A tryptophan metabolite made by a gut microbiome eukaryote induces pro-inflammatory T cells.

The large intestine harbors microorganisms playing unique roles in host physiology. The beneficial or detrimental outcome of host-microbiome coexistence depends largely on the balance between regulators and responder intestinal CD4+ T cells. We found that ulcerative colitis-like changes in the large intestine after infection with the protist Blastocystis ST7 in a mouse model are associated with reduction of anti-inflammatory Treg cells and simultaneous expansion of pro-inflammatory Th17 responders. These alterations in CD4+ T cells depended on the tryptophan metabolite indole-3-acetaldehyde (I3AA) produced by this single-cell eukaryote. I3AA reduced the Treg subset in vivo and iTreg development in vitro by modifying their sensing of TGFß, concomitantly affecting recognition of self-flora antigens by conventional CD4+ T cells. Parasite-derived I3AA also induces over-exuberant TCR signaling, manifested by increased CD69 expression and downregulation of co-inhibitor PD-1. We have thus identified a new mechanism dictating CD4+ fate decisions. The findings thus shine a new light on the ability of the protist microbiome and tryptophan metabolites, derived from them or other sources, to modulate the adaptive immune compartment, particularly in the context of gut inflammatory disorders.

Cost-Effectiveness of a Home Telemonitoring System for Asian Adults with Type 2 Diabetes Mellitus.

Background: Telemonitoring programs have been found to be effective in improving diabetic control by promoting patients' self-management of diabetes through medication adherence, dietary modifications, and exercise. Nonetheless, few studies have assessed the cost-effectiveness of telemonitoring for the self-management of diabetes based on real-world data. Methods: A randomized controlled trial entitled Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus was conducted among adults with Type 2 Diabetes Mellitus in Singapore. Individuals in the intervention group (n = 159) underwent a telemonitoring program comprising of remote patient monitoring, education, individualized health coaching, and teleconsultations, whereas individuals in the control group (n = 160) received regular care. Economic evaluation was conducted from health care system and societal perspectives in 2020 in Singapore dollars, using health outcomes and costs documented at baseline and at 6 month follow-up. One-way sensitivity analyses and bootstrapping to generate scatter plot on cost-effectiveness planes were done. Results: The adjusted reduction in HbA1c scores was greater in the intervention group by -0.41 (95% confidence interval [CI], -0.65 to -0.17), while the change in utility scores was higher in the intervention group by 0.011 (95% CI, -0.016 to 0.0378). From a health care perspective, the incremental cost-effectiveness ratio (ICER) of the telemonitoring program per unit improvement in HbA1c, per additional case of well-controlled diabetes, and per unit improvement in quality adjusted life years was SGD 580.44, SGD 9100.15, and SGD 21,476.36, respectively. From a societal perspective, the ICERs were SGD 817.20, SGD 12,812.02, and SGD 30,236.36, respectively. Conclusions: The Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus telemonitoring program was effective and potentially cost-effective for the management and control of diabetes among patients in primary care.

Detection of African Swine Fever Virus from Wild Boar, Singapore, 2023.

We detected African swine fever virus (ASFV) from a wild boar in Singapore. In <72 hours, we confirmed and reported ASFV p72 genotype II, CD2v serogroup 8, and IGR-II variant by using a combination of real-time PCR and whole-genome sequencing. Continued biosurveillance will be needed to monitor ASFV in Singapore.

Experimental colonization with Blastocystis ST4 is associated with protective immune responses and modulation of gut microbiome in a DSS-induced colitis mouse model.

