated with death from cardiovascular disease and tobacco-related cancer, respectively.

Ethno-Cultural Considerations in Cardiac Patients' Medication Adherence.

We aimed to develop an in-depth understanding about factors that influence cardiac medication adherence among South Asian, Chinese, and European White cardiac patients. Sixty-four patients were purposively sampled from an ongoing study cohort. Interviews were audio-recorded and transcribed for analyses. Physicians' culturally sensitive communication and patients' motivation to live a symptom-free and longer life enhanced adherence. European Whites were motivated to enhance personal well-being and enjoy family life. South Asians' medication adherence was influenced by the desire to fulfill the will of God and family responsibilities. The Chinese were motivated to avoid pain, illness, and death, and to obey a health care provider. The South Asians and Chinese wanted to ultimately reduce medication use. Previous positive experiences, family support, and establishing a routine also influenced medication adherence. Deterrents to adherence were essentially the reverse of the motivators/facilitators. This analysis represents an essential first step forward in developing ethno-culturally tailored interventions to optimize adherence.

Multiphoton luminescence imaging of chemically functionalized multi-walled carbon nanotubes in cells and solid tumors.

The intrinsic nonlinear photoluminescence (PL) property of chemically functionalized multi-walled nanotubes MWNTs (f-MWNTs) is reported in this study. f-MWNTs are imaged in fixed lung epithelial cancer cells (A549) and Kupffer cells in vitro, and in subcutaneously implanted solid tumors in vivo, for the first time, using multiphoton PL and fluorescence lifetime imaging (FLIM). Multiphoton imaging in the near-infrared excitation region (∼750-950 nm), employed in this study in a label-free manner, provides sensitivity and resolution optimal to track f-MWNTs within intra-cellular compartments and facilitates tumour imaging and sentinel lymph node tracking in vivo. Wider applications include employing this technique in live imaging of f-MWNTs in biological milieu to facilitate image-guided drug delivery.

Calcium silicate cement-induced remineralisation of totally demineralised dentine in comparison with glass ionomer cement: tetracycline labelling and two-photon fluorescence microscopy.

Two-photon fluorescence microscopy, in combination with tetracycline labelling, was used to observe the remineralising potentials of a calcium silicate-based restorative material (Biodentine(TM) ) and a glass ionomer cement (GIC:​Fuji​IX) on totally demineralised dentine. Forty demineralised dentine discs were stored with either cement in three different solutions: phosphate buffered saline (PBS) with tetracycline, phosphate-free tetracycline, and tetracycline-free PBS. Additional samples of demineralised dentine were stored alone in the first solution. After 8-week storage at 37 °C, dentine samples were imaged using two-photon fluorescence microscopy and Raman spectroscopy. Samples were later embedded in PMMA and polished block surfaces studied by 20 kV BSE imaging in an SEM to study variations in mineral concentration. The highest fluorescence intensity was exhibited by the dentine stored with Biodentine(TM) in the PBS/tetracycline solution. These samples also showed microscopic features of matrix remineralisation including a mineralisation front and intra- and intertubular mineralisation. In the other solutions, dentine exhibited much weaker fluorescence with none of these features detectable. Raman spectra confirmed the formation of calcium phosphate mineral with Raman peaks similar to apatite, while no mineral formation was detected in the dentine stored in cement-free or PBS-free media, or with GIC. It could therefore be concluded that Biodentine(TM) induced calcium phosphate mineral formation within the dentine matrix when stored in phosphate-rich media, which was selectively detectable using the tetracycline labelling.

Multimodal optical characterisation of collagen photodegradation by femtosecond infrared laser ablation.

Collagen is a structural component of the human body, as a connective tissue it can become altered as a result of pathophysiological conditions. Although the collagen degradation mechanism is not fully understood, it plays an important role in ageing, disease progression and applications in therapeutic laser treatments. To fully understand the mechanism of collagen alteration, in our study photo-disruptive effects were induced in collagen I matrix by point-irradiation with a femtosecond Ti-sapphire laser under controlled laser ablation settings. This was followed by multi-modal imaging of the irradiated and surrounding areas to analyse the degradation mechanism. Our multi-modal methodology was based on second harmonic generation (SHG), scanning electron microscope (SEM), autofluorescence (AF) average intensities and the average fluorescence lifetime. This allowed us to quantitatively characterise the degraded area into four distinct zones: (1) depolymerised zone in the laser focal spot as indicated by the loss of SHG signal, (2) enhanced crosslinking zone in the inner boundary of the laser induced cavity as represented by the high fluorescence ring, (3) reduced crosslinking zone formed the outer boundary of the cavity as marked by the increased SHG signal and (4) native collagen. These identified distinct zones were in good agreement with the expected photochemical changes shown using Raman spectroscopy. In addition, imaging using polarisation-resolved SHG (p-SHG) revealed both a high degree of fibre re-orientation and a SHG change in tensor ratios around the irradiation spot. Our multi-modal optical imaging approach can provide a new methodology for defining distinct zones that can be used in a clinical setting to determine suitable thresholds for applying safe laser treatments without affecting the surrounding tissues. Furthermore this technique can be extended to address challenges observed in collagen based tissue engineering and used as a minimally invasive diagnostic tool to characterise diseased and non-diseased collagen rich tissues.

Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with type 2 diabetes mellitus: a population-based cohort study.

AIM: To determine the prescribing of and adherence to oral hypoglycaemic agents, insulin, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statin therapy among South-Asian, Chinese and white people with newly diagnosed diabetes. METHODS: The present study was a population-based cohort study using administrative and pharmacy databases to include all South-Asian, Chinese and white people aged ≥ 35 years with diabetes living in British Columbia, Canada (1997-2006). Adherence to each class of medication was measured using proportion of days covered over 1 year with optimum adherence defined as ≥ 80%. RESULTS: The study population included 9529 South-Asian, 14 084 Chinese and 143 630 white people with diabetes. The proportion of people who were prescribed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statin or oral hypoglycaemic agents was ≤ 50% for all groups. South-Asian and Chinese people had significantly lower adherence for all medications than white people, with the lowest adherence to angiotensin-converting enzyme inhibitor treatment (South-Asian people: adjusted odds ratio 0.37, 95% CI 0.34-0.39; P<0.0001; Chinese people: adjusted odds ratio 0.50, 95% CI 0.47-0.54; P<0.0001) and statin therapy (South-Asian people: adjusted odds ratio 0.47, 95% CI 0.41 - 0.53, P < 0.0001; Chinese people: adjusted odds ratio 0.72, 95% CI 0.67 - 0.77; P<0.0001) compared with white people. CONCLUSION: Adherence to evidence-based pharmacotherapy was substantially worse among the South-Asian and Chinese populations. Care providers need to be alerted to the high levels of non-adherence in these groups and the underlying causes need to be investigated.