BACKGROUND: Blastocystis is a common gut protistan parasite in humans and animals worldwide, but its interrelationship with the host gut microbiota and mucosal immune responses remains poorly understood. Different murine models of Blastocystis colonization were used to examine the effect of a common Blastocystis subtype (ST4) on host gut microbial community and adaptive immune system. RESULTS: Blastocystis ST4-colonized normal healthy mice and Rag1-/- mice asymptomatically and was able to alter the microbial community composition, mainly leading to increases in the proportion of Clostridia vadinBB60 group and Lachnospiraceae NK4A136 group, respectively. Blastocystis ST4 colonization promoted T helper 2 (Th2) response defined by interleukin (IL)-5 and IL-13 cytokine production, and T regulatory (Treg) induction from colonic lamina propria in normal healthy mice. Additionally, we observed that Blastocystis ST4 colonization can maintain the stability of bacterial community composition and induce Th2 and Treg immune responses to promote faster recovery from experimentally induced colitis. Furthermore, fecal microbiota transplantation of Blastocystis ST4-altered gut microbiome to colitis mice reduced the severity of colitis, which was associated with increased production of short-chain fat acids (SCFAs) and anti-inflammatory cytokine IL-10. CONCLUSIONS: The data confirm our hypothesis that Blastocystis ST4 is a beneficial commensal, and the beneficial effects of Blastocystis ST4 colonization is mediated through modulating of the host gut bacterial composition, SCFAs production, and Th2 and Treg responses in different murine colonization models.

Development of Differentiating Infected from Vaccinated Animals (DIVA) Real-Time PCR for African Horse Sickness Virus Serotype 1.

African horse sickness (AHS) is a highly infectious and often fatal disease caused by 9 serotypes of the orbivirus African horse sickness virus (AHSV). In March 2020, an AHS outbreak was reported in Thailand in which AHSV serotype 1 was identified as the causative agent. Trivalent live attenuated vaccines serotype 1, 3, and 4 were used in a targeted vaccination campaign within a 50-km radius surrounding the infected cases, which promptly controlled the spread of the disease. However, AHS-like symptoms in vaccinated horses required laboratory diagnostic methods to differentiate infected horses from vaccinated horses, especially for postvaccination surveillance. We describe a real-time reverse transcription PCR-based assay for rapid characterization of the affecting field strain. The development and validation of this assay should imbue confidence in differentiating AHS-vaccinated horses from nonvaccinated horses. This method should be applied to determining the epidemiology of AHSV in future outbreaks.

Patient errors in use of injectable antidiabetic medications: A need for improved clinic-based education.

OBJECTIVES: This case series was designed to educate and inform health care professionals on the importance of providing adequate education on injectable antidiabetic agents and highlighting common medication errors related to diabetes care seen in ambulatory practice. The discussion following case descriptions will attempt to characterize patients who may be at high risk for these errors and identify ways to reduce the potential for error. CASE SUMMARY: In a diabetes care clinic, 4 cases were identified in which the patient experienced an escalation of insulin or other injectable antidiabetic medication doses with no improvement in glycemic control. Two of the cases involved failure to remove an inner needle cap because of a poor understanding of pen use. One case was attributed to switching formulations without providing proper education for an adult patient with a learning impairment, and the other was attributed to suboptimal absorption of insulin doses from lipohypertrophy. Three of the 4 cases resulted in multiple instances of hypoglycemia, and all 4 patients exhibited markedly improved glycemic control once the injection error was corrected. The clinic pharmacist played an essential role in identifying and correcting administration errors within an interdisciplinary team. PRACTICE IMPLICATIONS: Based on the observations from the 4 cases, clinicians should be prompted to review antidiabetic medication injection techniques before initiation and periodically thereafter with their patients. Factors that should prompt further education include low health literacy, language barrier, initiation of medication by another provider, switch of medication product or formulation, obvious discrepancies between refill history and patient's self-reported adherence, observed lipohypertrophy, and escalation of doses without any improvement in glycemic control. A referral to the clinic pharmacist should be considered to provide more detailed education for these patients.

Interaction between Antibiotic Resistance, Resistance Genes, and Treatment Response for Urinary Tract Infections in Primary Care.

Given increasing antimicrobial resistance, we aimed to determine antibiotic susceptibility and presence of resistance genes in uropathogens in primary care, factors associated with resistance to commonly prescribed antibiotics, and effect of treatment on early symptom resolution. We conducted a prospective study of primary care patients with urinary tract infection (UTI) symptoms and culture-confirmed UTI in Singapore from 2015 to 2016. Cohort characteristics and antimicrobial susceptibility of cultured isolates were analyzed. Among Enterobacteriaceae isolates, early symptom resolution (within 3 days) according to antibiotic prescribed and isolate susceptibility and factors associated with antibiotic resistance were evaluated. Of 695 symptomatic patients, 299 were urine culture positive; of these 299 patients, 259 (87%) were female. Escherichia coli was the most common uropathogen (76%). Enterobacteriaceae isolates (n = 283) were highly susceptible to amoxicillin-clavulanate (86%), nitrofurantoin (87%), and fosfomycin (98%), but >20% were resistant to ciprofloxacin and co-trimoxazole. Isolates resistant to appropriate indicator antibiotics were further tested to determine proportions positive for blaCTX-M (14/26, 54%), plasmid-mediated ampC (12/24, 50%), qnr (7/69, 10%), and fos (1/6, 17%) resistance genes. A total of 67% of patients given antibiotics with susceptible isolates reported early resolution versus 45% given antibiotics with nonsusceptible isolates (P = 0.001) and 27% not treated (P = 0.018). On multivariable analysis, Indian ethnicity and diabetes mellitus were associated with amoxicillin-clavulanate resistance. Genitourinary abnormalities, UTI in the past 12 months, and hospitalization in the past 6 months were associated with ciprofloxacin and co-trimoxazole resistance. Patients given active empirical antibiotics were most likely to report early symptom resolution, but correlation with in vitro susceptibility was imperfect. Factors associated with resistance may guide the decision to obtain initial urine culture.

Accuracy of urinary symptoms and urine microscopy in diagnosing urinary tract infection in women.

BACKGROUND: Women with urinary tract infections (UTIs) often present with urinary complaints such as frequency of micturition, dysuria, foul-smelling urine and other non-specific symptoms like fever. Physicians may order urine microscopy to guide empirical antibiotic prescription. However, the performance of this approach has not been assessed. OBJECTIVES: This study aimed to determine the accuracy of UTI symptoms and urine microscopy associated with culture-positive UTI in Asian women. METHODS: A cross-sectional study of adult women who presented with UTI-related symptoms was conducted at three public primary care clinics in Singapore. Demographic data and information on their symptoms were collected, followed by urine microscopy and culture to diagnose UTI. The sensitivity, specificity, positive (PPV), negative predictive values (NPV), accuracy (ACC) and area under curve (AUC) of combinations of symptom and urine investigations were analysed in association with culture-positive UTI, which was regarded as a benchmark. RESULTS: Data on 564 women (73.9% Chinese, 11.5% Malay, 8.2% Indian) were analysed, of which 259 (45.9%) had culture-positive UTI. Frequency and foul-smelling urine, pyuria (WBC ≥10/hpf) and semi-quantitative bacterial count (≥2+) were significantly associated with positive urine culture. The ACC and AUC for single or multiple urinary and/or general symptoms were low. Urine pyuria (minimally >10/hpf) alone or in combination with symptoms and/or semi-quantitative bacterial count achieved high sensitivity (>85%) and PPV, NPV, ACC and AUC of >70%. CONCLUSION: Urinary symptoms have limited accuracy in diagnosing culture-positive UTI. Concurrent urine microscopy showing presence of pyuria and/or bacterial count increased the diagnostic accuracy of culture-positive UTI.

RNA-Seq reveals transcriptomic interactions of Bacillus subtilis natto and Bifidobacterium animalis subsp. lactis in whole soybean solid-state co-fermentation.

Bifidobacteria are anaerobes and are difficult to culture in conventional fermentation system. It was observed that Bacillus subtilis natto enhanced growth of Bifidobacterium animalis subsp. lactis v9 by about 3-fold in a whole soybean solid-state co-fermentation, in a non-anaerobic condition. For the purpose of understanding the metabolic interactions between Bif. animalis subsp. lactis v9 and Ba. subtilis natto, the transcriptome of Bif. animalis subsp. lactis v9 and Ba. subtilis natto was analyzed in single and mixed cultures using RNA-Seq. Compared with the single culture, 459 genes of Bif. animalis subsp. lactis v9 were up regulated and 21 were down regulated in the mixed culture with Ba. subtilis natto, with more than 2-fold difference. Predictive metagenomic analyses suggested that Ba. subtilis natto up regulated transport functions, complex carbohydrates and amino acid metabolism, DNA repair, oxydative stress-related functions, and cell growth of Bif. animalis subsp. lactis v9. In the mixed culture with Bif. animalis subsp. lactis v9, only 3 transcripts of Ba. subtilis natto were over-expressed and 3115 were under-expressed with more than 2-fold difference. The highest down-regulated genes were those involved in carbohydrate and amino acid metabolism. The data presented here demonstrated a parasitic-like interaction regulated at the transcription level, between Ba. subtilis natto and Bif. animalis subsp. lactis in the mixed culture. The over-expression of genes involved in substrate uptake and metabolism in Bif. animalis subsp. lactis in the mixed culture nevertheless, led to its higher cell concentration in the nutrient rich whole soybean medium.

Health literacy and self-care among patients with chronic kidney disease in a primary care setting.

INTRODUCTION: The study objective was to determine the levels of self-care and health literacy (HL) and their associations among patients with chronic kidney disease (CKD). METHODS: This was a cross-sectional, questionnaire-based study conducted in a public primary care setting in Singapore. A total of 289 participants aged 21-80 years with hypertension were recruited. Self-care profiles were measured using the Hypertension Self-Care Profile (HTN-SCP; range 0-240, domain range 0-80). Health literacy was measured using the Short-Form Health Literacy Scale (HLS-SF12; range 0-50, limited literacy ≤33). RESULTS: The mean self-care score was 182.7 (standard deviation [SD] 23.2). The median HL score was 34.7 (interquartile range [IQR] 31.9-40.3), and 31.1% of participants had limited HL. Self-care was not associated with age, CKD status, household income and education, but was associated with gender and HL score. In the final regression model, lower HL scores (adjusted ß = 1.03, 95% confidence interval [CI] 0.7 to 1.36, P < 0.001) and male gender (adjusted ß = -5.29, 95% CI -10.56 to -0.03, P = 0.049) were associated with lower self-care scores. The HL scores were associated with self-care domains of self-efficacy (HL: ß = 0.30, 95% CI 0.17 to 0.42, P < 0.001), motivation (HL: ß = 0.40, 95% CI 0.26 to 0.53, P < 0.001) and behaviour (HL: ß = 0.38, 95% CI 0.26 to 0.50, P < 0.001). CONCLUSION: Thirty-one percent of the participants had limited HL. Self-care was not associated with age, race, CKD status, household income or education. Male gender and limited HL were associated with lower self-care. Self-care was associated with self-efficacy, motivation and behaviour. Future research could focus on more targeted approaches to improve self-care and HL among patients with CKD.

The Impact of a Revised National Childhood Immunization Schedule on Vaccination Defaulters.

Immunization schedules affect community vaccine uptake rates, especially in children who have defaulted on their regular immunization timelines. In 2020, Singapore revised its National Childhood Immunization Schedule (NCIS) to incorporate two new combination vaccines: the hexavalent hepatitis, diphtheria, acellular pertussis, tetanus (DTaP), hemophilus influenzae b (Hib), inactivated poliovirus (IPV) (6-in-1), and the quadrivalent measles, mumps, rubella, and varicella (MMRV) vaccines, thus reducing the mean number of clinic visits and vaccine doses by two. Our database study aims to evaluate the impact of the 2020 NCIS on catch-up vaccination uptake rates in children at 18 and 24 months of age and the catch-up immunization rates of individual vaccines at two years. Vaccination data from two cohorts, in 2018 (n = 11,371) and in 2019 (n = 11,719), were extracted from the Electronic Medical Records. Catch-up vaccination rates increased by 5.2% and 2.6% in children on the new NCIS at 18 and 24 months, respectively. The uptake of individual 5-in-1 (DTaP, IPV, Hib), MMR, and pneumococcal vaccines increased by 3.7%, 4.1%, and 1.9% at 18 months. Reduced vaccination doses and visits in the new NCIS bring direct and indirect benefits to parents and promote vaccination adherence for their children. These findings highlight the importance of timelines in improving catch-up vaccination rates in any NCIS.

Assessing the impact of educational methods on influenza vaccine uptake and patient knowledge and attitudes: a randomised controlled trial.

Introduction: Although influenza vaccination reduces rates of pneumonia, hospitalisation and mortality, influenza vaccination uptake remains low in older patients. The primary aim was to compare individualised counselling with educational pamphlets alone in improving influenza vaccination uptake. The secondary aims were to evaluate knowledge and attitudes towards influenza vaccination and factors influencing uptake. Methods: A randomised controlled study was conducted in two government polyclinics with 160 participants per arm. Patients aged 65 years and above attending for doctor consultation were recruited. All participants received an educational pamphlet on influenza vaccination. The intervention group received additional face-to-face counselling. Participants filled a pre- and postintervention questionnaire assessing knowledge of influenza and attitudes towards the vaccine. Follow-up calls and verification of electronic records was done at three months to determine actual vaccine uptake. Results: At three months, 16 (10%) patients in the intervention group and 20 (12.5%) patients in the control group had completed influenza vaccination (P = 0.48). Factors positively associated with vaccine uptake were willingness to receive vaccination immediately after intervention (adjusted odds ratio [OR] 12.15, 95% confidence interval [CI] 4.42-33.38), and male gender (adjusted OR 2.96, 95% CI 1.23-7.12). Individualised counselling was more effective in improving knowledge (P < 0.01). Overall knowledge scores did not influence actual vaccine uptake rates. (adjusted OR 1.10 [0.90-1.3]). Conclusion: Both arms of patient education increased uptake of influenza vaccination. Individualised counselling was not superior to pamphlets alone in improving uptake. Performing vaccination at the initial point of contact improves actual uptake rates.

Rabbit haemorrhagic disease virus 2 from Singapore 2020 outbreak revealed an Australian recombinant variant.

Rabbit haemorrhagic disease (RHD) is a significant and debilitating viral disease affecting lagomorphs. In September 2020, Singapore reported its first cases of RHD virus (RHDV) infection in domesticated rabbits. The initial findings reported that the outbreak strain belonged to genotype GI.2 (RHDV2/RHDVb), and epidemiological investigations could not identify the definitive source of the virus origin. Further recombination detection and phylogenetic analyses of the Singapore outbreak strain revealed that the RHDV was a GI.2 structural (S)/GI.4 non-structural (NS) recombinant variant. Sequence analyses on the National Centre for Biotechnology Information (NCBI) database showed high homology to recently emerged Australian variants, which were prevalent in local Australian lagomorph populations since 2017. Time-structured and phylogeographic analyses for the S and NS genes revealed a close genetic relationship between the Singapore RHDV strain and the Australian RHDV variants. More thorough epidemiological inquiries are necessary to ascertain how an Australian RHDV was introduced into the Singapore rabbit population, and opportune development of RHDV diagnostics and vaccines will be important to safeguard lagomorphs from future RHDV infection and disease management.

Effectiveness of an algorithm-driven home telemonitoring system on the metabolic control and self-care behaviour of Asian adults with type-2 diabetes mellitus: A randomised controlled trial.

AIM: Healthcare professionals are leveraging on telehealth to manage patients with type-2 diabetes mellitus (T2DM). This study aimed to determine the clinical outcomes of patients using a novel tele-monitoring system (OPTIMUM) as compared to the standard of care. METHODS: An open-labelled randomised controlled trial involving 330 Asian patients with T2DM, aged 26-65 years, and suboptimal glycaemic control (HbA1c = 7.5-10%) was conducted in a Singapore public primary care clinic. The patients were assigned in a 1:1 ratio by block randomization to the intervention group to receive: in-app video-based tele-education, tele-monitoring of the blood pressure (BP), capillary glucose and weight via Bluetooth devices and mobile application, followed by algorithm-based tele-management by the OPTIMUM telehealth care team for abnormal parameters. Patients received usual care in the control group. Clinical assessments and self-care-related questionnaires were administered for both groups at baseline and 6 months. RESULTS: Complete data of 159 (intervention) and 160 (control) patients with comparable demographic profiles were analysed. Those in the intervention group showed significantly lower HbA1c by 0.34% (95%CI = -0.57 to -0.11; p = 0.004); first measurement of systolic BP decreased by 2.98 mmHg (95%CI:-5.8 to -0.08; p = 0.044) and diastolic BP by 4.24 mmHg (95%CI = -6.0 to -2.47; p = 0.001); and total cholesterol by 0.18 mmol/L (95%CI: -0.34 to -0.01; p = 0.040) compared to the control group, after adjusting for baseline variables. Questionnaire scores showed significant improvements in medication adherence and self-care behaviour in the intervention group. No significant weight change was noted between groups. CONCLUSION: The OPTIMUM tele-monitoring system improved the glycaemic, BP and total cholesterol control in patients with suboptimal T2DM control by enhancing their medication adherence and self-care over 6 months.

Making shared decisions with older men selecting treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH): a pilot randomized trial.

BACKGROUND: Making high-quality decisions when selecting treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) requires a shared decision-making approach. However, older people with lower health literacy face barriers. The pilot study aimed to evaluate the feasibility of recruiting participants and evaluate the effectiveness of a multi-level intervention on decision quality for the treatment of LUTS/BPH. METHOD: In this 2-arm, randomized controlled trial, multi-ethnic Asian men aged ≥ 50 years with moderate or severe symptoms (IPSS ≥ 8 and/or QOL ≥ 3) and physicians were recruited at a Singapore public primary care clinic. Men were randomized to either physicians trained in shared decision-making and used a pictorial patient-reported symptom score (Visual Analogue Uroflowmetry Score) during the consultation or to physicians untrained in shared decision-making who did not use the score. Decision quality was measured using SDMQ-9 scores from men and their physicians after the consultation. RESULTS: 60 men (intervention [n = 30], control [n = 30]) receiving care from 22 physicians were recruited. Men's mean age was 70 ± 9 years: 87% were Chinese, 40% had no formal education, and 32% were of lower socioeconomic status. No difference in decision quality from the men's nor their physicians' perspectives was noted [for men: mean score = 70.8 (SD 20.3) vs. 59.5 (SD 22.4); adjusted p = 0.352] [for physicians: mean score = 78.1 (SD 14.1) vs. 73.2 (SD 19.8); adjusted p > 0.999]. CONCLUSION: It was feasible to recruit the intended participants. There was no difference in decision quality between men who used shared decision-making and usual care for the treatment of LUTS/BPH.

Effects of a serious game on knowledge, attitude and practice in vector control and dengue prevention among adults in primary care: A randomised controlled trial.

Objective: Dengue is endemic but vaccination against it is optional in tropical Singapore. Despite vector control measures to curb mosquito breeding, dengue infection continues to be prevalent. A serious game has been developed to raise the community awareness of dengue vector control programme among residents in Singapore. The study aimed to evaluate the effectiveness of this serious game on the knowledge, attitude and practice (KAP) in dengue prevention among adults. It also determined their willingness to be vaccinated against dengue. Methods: A randomised controlled trial was conducted among volunteer adults who were visiting a regional primary care clinic in Sengkang, Singapore. 400 participants were randomly allocated to receive information regarding dengue prevention from either playing a serious game (intervention) or visiting a dengue prevention website (control). Before and after receiving information on dengue prevention, participants completed a self-administered online questionnaire within a two-week interval to assess the KAP score and their interest to vaccinate against dengue. Participants, who played serious game, evaluated the game with the System Usability Scale (SUS). Results: A total of 374 participants, comprising of 178 participants (89%) from intervention group and 196 participants (98%) from control group, completed both questionnaires. 157 (78.5%) participants in the intervention group completed playing the serious game. Participants in both groups had increased KAP score from baseline, but the mean difference in score (SD) was greater when assessing participants' daily practice towards dengue prevention in the serious game group compared to the control group (1.0 (2.8) vs 0.3 (1.9), p = .009). There was a positive correlation (rho = 0.275) between mean change in KAP score and highest achievement attained within serious game (p = .001). The mean SUS (SD) was 61.8 (19.2) among participants who played the serious game. 84.2% of the study population was willing to undertake the dengue vaccination at baseline. Participants in both groups had increased proportion of participants who showed interest in dengue vaccination from baseline but the difference between serious game group and control group were not significant (5.6% vs 2.6%, p = .131). Conclusions: Serious game is at least equally effective compared to conventional web-based learning in promoting dengue prevention measures and vaccination intention among adults, and may be considered as a feasible alternative to digitally engage local residents.

Immersive Virtual Reality in Alleviating Pain and Anxiety in Children During Immunization in Primary Care: A Pilot Randomized Controlled Trial.

Background: Pediatric immunization is often associated with significant fear and anxiety among the children and their parents. Their distress may potentially affect their adherence to the childhood immunization schedule and the acceptance of other recommended vaccines by physicians. Objective: The study primarily aimed to assess the feasibility of using immersive virtual reality (VR) during immunization in children in primary care. The secondary aim was to determine the effectiveness of immersive VR in alleviating pain and anxiety among children, reduction of anxiety of their parents and attending nurses during immunization compared to usual care without VR. Methods: A pilot open-label randomized control trial was conducted at a public primary care clinic in Singapore. Thirty children, aged 4-10 years were randomized to an intervention group (n = 15) using VR and a control group (n = 15) without VR during immunization. Feasibility was assessed by the response rate to the use of VR. The Faces Pain Scale-Revised (FPS-R) and the Children's Fear Scale (CFS) were used to determine their pain and anxiety, respectively. The anxiety level of their accompanying parents and attending nurses were evaluated using Visual Analog Scale (VAS) prior and post-immunization of these children. The FPS-R and CFS scores, and anxiety assessment for parents and nurses were assessed using Mann-Whitney U test. Wilcoxon signed rank test was used to assess the difference in the nurses' experience of using the VR application. Results: One child refused to use the VR equipment, constituting a rejection rate of 6.7% (1/15) but no adverse event occurred in the intervention arm. The overall response rate of 88% (30/34) when the parents were approached to participate in the study, indicating feasibility of using VR in childhood immunization. In the intervention group compared to the control group, the change in scores for CFS (median -1, IQR -2 to 0; P = 0.04), parental VAS (median -4, IQR -5 to -1; P = 0.04) were significantly decreased. After immunization, nurses scored favorably for VR, in terms of simplicity (median 9.5, IQR 5.72 to 10; P = 0.01), acceptability (median 10, IQR 5 to 10; P = 0.005) and willingness to use VR in the future (median 10, IQR 5 to 10; P = 0.02). Conclusion: Immersive VR is feasible, safe and effective in alleviating anxiety among the children and parents. Nurses viewed the application of VR in childhood immunization favorably. Clinical Trial Registration: [https://clinicaltrials.gov/ct2/show/NCT04748367], identifier [NCT04748367].

The synthesis of extracellular vesicles by the protistan parasite Blastocystis.

Blastocystis is a genus of single-celled protist belonging to the stramenopile group. Prior studies have shown that isolates of Blastocystis subtype 7 (ST7) induced higher levels of intestinal epithelial cell damage and gut microbiota dysbiosis in comparison to other subtypes in in vivo and in vitro settings. Prior research has shown a link between gut dysbiosis and exposure to extracellular vesicles (EVs) produced by pathogenic microorganisms. This study demonstrates a protocol for the isolation of EVs from Blastocystis ST7 via ultracentrifugation. Nanoparticle tracking analysis and transmission electron microscopy were used to assess EV size and morphology. The protein content of isolated EVs was assessed by mass spectrophotometry and the presence of EV markers were evaluated by Western blotting. Finally, the EVs were cocultured with prominent human gut microbiome species to observe their effect on prokaryote growth. Our data shows that Blastocystis ST7 secretes EVs that are similar in morphology to previously characterized EVs from other organisms and that these EVs contain a limited yet unique protein cargo with functions in host-parasite intercellular communication and cell viability. This cargo may be involved in mediating the effects of Blastocystis on its surrounding environment.

The roles of parasite-derived extracellular vesicles in disease and host-parasite communication.

In recent years, several parasites have been shown to interact with their hosts through intra- and inter-community communication mechanisms, which were identified to be mediated by extracellular vesicles (EVs) through various uptake mechanisms. EVs are a heterogenous group of nanoparticles (~30-5000 nm) classified into three main types according to their size and biogenesis. EVs contain proteins, lipids, nucleic acids and metabolites from the cell of origin which are essential for genetic exchange, biomarker identification and diagnosis of pathological diseases. As important "forward lines of parasite infectivity", the parasite-secreted EVs function as information transmitters in the early-stage of host-parasite interaction and subsequent host-cell colonization. For this review, we summarize from the literature the relevance of EVs to the pathogenesis and development of human parasitic protistan diseases such as giardiasis, leishmaniasis, amoebiasis, malaria and Blastocystis-mediated gut pathology. Specific in vitro and in vivo interactions of the parasite-EVs and the host, with the reported cellular and immunological outcomes are discussed in this review. EVs have great potential to be further developed as diagnostic, immunomodulation and therapeutic alternatives to fill the knowledge gaps in the current parasitic diseases discussed in this review. Nanomedicine and vaccine development could be explored, with the utilization and/or modification of the parasitic EVs as novel treatment and prevention strategies.

Self-administered oral glucose tolerance test with capillary glucose measurements for the screening of diabetes mellitus in high-risk adults: a feasibility study.

INTRODUCTION: Early diagnosis of prediabetes based on blood sampling for the oral glucose tolerance test (OGTT) is crucial for intervention but multiple barriers hinder its uptake. This study aimed to assess the feasibility and precision of a self-administered capillary OGTT for type-2 diabetes mellitus (T2DM) in high-risk individuals. RESEARCH DESIGN AND METHODS: Participants with history of gestational diabetes or prediabetes were recruited in primary care. Due to their prediabetic status and previous diagnosis of gestational diabetes mellitus, a proportion of participants had previous experience doing OGTT. They self-administered the capillary OGTT and concurrently their venous glucose samples were obtained. They filled a questionnaire to collect their demographic information, views of their capillary OGTT, and their preferred site of the test. RESULTS: Among 30 participants enrolled in this feasibility study, 93.3% of them felt confident of performing the capillary OGTT themselves, and 70.0% preferred the test at home. Older, less educated participants found it less acceptable. Mean capillary glucose values were significantly higher than venous glucose values, with mean difference at 0.31 mmol/L (95% CI 0.13 to 0.49) at fasting, and 0.47 mmol/L (95% CI 0.12 to 0.92) 2 hours post-OGTT. Capillary and venous glucose measurements were correlated for fasting (r=0.95; p<0.001) and 2-hour-post-OGTT (r=0.95;p<0.001). The Fleiss-Kappa Score (0.79, p<0.0001) indicated fair agreement between the two methods. The capillary OGTT had excellent sensitivity (94.1%) and negative predictive value (NPV=91.7%) in identifying prediabetes or T2DM status, vis-a-vis to venous glucose samples. CONCLUSION: Self-administered capillary OGTT is feasible and acceptable, especially among younger adults, with excellent sensitivity and NPV compared with plasma-based OGTT.